Online Connectivity
January / February 2010
Online Connectivity
Linking Providers and Patients to Create a Community of Care
The government campaign to stimulate physician adoption of health information technology is focused on electronic health records (EHR). But other types of information technology that are considerably more affordable and less difficult to implement can also help improve safety and care quality. For example, electronic prescribing improves medication safety by providing drug interaction alerts and reducing drug dispensing errors at pharmacies (Institute of Medicine, 2006). Online transmission of hospital lab results supports clinical decision making by giving office-based physicians key information when they need it (Piva et al., 20009; Rosenbloom et al., 2004). And a secure electronic messaging system enhances communications among physicians and between doctors and patients, leading to better coordination of care (Hereford& Bell, 2003).
The best way to use these online tools is in conjunction with an EHR that automates clinical work and includes advanced decision support features. But the vast majority of physicians do not have EHRs (Hsiao et al., 2008). The good news is that online connectivity technologies that include ePrescribing can help those doctors provide higher quality care right now. At the same time, the tools can prepare them to move to EHRs and qualify for government financial incentives.
Likewise, hospitals that use these tools will be in a good position to meet the “meaningful use” requirements being developed pursuant to the HITECH Act, which offers federal subsidies to meaningful users of qualified EHRs. The HIT Policy Committee’s Information Exchange Workgroup has estimated that 45% of meaningful use criteria are supported by health information exchange (McGraw et al., 2009).
We represent three healthcare systems that came to these realizations in different ways. What we have all found is that physicians will use a secure, web-based Software-as-a-Service (SaaS) platform to communicate with their patients, their hospitals, and each other, to varying extents. But they have to be convinced that the technology will improve care and make their lives easier. Similarly, many patients are willing to communicate online with their providers, asking questions about their care, getting lab results, and requesting appointments, prescription refills, and referrals. But, like physicians, some patients need a nudge to try something new; therefore, together with our affiliated physicians, we have developed various techniques to market the service to patients. One of our common marketing strategies to increase enrollment is to brand the service with the names of our organizations and integrate it into our web portals.
Another shared realization is that we’re using the online communications technology to build health information exchanges (HIEs) in our communities. This has been the holy grail of health IT since President George W. Bush announced his goal of providing every American with an interconnected electronic health record in 2004. Today the government is promoting a National Health Information Network that, so far, mainly affects federal agencies (Ferris, 2008). But large-scale interconnectivity is not going to happen that way. Data sharing will occur first at the local level, and HIEs will connect with other local hubs to create larger networks. The impetus for data sharing is for local physicians, hospitals, and other service providers to create a seamless view of the patient experience.
The online service that we’re using offers a broad range of functionalities, and each of our organizations has chosen to introduce parts of the service in a different order and at a different pace. What we have implemented so far reflects our hospital systems’ individual philosophies and priorities. But in the end, we all want to connect our healthcare providers with each other and with our patients to provide the very best quality of care. What follows are descriptions of how each system has gone about deploying and using this technology to benefit our distinct needs.
Montefiore Medical Center
Bronx, New York
Our primary reason for implementing a web-based, secure connectivity service across our 4 hospitals and 25 ambulatory facilities was to improve communications with our patients. We wanted to be able to interact with our patient population using a medium that they are comfortable with. We have a call center that does traditional telephonic customer service, and we communicate with our patients through mail, fax, and office visits. But in this new consumer-driven healthcare environment, we are also finding that patients want to correspond with their doctor electronically via the web.
The opportunities to improve the quality of patient care through online communications were numerous. Physicians would have more time to spend with patients either online or in person, and could use the tool to manage patients with chronic conditions for follow up and between appointments. Patients would gain greater and faster access to their physicians and the practice staff. The opportunity to advance our doctor-patient communications through the Internet and future EHR deployments presented a real opportunity for positive change.
In 2006, Montefiore piloted the online service at two of our largest physician practices, totaling 40 doctors. In 2007, the health system rolled it out to all of our employed primary care physicians, and today 537 of them are using it. Last year, we also began bringing our employed specialists aboard At the end of 2009, a total of 747 physicians—nearly a third of our staff—were registered. Physician champions have been the key to building adoption among their peers. We’ve also marketed to doctors on our own website, stressing the efficiencies that online communication can drive in their practices. On the whole, it has been easier to convert primary care doctors than specialists. But we are making steady progress with the latter, as well.
We’ve also had considerable success in enrolling patients. Between December 2007 and December 2008, the number of patients sending online messages to their doctors jumped from 11,335 to about 25,000—a 120% increase. Enrollment is expected to hit 40,000 this year.
We use several marketing techniques to reach patients, including promotion on our website, in Spanish and English-language pamphlets, and in the monthly bulletins that we mail out. But the most important strategy has been to have our call center personnel promote the online service to every patient who calls.
Once patients are enrolled, we send them outbound messages that encourage them to manage their own health. The online communications boost attendance at flu clinics, contribute to the flow of appointment scheduling, and aid in alerting parents of pediatric patients about CDC warnings on the usage of cold medications for children under age two. Every time we send one of these messages, we see a spike in usage of the online service.
The physician champions believe it has been a boon for patient care. Arthur Hopkins, MD, praises online interactions for reducing “phone tag” with his patients. He has found that when he discusses the service with patients during visits, 20% sign up right away. While he and other physicians were initially fearful that they would be deluged with patient email, that has not proved to be the case. Most patients are respectful of his time, he says.
The online service can benefit patients of all ages. The Pew Internet & American Life Project found that 66% of people over 65 years old search the Internet for health information (Fox, 2005). These folks are quite capable of messaging their physicians, and those who can’t do it usually have caregivers who can. “For the family member caring for a senior citizen—and many do so from different locations than the patient—every one of them is very appreciative of the service,” says Dr. Hopkins.
Over the past 3 years, our online service has become a strategic component of our patient satisfaction and customer outreach. Middle executives’ and physicians’ advocacy of online communications gave us the strength to grow the connectivity network to where it is today and to continue building it. Montefiore’s senior leaders are convinced that a robust patient portal is good for business and good for quality.
Stephen Rosenthal is president and chief operating officer of The Care Management Company (CMO), a not for-profit subsidiary of Montefiore Medical Center. He may be contacted at SROSENTH@montefiore.org.
Atlantic Health
Summit, New Jersey
Atlantic Health considered taking advantage of the Stark III regulations to help the private-practice physicians on the staffs of our facilities acquire electronic health records systems. Most of our physicians, however, were not ready. So we decided to provide all of the 2,100 physicians on our staff with a secure, web-based communication service that would start them on the road toward an EHR while giving them an electronic prescribing system so they could qualify for CMS’s financial incentive.
Since we began to deploy the online service in late 2007, 600 enrolled physicians, half of whom practice at Atlantic Health’s Morristown Memorial Hospital and Overlook Hospital, have begun using components of the online service, including ePrescribing, physician-to-physician messaging, and doctor-patient messaging. The 20,000 patients who have enrolled so far can consult with their physicians and request appointments and prescription refills online. Early last year, our hospitals also began delivering lab results and reports online to physicians.
One benefit of using a web-based service to deliver results is that our IT department does not have to write multiple interfaces to different types of EHRs in our physicians’ offices. That alone has saved us $125,000 in labor costs, and we are also starting to see savings from not having to mail or fax results to practices. But the biggest benefit has come from the improved quality of care. Not only do hospital lab results, discharge summaries, and other reports get into physicians’ hands more quickly, but they can use that data to make better informed decisions.
“Importing clinical results online from Atlantic Health into our office computerized health record improves the quality of the medical care that we can provide for our patients,” says Robert Rosenbaum, MD, an endocrinologist at Summit Medical Group (SMG), a 150-physician multispecialty group in Summit, New Jersey. Noting that his practice focuses on preventive and chronic care, Dr. Rosenbaum points out that the ability to combine the hospital data with results from in-house labs in his EHR allows him to trend and graph all of a patient’s results, providing a more complete picture of the patient’s condition.
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Another important advantage of being able to deliver hospital data online to SMG’s doctors is the seamless routing to their ambulatory EMRs. Frequently, the patient is discharged from one of our two hospitals and soon afterward visits his SMG primary care physician. In the past, our discharge paper trail was left behind on the fax machine, snail mailed or misplaced. Now, once the hospitalist dictates the discharge summary, it reaches the SMG physician’s EHR within minutes through our online service. When the doctor sees his patient, he now can view the patient’s data in the EHR and can make informed decisions without jumping over to a secondary system.
Physicians are also using the system to communicate with patients. They send them preventive care reminders, let them make appointments online, and do web visits with them. Invariably, the connectivity leads to better patient care when patients become more engaged. Many patients want to use this service and get more involved in their care. This point became increasingly evident throughout the fall of 2009 at the height of New Jersey’s H1N1 epidemic. The increased communication required by and for patients regarding H1N1 was met through the secure patient messaging component of our service. The sudden and significant increase in patient messaging utilization was an unexpected surprise.
For our patient population to get the maximum benefit from the connectivity offered by this online service, we must get more of our physicians to adopt it. So we’re subsidizing the cost of the service to encourage our doctors to join the network. By the end of the year, we hope to have 1,000 physicians online. When all our physicians are using the service and encouraging their patients to do the same, we will have the basis for a true community information network.
Linda Reed is vice president of information systems and chief information officer of Atlantic Health. She may be contacted at Linda.Reed@atlantichealth.org.
References
Saint Luke’s Health System
Kansas City, Missouri
When our 11-hospital system started an enterprise-wide quality improvement program in 2006, we decided to incorporate a web-based, interactive service to get physicians more involved in the campaign, while using the online connectivity as a tool to enhance the quality of care. We also wanted to help physicians automate their practices, and we saw this as the first step toward that goal for some practices.
We introduced the online service in one fell swoop, offering physicians electronic prescribing, colleague-to-colleague messaging, appointment scheduling, prescription refills, and online consultations with patients, with all data archived to a personal health record (PHR). In 2007, we co-developed an electronic results management module to enable our hospitals to transmit results and transcribed reports online to physicians. The data goes directly into the EHRs of those physicians who have them and is also archived to the patient PHRs.
Deploying the online service takes 2 to 4 weeks per practice, and integration to a practice’s EHR for data exchange takes 4 to 6 weeks. The effort has required minimal resources from our IT staff, because of the SaaS connectivity platform and rapid deployment methodology. Fourteen months after our rollout began, we had 200 physicians using the online service. To date, 300 physicians have enrolled. That’s about half of our target group, which includes employed doctors.
Physician champions helped persuade their colleagues to try the service, and we also focused on persuading practice staff to support the program. Another factor in our success to date has been the CMS ePrescribing incentive, which has given physicians a financial incentive to use the service. There are also cost savings. For example, practices that use the service extensively to communicate with patients find that it reduces their phone calls by about half.
At present, 22,000 patients are interacting with their physicians online. The largest categories of patient messages concern questions for physicians (38%), appointments (31%), and billing questions or other administrative issues (21%)).,medication and test results (16%), and billing questions or other administrative issues (14%).
Aside from boosting patient satisfaction, the service also helps physicians coordinate care without increasing their workload. When results and reports come into a physician’s inbox, for example, she can forward them with her notations to other doctors who are caring for the same patients; if the physician has an EHR, she can also send ambulatory-care notes and other data to her colleagues online. All of these tasks can be accomplished with a few mouse clicks.
While Saint Luke’s continues to deploy the service to more physicians and to enroll more patients, we plan to connect to other stakeholders, including health plans, commercial laboratories, and other area hospitals. We’d also like to enable patients to uplink the content in our PHRs to Microsoft HealthVault, where it can be combined with other eHealth applications.
We also believe that linking the online connectivity to our organization’s quality initiatives reinforces our efforts to improve quality and patient safety. The more physicians adopt ePrescribing, for example, the safer patients are when doctors prescribe medications for them, whether in the office or in the hospital.
Overall, we consider this online service to be the cornerstone of our eConnectivity strategy to exchange and archive vital patient data in order to improve the quality and continuity of care. Electronic connectivity means better communication with patients, which leads to better outcomes of care.
Deborah “Debe” Gash is vice president and chief information officer of Saint Luke’s Health System. She may be contacted at dgash@@saint-lukes.org.