Meaningful Use from the Patient Perspective

As demonstrated throughout the preceding references, much of the rhetoric surrounding news reports, public statements, and government websites suggests that the entire purpose of this change is for the good of the patients in order that their shared participation might lead to better care, more care, and even less expensive care.57 Words and phrases include “instruments in their

55 _{This report also references an ONC study directed by the National Center for Health Statistics’ 2009-2012}

National Electronic Health Record Surveys and reveals a significant difference between 2009 and 2012 percent of physicians with computerized capabilities for meeting Meaningful Use. These statistics are also cited in iHealthBeat’s report on August 14, 2013 and may be found at http://www.ihealthbeat.org/picture-of- health/2013/what-percentage-of-physicians-were-using-computerized-capabilities-to-meet-selected-meaningful-use. The higher figures reported in the oral testimony, however, do not mention a specific source. Only the ones between 2009 and 2012 are referenced. When figures are so much higher and no citations are given, this questions the credibility of the source.

56 _{For the full testimony, see http://www.hhs.g/asl/testify/2013/07/t20130717b.html.} 57

own care,” “engaging the patient,” “patient-centeredness,” “cooperation,” “collaboration,” “shared decision making,” and “participatory care.” As these filter onto the pages of government documents, health literature, and educational policy for healthcare professionals, the image forms of physicians, hospitals, and even government services all working together to place patients at the center of concern. The ideal goal is to help patients help the providers improve care for all. Healthcare providers not only create benefits for patients themselves but they can also help insure that effective, patient-centered change actually occurs. As active participants, patients will have invested time, energy, and commitment to the process and therefore will hopefully be more likely to accept the transition into this new medium of communication when it comes into final force (Stage Three Meaningful Use or beyond). Implementation of technology, cost efficiency, reimbursements, time management, and the like are viewed as the necessary means to the end product of improved health for patients. Patients are as much a part of this transition as are physicians, hospitals, and government officials. In fact they are the most important part and the reason for this change in the first place. This is the ideal that seems to permeate the rhetoric of shared participation and improved standards of care.

The purpose of this segment is not to assess the legitimacy of these claims or the overall desire for physicians to meet their Hippocratic Oath, lawmakers to serve their people, and economists to meet the bottom line so that medical facilities can afford to keep their doors open. The problem is as complex as the entire economic situation surrounding the objectives to enforce, finance, and implement the HITECH Act itself. The real purpose is to determine what this really means to the patient who perhaps cares more about the heart attack grandpa just had, the breast cancer with which mom was diagnosed, or the laceration to the head that knocked

Tommy unconscious on the football field, than about which Stage of Meaningful Use his or her physician meets.

The whole medical situation today is complicated—to say the least. In fact, one of the reasons for describing in such detail the policies affecting the healthcare market is to place this entire scenario into perspective and to show that indeed many people are influenced by these standards, many are players in this complicated drama, and many simply react to the services they can or can’t acquire when they most need them in the midst of an illness, emergency, or tragedy.

The purpose of this segment is to explain in simple terms what Meaningful Use can, will, and should mean to the patient from a receivers perspective. What effect does this have on the lives of those who unknowingly enter a system that is not what it used to be? When an elderly patient walks into her physician’s office hoping to chat about her husband’s forgetfulness and her own debilitating arthritis, she may not anticipate a kiosk computer for “signing in” and a physician whose face hides behind a laptop screen. These technological mediums affect the fundamental process of communicating with one’s physician, and to some that process is all but “meaningful” when technology takes away the familiar environment of the traditional examination room and replaces it with (the backs of) computer screens.

Meaningful could be viewed as the desired transition into this new medium in a manner that is efficacious, a manner that is perceived to be working from the perspective of the patients, not only the providers. This perhaps is the real test of Meaningful Use, a test that is not so easily measured in numbers or dollars. Rushing to meet Stage One, Two, and Three deadlines in 2014, 2015, 2016, or 2020 for that matter means very little to patients. Their only concern will be when and if the familiar face-to-face office visit is replaced with something new and perhaps less

meaningful and more confusing, less personal and more isolated, less trusted and more suspicious, and less real and more artificial. Hopefully this list of negative possibilities will not be realized, especially if patients see themselves as part of the necessary process to achieve a better healthcare world that uses technology as a means for reshaping the focus back to the patient, the real center of concern. Until the patient navigates through the new and adjusts to the different, it may, however, be quite a foreign process. Fundamental for making this transition meaningful, is to explain to the patients how these stages affect their own communication within this dynamic system. With the exception, perhaps, of indirect references to technological problems within physicians’ offices, however, this explanation is not being made.58

It is also important to acknowledge that patient demographics influence how well this change is handled. Social status, educational training, and literacy levels (to name a few) have always had a direct effect on how easily and effectively patients navigate the healthcare system. Now, however, in addition to these is the issue of media literacy, which rises into paramount importance with the introduction of the new EHR medium. Some patients enter a physician’s office with a smart phone in hand and a list of potential diagnoses, treatments, and options ready to be discussed while others rely on newspaper articles, television and radio advertisements, and family conversations. Many forms of obtaining and transmitting health information exist; but not all forms are understood, accepted, or accessible by all. In short, a key demographic for measuring how meaningful the next visit to the physician’s office is, may very well have to do with the patient’s level of media literacy.

58 _{It is noteworthy to mention that in a recent talk with West Virginia University Surgical Residents (June 2013)}

about these Stages of Meaningful Use the first year residents didn’t even know to what I was referring. If the residents who are relatively new physicians working within the field are not familiar with these stages, how could

To make matters even worse, not only are some patients media illiterate or media challenged so too are many physicians. That means that as some physicians attempt to meet the technological demands of their new EHR system, they may spend more time trying to navigate the computer screen than paying attention to the worried looks on their patients’ faces.59 _{That is}

to say, if the medical communication is to be effective within the physician/patient dyad both parties must understand the challenges and shortcomings as well as the benefits and advancements of this new medium of communication. If patients are truly to “share” in the medical encounter, then they together with the physician must learn to navigate through the transition into electronic medical records. Sadly, much too much time has been spent in transitioning into the mechanics of the process than in the relationships that must survive and benefit from these so called advancements.

In an effort to begin this process of understanding, it is important to explain the key elements of the Stages of Meaningful Use from the perspective of the consumers, the receivers of and participants in their own medical care. Then and only then can this process be truly a joint endeavor towards physician/patient communication.

Just as the stages reflect a wealth of intricate changes and implications to physician and hospital practices, the stages in principal could be explained with the same level of complexity to

59 _{A personal experience may clarify: As Office Manager of my husband’s family practice and geriatrics office, I}

have witnessed firsthand the transition into EHRs. At age 55, my husband, J. Eric Wieczorek, MD, had to learn for the first time to use a computer and even to type. The learning curve was significant and affected how he communicated with his patients due to the added presence of a laptop that he did not know very well how to use. Often he discussed his frustrations with his own learning process, the difficulty he had trying to look at patients while navigating the EHR, and the overall feeling of entering an unknown medium that was forced upon him in order to meet government requirements which he did not necessary agree with. He readily complained to his staff and to me that it made his time with the patient less meaningful, more stressful, and quite frustrating for both parties. One thing that amazed him, however, was that the patients appeared to be understanding. He told me they would say such things as, “I’m not too good at that new-fangled stuff either, Doc. Better you than me!” In a way, empathic statements such as these, were indeed means for helping not only the physician get through the process but

patients. More practically, however, only the most basic implications of each stage are necessary for the vast majority of the patients to understand why change is being made, how this might affect their communication with their hospital or physician’s office, and what to expect throughout this transition period. Obviously, some physician offices may have introduced forms of technology at various times even prior to the HITECH Act. These may include emailing patients, referencing the Internet on smart phones, or using a computer to record information. This suggestion looks only at physician practices and assumes that the office made a cold transition from the physicians using no electronic technology with patients (other than perhaps secretary billing which has been around for the twenty or more years for most practices) to the minimum technology required for each stage.60

Quite simply, Stage One introduces computer technology to the physicians’ office through the active use of recording electronic health records (EHRs). Four key items affect patients: (1) electronic prescribing, (2) electronic recording of patient records, (3) some patient electronic access to medical records, and (4) likely introduction of computers into the examination room. First, prescriptions are sent to pharmacies electronically in an effort to reduce legibility errors, speed the process for patients, and maintain an accurate, updated record in the patient chart. Second, records are converted into electronic form. At first this may have meant that earlier paper chart records were merely scanned and uploaded into the electronic chart with updated insurance and demographic information. As physicians document subsequent appointments and interactions, the data is then recorded manually directly into the electronic

60 _{It is particularly important to stress that throughout this discussion of the stages’ effect on patient communication,}

this is by no means reflective of all the implications, nuances, or even influences on patients at every phase. These are only the items that this author believes are most important in light of the basic information patients should have on the stages in order to appreciate and become more involved in the process. This focus also presupposes

chart through either open-ended descriptions or predetermined, standardized “check-box” options entered through a “click” by the physicians (and sometimes nurses). Third, the option is provided for patients to access a copy of a portion of their chart (as approved by the physician) through an electronic means, typically a Computerized Disc (CD). Fourth, the computer, laptop, tablet, or iPad is brought into the room by the physicians and nurses. As discussed in subsequent chapters, this aspect for the most part is the most noticeable of all the changes since in fact the patients physically see the computer, watch the physicians put in data, and contend with the presence of this new instrument often physically standing between the physician and patient throughout the office visit.

Stage Two presupposes the following changes for patients: (1) increased visibility, access, and involvement in Stage One implementations and (2) invitation to participate in an online, secured patient portal. The first item simply means that each phase of Stage One will be continued but will be more actively and proficiently used within the practice (based upon the increased requirements that physicians need to verify through their Meaningful Use attestation). Patient involvement will likely improve as well as a result of the implementation of the second item: the secured patient portal. This means that patients can enter the EHRs through a private environment with a user name and password. This environment allows for patient access to such things as immunization lists, lab reports and test results (once reviewed and released by the physicians), appointment scheduling, e-prescribing information, billing questions, general medical information or office announcements, and medical communication with the physician/office staff. In short this single change transforms the availability of the office from regularly scheduled hours and answering machines to 24-hours-per day, 7-days-a-week access to patient information and (for the most part) communication with the staff. This window

provides—for the first time—online communication directly with members of the staff and physicians, opening the door for a totally new mode of medical communication.61 More specifically it also allows patients to see much of their medical information (again as permitted by the physician) and to participate more directly in their own care. Demographic, insurance, and health-related information may be entered even prior to seeing the physician for the first time. Records from other physicians can be uploaded and scanned immediately into the chart. The records are now accessible directly instead of only through an electronic copy (as in the CD) and the means for communication is potentially continuous.

Finally, Stage Three most likely will mean continued improvements in communication, accessibility, and document access. However, the change likely will be that now patient data will be entered into larger record-keeping data banks allowing decision support for national high- priority conditions (such as national emergencies or health conditions like flu epidemics), patient access to improved self-management tools (such as uploading glucometer readings for diabetics or heart monitor readings for cardiac patients), and access to comprehensive patient data through patient-centered Health Information Exchange (HIE) that allows for interoperable transference of health records and immediate access from one institution to the next (HealthIT.gov, 2013).62

The latter is particularly helpful to patients who travel, utilize a wide variety of specialists, or have testing done in more than one place for the same thing (such as when urban hospitals request repeat testing due to lack of access to rural hospital results or testing standards). This also means that data from patients may be entered into a national data bank which is

61 _{Note this is merely being mentioned herein, but the significance of this one factor is in this author’s opinion, the}

single most important communication change in the face of medicine since the telephone. For further discussion, see Chapter 2.

anonymously used to predict disease trends or data mine for information that could lead to scientific discoveries or cures. From the patient perspective, however, it is likely that the most important change to them will be the ability to have a more unified patient profile and to be able to coordinate care seamlessly from facility to facility.

In brief, the key to the entire process of describing the Stages of Meaningful Use to patients is to prepare them for how computer technology will alter their ability to communicate with and between their providers. That is, (1) the computer will likely be in the room with the patient as part of the exam process and (2) the computer will allow for continuous access to the physician office and medical information through the use of the online secured portal. The latter of these two is of course the most significant to the purposes of this dissertation in exploring how physician/patient electronic messaging within secured portals affect the dynamic, participatory relationship of this dyad and in turn help maintain the patients’ overall health.