Can physicians use all that patient-generated data to actually improve care?
By Mark Thill
Ask your physician customers: “How do you like your EMR?” Better yet, don’t.
Researchers reported in the March 2020 issue of Mayo Clinic Proceedings that the usability of current EHR systems received a grade of F by physician users. Physicians spend one to two hours on EHRs and deskwork for every hour spent in face-to-face contact with patients, and they spend an additional one to two hours on EHR-related activities outside of office hours every day, they reported.
Now add to that the plethora of patient-generated data finding its way into the medical record from mobile devices, apps and wearables. It’s a lot of data to manage.
Doctors say they are up for the challenge, in the name of better patient care. Research published by the American Medical Association this year shows that among digital health tools, “remote monitoring and management for improved care” has seen the biggest increase in adoption since 2016. (Televisits and virtual visits ranked second.) What’s more, remote care tools have the highest likelihood of adoption (among digital health tools) within the next three years.
But physicians do have concerns. Researchers from the New York University School of Medicine noted last year in the Journal of Medical Internet Research, “Although wearables have the potential to transform patient care, issues such as concerns with patient privacy, system interoperability, and patient data overload pose a challenge to the adoption of wearables by providers.”
Two years ago, Steven Waldren, M.D., made the following comment when he was appointed vice president and chief medical informatics officer for the American Academy of Family Physicians: “The doctor is the main generator now of records, but in the new paradigm, which we are calling the self-documenting record, the computer staff and patient would be the main data enterers. The physician will have to enter only those things needing a physician – and do it by speaking rather than typing.
“We are making progress on the integration of external data with EHRs,” he told Repertoire. “We have seen movement in the API space, which is needed to share data back and forth.” In addition, information-blocking rules – which prohibit IT developers, networks or providers from interfering with access, exchange or use of electronic health information – will likely lead to more information-sharing.
But many issues must still be addressed before patient-generated data reliably and consistently contributes to better patient care, he says. “I think the biggest hurdle is the integration of wearables data into the medical decision-making process, which includes integration and managing the large volumes of data.”
Waldren believes that providers of wearables need to understand how the data generated by their devices can contribute to better medical decision-making. Specifically, they should:
- Consider how that data must be aggregated and summarized to provide actionable insights.
- Understand what additional data is needed to determine the best course of action.
- Consider how they can help the physician or other clinician take the appropriate action.
“Many physicians are innovators and entrepreneurs, and companies could hire or engage with them to get the first version of the clinical interface to a place that supports a good user experience,” he says. “Companies should engage with physician users to refine their clinical user experience, just as they engage customers to improve their patient-facing user experience. With more transition to value-based payments in healthcare, companies will see a growing interest from physicians on how to incorporate wearables to help patients live healthy lives. At least, I have hope of such.”
COVID-19
Robert Tennant, director of health information technology policy for the Medical Group Management Association, believes that COVID-19 could stimulate the use of wearables and home monitoring among people with chronic illnesses.
“The ability to move data from the patient’s home to the physician’s office is becoming more critical,” he says. “But there is a caveat. There has been a lot of talk about patient-generated data being integrated into the EHR. The goal is clearly to have patient data flow seamlessly from the wearable device – such as a fitness device, blood pressure cuff or A1c monitor – directly into the EHR. But the reality is, healthcare hasn’t yet achieved that widespread level of interoperability.”
Three years ago, Tennant co-authored an article with Brendan Fitzgerald (then director of research for HIMSS Analytics) titled “Integrating Data from ‘Wearables’ into EHRs,” in which they noted, “An increasing number of patients now use wearables to help them track important metrics and better manage their health. Collecting that information, however, is only the first part of the solution. Transferring health data from the patient’s technology – electronics worn on the body – to the clinician’s EHR is critical if the information is to be effectively incorporated into the patient care delivery and care management process.”
In the article, the two authors list 10 action steps for physician practices that want to incorporate wearables data into the EHR, among them: 1) establishing which patients would benefit most, 2) determining the implications on clinical workflow, and 3) discussing the availability and cost with the EHR vendor.
Those action steps are still valid today, says Tennant. “Many practices have really looked at the first step, which is ‘Establish if your patient population would benefit,’” he says. “Physicians have to ask themselves, ‘How can our patients benefit if we move in this direction?”
Some mobile or home monitoring devices may be more expensive than others, he says. But for patients with chronic conditions, the cost is well worth it. “For people with diabetes, for example, tracking and managing A1c levels leads to better patient care and a better quality of life.” Remote monitors can also be used to “nudge” post-operative patients toward a better recovery, whether they are orthopedic patients who need to be on their feet and moving around, or post-surgical patients who need to make sure their dressings are changed promptly.
Physicians participating in risk-based contracts – that is, contracts that reward physicians on the basis of quality and cost of care – will probably gravitate toward remote monitoring as well, he adds. “Think about the implications if just one visit to the ER can be avoided thanks to remote monitoring.”
Some EHR companies are working aggressively to promote integration of patient-generated data into the EHR, says Tennant. “Give it five years and I think any company that wants to be competitive in the environment will be offering it.
“Consumers have increasingly higher expectations regarding leveraging technology for their healthcare,” he says. Many are turning to telemedicine, but without interoperable remote monitoring, its usefulness is limited. “Physicians will have to look at this issue more seriously if they want to remain competitive, he adds. “They will realize the advantages that remote monitoring can bring not just to the patient, but to their practice.”
Sidebar:
Ten action steps for physicians
Incorporating data from patient wearables into an EHR
1. Establish if your patient population would benefit. Those with ongoing primary care relationships (e.g., family medicine, pediatrics, gerontology) and those with certain ongoing chronic care relationships (e.g., cardiology, endocrinology, rheumatology, pulmonology) may be more likely to realize the value of an interface between wearables and health tracking apps and an EHR.
2. Discuss availability and cost with your EHR vendor. Determine if your EHR vendor offers an interface with wearable devices. How will the system incorporate external data into the patient’s medical record, and how will the clinicians see the information displayed? Can the vendor analyze and correlate the information or have a recommendation for a third-party application? Also, determine the upfront and ongoing costs to the practice for implementing a wearable device interface.
3. Consider targeting certain patients. Patients with chronic conditions such as diabetes and those focused on weight-loss may be the best candidates for wearable-EHR interfacing. Capturing data such as blood sugar levels, daily steps taken, and weight can link a patient activity with health outcomes more effectively.
4. Determine the implications on clinical workflow. Once data from wearables is imported into the EHR (potentially in voluminous amounts), the practice must decide who will review and make a determination on next steps. Does the data warrant, for example, a follow-up call from clinical personnel or the scheduling of an appointment?
5. Review care coordination opportunities. Practices increasingly are participating in pay-for-performance programs such as Patient-Centered Medical Homes and accountable care organizations, which reward care coordination and improved patient outcomes. Managing patients with chronic illnesses and identifying patients with emerging health issues is imperative. Customizing treatment plans based on data analytics better positions the organization for success in these new payment models.
6. Leverage wearables when participating in MIPS with 2015 CEHRT. The Advancing Care Information component of the Merit-based Incentive Payment System (MIPS) permits clinicians to count patient-generated data toward their performance score, but only when using 2015 Edition Certified Electronic Health Record Technology (CEHRT).
7. Test the reliability of the data. If data from wearables is to be relied on during staff decision-making, it is imperative that clinicians have confidence in its reliability. As a test, have patients on occasion transmit data such as weight or blood sugar level right before an appointment, and then match those numbers with what is captured during the appointment by practice staff.
8. Recognize and address security risks. Receiving data from any external source comes with an increased risk of unauthorized disclosure. Practices, as part of their required HIPAA Security Risk Analysis, should assess and document the risks associated with transmitting data from wearables to an EHR, -and how those risks were mitigated.
9. Engage patients. Engaging patients will maximize the opportunities afforded by incorporating wearable data into your clinical workflow. Remind patients that self-tracking key health metrics, especially with the aid of a wearable device, can allow them to be better stewards of their healthcare.
10. Market your capabilities. In a competitive physician practice economic environment, marketing your ability to engage patients with the use of consumer technology can be an important market differentiator, particularly with younger patients and those with chronic illnesses.
Source: “Integrating Data from ‘Wearables’ into EHRs,” Medical Group Management Association, www.mgma.com/data/data-stories/integrating-data-from-wearables%E2%80%9D-into-ehrs.