ONS: Health IT as a Tool for Improved, Patient-Centric Care

Integration of information technology (IT) into healthcare-such as the use of electronic health records (EHRs), patient portals that allow access to select personal health information online, and e-prescribing tools used with EHRs both in the ambulatory and inpatient setting-is growing by leaps and bounds, and cancer care is no exception.

At the 38th annual Oncology Nursing Society Congress on April 25, the keynote lecture was “The Role of Health IT in Healthcare Transformation.” It was delivered by Judy Murphy, RN, FACMI, FHIMSS, FAAN, who has more than 25 years of experience in health informatics and approaches health IT with an emphasis on patient advocacy, a patient-centric point of view, and use of technology to support evidence-based cost-effective care.

Ms. Murphy is the Deputy National Coordinator for Programs & Policy at the Office of the National Coordinator for Health IT, in the Department of Health and Human Services (HHS), Washington, DC. A pioneer in nursing informatics, she has served in a variety of capacities and has received many honors and awards in the field of health IT. These include serving on the board of directors of the American Medical Informatics Association (AMIA) and the Health Information and Management Systems Society (HIMSS); being named a Fellow in the American Academy of Nursing (AAN), the American College of Medical Informatics, and HIMSS; receiving the 2006 HIMSS Nursing Informatics Leadership Award; and participating in the Nursing Informatics History Project sponsored by AMIA, the National Library of Medicine, the AAN, and the Robert Wood Johnson Foundation.

In her keynote address at the ONS Congress, Ms. Murphy described federal and other programs to incentivize adoption of health IT; defined key priorities in the integration of health IT into patient care, including ways to improve EHRs and related tools, as well as patient engagement; and addressed challenges related to healthcare reform and meaningful use of health IT.

According to the Centers for Disease Prevention and Control’s National Ambulatory Medical Care Survey (NAMCS) on the provision and use of ambulatory medical care services in the United States, Ms. Murphy said, data from 2001 through 2012 show a steady increase in the use of EHRs. In fact, she noted that “ambulatory EHR use has doubled in the last 5 years; 72% of doctors now use an EHR.” A 2012 survey by the American Hospital Association showed a similar trend, she added, with hospital EHR use tripling since 2010 alone, so that “45% of hospitals now use EHRs.”

Meaningful Use: What Does It Mean?

Part of the upswing in EHR use results from federally sponsored multibillion-dollar incentivization programs that provide technical and monetary support and training aimed at moving beyond simple adoption of EHRs and toward achieving “meaningful use” of EHRs-that is, use by providers that achieves significant improvements in care.

In her presentation, Ms. Murphy described examples of select “meaningful use” core objectives developed by HHS’s Office of the National Coordinator for Health Information Technology (ONC). For office-based providers, these include having a computerized provider order entry (CPOE) for medication orders; ability to record patient demographics; use of e-prescribing (in which a physician, nurse practitioner, or physician assistant electronically transmits a new prescription or renewal authorization directly to a community or mail-order pharmacy); having an active medication list and the ability to perform drug-interaction checks; ability to maintain a “problem list”; and having clinical summaries that can be provided to patients, a clinical decision support rule, and clinical quality measures. For hospitals, select meaningful use core objectives described by Ms. Murphy include having active medication lists, a clinical decision support rule, drug-interaction checks, clinical summaries, advanced directives, maintaining problem lists, and having a CPOE for medication orders.

Among office-based providers, said Ms. Murphy, an ONC analysis of National Electronic Health Records Surveys between 2011 and 2012 alone shows significant improvement in capabilities to meet these select core meaningful use objectives, most notably in use of the CPOE for medication orders (from 65% of physicians in 2011 to 80% in 2012), e-prescribing (55% vs 73%), drug-interaction checks (51% vs 67%), providing clinical summaries to patients (38% to 56%), and including clinical quality measures (30% vs 43%).

Similarly, an American Hospital Association survey on changes in the percentage of hospitals with capabilities to meet select core meaningful use objectives between 2008 and 2012 showed notable improvements in all of the aforementioned objectives, with the most dramatic being in maintaining problem lists (from 44% of hospitals surveyed in 2008 to 78% in 2012) and using CPOE for medication orders (27% in 2008 vs 72% in 2012).

Provisions of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 (enacted as part of the American Recovery and Reinvestment Act of 2009) emphasize development of a healthcare structure that not only achieves “meaningful use” but also includes goals such as EHR systems in which both intra- and inter-state care information is coordinated and aligned, and systems that are connected to the public health community in case of emergencies.

Title IV, Division B of the HITECH Act establishes incentive payments under the Medicare and Medicaid programs for eligible hospitals and eligible professionals (with eligibility determined by the percentage of Medicare and Medicaid patients served) that meaningfully use Certified EHR Technology (CEHRT). These incentive programs are being developed by HHS’s Center for Medicare and Medicaid Services (CMS).

The Rewards of Meaningful Use

CMS’s EHR Incentive Program, Ms. Murphy explained, tracks and provides monetary rewards for meaningful use. Consistent with the positive changes in eligible providers and hospitals meeting meaningful use objectives as outlined by the ONC, total EHR incentive payments to all eligible providers and hospitals surged between January 2011 and December 2012. Program data as of late December 2012 show that of 521,600 total eligible professionals identified, 67% were registered into the program and 36% were paid. Of 5,011 eligible hospitals, 84% have registered and 70% were paid. The average hospital is able to recoup about $10 million from CMS for their meaningful EHR use.

EHR Exchange and Health IT System Interoperability

However, the functionality of our key health IT systems needs to be improved, emphasized Ms. Murphy. As previously noted, under HITECH there should be an ability to exchange patient records between EHR vendors, for example. The good news is that “exchange is growing,” and “lots of IDNs [integrated delivery networks] and hospitals are spearheading exchange,” said Ms. Murphy, noting, for instance, that currently “three EHR vendors (Cerner, eCW, and EPIC) are each exchanging millions of patient records a month.”

Achieving interoperability of information systems-such as being able to coordinate inpatient and ambulatory data for a patient; share data with public health agencies and cancer registries; create and transmit transition-of-care summaries; and make patient data portable (eg, so the patient can view, download, and transmit their health data to a third party, and create an export summary of their data)-is essential.

Making Patient-Centric Care a Priority: Action, Access, Attitudes

One of the key priorities in healthcare today, stressed Ms. Murphy, is “keeping the patient at the center of all we do.” Methodologies for facilitating interoperability between EHR systems and health information exchange are critical for meeting this goal. So is the development of strategies that increase patient engagement and make the patient a “partner” in health IT, Ms. Murphy said. In fact, she noted, the concept that patients share the responsibility for their own health care is incorporated into the American Medical Association’s current code of medical ethics, and when it comes to communication with their healthcare providers, “patients increasingly expect engagement via IT, as in many other aspects of their lives.”

In this newer patient-centric world of healthcare, with patient-as-consumer, Ms. Murphy said it’s helpful to consider “the three As approach” to consumer engagement: Access, Action, and Attitudes. “Access” refers to programs and strategies aimed at increasing consumers’ access to their healthcare information. “Action” represents efforts to enable consumers to take action with their health information. “Attitudes” addresses the need to shift consumer and healthcare provider attitudes to better support a patient-provider partnership. “We nurses own this space,” Ms. Murphy said during her keynote presentation, “and Health IT is the hook to promote patient engagement.”

There are a number of ways that patient access can be improved, said Ms. Murphy, such as providing reminders for preventive or follow-up care; identifying and distributing educational resources; enabling patients to have online access to their health and treatment information, through patient portals or personal health records (PHRs); giving patients visit summaries; and providing patients with information that is downloadable/transmittable to a third party.

The HHS’s ONC, she added, has led the way on Access through a consumer e-health pledge program on its website (healthIT.gov), with more than 400 organizations pledging to provide access to personal health information for one-third of Americans. On the US General Services Administration’s website, challenge.gov (whose motto is “Government Challenges, Your Solutions”), explained Ms. Murphy, there is a link that invites designers and developers to redesign the patient health record (see healthdesign.challenge.gov). The US Surgeon General’s Healthy Apps Challenge (available at sghealthyapps.challenge.gov) notes that “[t]he Surgeon General is challenging developers to create apps that provide tailored health information and empower users to engage in and enjoy healthy behavior.” The website provides links to winners of the challenge, with background information on their apps.

Among nursing organizations, the American Nurses Association and the Alliance for Nursing Informatics have asked their members to obtain their personal health records from their healthcare providers, develop or maintain them online, and use these records to make decisions about their own health, to gain first-hand experience of patient-centered care-and promote it more widely among their patients.

There have been a variety of creative Action strategies that aim to make it easier for patients to use health IT, including not only Challenge.gov’s medical record “Design Challenge” but also the “Blue Button Mash-Up Challenge” to create an app that integrates personal and general health-related data and information.

Importantly, said Ms. Murphy, in May 2012 Leon Rodriguez, HHS’s Director of the Office of Civil Rights, posted a letter to consumers encouraging them to educate themselves about their right to access their personal health information (and correct it if necessary) under the HIPAA (the Health Insurance Portability and Accountability Act of 1996; information available at hhs.gov/ocr). The letter provides links to additional helpful educational videos and pamphlets about health information and privacy. It encourages the use of EHRs/PHRs by stating that “[I]mportant tools like Electronic Health Records (EHRs) and Personal Health Records (PHRs) will make it easier, safer, and faster for you to get access to your health information and stay engaged. These tools help you become a true partner in your healthcare and wellness.”

In terms of shifting consumer and healthcare provider Attitudes to be more accepting of the patient-provider relationship as a partnership, the ONC’s healthIT.gov website offers 1-minute and 3-minute animations that healthcare providers can use to educate patients about accessing their medical records. “I encourage you to use it,” said Ms. Murphy, “in your waiting room or closed-circuit TV systems.” The challenge.gov website offers a consumer video challenge called “What’s in Your Health Record?” that invites consumers to share their stories of why they think the ability to access and review their health records can improve the quality of healthcare they receive, as well as similar video challenges, including one that empowers patients to take on a greater role in achieving blood pressure control. An important resource for nurses, Ms. Murphy said, is the September 2013 Institute of Medicine report, “Best Care at Lower Cost: The Path to Continuously Learning Health.” which “does a wonderful job of explaining what we need to do” to improve healthcare in America, with automation and health IT essential to the effort.

The Three-Part Goal of Healthcare IT

Echoing the sentiments of HHS’s previous National Coordinator of Health IT, Dr. David Blumenthal, Ms. Murphy emphasized that health IT should be viewed as “the means, not the end” in terms of improving healthcare. The ultimate three-part goal, she said, is to provide better healthcare within the Institute of Medicine’s six domains of quality (safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity); to increase the overall health of populations (eg, by addressing behavioral risk factors and focusing on prevention); and to deliver higher-quality care at a lower cost (eg, reducing Medicare, Medicaid, and CHIP [Medicaid’s Children’s Health Insurance Program] expenditures).

“Nurses are the most trusted health professionals,” said Ms. Murphy. “We have had the patient advocacy role forever, and patients look to us to see what they should be doing,” when it comes to taking more responsibility in managing their own health. Through patient engagement using health IT, she told the audience, nurses can help their patients “get that extra ‘oomph!’ in quality care.”