February 19, 2007

Wired Clinics Meet Wired Patients
By Aggie Stewart
For The Record
Vol. 19 No. 3 P. 24

Nearly 200,000 New Hampshire consumers have enrolled in a powerful online program that combines administrative and clinical functions.

For most wired healthcare organizations, being wired has become more than having the fiber optics and cables in place to support IT connections throughout their bricks-and-mortar operation. It’s become a communications state of mind.

Successful HIT implementations are viewed as midpoints, or even starting points, for improving and optimizing communication and information exchange rather than end points. Significant time, energy, and resources continue to be devoted to developing and honing in-house linkages among providers and administration. And increasingly, more time, energy, and resources are being devoted to developing organization-sponsored, Web-based portals to provide patients with health information and education.

Together, these activities are creating fundamental changes in the nature of the patient-provider relationship and empowering consumers to become more active participants in their health management, a key recommendation in the Institute of Medicine’s 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century.

With IT more integrated into day-to-day provider and administrative workflows and patients more familiar with using online resources to be better informed about their health, the time has been right for some healthcare organizations, such as New Hampshire’s Dartmouth-Hitchcock Medical Center, to establish a Web-based communication link that connects its three locations. For Dartmouth-Hitchcock, this link occurs vis-à-vis an application called Patient Online (POL).

Developed by Vermont-based IDX, now part of GE Healthcare, POL enables 24/7, HIPAA-compliant, secure electronic communication between patients, providers, and administrative staff. At Dartmouth-Hitchcock, POL serves all its group practices in southern New Hampshire, which includes 340,000 providers and 190,000 patients.
Operating in one of the nation’s most wired states, Dartmouth-Hitchcock has a solid history of early HIT adoptions. In the late 1970s, it began developing its own electronic medical record (EMR), and e-mail was its regular method of internal communication, well ahead of other provider organizations. Dartmouth-Hitchcock also became an early partner of IDX and codeveloped its business application with the company, remaining an IDX customer.

Dartmouth-Hitchcock’s interest in the developing field of informatics coupled with its desire to improve patient satisfaction around telephone communications dovetailed nicely with the release of POL in spring 2001. “Our No. 1 patient complaint, probably to this day, is that they couldn’t get through on the phone to get all the information that they need,” explains Barbara Walters, MD, Dartmouth-Hitchcock’s senior medical director. “So we thought we could offload a bunch of administrative tasks to online—like the banking industry did. We also thought it might be a market differentiator for us. At the same time, IDX was just developing [POL], which could be used as a patient portal. All these factors converged and we decided to give it a shot.”

A Phased Implementation
Dartmouth-Hitchcock has taken a phased approach to implementing POL, adding more functionality as IDX made it available. Phase 1 went live in the summer of 2001, followed 18 months later by phase 2 and phase 3 in 2005.

Initially, the organization’s leadership thought its patients would be most interested in using the Web portal for administrative tasks that didn’t require interaction with either clinical or administrative staff: providing updated insurance and demographic information, scheduling appointments, and requesting prescription refills. These functions, along with the ability to send secure clinical messages to members of the patient’s healthcare team, were included in the phase 1 rollout.

POL was a hit with patients. Rather than the administrative functions leading the usage pack, however, it was the clinical messaging function that patients used the most. Clinical messaging in POL occurs via a password-protected Web page that sends encrypted messages between users.

According to Walters, the heavy usage of clinical messaging led Dartmouth-Hitchcock to develop more clinical integration—that is, using POL to provide more support for clinical care. So, while phase 2 allowed patients to view their account balances, make payments, and request their medical records, it also gave them the option to have an e-visit with a provider.

At Dartmouth-Hitchcock, an e-visit is an electronic communication exchange that takes the place of an office visit. “There is a very specific CPT code and definition of what an electronic visit must contain to be classified as a billable visit,” says Walters. “It has to have clinical decision making and a review of subjective and/or objective symptoms and clinical advice given to a patient that could be done electronically.” For example, a patient could have an e-visit for a recurrent urinary tract infection, since the electronic clinical exchange would involve a description and review of symptoms, clinical decision making, and provision of clinical advice, such as a prescription.

Clinical message exchanges and e-visits on POL become part of the patient’s EMR. As Walters describes it, just as a message slip would be inserted into a patient’s paper medical record, electronic clinical messages or conversations with the patient are posted to the messages section in the patient’s EMR. When an e-visit occurs, the visit gets posted in the EMR’s office notes or progress notes section.

Dartmouth-Hitchcock has set a standard of one business day for responding to both clinical messages and e-visit requests, striving to respond within the morning or afternoon session after the message was received. “We’re probably about 90% compliant with that,” says Walters. “We post all over the POL site that patients should not use clinical messaging or e-visits for anything urgent, and out of the 50,000-plus messages we’ve gotten, we’ve never had someone use these functions inappropriately.”

Although not offered in all Dartmouth-Hitchcock’s group practices, phase 3 of its POL rollout included allowing patients to view parts of their medical record, such as progress notes, medication lists, allergy lists, immunizations status, and certain types of test results. Despite the inclusion of this information, which begins to blur the line between patient-provider communication and the health record, Walters remains clear that POL operates as a communication tool not as a health record.

Implementation Challenges—or Lack Thereof
When patients learn about POL, they want to start using it as they would any other Web application: sign up online and access its functions immediately. POL, however, requires authentication of the user’s identity, which requires the use of regular mail. This extra step creates lag time between registration and initial use, making it slightly more challenging to get patients to adopt the technology.

“When you have patients who have something they want to do via the product, you would like them to be able to use it right away, rather than explaining it to them during a visit then making them wait to use it,” explains Walters. “It’s slowed down adoption.” Until IDX builds an electronic authentication function into POL, this lag time will continue. In the meantime, Dartmouth-Hitchcock promotes POL at every possible point of patient contact, as well as through direct mail and other marketing campaigns.

Another challenge has been transforming POL from a niche product to a tool more fully integrated into day-to-day workflows. A certain amount of patient volume needs to flow through POL for efficiencies to be realized from its use, and Dartmouth-Hitchcock is just now reaching that patient volume. To get there, it has marketed POL internally and dedicated staff to act as POL task monitors. These monitors review outstanding tasks, then work with the staff responsible for those tasks to better integrate POL into their daily workflow.

As Dartmouth-Hitchcock has worked to increase POL’s clinical integration, physician acceptance of the tool has not been an issue. “POL is transparent to physicians, unless they’re engaged in an e-visit,” notes Walters, who says Dartmouth-Hitchcock follows the informaticists’ mantra “do no harm to physicians” when it comes to electronic implementations.

Walters maintains that implementing POL has not presented any new or different ethical challenges. “Every ethical issue is the ethical issue whether you’re communicating electronically, in person, or by telephone,” she says. “From a standards perspective, the standards hold no matter what the method of communication. For example, I have to document abuse—and tell someone I have to do it—no matter where the allegation comes from.”

Products such as POL are potentially as vulnerable to hackers and other malicious threats as any Web-based software. In an era of increasing concern around the privacy of personal health information, ensuring the security surrounding the more sensitive aspects of care—those involving instances of abuse or neglect, mental health conditions, and certain diseases, such as AIDS—is no small feat.

Software products that deal with personal health information build in the most current encryption standards. For example, connections to POL are authenticated and secure, using 128-bit encryption and a secure sockets layer to ensure privacy. This leaves organizations with little extra to do other than monitor adherence to their own privacy, security, and confidentiality policies and procedures and conduct periodic audits.

Enhanced Clinical Support, Expanded Access
POL’s streamlined design not only makes it simple to use but easy to fit into an organization’s established Web site. It’s also customizable, so organizations can include selected additional features, such as a link to a health information resources page or a health questionnaires page. Dartmouth-Hitchcock’s POL includes both, lending more support and encouragement for patients’ participation in their own health management.

The inclusion of limited medical record data available through POL has enhanced its clinical support function and begun taking the tool in the direction of becoming a personal health record (PHR), something Walters would like to see it evolve into down the road. “I would like to be able to collect survey information, do office prework, send push messages to help patients know it’s time to do x, y, or z—all of that,” she says. “In the end, I think it would be a great PHR. Patients could put it on a thumb drive and carry it around with them.”

Patients’ access to their own personal health information coupled with access to broader information about health management and specific conditions represents perhaps one of the most exciting benefits of HIT. At the same time, presentation of the information, including the context in which it’s presented and its precision, carries risks. “We need to be careful about the precision of the information and the suggestions that we ultimately render,” cautions Lonny Reisman, MD, CEO of ActiveHealth Management, a clinically-based, technology-driven health management services company that has launched ActiveHealth PHR.

Reisman believes a patient’s health information needs to be appropriately qualified and couched to avoid unnecessarily or inappropriately frightening patients. With this adequately addressed, however, the benefits to patients and providers become significant, starting with addressing the fragmentation of the healthcare system. “One of the things that the PHR will do is present to all providers and patients a comprehensive single-source look at all their data with regard to how many doctors, hospitals, pharmacies they’ve looked at. This will very significantly address the fragmentation issue,” says Reisman.

In Reisman’s view, a single source of comprehensive patient data also makes it possible for clinical decision support rules to be applied to that data, potentially increasing the safety and efficacy of care. “The findings in [Crossing the Quality Chasm] and the Rand report [The First National Report Card of Health Care in America] about our failure to provide evidence half the time need to be addressed by applying clinical decision support capability to a comprehensive data set,” explains Reisman, who sees PHRs as the ideal vehicle for providing that kind of data.

While POL remains some distance away from a potential PHR future, it’s clear that this communication tool provides an opportunity for patients to begin participating in their own health management in a more specific and meaningful way through the use of information technology tools, such as Web applications. As Walters sees it, POL empowers patients to be compliant with their treatment, a critical step in the direction of a healthier future.

— Aggie Stewart is a freelance writer and editor specializing in HIM and HIT, who also serves as consulting editor of Health Information Management Manual, 2nd edition. She can be contacted at s-p-s@earthlink.net.

What’s Online at DHMC
Patient Online enables patients at Dartmouth-Hitchcock Medical Center to:

• request, reschedule, or cancel an appointment;

• receive appointment reminder notifications;

• view bill balances and make online payments using a credit card;

• request prescription renewals;

• request referrals to see a specialist;

• have an online medical appointment with a doctor through an e-visit; and

• view certain test result information and clinical notes as documented in their electronic medical record.

— AS