Meaningful Use Stage 3 Could Include Patient-Generated Health Data

The Health IT Policy Committee is seeking public comment on proposed recommendations for Stage 3 of meaningful use under the Medicare and Medicaid Electronic Health Record Incentive Program. One of the recommendations requires participating health care providers to electronically accept patient-generated health information.

The goal of the proposed requirement is to increase patient engagement in health care. Because health care providers generally have little experience with the practice, some are asking: What exactly is patient-generated health information and what are the benefits and challenges of accepting it electronically?

Background

Stage 3 of meaningful use is expected to take effect in 2016 for select health care providers. The Policy Committee's request for comment sets out a number of proposed recommendations for Stage 3 and solicits feedback on their pros and cons.

One menu set recommendation would require participating hospitals and physicians to "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."? Patient-generated health information could include but is not limited to patient experience (e.g., exercise), pre-visit information, patient-created health goals and advance directives.?

According to the Policy Committee, one way health care providers could electronically accept such information would be to develop "semi-structured questions" and choose information "that is most relevant for their patients and/or related to high priority health conditions they elect to focus on."? With regard to the proposed requirement, the committee is seeking answers to the following questions:

• What information would providers consider most valuable to receive electronically from patients?
• What information do patients think is most important to share electronically with providers?
• How can the meaningful use program support allowing doctors and patients to mutually agree on patient-generated data flows that meet their needs, and should the functionality to collect those data be part of EHR certification?

The Policy Committee also is seeking information about whether existing standards could incorporate medical device data from the home and how patient-reported data could be incorporated into clinical quality measures.

What's Driving Interest in Patient-Generated Health Information?

Patients have always played an important role in their own health care. But new digital health information management tools are enabling patients to become even more engaged. Patients now have access to personal health records, mobile applications, social networking sites and other interactive websites designed to help them meet their health and wellness goals. About 11% of all mobile phone users and 19% of smartphone users have at least one health app on their device, according to Pew Internet & American Life Project's Mobile Health 2012 survey.

Twenty-nine percent of survey respondents who reported a "significant change," such as gaining or losing a lot of weight, becoming pregnant or quitting smoking were health app adopters. Of the 254 health app users in the survey, use of fitness and wellness apps dominated. Thirty-eight percent used apps to track exercise, fitness or heart rate, 31% tracked diet or food and 12% tracked weight.

Advances in wireless technologies also are quickly enabling continuous data capture and monitoring. Technologies like wireless sensors collect blood sugar levels, number of steps taken a day and sleep cycles, for example, and can transmit the information to health care providers to enable remote monitoring.

Meanwhile, national health care policy initiatives, such as those included in the Affordable Care Act, are beginning to support models of care that reward health care providers for achieving good health outcomes for patients. Stakeholders suggest that health care providers may have greater success in helping patients improve their health outcomes if they encourage their patients to use PHRs and other self-management tools to record and share information about their health. Some payment and care delivery approaches that tie reimbursement to the achievement of good health outcomes for patients, for example, appear to be driven by a recognition that patient-generated health information can be useful to health care providers.

Benefits and Challenges

It is widely accepted that engaging patients to play a more active role in their health can lead to better outcomes and more efficient care. However, recent studies have zeroed in to show the specific benefits of health care providers' electronically accepting and incorporating patient-generated health information into their clinical workflows.

For example, the Robert Wood Johnson Foundation announced in September that five research teams had demonstrated potential for improving health care delivery and outcomes -- as well as patient engagement -- through the use of technologies such as smartphone apps, sensors, iPads and others to collect information from patients' daily lives and share it with their health care providers.

Since 2006, Project HealthDesign -- led by experts at the University of Wisconsin-Madison School of Nursing -- has supported interdisciplinary teams of researchers, technology experts, clinicians and patients to develop tools to be used by real people to improve their health, better engage in their care and enhance communication with their providers.

A key hypothesis underpinning the Project HealthDesign teams' work is that "observations of daily living" (ODLs) -- the feelings, thoughts, behaviors and environmental factors that give people clues about their health -- can be applied to the clinical setting to improve care. ODLs studied in Project HealthDesign include mood and pain levels, eating habits, fussiness of infants and other things that people notice each day as they go about their lives.

Researchers worked with patients and providers to track ODLs that were meaningful to the patients and explored how they could be incorporated into clinical care. For example, Chronology.MD -- led by a team at University of California-Berkeley, the Healthy Communities Foundation and UC-San Francisco -- worked with Crohn's disease patients. By sharing their ODL data, patients helped clinicians readily identify the disease's triggers, significantly reducing the discomfort that accompanies this chronic condition.

Project HealthDesign showed that when it is easy for people to capture information from their lives and share it with clinicians, they feel empowered to take a more active role in their health -- and this engagement can lead to better outcomes. The research teams found that ODLs can give providers a more detailed and accurate picture of a patient's health, facilitating better clinical treatment plans and more informed decision-making.

There are, of course, challenges that must be addressed as health care providers begin to electronically incorporate patient-generated health information into clinical care. One example is fear among health care providers that electronically accepting patient-generated health information from a PHR or other patient-controlled tool could subject them to heightened risk for claims of medical malpractice. Questions that arise in this context generally relate to whether health care providers can trust the accuracy of patient-generated data, whether physicians would be liable for the failures of their staff to respond to or accurately interpret electronic health information from patients and whether health care providers would be expected to monitor patient-generated health information on a real-time basis.

Another challenge is that use of mobile devices to generate and communicate health information subjects this potentially sensitive information to security risks. Health care providers are subject to the HIPAA Security Rule, which outlines the safeguards that must be used to secure electronic, individually identifiable electronic health information. But HIPAA regulates providers, not patients. When patients generate health information using applications on their mobile devices, whether they share it with their health care providers or simply use it to engage in their own self-management activities, the Security Rule -- or other clear legal standards for how to protect the information -- do not apply.

Next Steps

While some have suggested that the Policy Committee's patient-generated health information recommendation may be difficult to meet, its inclusion in the RFC is consistent with prior signals that the bar for what constitutes meaningful use would be raised in Stage 3 in order to improve advanced care processes and health outcomes. According to the Policy Committee, "Stage 3 is the time to begin to transition from a setting-specific focus to a collaborative, patient- and family- centric approach."?

The committee further indicated that, to be considered for Stage 3, an objective had to, among other things, support new models of care (e.g., team-based, outcomes-oriented models), address national health priorities, and have broad applicability to provider specialties, patient health needs and different areas of the country. A requirement that health care providers electronically accept patient-generated health information would meet these criteria.

Regardless of the ultimate status of the proposed Stage 3 recommendation, there seems to be momentum behind the concept of encouraging -- if not requiring -- health care providers to electronically accept and incorporate patient generated health information into their care.

The National eHealth Collaborative recently released a "Patient Engagement Framework" to guide health care providers in developing and strengthening their patient engagement strategies through the use of electronic tools and resources. More than 150 stakeholders collaborated to create the guide, which places a strong emphasis on patient-generated data, ranging from symptom assessments and care experience surveys to shared decision making, advance directives and home monitoring data. The guide recommends the following five-phase approach.

• Phase 1 (Inform Me): A health care provider in this phase demonstrates basic levels of patient engagement with an emphasis on the use of simple tools that make health care more convenient and accessible (e.g., providing patients with standard forms and information about advance directives, privacy and specific conditions).
• Phase 2 (Engage Me): In this phase, patients have access to data in their EHRs, are encouraged to use fitness trackers and other e-health tools and are able to complete administrative tasks online.
• Phase 3 (Empower Me): Attributes of this phase include use of secure messaging between patients and providers, integration of basic patient-generated data into EHR systems, online quality, safety and patient experience ratings and participation in a health information exchange or similar effort.
• Phase 4 (Partner with Me): Providers at this phase support patients with condition-specific management tools and access to care summaries. They also integrate significant amounts of ongoing patient-generated data, such as preferences, self-care, wellness and home health device data, into their EHR systems.?
• Phase 5 (Support My e-Community): Patients and caregivers are provided with online community support from providers, opportunities for e-visits, and information like cost comparisons and outcomes reporting to help them make more informed decisions about their care and treatment. Providers will likely participate in an accountable care or patient-centered medical home model.

The Policy Committee's RFC is open for comment until January 14, 2013. Comments should be submitted electronically via www.regulations.gov.

Source: http://www.ihealthbeat.org/features/2012/meaningful-use-stage-3-could-include-patientgenerated-health-data.aspx

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