Bridget M. Kuehn

On the day after Congress repealed the Medicare Sustainable Growth Rate (SGR), Farzad Mostashari, a former Brookings Institution fellow and U.S. National Coordinator of Health Information Technology, was prepared to wager that the winners in this new era of healthcare payments would be primary-care physicians and practices.

"Who's going to win in this new world?" he asked during one of his sessions at the 

Healthcare Information Management and Systems Society (HIMSS) Annual Conference

. "I would say it's the people who have the least to lose and most to gain."

Many large health systems are reliant on the fee-for-service model for survival and have a disincentive to prevent hospitalizations because they make money when patients' conditions worsen, explained Mostashari, who created and now runs start-up Aledade to help practices form accountable care organizations (ACOs). But primary-care physicians have long taken a more holistic view of their patients and are in a good position to take charge of keeping their patients healthy through physician-led ACOs.

This path is not an easy one, however. He cautioned that so far, 75 percent of the physician-led ACOs aren't yet profitable. But by 2018 the changes in reimbursement associated with the SGR repeal, which offers physicians a 0.05 percent annual fee increase, will make ACOs and other Medicare-driven alternative models more attractive, Mostashari said.

"We have to nail [ACOs] in the next two- to two-and-a-half years," he said.

Fortunately, the secrets to physician-led ACO success have been well publicized. Mostashari and his former Brookings Institution colleagues published 

a free toolkit describing the keys to ACO success

. During his talk at HIMSS15, Mostashari summarized this information.

The first thing successful ACOs must do is harness their data to identify the highest-risk patients so they can prevent them from being hospitalized or having other expensive negative outcomes. But it is not as easy as just finding the most expensive patients, he said.

"Often we can't do anything about the highest-cost patients," he explained. "It's too late; the springs have come off. We've failed them."

Instead, he said ACOs must to use data to identify the patients helped before they become high-cost patients. For example, patients who have a high fall risk, who are taking several medications, who have congestive heart failure, or who are living in a dangerous home situation. Mostashari acknowledged, however, that it may be difficult to extract relevant data from current EHRs leaving some practices to rely on a separate population health system.

He noted it is important for ACOs to also tap their physicians' clinical experience and intuition because they may know about factors that mitigate or exacerbate the risks outlined in the data. For example, if a patient has regular family visits and support with their medical care.

Physicians also need to be alerted when their patients enter a hospital and be prepared to respond and share data with hospital clinicians.

"You are not doing population health if you don't know when your patient is in the hospital," he said. "Good luck managing health costs if you don't know that."

A primary-care physician sending an emergency department physician relevant patient data or discussing the case may well be a deciding factor in whether the patient is admitted, Mostashari explained.

Additionally, physicians must build a network of other physicians and facilities so they can ensure the quality and continuity of their patients care. Finally, Mostashari emphasized the importance of engaging patients and their families in care.

"Do what is right for the patient and the quality measures will follow," he said.

Articles

Using available data to identify potential high-risk patients before they become high-cost patients can reap rewards for accountable care organizations.

Smart Data Use a Key to Physician-Led ACO Success

Before a patient even walks in the door, he's already generated a first impression of his physician and practice based on what he's found online.

"Our patients have formed an impression before they've met us [in person],"said Nick Van Terheyden, the chief medical informatics officer for Nuance Communications during the 

To make sure that first impression is a good one it helps for physicians and practices to have an active presence on social media platforms such as Twitter, Facebook, and LinkedIn, he said.

cited data from a recent survey by Nuance

 that found about 40 percent of patients check online sources in advance of a visit with their physicians. Data from the 

 suggest that one of the first places patients stop is Google or other search engines. Among the first results for such searches are usually social media accounts.

"This is happening, and if you aren't accessing it you are missing an opportunity to interact," Terheyden cautioned.

For example, he noted that one of the things that patients may find when they search for a physician's name are patient reviews on physician review sites. These sites offer the opportunity for physicians to post a profile picture and may offer an opportunity to respond to reviews. He suggested that physicians be aware of the reviews they are receiving online and to post photos and other information on such sites to create a positive impression.

Many businesses and organizations, including Dell, actively monitor social media for mentions and complaints about their company and products. This monitoring gives them an opportunity to quickly respond and provide a better impression of their service, Terheyden explained.

Hospitals and practices are also getting in on the act with their own social media patient outreach. Terheyden highlighted several ways healthcare organizations can use social media to enhance patient engagement, including community engagement, real-time patient education, outreach to referring physicians, customer service, and crisis communications.

It can be intimidating for physicians and practices to dip a toe in social media, Terheyden acknowledged. But he suggested they start slow by setting up accounts and following what other practices and health organizations are doing on social media. He suggested that physicians follow colleagues and others they know in the industry. One way to follow conversations on Twitter is by following hashtags (#). For example, typing in #HIMSS15 allows Twitter users to view tweets relevant to the HIMSS meeting.

Practices should establish policies for social media use and train staff to avoid inappropriate posts or posts that could violate patient privacy, he said. For example, the Mayo Clinic 

Ultimately, Terheyden said that interacting with patients is really the key to successful social media use and it can be a powerful tool for patient engagement.

"It's about collaborating, interacting, engaging, and learning from our patients," he said.

Practices can interact with patients in many ways using social media: from community engagement to patient education to crisis communications.

Social Media Leads the Way in Patient Engagement

Too many organizations focus on the initial implementation of an EHR and too few spend enough time on sustaining successful adoption and use of the system over the long term.

That's, according to Heather Haugen, senior vice president of research at the Breakaway Group during a session at the 2015 

"Sometimes we get caught up in the wedding and forget the marriage," said Haugen. She explained that organizations will spend years preparing for the "go-live event," but afterwards don't put in the continued effort needed for success.

As a result, many organizations implement EHR systems but never get the value they were hoping for. Research by Haugen and her Breakaway colleagues that included interviews with more than 3,000 clinicians and executives found four keys to successful adoption of an EHR: engaged leadership, efficient and effective training, data sharing, and sustained efforts to support adoption.


First and foremost, she said it is necessary for practice leadership to be focused and actively engaged in the process of adopting an EHR. Too often, she said competing priorities cause executives not to be engaged.

"If an EHR adoption is not in your top three priorities [as a practice] it is very hard to get it done," she said. "As leaders, we should ask: What are the things we are going to stop doing to do other things well?"


The next key is how quickly the organization is able to get its staff proficient in using the new system to provide care. Haugen said it is important for training to be provided in "bite-sized" time periods and as close to implementation as possible.

"Time may be the most precious asset to any clinician," she said.

Training should ideally focus on realistic simulations that help walk clinicians and staff through the specific tasks they will be using the EHR for, she said. It should not spend a lot of time detailing the various features of the EHR.

"The clinicians don't care [about functions], they want to provide care," she said.

Organizations should also test staff to assess their proficiency at using the application, and leaders should observe the use of the EHR in action to identify what's not working well in order to address corrective measures.


Another key is early and frequent use and sharing of data from the system. Haugen explained that the first thing that practices and hospitals should measure is how proficiently staff is using the EHR. Otherwise, any data may be inaccurate. Next, they should focus on a few data areas and share that information with their clinicians to help them improve care.

She said that physicians are naturally analytical, so having data will inspire them to look for ways to improve care and will help them see value in using the EHR efficiently.


The final key is ongoing leadership and continued efforts to maximize adoption of the EHR over its lifespan. Haugen said many organizations assume that they are proficient years after an application has been installed. However, proficiency can fall off over time if new employees aren't trained well and staff share work flow workarounds. Additionally, someone needs to be in charge of preparing staff for upgrades and training incoming staff.

"You have to stay engaged for the life of the application," she said.

Research indicates there are four keys to successful EHR adoption. Here's how to implement them at your medical practice.

Ongoing Engagement Critical To EHR Success

Leaders at a 100-physician practice in Kansas and a neighboring hospital system shared the same concern when they launched separate patient portal systems: What if patients chose to use one portal over the other? Patient choice could have a huge impact on both systems' attestation to CMS' meaningful use program.

That was the dilemma described by Laura McCrary, executive director of the Kansas Health Information Network (KHIN), a non-profit member health exchange, and a speaker at this year's 

But using the statewide patient portal offered by KHIN could have solved both organizations' problems, she said.

"If you share a portal, every time a patient looks at info in the portal it counts for [both the hospital and practice]" McCrary said. "It allows our providers to work together."

Statewide portals such as KHIN's are one solution to the emerging problem of patients accumulating multiple portal logins and passwords from multiple providers as more organizations embrace these electronic patient engagement solutions. They offer other advantages as well, including allowing organizations that couldn’t afford a portal of their own to use one and giving patients an easy to use and comprehensive portal for their health information.  But there are also technical and other challenges to creating a statewide portal system, explained McCrary.

So far, 38 organizations of KHIN's 1,000 member organizations have opted to use the statewide MyHealtheRecords portal. The portal is one of two available in the state. Kansas required both of its private health information exchanges (HIEs) to offer a statewide portal.

Convenience for patients is a big benefit of a statewide portal like KHIN's system. Patients get all the information included in the summary of each patient encounter in one location. They can upload other information, and print out a pocket-sized summary of their medical information for emergency service providers, said Michelle McGuire, the senior project manager for KHIN. It also includes linked and searchable patient education materials from Healthwise. Individuals who are managing care for a child or older parent can also tie their portal accounts together.


But there were initially some challenges for providers who had to manually upload the patient summary and securely e-mail it to the patient, McCrary said. That step has since been automated. Physicians currently have to authenticate patients onsite in order for them to set up their account in the portal, but eventually patients will be able to self authenticate.

There were also technical challenges KHIN didn't anticipate. Currently, the patient portals query the HIE every six hours for new information. But now that more than 10,000 patients are using the system, this is becoming unsustainable, McCrary said. So KHIN is working on a way for the HIE to automatically push new data to the portals.

Another challenge was managing the links between parent and child portal. The system can automatically unlink a child's portal from their parents when they turn 18. But the state of Kansas allows children to have medical privacy from their parents as soon as they become sexually active, McCrary explained. So the system had to create a way for physicians to mark some information as only viewable by the child.

Going forward, several upgrades are planned for the patient portals, including adding more patient information.

"We are always looking for ways to expand and make it better," said McGuire.

For more information on how KHIN assists physicians, visit 

"Health Information Exchanges: A Progress Report."

In Kansas, one of two statewide patient portal systems has overcome a series of challenges to improve communication between physician and patients.

Shared Patient Portals Have Benefits and Drawbacks

Patients are taking a greater role in their healthcare than ever before, and a growing array of electronic tools are available to help physicians engage them, according to Shannon Vogel, director of health information technology at the Texas Medical Association during the 

Healthcare Information and Management Systems Society (HIMSS) 2015 annual conference

Nearly 90 percent of U.S. adults use the Internet and nearly three-quarters of them have used the Internet to search for health information, according to 2012 data collected by Pew Research Center. Additionally, 58 percent of U.S. adults own a smartphone and more than half of smartphone owners have used their device to access health information. Vogel summarized the growing tool chest of electronic patient engagement options for practices, including patient portals, personal health records, Health Information Exchanges (HIEs), direct protocol e-mails, and health applications, and their respective advantages.

Vogel explained that the use of all health information technology in practice is still in its infancy, but patient demand and CMS meaningful use incentives are driving rapid growth in the use of these technologies. A survey by the Texas Medical Association found that between 2005 and 2014, the use of EHRs in Texas grew from 25 percent to 69 percent of practices.

Patients often want e-mail reminders, online scheduling, the ability to e-mail their physician, and online access to test results and their records. The most common way practices are working to meet these demands is by creating patient portals, Vogel said.

Patient portals are often part of the practice's electronic medical record, Vogel explained. All portals offer secure messaging between the practice and patient and a summary of the patient's clinical information. They may also include appointment scheduling, bill paying, or customized options.

Portals can help to reduce a practice's administrative costs and streamline workflows. They can also help practices meet meaningful use requirements, such as patient access to their medical records, patient reminders, and secure messaging, Vogel said.

"It's a great way to bring value back to the practice," said Vogel.

But one downside of portals is that patients with multiple physicians may wind up with multiple portals. One option that has emerged to help patients keep all their health information in one place is the patient health record (PHR). Patients can upload medical records from their physicians into their PHR and they can also enter information about supplements, data from health apps, and other information into the record. Patients can share access to this record with their physician. But Vogel said use of PHRs so far has been low. She explained that they may not help physicians meet meaningful use requirements, though CMS is looking into ways to help with this drawback.

Some practices are offering secure e-mail messaging only, Vogel said. And in some states, HIEs are beginning to offer some electronic engagement functionality. Additionally, practices may make use of the growing array of health apps that patients can use to track their health data. She noted that physicians might use these tools to ask patients to call or schedule an appointment if the patient's readings are outside of certain parameters.

No matter what electronic tools practices chose, Vogel emphasized that it is important for the physician and practice staff to become very familiar with the tool and familiarize themselves with the patient interface. She also noted that while some patients are eager to reach out online, others may not be comfortable with this or may lack access.

"Many patients are interested, but not all have the desire, time, and access to the tools," she said. "We need to meet them where they are."

"Evaluating Six Electronic Patient Engagement Tools."

A growing array of electronic tools are available to patients, but physicians and practices must first embrace them.

Online Patient Engagement Requires Practice Buy-In

With the demand for mobile health apps exploding, practices may be tempted to get in on the act by creating apps for their patients. But before they dive in legal experts at 

the Healthcare Information Management and Systems Society 2015 Annual Conference

 said it is important to understand the potential risks apps can pose to patient data and how mobile software is regulated in the United States.

By any measure the market for mobile health (mHealth) apps is exploding. The number of smart devices in the United States is doubling every five years, according to speaker Sharon Klein, a lawyer who specializes in mHealth and partner at Pepper Hamilton LLP. There is a growing, multi-billion dollar market for health apps, Klein said, yet the framework for regulating these products and the risks associated with them are still evolving.

"mHealth is facing a perfect storm of regulation," Klein said. She explained that there is currently a spider web of regulations related to health apps from the U.S. Food and Drug Administration (FDA), the Federal Trade Commission (FTC), the Federal Communications Commission, and HHS.

One of the chief concerns of regulators is the privacy and security of patient data collected and transmitted by health apps. This is a growing concern, Klein said, because medical identity theft is rampant, affecting 1.5 million Americans and costing the healthcare industry $30 billion a year.

Data thieves are commanding $50 for a complete medical identity - compared with $1 for a social security number - on the black market, Klein said. With such a premium on health data, thieves are selling any medical data they can acquire, even if it is not enough alone to commit medical identity fraud. Online data from multiple data breaches is often pooled allowing fraudsters to piece together enough of an individual's identity to fool insurers or healthcare institutions, Klein explained.

"It's becoming a sophisticated process," she said.

Once a patient's medical identity has been acquired that patient and his insurance company may be fraudulently charged for procedures the patient never received, she said.

While most practices may be familiar with the patient privacy regulations associated with HIPAA and the Health Information Technology for Economic and Clinical Health Act, understanding these laws is not enough for app developers, according to Klein. For example she explained that the FTC has taken action against an app developer for not adequately disclosing to users how their data was being used.

The FDA's regulatory requirements for apps vary based on the risks associated with the app and the intended use of the app, explained speaker Colleen Hittle, managing director of Navigant Consulting, Inc, which advises developers on the FDA approval process. Hittle noted that it is wise for app developers to talk with the FDA about which process their app should go through.

Knowing what is required of developers by various regulatory agencies is critical, according to both Hittle and Klein. Hittle emphasized the importance of carefully documenting every step in the app development process. Klein recommended that would-be developers read the guidelines set out by U.S. regulatory agencies, including the FTC's 

Protecting Consumer Privacy in an Era of Rapid Change

"Start thinking before you build an app," Klein said.

Medical apps are a hot commodity, but before you jump in to the development market, take time to fully understand federal regulatory requirements.