Consumer health informaticsPromise of and Potential for Patient-Facing Technologies to Enable Meaningful Use
Introduction
Substantial evidence demonstrates that patients today use health information technology (HIT) for a variety of purposes including to seek out relevant health information for themselves, friends, or family1; access healthcare services such as appointment scheduling and medication refills2, 3; communicate with providers via secure messaging4; engage with computerized tailored interventions, commonly referred to as eHealth tools, to manage a chronic condition or to change a health behavior (e.g., smoking) 5, 6, 7; employ a personal health record (PHR) or web portal to store personal health information8; use remote monitoring devices (e.g., blood pressure monitors and glucometers) 9; and seek support from others with similar health concerns or conditions through list-serves and social networks.10 In addition to these many functions for which patients use HIT, they report that these technology resources increasingly influence their health decisions and the actions they take to manage and improve their health.1 In this way, patients are revealing what they believe are the meaningful uses of HIT from their unique perspectives and can guide policymakers and providers about how to organize and offer services that are truly patient-centric and responsive to their wants and needs.
On November 5–6, 2009, representatives from the National Cancer Institute (NCI), along with the National Library of Medicine, the Agency for Healthcare Research and Quality, the CDC, and others were invited to participate in the Informatics for Consumer Health summit in Potomac MD.11 The overarching goal of the summit was to increase the quality and utilization of evidence-based consumer products that may be integrated into health information exchange networks. Objectives included increasing collaboration and partnerships; developing knowledge products including a journal supplement (this issue), alert service, and policy-oriented white paper; and stimulating development of commercially viable products for the consumer market. As part of the summit, breakout sessions were offered that covered a broad range of topic areas. The “meaningful use” of HIT from the consumer/patient perspective was one. The senior author of this article moderated that session, and the remaining authors (with the exception of ML) participated along with others (who are acknowledged below). The terms “consumer” and “patient” are used synonymously in the current discussion of these topics.
Questions that were posed to participants during the session included:
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What are examples of meaningful use of HIT by patients?
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How will meaningful use of HIT by patients improve healthcare quality, safety, and efficiency?
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How can we ensure access and salience of patient eHealth tools for diverse populations?
The purpose of this article is to discuss and elaborate on these questions in light of the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act within the American Reinvestment and Recovery Act (ARRA), and the important role of meaningful use of HIT. On July 13, 2010, the Centers for Medicare and Medicaid Services (CMS) released the final rule regarding the definition of meaningful use. It provides some guidance with respect to the role of the patient but largely focuses on the provider in its initial set of requirements. An explanation is provided of the potential role and benefits of existing and emerging patient-facing technologies as essential to a full definition of meaningful use of HIT.
The CMS meaningful-use rule includes three objectives for the first 2 years (2011 and 2012), referred to as Stage 1. Only one of the 15 core objectives that are required for meaningful use by eligible professionals12 is patient-facing, stating, “On request, provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, allergies).” This is also one of the 14 core objectives for eligible hospitals. In addition, hospitals have a second patient-related core objective: providing patients with an electronic copy of their discharge instructions at the time of discharge, if requested. These objectives address the strong desire by patients to have guaranteed access to their health information and directives in electronic form. With this provision, patients will be able to identify more easily any errors in their record that warrant correction, as well as facilitate transmission of health information to other providers involved in their care until such time as robust electronic health information exchange is in place. Although no compelling evidence exists to date, it is anticipated that both quality and safety will be improved by providing patients with unfettered access to their records and treatment plans through enhanced coordination of care, reduced duplication of tests and procedures, and avoidance of adverse drug events and side effects.
Two other patient-specific objectives are part of the Eligible Professional Menu Set, which include ten additional functionalities; eligible professionals are expected to choose five of these to achieve in the first 2 years. The first objective within the Eligible Professional Menu Set (which is replicated and is the only patient-targeted objective in the Eligible Hospital Menu Set) refers to the “use of EHR technology to identify patient-specific education resources and provide those to the patient as appropriate.”12 Here, relevant data elements from the EHR including the problem list, diagnostic test results, and medication lists can be used to identify specific information resources that are targeted to patients' particular problems. This process, also sometimes referred to as “Information Therapy,” has been promulgated as one way to activate patients to become more involved in their care and improve their health.13, 14 The second patient-centric Menu Set objective for eligible professionals involves “sending reminders to patients (per patient preference) for preventive and follow-up care and providing patients with timely electronic access to their health information.”12 These provisions are based on the evidence that patient reminders are effective methods for increasing participation in preventive services and improving medication adherence.15, 16, 17, 18
Despite these advances in enabling patients' meaningful use of HIT, they do not yet achieve the level of decision support that is available to providers, and they leave ample room to address gaps in patient support in future stages of the CMS rule making. What follows is a “deep dive” into the myriad ways in which patients use the Internet and other technologies today for health improvement, providing a framework for organizing these activities as examples of meaningful use.
Section snippets
Patient Engagement Through Health Information Technology
There are quiet revolutions, and then there are sea changes moving society in a new direction with no promise of return to a prior state. The Internet and wireless technology have altered consumer behavior, creating an unparalleled landscape where patients can readily find information, perform transactions, and connect and share with one another. Patients traditionally seek health information in three ways: on their own, from professionals, and from friends and family. The Internet does not
Health and Healthcare Quality
The IOM advocates transforming health care from episodic to continuous care. To achieve this goal, patients must be provided tools to efficiently interact with the healthcare system outside of face-to-face episodic visits. Secure messaging, home monitoring devices, and other eHealth tools that increase continuous care should be considered meaningful use of HIT. A recent landmark report by Kaiser Permanente in Portland OR noted differences in patient outcomes, comparing users of secure messaging
Healthcare Efficiency
The U.S. healthcare system must reform not only the quality of care provided, but also the efficiency of care. Providing more care at the same cost is not a sustainable option. Although implementation of patient-facing technologies is limited, evidence for enhanced efficiency of care does exist. Liederman and colleagues published results of use of a personal health record with electronic patient–provider communication through secure messaging, noting that telephone care declined as secure
Self-Management and Adherence
Several studies have tested shared EHRs with professional communication and secure messaging among patients for patients with a chronic condition. Results find that patients believe that knowledge of their condition and self-care improves, and that tailored feedback is a key component to that change.37, 39, 56, 57, 58 Overall, evidence is mounting that PHRs and portals can provide considerable consumer-perceived value.8 Further, discovery of factors that explore the relationship between patient
Reducing Disparities
Not all patients have access to the Internet or computer literacy levels needed to use new patient-facing technologies. In an evaluation of adoption of the Kaiser Permanente PHR in Georgia, Roblin et al.59 noted that African-American patients were less likely to use the system, even after adjusting for baseline education, co-morbidity, patient activation, and Internet access. Thus, cultural differences may remain as well as access and computer literacy limitations.
In the short term,
Population Health
The above review indicates that patient-facing technologies enable patient engagement and empowerment in their own care. The value of these technologies is not only in meeting the needs of individual patients, but also contributing to improved population health in several ways. Table 1 highlights the potential value of patient-facing HIT for individuals and population health.
As noted previously, emerging evidence suggests that patient-facing technologies can lead to improved health outcomes and
Barriers and Unintended Consequences
As with any new system or innovation, there are often barriers to implementation and unexpected results when the execution and use of these practices is launched. HIT is no exception.
Consumer-facing systems are often dependent on existing provider-sourced information. Unless this is available through an electronic interface, it may not be timely. However, duplicate data entry by the patient is often required for at least some of their data. PHRs that require patients to re-enter their
Future Perspectives
Our list of patient-facing HITs to achieve meaningful use focuses on what is available today. Future points of engagement should include inpatient patient-facing technologies and patient-facing HITs to enable care transitions that also support caregivers in their role. Indeed, substantial care provision is delivered by families and informal caregivers, and the Veterans Health Administration is leveraging technology to support caregivers of veterans in the home. Surveys from the Pew Internet &
Conclusion
The success of healthcare reform is predicated on achieving improved health outcomes and reduced costs, which can only be accomplished by activating patients to become more engaged in their own care. Patient-facing technologies are likely to play a critical role in supporting patients to become more informed and activated and may also improve efficiencies. Further research is needed to identify the most useful and effective technologies for patients.
To this end, research agendas for
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