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Patient and Family Engagement: Emerging Best Practices and Lessons Learned from Primary Care Practices

Robert Furberg, PhD, MBA

Jennifer Webb, MA

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Background

Benefits of Patient and Family Engagement: Increases patients’ understanding of their health condition and

health care Enhances patients’ self-management skills, including self-care

of chronic conditions Improves patients and family members’ ability to navigate the

health care system Creates a sense of partnership among patients, families, and

clinicians Facilitates and support informed and shared decision making Fosters patient satisfaction

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PFE: The Provider’s Perspective

Advantages: Patients better prepared for appointments Fewer patient calls Increased patient satisfaction and loyalty

Concerns: Impact on workflow Sharing certain types of information with patients

Making it work: Practice culture of patient-centeredness is important Need to promote patient portals to patients Involve patients in the development process

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PFE: The Consumer’s Perspective

Patients enthusiastic about patient portals and use the following features frequently:

– Checking lab results– Viewing after-visit summary– Secure Messaging– Scheduling appointments– Requesting medication refills

Patients feel more knowledgeable about their health and health care

Patients feel more connected to doctor Patients feel increased trust in doctor and system

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Federal Strategy for Consumer e-Health

•Give consumers secure, timely electronic access to their health information.

Access

•Support the development of tools that help consumers to take action using information.

Action

•Help expectations about consumer (and provider) roles to evolve.

Attitude

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Meaningful Use PFE Measures: Stage 1

Core objectives: Provide patients an electronic copy of their health information. Provide patients with clinical summaries of office visits/hospital

discharge summaries.

Menu objectives: Provide patients with timely electronic access to their health

information. Use certified EHR technology to identify patient-specific

education resources and provide those resources to the patient, if appropriate.

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Meaningful Use PFE Measures: Stage 2

Updated Core Objectives: Provide patients timely online access to their health information

within 4 business days (more than 50% of patients). More than 5% of patients to view, download, or transmit their health

information. Clinical summaries provided to patients within 1 business day for

more than 50% of office visits. Use EHR technology to identify and provide education resources (more than 10% of all office visits).

New Core Objective: A secure message must be sent using the electronic messaging

function of Certified EHR Technology by more than 5% of unique patients seen by an EP during the EHR reporting period.

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Meaningful Use PFE Measures: Stage 3 Proposed core objectives:

Provide patients with access to health information within 24 hours if generated during course of visit.

For the top 5 non- English languages spoken nationally, provide 80% of patient-specific education materials in at least one of those languages based on EP’s local population, where publically available.

More than 10% of patients use secure electronic messaging to communicate with EPs (Assess readiness of raising threshold to 30% based on experience in Stage 2).

Proposed menu objectives: Provide 50% of patients the ability to designate to whom and when (i.e. pre-set

automated & on-demand) a summary of care document is sent to patient-designated recipient (automated transmit).

Provide 10% of patients with the ability to submit patient-generated health information to improve performance on high priority health conditions, and/or to improve patient engagement in care.

Provide patients with the ability to request an amendment to their record online through a patient portal in an obvious manner.

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CLINICAL SUMMARIES

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Clinical Summaries

Importance The clinical summary supports continuity of patient care by providing patients and their families

with relevant and actionable information. The clinical summary highlights information that is relevant to the patient’s care at a particular

time.

Barriers A provider frequently forgets to print the AVS Patients are leaving their AVS behind What about the portal? Patients don’t understand the AVS

Best Practices Stick to basic required information that can be updated during visit Include vital signs so patients can review their BMI and BP—initial steps leading toward

improved self-management Print summary prior to patient leaving practice to avoid additional work on staff (~ Stage 2 = 24

hours) Encourage patients to review and update medication list when visiting other providers Encourage and educate patients on use of patient portal (if available)

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Clinical Summaries

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Provider and Patient Quotes

“There is a symbolic gesture of handing somebody the after-visit summary, and I try to make that explicit. At the end of the visit, handing them the summary is like saying, “what you do is in your hands now.”

- Neil Calman, CEO, Institute for Family Health

“When mom comes back from the doctor, she can’t tell us everything that happened. Now we have this clinical summary and we can see what happened in the visit and any changes, like if you [referring to provider] discontinued or changed any medicines.”

- family member of elderly patient, Family Medicine Clinic of Danville

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PATIENT-SPECIFIC EDUCATION

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Patient-Specific EducationProviding patients with appropriate health education resources can

Help patients remember important information Improve patients ability to manage their own health Increase patients participation in informed decision making

Challenges and Best Practices Concern that patients don’t value education resources

– Provide education resources during the consultation (vs. at check out)– Providers review information with patient, highlight points, and check for understanding

Time and convenience issues– Automate the process to avoid the need for manual searches– Places printers strategically so providers can easily access materials during the consultation

Need for resources in other languages and suitable for range of patients– Select a source that offers resources in multiple languages and that are appropriate for

patients with lower literacy levels Patient information preferences and needs vary

– Ask patients about their information preferences and needs– Offer information in various formats and at different levels of depth– Provide patients a way to get more information

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Patient-Specific Education

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Provider and Patient Quotes

[Discussing the need for up-to-date, accurate, evidence-based patient education materials] “We’ve realized as we implement evidence‐based medicine we have to use national guidelines. The days of pulling out a handout and using it year after year are gone.”

- David Peterman, MD, Primary Health Medical Group, Idaho

“I’ve gotten into a habit of trying to identify at least one of the chronic problems a patient has and giving them patient education on it and rotating that so I just give them a different patient piece each time.”

- Richard Hempel, MD, Family Medicine Clinic of Danville

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SECURE MESSAGING

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Secure Messaging

Secure messaging can be used to Promote care coordination between visits Handle routine health issues and nonclinical tasks

(such as medication refills, referrals) Address patient questions and concerns Monitor patient condition(s) Adjust the care plan in a timely manner Help patients better manage their condition

Benefits Increases patient satisfaction with care and communication Convenient and saves time, avoids frustration of “telephone tag”, Communicate in unpressured setting May be more comfortable for patients wanting to discus sensitive issues Patients can follow up with questions they forgot during the appointment Can address many routine health issues Automatically documents communication with patients in the EHR Staff can triage patient messages and batch answers, which improves efficiency and saves time

if auto-replies are used for routine issues

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Secure Messaging

[Dr. Name]I wanted to let you know that the [medication name] had an almost immediate impact once I began using it, and I no longer have any trouble urinating. Does this medication need to be taken on a continual basis, or can it be discontinued once the problem is corrected?

Addressed To: [Dr. Name][Patient Name] has his med check apt tomorrow and I was wanting to get his flu shot at the same time but he’s been running a low grade fever (99) since last night. Will he still be able to get the flu shot?

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Provider and Patient Quotes

 “When we first roll it out to the doctor they’re like, ‘I’m not going to have time; this is going to be a burden.’ Then they realize it actually cuts down on the phone calls and the back and forth.”

- Tracy Morris, Primary Health Medical Group, Idaho

“[Secure messaging] is a lot less stressful way to ask questions. You can actually take time to think about everything that you want to say. When you’re talking to a healthcare provider, something might slip your mind. With secure messaging, you’re able to clearly divulge and document everything that you want to communicate to your healthcare provider. “

- Patient, Family Medicine Clinic of Danville

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(PATIENT PORTAL)

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Patient PortalsMany providers are turning to patient portals to meet patient needs and achieve MU objectives:

Use of secure electronic messaging

View, download, and transmit health records Provide clinical summaries Provide patient-specific education resources

Promoting the Patient Portal to Patients:

Plan a strategy for promoting the portal—prior to launch and ongoing– Post signage and fliers throughout the clinic– Send postcards and letters – pre-launch and ongoing (e.g., to announce new features)– Include information in telephone on-hold messages, waiting rooms, or exam room video– Have staff wear “Ask me about the portal” buttons or T-shirts

Make it everyone’s job to encourage using the portal from front-desk and telephone staff to physicians

– Develop talking points for staff– Encourage one-on-one with provider, particularly persuasive

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Patient Portals

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Provider and Patient Quotes

“As doctors gained experience with the portal, they realized it was a very efficient way to communicate with patients. Phone encounters can be long because patients get talkative and ask a lot of questions. Using messaging, their questions are more pointed.”

- James Weiss, MD, Primary Health Medical Group, Idaho

“There are things, not only that you might forget or that would not be communicated in a regular doctor visit, but there’s also just the kind of cumulative stuff that happens between doctor visits that you might forget. I mean, it’s kind of a way for you to document what’s happening to you.”

- Patient, Family Medicine Clinic of Danville

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VIEW, DOWNLOAD, TRANSMIT

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VDT/ Online Access to Health Information

Online access provides patients with more significant access to their health information.

Continuous access, coupled with the ability to download a comprehensive point-in-time record, provides more utility than a single or one-time provision of an electronic copy of health information.

Information To Be Made Accessible Online: Patient name Provider’s name and office contact information Current and past problem list Procedures Laboratory test results Current medication list and medication history Current medication allergy list and medication allergy history Vital signs (height, weight, blood pressure, BMI, growth charts) Smoking status Demographic information (preferred language, sex, race, ethnicity, date of birth) Care plan field(s), including goals and instructions Any known care team members, including the primary care provider (PCP) of record

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VDT/ Online Access to Health Information

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Provider and Patient Quotes

“Our EHR system has increased access for patients and improved our ability to evaluate patient care. Patients can access their health records from their living rooms—even send and receive e‐mails from their doctor if they have questions. The opportunities being presented to patients to take control of their health are quite remarkable.”

- David Peterman, MD, Primary Health Medical Group, Idaho

“Timely patient access to the electronic medical record is the foundation stone to creating patient centered care and better health outcomes. Access empowers patients in their decision making, promotes informed choice and supports mental health; for there is no worse emotion than feeling uninformed and ignored while navigating the healthcare system”.

- Regina Holliday, family member, consumer advocate

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Resources and Fact Sheets

Clinical Summaries http://www.healthit.gov/sites/default/files/nlc_providingclinicalsummary_ambulatorycare.docx http://www.healthit.gov/sites/default/files/measure-tools/NLC_Clinical_Summary_FAQs.docx

Patient Education Resources http://www.healthit.gov/sites/default/files/providing_patients_with_patient-specific_education_resources.docx http://www.healthit.gov/sites/default/files/measure-tools/nlc-faqs-about-patient-portal.docx

Patient Portals http://www.healthit.gov/sites/default/files/measure-tools/nlc-using-patient-portals-ambulatory-care-settings.docx http://www.healthit.gov/sites/default/files/measure-tools/nlc-faqs-about-patient-portal.docx

Online Access to Health Information http://www.healthit.gov/sites/default/files/nlc_providingehinformation_ambulatorycare.docx

Secure Messaging Will be posted to healthit.gov soon

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Discussion and Questions

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Contact

Robert Furberg, PhD, MBA

Senior Clinical Informaticist

Center for the Advancement of Health IT

919.316.3726

rfurberg@rti.org

Jennifer Webb, MA

Health IT Scientist

Center for the Advancement of Health IT

919.541.6746

jrwebb@rti.org