Altura FQHC is among those providers where tech means abandoned phone calls are dropping.

Lengthy telephone hold times have frustrated patients long before the COVID-19 pandemic. New technology lets providers move those patients into texting sessions before patients simply hang up their phones.

The technology works with Cisco and GoToConnect office phone systems in two ways. First, it can prompt on-hold callers to opt to continue the call via texting instead; second, it can sense when callers have abandoned calls, and send them texts inviting them to get answers via text instead of a return call.

Arnie Reynoso, chief information officer, Altura Centers for Health. Photo courtesy of Altura Centers for Health.

One provider that has found the technology to be beneficial to its patient experience is Altura Centers for Health, a federally qualified health center (FQHC) serving populations in California's Central Valley.

"As a nonprofit FQHC, finding the appropriate staff or staffing levels is kind of hard, because we have a very fixed budget," says Arnie Reynoso, chief information officer of Altura. "As our patient population increased, we saw an increase in actual abandonment rates."

Altura was already using technology from WELL Health to send texts to patients, and then integrated the technology with its phone systems. Within 90 days, its call abandonment rate dropped from 20% to 15%, a drop of nearly 1,000 abandoned calls per month, Reynoso says.

"For our patient demographics, they're usually [working] eight to five, or sometimes two jobs," Reynoso says. "So being on hold is quite precious time."

Patients benefit from being able to move to asynchronous texting communication that allows them to periodically check back and keep a conversation going with their providers, Reynoso says.

Initial use during the pandemic proved the value of the technology to Altura.

"During COVID, we were short-staffed, yet we were still able to handle the volume we typically handle," Reynoso says.

A typical engagement begins while the patient is on hold. The provider's phone system prompts the patient to press the star key on the phone, which triggers a pre-recorded response that the provider will follow up with the patient via text message.

The system is also able to detect if the patient response is coming from a landline, in which case it will check available records and attempt to locate a mobile number for the patient, then text to that mobile number.

If staff cannot locate a mobile number, they follow up with an actual return phone call to the patient, Reynoso says. "It hasn't been a huge issue," he says.

When surveyed, between 90% and 95% of Altura patients say they appreciate the ability to reach their providers via text, Reynoso says.

Front office and call center staff, who are typically the personnel who patients are initially contacting, approve of the shift to texting. Such staff "would love for everyone to utilize the texting feature," Reynoso says. "It's less burdensome, and it allows them to handle multiple patients almost simultaneously, in a sense."

The increased usage of texting has another benefit to Altura's patient engagement goals: it increases usage of the FQHC's patient portal.

Once enough patients were connected to Altura's texts via mobile messaging apps, Altura was able to massively send text messages and reminders to patients, including prompts to utilize the patient portal, or select URLs to initiate medical record requests, Reynoso says. Texting "eliminates the need to actually make a phone call and talk to someone," he adds.

In the last six months, Altura has seen an increase in call volume, and also a slight increase in patients opting to continue calls via text messaging, Reynoso says.

Once patients are aware they are connected to Altura via messaging apps, often these patients "don't even initiate a call anymore," Reynoso says. "They just text us to request an appointment or a medical record. It's pushed them in that direction."

In the future, Altura plans to expand the capabilities of its texting interface, so that, for instance, patients could self-schedule appointments. The technology is capable of doing this, but "we need to iron out the details," Reynoso says. Similar issues, as well as security considerations, are behind not yet permitting prescription refills via texting, he adds.

WELL Health's technology also integrates deeply with multiple vendors' EHR technology, says founder and CEO Guillaume de Zwirek. It also brings in ADT data and interfaces with scheduling, referrals, and orders interfaces, he adds.

All told, the technology is already deployable to 30 million patients nationwide, and is in use by Houston Methodist, Cedars Sinai, and MemorialCare Health System, among others, de Zwirek says.

All this is possible without requiring patients to download another app, and this is by design, de Zwirek says.

"Apps are important for high-utilizers" with chronic conditions, he says. "For the 90% of people who visit the health system three times a year, you need to reach them where they are," which is texting, and maybe only move some of them to apps if they acquire chronic conditions, he adds.

Spur-of-the-moment care and research is enabled by posing questions in plain English.

Clinicians and researchers are benefitting from new self-serve analytics software in use at Intermountain Healthcare.

The Utah-based system, which operates 24 hospitals and 215 clinics in Utah, Idaho, and Nevada, has been using software from MDClone to investigate everything from cardiology to genetics to hyperbaric medicine, according to officials at the health system.

The software taps Intermountain's electronic health record (EHR) system to perform English-like queries on the 3 million lives of current patients, but also on an enterprise data warehouse on Intermountain patients dating back 25 years, says Jeffrey L. Anderson, MD, a clinician and research physician at Intermountain, and immediate past director of cardiovascular research at the Intermountain Medical Center Heart Institute.

The MDClone software tools are also being applied to Intermountain's HerediGene™ population study, which the healthcare system says is the largest single-population genome study in the world, Anderson says.

The population study is being undertaken with deCODE genetics, a biopharmaceutical company based in Ireland.

"We're being courted by many companies, to see if we have the patients they would like to test with their new therapeutics," Anderson says. "So we need to answer questionnaires. And what we need to do is find out really who we have in the Intermountain system and within a certain distance that can come in and potentially participate in these intervention trials."

The prior way to perform these queries relied on the expertise of Intermountain data analysts, whose very expertise made them so popular, researchers had to "get in line, and wait weeks, even months to have an analysis done," Anderson says.

The new analytics tool allows untrained investigators to pose sophisticated queries without knowledge of the structure of the underlying databases and tables where the data is stored.

Previously, such queries would require sophisticated knowledge about table structures, plus a working knowledge of Structured Query Language (SQL), says Viet Le, a researcher and physician assistant in cardiology at Intermountain, who studies mobile health technologies and cardiovascular genetics.

"MDClone is democratizing our ability to query quickly, to allow us as clinicians to ask very important questions at the point of care," Le says.

In certain cases, in the previous arrangement, researchers could forget the original impetus for the question they posted to expert analysts in the gap of time between submitting the question and receiving an answer, Le says.

This level of ad-hoc query is particularly useful to formerly frustrated researchers at Intermountain, such as the hyperbaric medicine department.

Kayla Deru, who started in the department as a secretary, became a department researcher, and developed research skills to the extent that she recently joined the Intermountain Connect Care team, Intermountain's telehealth division.

The hyperbaric department "never had analytical support, ever," Deru says. "I'm not a statistician, or a computer programmer. These intellectual curiosity questions, or even patient care questions, tend to be fairly time-sensitive. And you don't want to wait for six months, a year, or never, to find out the answer to your question."

The technology works by creating a history of each patient's interaction with the health system, not limited to EHR data, but also including admissions, discharges, transfers, genomics data, claims data, and administrative data. This data is organized as events on patient timelines, making it easier for would-be analysts to query. Natural language processing (NLP) brings in unstructured notes from physicians.

This timeline approach makes it much easier for researchers to search for and find data related to readmissions, queries that would otherwise have required intimate knowledge of underlying data structures, according to Jon D. Morrow, MD, senior vice president and physician executive at MDClone.

One area of inquiry pursued by Deru allowed clinicians to look at connections between carbon monoxide poisoning and blood clots, and on-the-fly results from queries help accelerate the presentation of research papers, Deru says.

In another example, Le used the ad-hoc queries to investigate histories of elevated lipids on relatively young patients coming through Intermountain's cath lab. "I would prefer we catch these individuals before they have their first [adverse] event," Le says.

This ability to quickly ask and get answers back also is helping Intermountain to rapidly respond to opportunities to host clinical trials, and thus to become one of the early places where a particular breakthrough treatment becomes available.

"It seriously has helped our department and other departments in our system enormously well" in this regard, says Lindell Weaver, MD, medical director of the Intermountain Hyperbaric Medical Center at Intermountain's LDS Hospital.

Another area where the queries of Deru and other researchers aided clinicians was focusing on the importance of blood pressure control and renal function to patients with diabetes and a risk of foot ulcers and amputations, Weaver says.

At the Heart Institute, another set of ad-hoc queries zeroed in on patients with hypertriglyceridemia to examine how many had experienced pancreatitis and found that half the patients had done so. "Those are numbers we could not have gotten otherwise," Anderson says.

Finding this connection in the traditional way that would have allowed the Heart Institute to qualify as a candidate site to offer a new therapeutic would have taken "weeks or months to do," Anderson says.

"These trials come along all the time in premier medical centers and medical systems," Anderson says. "That's just part of our everyday existence to try to be on the cutting edge when new therapeutics come along."

Ultimately, tools like this will remove the kind of monopoly on data analysis that more highly skilled but short-staffed data analyst staffs have enjoyed until now, according to officials at MDClone.

In Q3, the Ripple app will gain a biometric facial recognition alternative to the login name and password.

In a break with tradition, a Wisconsin healthcare system is using cutting-edge digital technology to reach out to patients and non-patients alike during the pandemic.

The initiative is the first to incorporate identity based on facial recognition and other identity management services provided by Mastercard, the financial services company, in conjunction with the startup that built the digital-first app for ThedaCare, the Wisconsin health system, which serves a community of 600,000 residents in 18 counties.

The tech push helps ThedaCare move ahead while national efforts to identify patients remain stymied, says Jim Albin, chief information officer of ThedaCare.

"It's answering a broader question, which is, how do you identify a patient and individual across all the different venues of care," Albin says.

Mastercard and app designer b.well Connected Health, will activate the facial recognition feature by early in the third quarter of 2021 in Ripple, ThedaCare's "front door" app for Apple iOS devices, Android devices, desktops, or laptops, to patients and to the larger community. Ripple, built by b.well for ThedaCare, was introduced in June 2020.

Prior to the biometric sign-in, Ripple required a traditional login and password, which is still available if necessary. "To really have a handle on patient care being delivered to our communities, we have to transcend all the different organizations that that patient touches," Albin says.

Jim Albin, chief information officer, ThedaCare (Photo courtesy of ThedaCare)

ThedaCare and b.well's intent is to give patients, as well as non-patients in the community who are interested in keeping track of their health, the ability to log in with a glance, in a single place, incorporating all their disparate medical records.

"We've been dealing with health information exchanges for years, and they have always faltered because of this very same issue of patient identification," Albin says.

The underlying b.well technology utilizes healthcare industry standards to be easily integrated with the electronic health records in use by physicians, as well as specialists, in a way that previously would have required patients to maintain multiple logins and passwords in order to view their medical records, Albin says.

Albin describes ThedaCare as "a typical sort of Midwestern provider" with a payer mix of Medicare, Medicaid, commercial, and private insurance. ThedaCare also operates a nationally recognized accountable care organization (ACO) carrying risk-type agreements. Ripple represents another step for ThedaCare into managing population health, he adds.

"That will be the predominant model going forward, where patients interact with health systems, but also, health systems are charged with truly taking care of their communities, whether they're patients or not."

That's why Ripple was also designed for community members not part of the healthcare system. "You can be a Ripple participant and not be a patient of ThedaCare," Albin says. "We're looking at it as a tool for us to reach out to our communities and to make sure that they know we're there and we have their back."

ThedaCare has seven hospitals, two in urban environments, and the other five in rural locations. Ripple helps those in smaller rural communities, by giving them state-of-the-art information on healthcare, COVID-19, and other access points to care in their communities, Albin says. "We're proud of that, and our presence in the rural environment," he adds.

Independent physicians in the ThedaCare community can also utilize Ripple for their patients. "Currently, we are bringing information in from third-party insurance companies, from pharmacies, from a lot of different places," Albin says. "The momentum is building."

Last summer, while the COVID-19 pandemic raged, "we didn't know how bad it was going to be, but we did think that Ripple provides an open conduit with comprehensive information to patients," Albin says. "It's become indispensable now, as we're distributing information on the latest in COVID."

The innovation represented by Ripple indicates the changing role of information technology in healthcare, Albin says.

"Our job traditionally is to make sure the lights are on," he says. "We have good information being distributed, good tools for our providers, and there will be tools like Ripple that are out there moving in new directions, allowing us to jump out of our health system to the public in general."

b.well itself is a company founded by a former United HealthCare official whose daughter suffered a near-fatal event "because two electronic medical records couldn't communicate with one another," says founder and CEO Kristen Valdes.

"We are the off-the-shelf digital transformation platform," Valdes says. "We are particularly aligned to folks who have not build their own solutions, and who do not have agile development teams, where they can do this easily." The b.well app can be delivered with the brand of the customer, such as ThedaCare, she adds.

In part, the company exists because of the assumption that the first patient encounter with a physician practice may occur through telehealth, Valdes says.

The b.well app, in all its manifestations, assumes the patient has a mobile phone. The patient's mobile phone number, as well as the biometric token of a photo of their face easily taken by today's smart phones, provide healthcare with identifiers beyond traditional driver's license and insurance cards, Valdes adds.

Correction: An earlier version of the story incorrectly stated that Mastercard had been an investor in b.well.

Providers face education of workforce; penalty phase remains a mystery.

Faced with the threat of penalties if they do not comply, healthcare providers are figuring out as best they can how to comply with new information blocking rules that took effect April 5, but one size definitely does not fit all.

One month in, many questions remain, and some providers find themselves in the middle between how patients want to receive their medical records, and how electronic health record (EHR) vendor suppliers want to provide them.

"We're required to follow this information blocking rule, but a lot of our software vendors are not prepared to do that," says Randi Terry, director of IS at Munson Healthcare, a nine-hospital system in northern Michigan.

This is despite the fact that some of the EHR software in question, which Terry declined to name, attests that its EHR software meets the certification standards promulgated by the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Information Technology.

A big example of lack of preparation centers around patient demand for interoperability with Apple Health, a longitudinal health record and tracking app preinstalled on millions of Apple iPhones. The information blocking rules say that if a patient requests their data in digital form, one way it can be provided is through a link between the EHR vendor's software and the application programming interface for Apple Health, known as HealthKit.

"Vendors say, 'Yep, can't do that,' " Terry says. "Or if they do it, they give us a 37-page document, and say, 'tell your patient to go talk to Apple Health.' There's no patient in the world that's going to follow through." Munson has been trying to get this particular certified  EHR vendor to implement the link for three years, Terry adds.

Other EHRs, including Epic, have provided interoperability with Apple Health for several years, according to Terry, who also is a member of the policy steering committee of the College of Healthcare Information Management Executives (CHIME), which meets regularly to discuss, among other things, issues around implementing the April 5 information blocking rule.

Standard Interface Coming in 2023

The situation is set to improve in 2023, when EHR providers will be required to support an ONC-certified, standardized application programming interface (API) defined by the HL7 organization as Fast Healthcare Interoperability Resources (FHIR), providing a lingua franca between applications such as Apple Health and EHR software, and between different vendors' EHR software.

In the meantime, providers are required to find some other way to digitally share requested patient medical records, in order to appear to be complying with the April 5 rule. "It's very definitely an issue that we're facing right now," Terry says.

In addition, providers are still in the dark about the precise date when enforcement of the April 5 requirements will begin, says Andrew Tomlinson, director of federal affairs at CHIME.

"We don't want enforcement until we have the education piece," Tomlinson says.

"This whole information blocking [rule] is a fundamental shift in how we have to educate every person in healthcare," Terry says. "It's a fundamental shift in the way we release records, and that's really difficult."

Initial steps at Munson include providing scripts to all offices, for those answering the phone, who may be receiving requests for medical records, Terry says.

Requests are being considered on a case-by-case basis, with the general rule being what is best for the patient, she adds.

Areas of Friction are Causing Provider Concern

Three areas of particular friction are disparities of action based on organization size, confusion over which organizations the April 5 rule covers, and the rule's insistence that lab results be delivered to patients without a waiting period for a clinician consult, which the ONC's Information Blocking FAQ cites as an example of information blocking.

Smaller healthcare organizations and medical practices, where a physician may double as a chief information officer, "are going to feel that stress" of having to abide by the April 5 rule, lacking the number of resources that large healthcare providers can apply to conformance, Tomlinson says.

Another area of friction arises because many U.S. healthcare organizations believe that just because they do not participate in CMS payments or incentives to purchase certified EHR software, they are not subject to the provisions of the rule.

Instead, the information blocking rule applies to all U.S. providers, Tomlinson says.

"That's part of the education gap," he says. "Even if they don't collect Medicare or Medicaid, they still have to comply with these requirements."

Those providers who are not necessarily familiar with programs run by CMS or ONC are now having to familiarize themselves with those programs, because of the information blocking rule, Tomlinson says.

"For [the] information blocking [rule] and interoperability to work, it has to be everyone," he says. "We can't leave any provider behind. We have to go together as one, or it won't work, long term."

An earlier effort to provide a national registry of all providers, through which C-CDAs could flow via Direct messaging, remains a hit-and-miss way to find and forward or receive patient records between providers. This is true even though any HIPAA-covered provider, or provider who bills Medicare, is required to have a national provider identifier number in the National Plan and Provider Enumeration System (NPPES). "It's kind of a misnomer to say that everybody is now putting their Direct Trust addresses in NPPES, because they're not," Terry says. Smaller providers are among those most missing in the NPPES database, she adds.

Yet another promising method is the growth of national data exchanges such as CommonWell, Terry says. Munson uses CommonWell to keep track of "snowbird" patients who winter over in Florida and Arizona, she says. Munson has also successfully tested Carequality, another vendor-driven national healthcare data interoperability framework.

The requirement to release lab results when they are available runs counter to many organizations' waiting periods before patients get to see their lab results. "ONC has outlined in their FAQ that an organizational policy of a delay from releasing the results does not comply with [the] information blocking [rule]," Tomlinson says.

Additional Complexities

There are some exceptions to the April 5 rule, one being preventing harm, and corner cases will likely result in an initial surge of use of those exceptions, Tomlinson says. Examples include EHR records of teenagers, some portions of which teenagers can by rights withhold from their parents, even though the supporting EHR software has no way to send only selected portions of the records.

A further complication involves the dates by which the FHIR API must be implemented. Right now, both EHR vendors and providers are expected to turn on this interoperability by December 31, 2022. "Providers need time to be able to implement those new pieces of health IT," Tomlinson says. Fortunately, recent clarifying rules state that providers will be able to attest during any 90-day period in 2023, he adds.

Providers can also demonstrate compliance by transmitting medical records as C-CDA documents. If patients request the digital files via a technical means that the provider does not have, providers are permitted to pass along the costs of such delivery, such as building or purchasing a patient portal or buying a Zip drive, Tomlinson says. If the patient doesn't want to spend that money, provider and patient can negotiate an alternate digital delivery format, he adds.

Lastly, says Tomlinson, ONC needs to do a better job of showing providers how to document the process of attempting to comply with the rules, and documenting procedures once a provider actually receives notice of an information blocking complaint.

"The information blocking requirements are about attempting to get patients their data when they need it," Tomlinson says. "We can provide the education and the policies and procedures, and the understanding, but we do need a little bit more understanding of what exactly [ONC] may be looking for."