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Implementing Secure Electronic Messaging: A Process Change in the Medical Home Model Research Paper Assignment Essay

Abstract Secure electronic messaging (SM) between providers and patients in the primary care clinic is associated with positive benefits. Benefits to patient are: Communication that extends beyond regular office hours, decreased travel and time lost from work, and the potential for improved outcomes of some chronic diseases, all of which promote care that is patient-centered, timely, efficient, and effective. Benefits to provider are: Increased reimbursement rates if meaningful use criteria are achieved, reduced walk-in visits and phone call volumes, and potential for increased market share due to a more modern electronic approach to care that savvy patients expect. The purpose of this process improvement paper is to advocate for inclusion of SM in the outpatient primary care population, specifically the medical home model. The process measures developed are SM training for patients, clinic initiated SM threads to patients after each appointment, SM endorsement by provider, and answering patient initiated SM threads within 48 hours. The outcome measure is patient satisfaction that will be scored using a short four-question survey, adapted from the Adult Primary Care Questionnaire.

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The potential for increased patient engagement, patient satisfaction, improved outcomes of some chronic conditions, increased reimbursement, and potential for increased market share due to technology that the modern consumer expects, not only makes this initiative practical, but urgently needed. Implementing Secure Electronic Messaging: A Process Change in the Medical Home Model In today s primary care setting, the available face-to-face time between patient and provider has steadily decreased in an effort to reduce cost and increase clinical productivity. At the same time, the outpatient primary care population has become increasingly complex, due to many factors, which include extended life spans and patients living with multiple chronic diseases (Wakefield et al., 2010). Secure electronic messaging (SM) through a patient web portal is associated with many benefits to the patient that include communication with providers that extend beyond office hours. Other advantages to the patient include increased satisfaction and resources saved in the form of decreased travel and time lost at work. Improvements to the primary care clinic from SM may include reduced walk-in visits and phone call volumes, in addition to qualifying for federal meaningful use criteria, that translate into increased reimbursement (Wade-Vuturo, Mayberry, & Osborn, 2013). The purpose of this process improvement paper is to advocate for inclusion of SM in the outpatient primary care population, specifically the medical home model, with increased patient satisfaction as the targeted outcome measure. This writer will further provide supporting evidence for SM use, rationale for and operational components of performance improvement project, and finally data metrics used to monitor success. Background Furukawa et al. (2014) report that SM use has been rapidly growing among ambulatory care providers. As of 2013, they found that 30% of ambulatory care physicians use SM with their patients on a regular basis. In another article, surveys indicated that the majority of providers and patients support the use of SM to share information with each other (Ricciardi, Mostashari, Murphy, Daniel, & Siminerio, 2013). Ralston, Coleman, Reid, Handley, and Larson (2010) found that after adding SM capabilities to the electronic health record (EHR) of a large physician group system, 30% of the groups primary care encounters were conducted through SM, while phone encounters were 15%, and face-to-face visits decreased to 54 percent. According to Chen, Garrido, Chock, Okawa, and Liang (2009), after the introduction of SM, between 2004 and 2007, total office visits decreased by 26.2 %, while SM messaging increased six-fold. By contrast, another study found that proportional increases in SM where associated with increases in face-to-face visits (Liss et al., 2014). Interestingly, these increases in live visits may signify increased patient participation through SM by reducing access barriers and allowing unmet needs to be addressed. In addition and not surprisingly, several studies have documented an association with increased patient satisfaction and SM in primary care (Lam et al., 2013; Ralston et al., 2010; Ricciardi et al., 2013; Wade-Vuturo et al., 2013). Lastly, SM was found to be associated with control of glucose levels, cholesterol levels, and blood pressure (Wade-Vuturo et al., 2013; Zhou, Kanter, Wang, & Garrido, 2010). It appears that SM is beneficial to the patient s health as well as to the healthcare system. Rationale for Improvement The impetus for this process improvement proposal started because increased numbers of patients were complaining of long wait times for return phone calls. These patients expressed concerns that their appointments were too rushed and they did not have enough time to ask questions and clarify instructions, so the main reason for this project was to improve delivery of care so that it would be more patient-centered, timely, efficient, and effective (Institute of Medicine, 2001). At the same time we wanted to take advantage of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 that provides increased reimbursement for meaningful-use and patient engagement, which SM helps to achieve if a certain percentage of patients communicate electronically with their provider (Furukawa et al., 2014). Lastly, we wanted to bring our services into the modern era where other industries such as banking, travel, and retail have taken advantage of electronic technologies that allows customers to go online to access and act on current information about their accounts at any time  (Dixon, 2010, p. 1364). The potential for increased patient engagement, patient satisfaction, improved outcomes of some chronic conditions, increased reimbursement, and potential for increased market share due to technology that the modern consumer expects, not only makes this initiative practical, but urgently needed. Operational Components Setting The setting for this process improvement project is a private, medium sized primary care clinic that instituted the medical home model approach one year ago and has been using the Allscript EHR with dashboard capabilities for six months. This commercial EHR is federally certified and compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPPA), ensuring privacy and protection of personal health information. The SM component of the EHR can easily be added. Interestingly, the success of SM in relation to patient satisfaction in one study spurred an ambulatory care group to move to the medical home model approach (Ralston et al., 2010). Lam et al. (2013) found that 83.9% of study participants in a geriatric and internal medicine clinic preferred to communicate via SM and found no significant difference in usage rates between older and younger patients. These results indicate that a SM platform may not need to be tailored to any specific age group, which is advantageous for patients of the medical home model who may be older. Process Improvement Framework The quality improvement (QI) methodology this writer endorses in the Plan-Do-Study-Act Cycle. This QI approach illustrates that process improvement in not linear but rather cyclical, which leaves room for testing, making small changes and expanding interventions anywhere along the way. This writer understands that a team approach must be instituted with multiple stakeholder buy-in. The major phases of this cycle are: Plan- in this phase a team is selected, goals are chosen, and research interventions are established. Do- in this phase a strategy is developed, process and outcome measures are selected, and the team adapts to changes. Study- in this phase the team monitors strategies, implement changes, hold gains, and evaluate progress. Act- here the team monitors process and outcome measures, assesses what was effective or not, and spreads successful innovation (Agency For Healthcare Research And Quality, n.d.). Barriers and Plan to Address Them Though SM has been successfully instituted in primary care and the medical home model, there are two types of barriers to address: Patient barriers and provider barriers. Wade-Vuturo et al. (2013) discuss the three patient barriers of preconceived beliefs about SM rules, prior negative experience with SM, and the perception of low provider endorsement of electronic communication. These researchers discovered that some patients were unsure if they should SM their providers for urgent needs, or just for minor administrative requests. In addition, some patients were less likely to use SM if in the past they received a late response to a SM thread they initiated. The last patient barrier is perception of low provider endorsement of SM. It was noted that patient SM uptake was associated with the quality of instruction and discussion about its use the provider furnished. The above three patient barriers of preconceived beliefs about SM rules, prior negative experience with SM, and perception of low provider endorsement, can be mitigated by strong provider buy-in and requiring education of SM use. Wakefield et al. (2010) recommend involvement of providers and frontline staff in the implementation team to discuss integration of SM into workflow. Instruction on SM use by the provider should be instituted as a policy and may be used as a process measure. At a minimum, the instructions should include what types of messages will be accepted such as prescription refills, appointment scheduling, or clarification of instructions in a recent face-to-face-visit. It is also important to discuss turn around times for SM responses that can also be used as a process measure. Lastly, patients should understand that SM should not be used for urgent or emergent medical issues (American College of Physicians, 2008). In terms of the main provider barrier, Chen et al. (2009) and Dixon (2010) admit that lack of provider reimbursement is a major hurdle for SM use and illuminate the need for national policies to reward online care. This may be overcome by communicating that SM increases the likelihood of achieving federal meaningful-use criteria that qualifies providers to receive higher reimbursement rates (Furukawa et al., 2014). Additionally, it must be convincingly communicated that non-financial incentives that provide consumer choice and create satisfaction produce loyal customers and patients. In one study, internal surveys revealed that online services influenced patients to stay with the medical group (Ralston et al., 2010). These arguments, coupled with the fact that today s savvy consumers expect the types of online services provided by other industries, may mitigate lack of direct compensation for SM, due to the potential for increased market share. The final two provider barriers are fear of increased workload and patients using SM inappropriately, which are closely related. Chen et al. (2009) found that implementing SM decreased office visits by 26% while SM increased six fold, during a three-year period. On the other hand, Liss et al. (2014) found face-to-face visits increased proportionally to SM use. These results indicate the need to adjust provider schedules throughout the day to provide time to respond to SM threads, such as dedicating 30 minutes in the morning and afternoon for this purpose. In an effort to avoid patients using SM as a forum of complaints, Dixon (2010) recommends using templates in SM threads that guide patient communication toward the agreed upon reasons for its use, such as prescription refills or clarification of instructions received during an earlier face-to-face encounter. The above workflow adjustments should help decrease provider barriers due to fear of perceived increased workloads and help guide patients with proper use of SM. Future Impact Secure messaging has been shown to provide safe, effective and efficient care. As discussed earlier, SM is safe and effective because it is associated with increased glycemic, cholesterol, and blood pressure control (Wade-Vuturo et al., 2013; Zhou et al., 2010). Secure messaging demonstrates efficiency by reducing unnecessary office visits to address needs that can now be conducted electronically. Secure messaging is efficient for providers because it is asynchronous and there is time conveniently afforded for a well-crafted response to patient inquiries. Lastly, being available beyond the face-to-face visit is more convenient and can strengthens the patient-provider relationship, thereby increasing effectiveness and satisfaction (American College of Physicians, 2008). Though Chen et al. (2009) and Dixon (2010) have established that lack of direct reimbursement for SM as an implementation barrier; its use can still improve financial performance and reduce costs. Furukawa et al. (2014) established that achieving federal meaningful-use criteria translates into increased reimbursement. Lastly, SM may decrease administrative costs because of decreased live visits, fewer disruptive telephone calls, and a form of communication that is inexpensive (American College of Physicians, 2008). The patient benefits from SM because it allows for choice on how care is received. It has been shown to make face-to-face visits more productive because the provider is more informed of the patient s health status. Additionally, it provides an easy way to provide supplemental information or education at a distance. These benefits make care more patient-centered, timely, efficient, and effective (Institute of Medicine, 2001). Lastly, the provider and clinic benefit from less crowded waiting rooms, shorter waiting times, potential for greater market share, and more satisfied patients (American College of Physicians, 2008). Data Measurement Process Measures The following are the four main process measures for the implementation of SM in the medical home model clinic: 90% hands-on SM training for all patients. This may be conducted by nursing staff during the intake process and can be documented in the EHR as a clinical reminder once a year and monitored through the dashboard. 90% clinic initiated SM thread to patient after every visit to ask if their needs were satisfied and if they have any questions (Masucci, 2014). This can be monitored through chart reviews. 90% provider endorsement discussion during first live visit and then once a year. This can also be a clinical reminder and monitored through dashboard. Patient initiated SM thread must be answered within 48 hours (Wade-Vuturo et al., 2013). This can be monitored through chart reviews. Outcome Measure The outcome measure for this process improvement project is increased patient satisfaction. The idea for this initiative started because of multiple patient complaints of long wait times for return phone calls and truncated face-to-face clinic appointments. These complaints serve as the baseline of patient dissatisfaction with provider communication. In an effort to measure satisfaction, this writer created a short four-question patient satisfaction survey adapted and modified from the Adult Primary Care Questionnaire (Agency for Healthcare Research and Quality, 2011). This survey uses a four-point frequency scale of never, sometimes, usually, or always. We will consider increased patient satisfaction with scores in the four ranges, meaning always achieving the patient satisfaction objective. The following are the four questions: In the last six months, when you secure messaged your doctor s office to get an appointment, how often did you get an appointment as soon as you thought you needed? In the last six months, when you secure messaged your doctor s office during regular office hours, how often did you get an answer to your medical questions within 48 hours? In the last 6 months, when you secure messaged your doctor s office after regular office hours, how often did you get an answer to your medical questions as soon as you needed? In the last 6 months, when you secure messaged your doctor s office for a medication refill, did you get your medication refill as soon as you thought you needed (Agency for Healthcare Research and Quality, 2011)? Financial Measures This process improvement project is an investment, so the financial gains will be incremental and not immediate. There will be minimal upfront costs for adding the SM feature to the existing EHR, but the potential for increased reimbursement in achieving federal meaningful use standards is an incentive. The meaningful use criterion is met when more than five percent of patients send a SM to their provider through the EHR or patient portal (Centers for Medicare and Medicaid Services, 2012). Interestingly, Masucci (2014) recommends sending patients a secure message after each appointment to ask if all of their needs were met in an effort to kick-start the five percent patient population outreach, which this writer has incorporated as a process measure. Additionally, by providing services more in line with other industries that consumers expect, the potential for increased market share exists. Summary and Conclusion Secure electronic messaging has been shown to have many benefits for the patient as well as the primary care provider in the medical home model. For the patient, these benefits include extended communication with the provider beyond regular office hours, decreased travel and time lost from work, and potential for improved outcomes in relation to some chronic diseases such as diabetes and hyperlipidemia. These advantages, coupled with the fact that SM gives patients a choice of where and how they receive health services, promotes care that is patient-centered, timely, efficient, effective, and ultimately, highly satisfactory. For the provider, the benefits include the potential for less crowded waiting rooms, reduced walk-in visits and phone call volumes, as well as increased market share due to a more modern electronic approach to care that savvy customers have come to expect. Lastly, the potential for increased reimbursement if meaningful use criteria is achieved, improves the financial outcome of the primary care practice. This writer has identified several patient and provider barriers to SM implementation. The patient barriers of preconceived beliefs about SM rules, prior negative experience with it, and perception of low provider endorsement, can easily be addressed with strong provider buy-in and patient education during the process improvement implementation. The lack of provider reimbursement for SM and care at a distance is a major hurdle that policy makers in this country urgently need to address. It is this writers hope that researchers focus on innovative ways to reward and reimburse providers for this form of healthcare. In conclusion, SM is a powerful tool that improves the health of the patient as well as the healthcare institution, and should be more widely applied and used. References Agency for Healthcare Research and Quality. (2011, September). CAHPS Clinician and group surveys: Adult visit survey 2.0. Retrieved from http://cahps.ahrg.gov Agency for Healthcare Research and Quality. (n.d.). Plan-Do-Study-Act (PDSA) Cycle. Retrieved February 7, 2015, from http://www.cahps.ahrq.gov/quality-improvement/improvement-guide/qi-steps/QI-Methods_Models/ThePlanDoStudyActCycle.html American College of Physicians. (2008). Communicating with patients electronically. Retrieved from http://www.acponline.org/running_practice/technology/comm_electronic.pdf Centers for Medicare and Medicaid Services. (2012, October). Stage 2 eligible professional meaningful use core measures: Measure 17 of 17. Retrieved February 8, 2015, from http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/Stage2_EPCore_17_UseSecureElectronicMessaging.pdf Chen, C., Garrido, T., Chock, D., Okawa, G., & Liang, L. (2009). The Kaiser Permanente electronic health record: Transforming and streamlining modalities of care. Health Affairs, 28(2), 323-333. doi:10.1377/hlthaff.28.2.323 Dixon, R. F. (2010). Enhancing primary care through online communication. Health Affairs, 29(7), 1364-1369. doi:10.1377/hlthaff.2010.0110 Furukawa, M. F., King, J., Patel, V., Hsiao, C., Adler-Milstein, J., & Jha, A. K. (2014). Despite substantial progress in EHR adoption, health information exchange and patient engagement remain low in office settings. Health Affairs, 33(9), 1672-1679. doi:10.1377/hlthaff.2014.0445 Institute of Medicine. (2001, March). Crossing the quality chasm: A new health system for the 21st century. Retrieved from http://iom.edu Lam, R., Lin, V. S., Senelick, W. S., Hong-Phuc, T., Moore, A. A., & Koretz, B. (2013). Older adult consumers attitudes and preferences on electronic patient-physician messaging. American Journal of Managed Care, 19(Special Issue), 7-11. Retrieved from http://0-search.ebscohost.com.lib.utep/login.aspx?direct=true&db=cin20&AN=2012409283&site=ehost-live&scope=site Liss, D. T., Reid, R. J., Grembowski, D., Rutter, C. M., Ross, T. R., & Fishman, P. A. (2014). Changes in office visit use associated with electronic messaging and telephone encounters among patients with diabetes in PCMH. Annals of Family Medicine, 12(4), 338-343. doi:10.1370/afm.1642 Masucci, P. E. (2014, July 16). How we met difficult meaningful use stage 2 measures while improving care [Web log message]. Retrieved from http://www.athenahealth.com/blog/2014/07/16/met-difficult-meaningful-use-stage-2-measures-improving-care Ralston, J., Coleman, K., Reid, R., Handley, M., & Larson, E. (2010). Patient experience should be part of meaningful-use criteria. Health Affairs, 29(4), 607-613. doi:10.1377/hlthaff.2010.0113 Ricciardi, L., Mostashari, F., Murphy, J., Daniel, J. G., & Siminerio, E. P. (2013). A national action plan to support consumer engagement via e-health. Health Affairs, 32(2), 376-384. doi:10.1377/hlthaff.2012.1216 Wade-Vuturo, A. E., Mayberry, L. S., & Osborn, C. Y. (2013). Secure messaging and diabetes management: experiences and perspectives of patient portal users. Journal of the American Medical Informatics Association, 20, 519-525. doi:10.1136/amiajnl-2012-001253 Wakefield, D. S., Mehr, D., Keplinger, L., Canfield, S., Gopidi, R., Wakefield, B. J., ?Kochendorfer, K. M. (2010). Issues and questions to consider in implementing secure electronic patient-provider web portal communication systems. International Journal of Medical Informatics, 79, 469-477. doi:10.1016/j.ijmedinf.2010.04.005 Zhou, Y. Y., Kanter, M. H., Wang, J. J., & Garrido, T. (2010). Improved quality at Kaiser Permanente through e-mail between physicians and patients. Health Affairs, 7, 1370-1375. doi:10.1377/hltaff.2010.0048

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