Does Improving Patient Engagement Result in More Appropriate Utilization

Please join me for a webinar tomorrow:

Does Improving  Patient Engagement Result in More  Appropriate Utilization?     A special online seminar for senior executives, administrators, practice managers and patient outreach specialists from physician groups, emerging Accountable Care Organizations, Health Systems, Patient Centered Medical Homes, health plans, and government agencies. To register, please click here.                                                               To register, please click here. Answers to Your Specific Questions Have questions on our webinar and/or webinar formats? Please contact us at: marketing@vermedx.com Event Date:  Thursday, March 24th Time:  12:00 pm Eastern The risk-reward dynamic is shifting within healthcare.  Improving patient engagement is widely accepted as a critical foundation for emerging care practices, such as the patient-centered medical home.  As provider-patient interactions evolve, provider groups are realizing more and more that informed, prepared patients lead to more efficient encounters.  This is especially so when managing chronic conditions.  Benjamin Littenberg, MD FACP will share from both academic and actual business cases how low cost, high touch programs can reduce avoidable health utilization and improve patient satisfaction within normal provider practice workflow. Focused Discussion Attendees will learn: · What published, academic research has established about how patient engagement improves the overall clinical experience and what that means for providers? · How large physician-lead groups have implemented technology solutions that better prepare both providers and patients for more effective clinical encounters, and how they measure it? · What are the anticipated impacts - risks and rewards - of pay for performance and health care reform on how providers and patients interact? To register, please click here. Seminar Speaker Benjamin Littenberg MD, FACP   Henry and Carleen Tufo Professor of Medicine, Professor of Nursing, Director of General Internal Medicine Division of General Internal Medicine, University of Vermont Chief Medical Officer, Vermedx, Inc. Dr. Littenberg is the Henry and Carleen Tufo Professor of Medicine, Professor of Nursing and Director of General Internal Medicine at the University of Vermont. He received his medical degree from CaseWestern Reserve University and trained in internal medicine at Hartford Hospital in Connecticut. He was a Robert Wood Johnson Clinical Scholar at Stanford University before becoming Assistant Professor of Medicine at Dartmouth. Following an appointment as Associate Professor of Medicine at Washington University in St. Louis, he assumed his present position in 1999. Dr. Littenberg practices General Internal Medicine in Burlington, Vermont. His research interests center on technology assessment and quality improvement. Recent projects include new ways to measure quality of care in cancer, novel strategies for reporting test results to patients, better approaches to antibiotics in sinusitis, safety improvements in outpatient prescriptions, and strategies to address health literacy. In Vermont, Dr. Littenberg has been active on the Board of the Vermont Program for Quality in Health Care. He has developed statewide registry-based approaches to quality and safety improvement with the Vermont Breast Cancer Surveillance System and as Principal Investigator of the NIH-funded research grant for the Vermont Diabetes Information System which engendered Vermedx.   This event is sponsored and produced by Vermedx, Inc.           89 Beaumont Ave. Given Courtyard, 4 South Burlington, VT 05405 (802) 656-4576 www.vermedx.com       About Vermedx® Vermedx® technology enhances patient engagement by fostering communication between patient and caregiver, and by delivering decision support to health-care providers. The Vermedx system has been proven in a National Institute of Health clinical trial to improve health outcomes and reduce costs. The patent-pending Vermedx technology uses automated blood test reports and notification letters to help providers better care for their patients, and patients better manage their chronic conditions. Vermedx has been used by thousands of patients with diabetes in Vermont, New York, California and Texas. Clients include municipalities, private hospital systems, physician organizations, and managed care organizations. Visitwww.vermedx.com for more information.

Are we persuasive enough?

Joseph Kvedar, M.D. at the Center for Connected Health wrote recently about embedding the basic tools of persuasion into automated interchanges for better health. Messages that take advantage of reciprocation, consistency with personal commitments, expert authority, access to scarce resources, liking the source, and social norming are more likely to be persuasive. Marketers and sales people have long known this. I also agree with him that increased demand for health care as will require some sort of efficiency gains to maintain any semblance of access and equity.

In fact, the gains had by engaging patients in their own care, combined with the efficiencies of automation, are the "secret sauce" behind the success of the Vermedx Diabetes Information System in reducing the need for hospital and Emergency Room care as well as in reducing total costs of care.

His column got me thinking about our own automated messages within the Vermedx system. The letters to patients clearly take advantage of personal commitments and expert authority, but they could make better use of social norming and access to scarce resources. However, we take advantage or another technique that wasn't mentioned: specificity. Vermedx messages include information that is timely, specific, and actionable. Rather than say "You ought to get blood tests regularly," Vermedx tells the patient exactly when the test was due and what to do about it now.

We're going to be working on better ways to incorporate all the positive aspects of the Psychology of Persuasion (or Behavioral Economics, if you prefer) to make even greater gains in health outcomes.

How big a chunk of information do we want to exchange?

John Halamka and Wes Rishel have a very interesting approach to the recent debates on just what it is we might be exchanging in Health Information Exchanges. The problem arises from a tension among the need to care for the individual patient in front of you right now, to put that patient's care in the context of their history over time, and to take a broader view of a population of patients.

The provider with an individual case in the here and now traditionally generates a progress note - a document with whatever he or she thinks is required for the purposes of care. Much of professional education is transmitting the law and lore of what must/may/mustn't go into these documents and how to organize them for their various audiences. In general, they are free text, minimally organized with perhaps a few headings (Chief Complaint, Past Medical History, Assessment, etc.) and highly variable both across and within practitioners. (Some ten years ago, when Medicare mandated the presence of a Review of Systems for most office and hospital visits, the push-back from providers was huge and some actually left the profession rather than comply with this minimal nod towards standardization.)

Caring for patients in context requires the assembly of data across time and space and is the first place that electronic health records really shine. Knowing that the patient has an abnormal cardiogram now is valuable. Knowing that it is unchanged from one taken a year ago by another physician is gold. Sharing  documents across settings and providers accomplishes much of this, although it can certainly be improved upon with a little more granular organization.

At the population level, however, unstructured documents are not all that useful. Searching for the incidence of diabetic foot examination in our institution required natural language processing of many thousands of documents and failed to produce a reliable estimate [Kost, Chen, Littenberg et al. AMIA 2009]. Rather, we need standardized components of documents that can be extracted, transmitted, understood both as stand-alone entities and in the context they arose from, and analyzed for population as well as individual purposes.

Clinical laboratory data have long had these characteristics. A more-or-less complete documentation of a clinical chemistry test will consist of patient identifiers, specimen source (blood, urine, etc.), date and time of acquisition, analytic method, result, and units. However,  even these simple concepts are represented by a bewildering array of formats and definitions. To make matters worse, clinical labs routinely change their analytic methods, units, test names and any of these details, sometimes without even warning the users! A huge amount of effort goes into maintaining the clinical laboratory interfaces at Vermedx to ensure that these data continue to be useful over time.

More complex and less structured data such as pathology reports, operative notes, and discharge summaries are going to require a very large amount of work to make them transmissible and useful at this level. The first steps seem to be to agree upon what the smaller, irreducible units of information should be. This will undoubtedly be the battlefield of yet another IS standards war, but the outcome will have very big implications for how, and even whether, we can exchange health information into the future.

Consumer Health Information Quality

We usually write about the exchange of individual patient's information here at HealthInfoEx, but a recent article by R. Scott Braithwaite at New York University Medical Center, published in the Journal of General Internal Medicine, brings up a very fine idea about the quality of consumer health information.  To help stem the tide of over-hyped scientific trivia passed off as "breakthrough in health care," Braithwaite suggests that medical journals  include a consumer rating scale.  He very reasonably suggests using the US Preventive Services Task Force quality of evidence scale as a template and has a number of clever ideas to encourage lay media outlets to use it.

Braithwaite is worried about blogs (which he refers to, with a bit of a sniff, as "gray literature") and fears they wouldn't play along. Perhaps the blog certification services, like the Health on the Net Foundation, should require it to earn their seal of approval. (HON puts HealthInfoEx through the wringer on a regular basis.)

Kudos to Scott Braithwaite for a good idea on a vexing problem!

Clinical, Technical and Policy Issues in Exchanging Health Information

Every once in a while we get a request by a reader to post a guest entry on the blog. Frankly, we remain a bit dubious. But they are so eager, we allow the better angels of our otherwise controlling nature some free rein. So, here is a guest post for your interest and enjoyment.  Many thanks to author Rachel Davis who more often writes on Radiology degrees . She welcomes your comments at racheldavis65[@]gmail[.]com.

Clinical, Technical and Policy Issues in Exchanging Health Information

Health Information Exchange (HIE) has been proposed as one of the best ways to reduce waste and bring down costs in the healthcare system – when patient information is shared electronically across disparate healthcare systems without compromising on security, meaning and accuracy, it enables optimal provision of health care. For HIE to achieve success and attain its goals, the clinical, technical and policy issues relevant to the exchange of health information must be defined clearly and followed accurately.

Clinical issues are those that relate directly to patient care and which facilitate the provision of effective care in the shortest possible time and at the least possible cost. A study conducted by the Medical College of Wisconsin has found that ER doctors who have electronic access to patient data through a HIE spend less time in gathering information and make clinical decisions that are better informed and lead to better care for the patient. Clinical issues of a HIE deal with the accurate collection and compilation of information such as lab procedures, prescribed medication, patients’ main complaints, prior visits and treatments, and any other data that helps the attending doctor gain a more comprehensive picture of the medical history of the patient. When clinical information is accurate, it prevents errors, reduces wastage of time, effort, and money, and eliminates redundancy – time and money are not wasted on tests that have already been done, and medicines that cause allergies and adverse reactions are not prescribed inadvertently. 

The technical issues relate to the software and hardware requirements for the implementation of the HIE. The underlying architecture of the HIE must be designed and implemented, and it should include information relating to medication history standards, laboratory result standards, issues that relate to data quality, and the implementation of a record locator service.

Policy issues relate to the privacy aspects in a networked HIE, privacy policies and procedures that relate to a HIE, notification and consent when using a record locator service, matching patients to their records correctly and without any mix-ups, authenticating and setting levels of access for users, deciding on patient access to their own information (and protecting information of other patients), auditing access to a HIE, breaches of confidential health information, and a common and standardized framework for networked personal health information.

A Health Information Exchange must resolve clinical, technical and policy issues before it can be implemented successfully in any healthcare setting.

The Little Blue Button

The Markle Foundation is promoting easier access to health information for patients. They propose that systems that contain personal health information have "a little blue button" that allows the patient to download all their own data.  What are the upsides?  This Markle Policy Brief suggests that it would::

• Change consumer expectations and help them become more efficient in managing
their health information.
• Increase market pressure for technical standards to exchange electronic health data.
• Enable innovation through a host of applications and services that could add
significant value to individuals by using their information with their permission, such
as tools to help people with diabetes track their blood sugar, medication use, and
preventive care.

We're all for that!  How about downsides? Well, privacy certainly seems an issue. Can we be sure that others aren't downloading our embarrassing details? The technology is available for encryption, passwording, and the like. The biggest threats will be the usual "social hacks" like phishing, password guessing, and just conning folks out of their passwords.

What about erroneous information? We certainly don't want to be telling patients stuff about their health status that isn't true. Thinking that you have a nasty health problem because of an erroneous billing entry can cause some pretty sleepless nights. So, we need real clarity on what is valid personal health information (such as a confirmed diagnosis) and what is merely a weak proxy (a single test result, a billing code, a possibility mentioned in a differential diagnosis list, etc.).  However, the best strategy for errors in the data stream is to have someone who cares check it out. Giving patients an easy way to review their medical record and give corrective feedback ("I had heartburn, not a heart attack.") would be a great leap forward.

It looks like the VA may be among the first systems to offer a blue button. They have announced that it is available to users of their MyHealthVet portal. However, the sample report they show seems awfully long on patient-entered data and awfully short on the diagnoses, lab results, procedures, problems lists, and progress notes that make up the VA's medical records.

So, there is a lot of good in the idea of the "Little Blue Button" (beyond the wonderful pirating of a ubiquitous pharmaceutical marketing campaign), but, as always, the devil will be in the details.