Involving Patients in their Health Care

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Patient Web Portals

• Involving Patients in their Health Care
• Connecting Patients, their Personal Health
  Information, and their Providers

Jim Jirjis MD MBA Co-CMIO VUMC
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The New Problemor Solution

• Historically lack of interest, use
• Growing number of people using internet
• Now being online is part of life
• Banking
• Netflicks
• Amazon
• EBay
• Homework
• News
• Email

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To be online or not to be

• Patient want it
• Test results
• Messaging
• Explanations
• Appointments
• Refills
• Pay Bills
• PHR/communities (MySpace)

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To be online or not to be

• Infrastructure is in place
• Secure web and data transfer capabilities
• Strong penetration of web
• Habits are now aligned to use web
• Is the practice ready?

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Physician Meeting

• When asked about
• Messaging
• Put me down for never on that!
• Lab results
• Patients cannot handle the truth
• I will get barraged with calls

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Different approaches

• Fragmentation of data and relationships limits
  the power of these tools
• Practice-based
• Doctor-patient relationship
• MD ability to execute an order
• Granular knowledge of clinical data
• Ability to personalize
• More Global Plan based
• Wealth of claims data
• Capital to invest in rapidly scaleable solution

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The challenge

• Messaging
• Win-win-win doc/patient/staff
• Pitfalls information flow
• Must be responsive to patient
• No dropped messages
• (Safety)
• Sign-on
• Must transition a large of patients from email
  to this
• Must be easier and give them more than email

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So what is the matter with just using email?...

• Brock
• Multiple sites
• Anticipate the problems before the solution is
  rolled out.
• Know the risks to the success of your project.

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MyHealthatVanderbilt
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Screensaver / KIOSK Sign-up

LEVEL 1 Partial Access LEVEL 2 Full Access
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Messaging

• Must be in the workflow, gradual change,
  insidiously getting people used to one change
  before the next layer.
• 3 step layered process
• Create paperless messaging within EMR
• Self-filing
• Intra-departmental
• Create Inter-departmental messaging
• Non-productive time
• Take advantage of current workflow (triaging)
• Create web portal and add messaging
• Same model as Inter-departmental

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Patient Messaging

• Intradepartmental
• Interdepartmental
• Web Portal
• Advertise
• introduce the model (in advance)
• plan for the next
• introduce to key leadership to get input and
  buy in

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Intradepartmental Messaging
PCP MD
Message
PCP Nurse
PCP Sec
Partner MD
PCP Sec
PCP Nurse
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Interdepartmental Messaging
PCP MD
Message
PCP Sec
Endo Sec
Endo MD
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Interdepartmental MessagingClinical
Communication
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Interdepartmental MessagingClinical
Communication
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Interdepartmental MessagingClinical
Communication
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Patient Messaging
PCP MD
PCP Sec
Patient
Message
Endo Sec
Endo MD
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Web PortalMyHealthAtVanderbilt
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Patient MessagingPatient end
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Messaging

• Patients are able to log on to My
  HealthatVanderbilt remotely and send a message
  to their providers office
• These messages always go to a designated message
  basket (secretary or nurses basket) , mimicking
  what would happen if they had called on the
  telephone, and should be handled in the same way
• They do not go directly to the doctors basket

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Initiating messages

• The only part of a message that the patient
  will see is when you intentionally hit the green
  button.  Then it ONLY sends what is currently in
  the text box, nothing prior to it 

• The provider can dialogue back and forth with
  the nurse about an issue and the patient is not
  able to see anything until it is finally typed
  into a message to the patient and sent with the
  green The button . Then, only the most recent
  message that you type into the text box goes to
  the patient

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Patient Email Notification

• Every time you send a message to the patient
  through their My HealthatVanderbilt account, an
  email will be sent to their regular email
  account, notifying them that they have a message
  from their provider and allowing them to click on
  a link that takes them to My HealthatVanderbilt
  home page 

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Patient MessagingBounce-back feature
Patient
PCP MD
PCP Sec
Message
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Patient MessagingBounce-back feature
Message
Patient
PCP MD
PCP Sec
1-5 day bounceback (default 5 days)
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Patient Messaging

• Enterprise-wide (faculty, staff meetings,
  newspaper, tutorials, etc)
• All patients have access to all of their doctors
• New ongoing costs
• Maintaining directory
• Support/training
• Decision to Audit

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First Audit

• Tens of thousands of messages a week
• 12,000 messages unanswered
• 3000 in 2 months unanswered
• Weekly audits
• Myself, Project Coordinator, EMR team
• Positive Feedback

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Weekly emails to managers and medical directors
When we added the good list it really took off.
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Unattended Messages
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Unanswered MHAV (patient) Messages
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Other EnhancementsArising in the iterative
process of improvement

• Email notification (provider)
• Out of office
• Merged baskets
• Priority tagging
• Recover taken message
• Show open messages throughout medical center
• Attach reports/labs to messages
• Delegates/Surrogates

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Lab Result Reporting

• Should we?

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Test Results Available For Patient View

• Laboratory and radiology results are organized
  into three groups
• Group A consists of a limited group of tests
  with results that have high value for immediate
  patient viewing with low risk of untoward
  reaction to the information (cholesterol,
  diabetes tests, and glucose results)
• Group B consists of the largest number of lab
  and x-ray result- labs will have a 7 day delay,
  x-rays will have a 14 day delay allowing for the
  provider to confirm the accuracy and communicate
  the result to the patient
• Group C consists of labs and x-rays that will
  not be released through MyHealthatVanderbilt
  (e.g. HIV results, cancer pathology results,
  urine drug)

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Lab Test For Patient View
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Radiology Results For Patients View

• All radiology reports will have a 14 day delay
  to allow for the provider to confirm accuracy and
  relay explanation of test results to patients

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Direct Patient Lab Result

• Patients are now part of the quality/safety
  process
• Examples

• Information toxicity

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Lessons Learned

• It is an iterative process
• Anticipate the pitfalls and deal with them in
  advance
• When unanticipated events happen, rapid cycle
  change
• Keep upper management and the grass roots aware
• Address incentives of all players
• Measure any behavior that can introduce safety
  risks.
• One project done well helps the next (atmosphere
  of change)

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Future

• Integrate fragmented healthcare information
  sources.
• Improving patient-friendly presentation of
  clinical information
• Personal health record.
• Support groups
• Personalized clinical quality dashboards directly
  to patients
• More patient information entry and coaching tools
• More devices to record data in the home.