October 25, 2010

The Challenge of Timely Access
By Selena Chavis
For The Record
Vol. 22 No. 19 P. 20

As a so-called menu option in the scheme of meaningful use requirements, this provision figures to cause consternation in HIM departments and physician practices.

The wait is over. The 25 stage 1 meaningful use criteria that were hanging in the balance for months were officially introduced in July, and now the healthcare industry is quickly trying to grasp the nature of how this piece of the HITECH Act will shape the future of widespread EHR adoption across the country.

And as providers try to wrap their heads around what the final criteria will mean in terms of cost and workflow changes, one requirement has stood out as particularly challenging to a number of HIM professionals.

The criterion in question? It falls in the menu set of rules specific to eligible providers (EPs) and reads that EPs will “provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies).” Also garnering attention is the accompanying measure that requires “more than 10 percent of patients are provided electronic access to information within four days of its being updated in the EHR.”

“In large part, few EPs are ready for that,” says Kelly McLendon, RHIA, president of Health Information Xperts, LLC. “It’s going to be very dependent on the vendors to make that available.”

The final rules regarding timely access have been toned down from their original form following the comment period in which concerns were raised over EPs’ ability to comply. Previously, the criterion required access within 96 hours and was all encompassing as far as which EPs had to comply. The criteria now are broken down into two categories: the core set and the menu set. While all EPs must comply with the core set of objectives, they may now choose up to five from the menu set, where the timely access option currently resides.

“Some of the comments and concerns were listened to and acted upon,” says Cassi Birnbaum, RHIA, CPHQ, health information director and privacy officer for Rady Children’s Hospital of San Diego. “It will still be challenging if an EP chooses that particular option from the menu set.”

Aviva Halpert, MA, RHIA, CHPS, chief HIPAA officer at Mount Sinai Medical Center in New York, says it’s not just EPs who lack readiness; vendors are also behind the curve. And many in the industry are looking to this group to provide the basis for making the criteria happen.

“Theoretically, it’s a huge problem,” she says. “Systems are not designed to provide electronic copies or information sharing via e-mail.”

Justin Barnes, vice president of marketing, corporate, and government affairs for Greenway Medical Technologies and chairman emeritus of the National EHR Association, expands on those sentiments, suggesting that “if you want to go out of the gate January 1, then there will be a handful of companies that will be ready. Over the next six to nine months, that readiness will evolve very rapidly.”

Readiness Factor
McLendon notes that many of his clients have not honed in on the challenges that could potentially accompany the ability to create timely access to patient data. In fact, he suggests many are just beginning to come to terms with the need to get an early start on meaningful use preparations.

“Most of them don’t understand any of the criteria yet,” he says. “A couple of clients are early adopters. They understand what’s driving it … they just don’t like the cost.”

Birnbaum points out that readiness for the timely access objective correlates directly with how far along an EP is with its EHR and whether there is an established patient portal. “It really depends on where they are with their EHR migration,” she says. “There are some providers that are still very paper or hybrid based.”

The primary challenges will be centered on presenting the data in a digestible format to patients through a secure and convenient access point. “From a practical standpoint, electronic access equates to viewing this information on a secure patient portal or other mediums that can offer accessibility and security for the patient and the clinical information,” says Scott Fannin, vice president at Greenway Medical Technologies. “Many personal health records include the capability to contain the content required by the criteria, but the need for the health information from the electronic health record—as opposed to the patients’ manual entry of data—to populate these PHRs present challenges to many in the industry.”

For help in meeting these criteria, numerous EPs will look to their EHR vendors, many of which are not ready to provide an avenue for meeting this need, according to Halpert.

“Most current applications don’t create what is needed,” she explains, acknowledging that this obvious missing link will be quickly remedied now that the final rules are in play. “Every system will have to create a version that is readable by a patient.”

Hospitals have an advantage in that they have IT departments available to brainstorm and create solutions. The average physician office does not have these resources to draw on.

“The health information exchange [HIE] model will help. If information is being shared through an HIE, then it becomes a nonissue,” Halpert says. “These are solutions that are far away, though.”

Another concern, according to McLendon, is timeliness in taking action. Because EPs will have to show three months of continuous meaningful use to meet incentive requirements, he says providers should be ready to start by September of next year.

“There is going to be a rush of physicians trying to get [meaningful use] in place next year. Vendors aren’t going to be able to handle it,” McLendon explains.

To begin getting ready to specifically meet the timely access menu choice, EPs will need to first identify which patients they are going to target. “Who is going to be most open? What are you giving them … what are you trying to offer them?” McLendon says, suggesting that these are all questions EPs should be asking now.

Along with targeting an appropriate patient population, EPs must quickly identify how they will keep track of this provision for reporting purposes, McLendon says.

HIM departments will also need to align their processes with the new expectations, according to Fannin, who suggests the greatest initial adjustments will center on the need for a mindset change geared more toward consumerism.

The electronic provision of medical records to patients as a way to share clinical data is not common practice in the industry today; it’s traditionally been handled by making paper copies of the records and handing them to the patient.

“This criterion necessitates a change in how this information is delivered as well as the frequency with which this information is provided. HIM departments that do not have public access to practice services will need a strategy and a plan to roll it out to their patients,” Fannin says. “Furthermore, in order to meet the 10% requirement, workflows in practices may need to be altered to provide this information to enough patients.”

Departments that are working in a hybrid mode—with both an EHR and paper documentation—are going to have additional challenges in meeting these requirements, Fannin adds.

Specifically, patients must have electronic access to their health information, which means all paper-based data must first be entered into the EHR before being made available to the patient. Scanned documents will also make it challenging for the EHR to format the information into a practical and understandable “document” for the patient.

Besides internal readiness, Birnbaum has identified several potential conflicts with the provision as it relates to state law. Specifically, in California, all lab results have to be reviewed before they can be released electronically to patients.

“[The time frame] doesn’t really provide much time for extenuating circumstances,” she says. “For organizations without a patient portal, I don’t know how they will manage the timeframe effectively.”

Securing the Process
As EPs begin distributing patient data either by electronic interchange or by handing patients a CD, proper encryption will become paramount. As a result, healthcare organizations must add layers of security technology, McLendon says.

“When someone is accessing information outside of in-house staff, that compounds the security issue,” he notes, further explaining that this consideration has not been a major focal point for EPs in the past. “It’s a higher level of security than they are used to having.”

Halpert adds that meeting the conditions of timely access raises questions as to who becomes responsible for the security of data sent by e-mail or contained on a CD. “With paper records, once I hand the information to a patient, it’s not my problem,” she says, adding that software interoperability between physician and patient looms as another potential hurdle to clear.

In the case of an organization such as Rady Children’s Hospital, the largest source of comprehensive pediatric medical services in San Diego, security becomes even more complex. In most cases, the information is released to the legal guardian, but in others, minors have the right to withhold information from their guardian.

“The EHR system would need to possess a content-filtering mechanism associated with the sensitive data,” Birnbaum says. “If a third-party contractor is used, manual intervention would be required to make sure third parties are managing access to data correctly. There are a lot of implications, and I’m not aware of an EHR system that presently facilitates the segregation of sensitive data and information.”    

The Cost Factor
EHRs will bring EPs and patients many benefits—industry professionals readily acknowledge that point. But when it comes to the initial investment and the ratio of incentive money to time and cost issues associated with getting ready for criteria such as the timely access option, many experts believe breaking even will be an EP’s best hope.

“I don’t think you can even measure the cost; we don’t have the resources available to provide all this,” Halpert says. “I don’t think there is an entity out there that will come out ahead on this. … it’s going to cost and it’s going to be a great cost to physicians.”

Fannin points out that the capability to meet the needed functionality necessitates providing patients with a publicly accessible application such as a patient portal or an integrated PHR.

“A patient portal oftentimes will offer a PHR along with other useful features for both the patients and the practice. There are also multiple products that offer free or inexpensive personal health records as part of their solution, including Microsoft HealthVault and Google Health,” he says.

Fannin cautions that patient portals and PHR products must be able to integrate with the populating EHR to be considered an effective solution for meeting the timely access requirement. ”Stand-alone patient-facing solutions that are not integrated into the practices’ EHR will have difficulty being a realistic solution for this menu item,” he says.

If a provider decides to use a third-party source to create a patient portal, McLendon says the cost will be on top of what the provider pays for regular EHR maintenance. “Most companies will charge per physician to provide the information,” he says, pointing out that for a large practice that can equate to upward of $5,000 to $6,000 per year. “It starts eating away at the [meaningful use] dollars that they are getting from the government.”

Industry statistics suggest that while the cost of EHR products vary widely, the initial investment plus maintenance will on average cost a physician practice about $43,000 over a five-year period. Meanwhile, the maximum incentive for EPs is $44,000.
Still, many view the timely access requirement as further evidence that consumers are becoming more empowered when it comes to managing their health information. “This is very important to consumerism in the industry … and where the country needs to move toward engaging patients,” Barnes says.

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to healthcare and travel.