Personiform whitepaper

Personiform: The Case for a Social Health RecordNecessary changes to the healthcare system will require new avenues of communication, novels ways to engage patients, and the capture of patient-generated health data

S P E C I A L R E P O R T

Table of ContentsAbout Personiform...............................................2

Introduction.........................................................4

The Benefits to Providers....................................5

Capturing New Revenue Through More Efficient Office Visits..................................6

Capturing Lost Revenue for Care Plan Oversight............................................9

New Revenue for Electronic Communications...............................................10

Moving Away from Fee-for-Service...................12

Avoidable Readmissions and the Global Period...............................................15

Meaningful Use and Patient Engagement..........................................16

Conclusion........................................................18

References.......................................................19

S P E C I A L R E P O R T : The Case for a Social Health Record 2

In the age of social networks, patients want the same personalized and efficient communication about their health as they do with everything else in their lives. Healthcare organizations providing this capability can reap enormous benefits, but most do

not take the steps to support and engage with their patients in this way. So patients take to social media, connecting with others about their healthcare. Their interactions are neither private nor secure, and critically do not involve their doctors. This valuable data from these social interactions is not structured, nor synchronized with the patient’s formal care team, and hence forgone.

Personiform changes all of this. It is a secure and private social network for healthcare connecting patients, families, friends, and medical professionals. Patients log their symptoms, in their own terms, into a “Chronicle”, share this with their “Care Rings”, and ask for medical evaluations from their providers through the “Consult” function. Chronicle activity can be converted into medical codes, as used by leading Electronic Medical Records (EMRs) for billing and health records and presented to Care Team members in a useful format they can easily digest.

Driven by government regulation, the transformation of healthcare has created a critical mass in the adoption of health information technology among hospitals in the US, yet consumers hoping to communicate electronically with fellow consumers and health care professionals still have very limited options. Personiform was created to provide efficient, transparent, and integrated collection and communication of health data, while leveraging the role of social networks to bring together vibrant communities of engaged and informed patients. Personiform is the world’s first “social health record.”

How it works:

1. Users log in and invite family, friends, and providers to join their Personiform network.

2. Users create one or more, self-defined groups of providers, family and friends called Care Rings.

3. Users create Chronicles to track a given health concern. Each Chronicle is built upon an intuitive set of symptoms that will be recorded as structured data, and include important attributes such as severity, duration, and intensity.

4. Users input their basic personal health history including past medical history, past surgical history, medications, and allergies.

5. Users can choose to share all or portions of their Chronicles, selectively with specific Care Rings. The privacy controls are granular enough such that any piece of data can be independently restricted.

6. If desired, patients can directly request provider evaluation of a Chronicle by initiating a Consult, at which point the provider may engage other professionals in a Care Team to respond to the Consult.

7. Once the Consult is completed, the provider can automatically generate precise medical coding based on the patient’s chronicle that will enable integration with enterprise EMR systems.

Quick facts:

• The platform is fully HIPAA compliant, and uses highly-advanced security measures to combat hackers and other cyber-security threats.

• Personiform adheres to privacy best practices, providing users with complete and robust control over their data and how it is shared with others.

• Personiform generates ICD-9, ICD-10, and SNOMED codes for over 2500 medical conditions. The library of medical conditions is from the National Library of Medicine.

• In addition to the symptoms, users can also provide photos, documents, measurements, and location.

• The provider platform can be extended and customized to meet the needs of various providers.

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IntroductionIn this paper we discuss the fundamental need for a new health information platform to meet the challenges faced by the US healthcare system in the 21st century. We review evidence of the need for effective patient-provider communication systems, patient demand for online access to dynamic health information, and the value of real-time provider feedback to patient engagement. We also acknowledge the limitations of existing health IT solutions in their ability to foster meaningful interactions and patient engagement.

We then evaluate trends in the federal incentive programs for providers designed to improve care and lower costs across the system. Finally we look at the federal government’s Meaningful Use incentive program for use of healthcare IT and its momentum. These trends align to demonstrate the need for the new approach to patient-provider interaction and health data offered by Personiform.

What is at stake in US healthcare?

Statistics abound highlighting the US healthcare system’s exceptionally high costs paired with inconsistent and often sub-par outcomes. At least 30 million newly insured patients are set to engage with the system in coming years. Costs are projected to continue their upward spiral. The resulting pressure on the federal and state budgets is grave. Stakeholders resoundingly agree that something must be done. Healthcare experts all say that we must to create incentives for better health outcomes with less unnecessary care.

We believe that the patient has long been left at the periphery of the healthcare system. Patients find themselves caught in a web of inconsistent access to information and a myriad of providers and care settings. They must manage multiple appointments, repeat their history to multiple caregivers, and struggle to pull together a comprehensive picture of their care to share with family members. We also believe it does not have to be this way.

Reforms are already underway

The system is already in the midst of a series of reforms that will alter delivery, payment incentives, and quality measures. First, the 2009 Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH) solidified the trend toward adoption of electronic medical records and set the standards for their Meaningful Use. Then the 2010 Patient Protection and Affordable Care Act (ACA) gave the Centers for Medicare and Medicaid Services (CMS) broad authority to pilot new payment models and incentives for improved quality and lower costs.

New payment models require better coordinated, more patient-centric, and integrated care. They reward seamless transitions of patients and care plans between primary care providers, specialists, and other caregivers. They also require more efficient, secure, and useful electronic avenues of communication.

Electronic medical records and other existing forms of health information technology currently form the backbone of this information exchange. However, these systems

New payment models require

better coordinated, more patient-centric, and integrated care.

Changes to the US healthcare system will require new

approaches to communication, patient engagement, and

collection of patient-generated health data

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often fall short in terms of the interoperability, connectivity, user-friendliness, and timeliness of their data. There exists a need for improved data to support EMR systems and platforms that enable and capture communication between patients and caregivers.

The healthcare system fails to meet patient demand for online tools

There is growing evidence that patients want more online interaction with healthcare providers and data. In a 2011 survey, 73% of patients said they wish to use a secure online tool for communicating with their physician. Nearly half of patients said they would consider switching physicians in order to use such a tool.1

Despite this demand, most physicians still do not regularly interact with patients via email. A survey by the Center for Studying Health System Change found that in 2008 only 6.7% of all office-based physicians regularly emailed patients. Even among those physicians who had ready access to email in their practice, only about 20% routinely used it to interact with patients. That same survey cited several key barriers to physician use of email.2

• Lack of reimbursement mechanisms

• Potential for increased workload

• The challenge of maintaining data privacy and security

• Concerns over increased liability

In addition to those concerns, emails raise issues as unstructured messages. Unstructured text is difficult to integrate into electronic medical records. While some EMR system add-ons and patient portals do support basic messaging, their use remains limited.

Existing tools provide patients with static access to their health data and providers. Patient portals and personal health records (PHRs) typically allow patients to schedule appointments, view lab results, and access other health data downloaded from the EMR system. They do not provide a true platform for tracking and recording of new health data or sharing information dynamically with providers and caregivers.

The Benefits to Providers Patient Satisfaction

As CMS and private insurers introduce pay-for-performance initiatives, providers will face new evaluations of their performance based on patient satisfaction ratings. The two most common measures of performance are the effective use of health IT and patient satisfaction.3 Increased access to physicians and other members of the care team through use of Personiform should contribute to overall patient satisfaction and loyalty.

Patient Engagement and Self-Management

The proliferation of chronic diseases is exacerbated by the challenges associated with managing them in a fragmented health system. Managing these conditions

73% of patients said they wish to use a secure online tool for communicating with their physician. Half said they would consider switching physicians to use such a tool.

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Only 6.7% of office-based physicians regularly email patients. “

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A social health record offers unique advantages to any

physician organization


effectively is at the heart of the US healthcare system’s crisis. Patients that take an active role in tracking their symptoms and interfacing directly with providers are more likely to adhere to their course of treatment. However, effective patient engagement tools must fit into the patient’s daily life and also within the existing workflows of the provider. Personiform’s platform engages patients in the critical period between office visits and improves that engagement and adherence. It closes the loop on treatment plans, ensuring that patients do not forget everything they heard in the exam room. This puts patients at the center of their own care plan and places providers ahead of the curve in managing chronic disease.

Practice Efficiency

Studies have repeatedly shown that use of patient portals and other online tools lead to drops in call volume and decreased staff costs. However, the Personiform platform goes beyond those immediate benefits. The platform allows staff members segment and message certain groups of patients based on their conditions and reported symptoms. It streamlines patient communications as well as reminders to schedule new appointments. It allows providers to interface with more patients more efficiently.

Regulatory Compliance

Providers seeking to meet Meaningful Use requirements will need to engage with patients in deeper and new ways in Stage 2 of the program. Proposed requirements that 10% of patients use electronic messaging and 50% receive care summaries necessitate a captive and engaged patient audience. By virtue of its patient-centered design, Personiform’s social health platform will help build that audience for providers. Data captured through regular use of Personiform will also support many of the other proposed Stage 2 core objectives.

Capturing New Revenue Through More Efficient Office VisitsBoth physicians and patients alike lament insufficient time together in the exam room. Patients are unable to fully express themselves and their personal health story. Physicians feel pressure from the volume-driven payment system, frustrating their efforts to deliver quality care. A 2005 study of how primary care physicians allocate their time, found that 45% of an average day is spent outside the exam room.4

A social health record can increase provider revenue through

more efficient office visits and better documentation


Driving this trend are requirements from payers to comprehensively document services provided. Any slip-up can result in partial or zero reimbursement from payers. As a result, providers and their staff often err on the side of caution when selecting billing codes. This practice of “down-coding,” can significantly decrease provider revenue. According to an 1998 article in Medical Economics, one physician regularly down-coding by just one level can cost a practice $40,000 to $60,000 each year.5

Health IT vendors often claim that patient data captured in EMRs will improve the efficiency of healthcare. However, the quality of patient data available in EMRs is often uneven. Data may be incomplete and stored in multiple incompatible systems. In the best case scenario, the EMR provides a comprehensive list of a patient’s allergies and medications, lab results and imaging studies, notes from recent visits, and procedures. Physicians need access to a more robust and complete patient narrative.

Patient history is a significant contributor to physician reimbursement

When seeing a new or established patient in the office, physicians must closely follow CMS’s Evaluation and Management (E/M) service guidelines. The reimbursement level for any E/M office visit depends on the documentation of seven components.

The first three—History, Medical Decision-Making, and Exam—are considered the key components used in selecting the appropriate E/M code. The most commonly used E/M codes for new and established patients, 99211-99215 and 99201-99205, require extensive documentation of Patient History. The complexity of that history is a key determinant of which level of consult and reimbursement a physician receives from payers. Three different elements comprise the overall Patient History.

• History of Present Illness (HPI)

• Review of Systems (ROS)

• Past Medical, Family History, and Social History (PFHS)

The level of history recorded is determined by the number of history elements captured in each of the three history areas. A patient visit may include a problem-focused history, expanded problem-focused history, detailed history, or comprehensive history. Each of those more detailed levels of patient history is associated with a higher level of E/M reimbursement code.

For example, established patient code 99213 requires an “expanded problem-


focused history,” while 99214 requires a “detailed history.” Subtle differences in the number of HPI elements, bodily systems, and whether a PFHS is taken can determine whether a provider can bill the code 99214 with the higher reimbursement level. Even if the medical decision-making and exam were complex, simply not documenting enough detail about the HPI can result in down-coding to 99213. A study evaluating the coding accuracy of family physicians found that in 33% of the visits involving established patients, physicians’ code selections were lower than those of expert coders.6

Let’s assume that a family physician sees 30 established patients per day and down-codes 30% of them one level. At an average lost revenue of $27, that’s $57,600 per annum lost revenue per physician just for established patient visits.7

Personiform can capture much of a patient’s history before an office visit, improving efficiency and quality

While some of this data is captured on a waiting room form, physicians must still transcribe the much of a patient’s history by hand each time a patient visits the office. However, this could be documented or retrieved in advance of an office visit utilizing customized Personiform forms and surveys.

For example, the History of Present Illness (HPI) requires documentation of location, quality, severity, duration, timing, context, modifying factors, associated signs and symptoms, and the status of chronic or inactive conditions. The more of these elements the physician captures the greater chance of appropriate reimbursement and coding of the visit. Using Personiform, the physician or staff could send a form in advance of a Consult asking the patient to describe the condition. Similarly, existing Personiform data captured in the patient’s Health Profile would support the Review of Systems (ROS) and Patient Family and Social History (PFSH) components.

This would ensure that in more complex cases in which higher E/M codes are justified, physicians would be able to bill with confidence. Structured data captured in Personiform can also be transferred into the EMR for billing and record purposes. Most importantly, the physician is freed up to spend more time working with patients face-to-face to get to the root of the problem.

In 33% of the visits involving established patients, physicians’ code selections were lower than those of expert coders.

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Capturing Lost Revenue for Care Plan Oversight Care plan oversight (CPO) reimbursement is another type of reimbursement physicians often miss due to documentation challenges. It is available to physicians of Medicare patients receiving care from approved Home Health or Hospice providers. Often physicians may perform services covered by the CPO reimbursement codes, but they are focused on patient care and overlook the documentation of CPO and subsequently cannot bill for them. These tasks include:

• Review of charts, reports, treatment plans, lab and other test results that were not ordered during the face-to-face encounter qualifying patient for CPO

• Telephone calls to other health care professionals involved in care of patient

• Team conferences

• Telephone call/discussions with pharmacist about medication therapies

• Medical decision making

• Activities to coordinate services requiring the skills of a physician

• Documenting the services provided (includes time to write a note about service provided, decision making performed, amount of time spent on countable services)

• Time spent on activities undertaken on day of hospital discharge separately documented as occurring after physical discharge from hospital

Physicians and their staff spend time coordinating with home health and hospice facilities but miss out

on opportunities for reimbursement

Use of Personiform could significantly improve a physician’s

bottom line


Physicians must simply document that 30 or more minutes is spent on these activities each month. The potential to regain revenue is significant. The code G0181 for home health patients reimburses $104.84 while G0182 for hospice is $106.20. In addition physicians are eligible for code G0180 ($51.96) for developing and certifying initial care plan, and code G0179 ($38.97) for periodic recertification.

Personiform supports these care coordination activities and can capture them for billing purposes. For example, Personiform will record physician time spent reviewing a patient’s specific Chronicle. Personiform also records a follow-up action, such as data forwarded to the home health facility or to other Care Team members for review.

Care coordination is at the heart of many new payment incentives to improve care and lower costs. Though this application is limited to a pool of Medicare patients, future incentives should encourage the same coordination activities for broader pools of patients. Providers who utilize Personiform will have increased visibility into the time and effort spent on care coordination activities.

New Revenue for Electronic CommunicationsAs discussed, despite patient demand, physicians are generally reluctant to use email to communicate directly with their patients. There are data security concerns associated with sending health information via email. Physicians also fear becoming inundated with unstructured patient questions that further depletes their already limited time. However, several insurers now reimburse physicians for online interactions known as “E-Visits.”

E-Visits require that the patient initiate the visit, which cannot be related to an office visit in the previous week. It must occur via a secure HIPAA-compliant online connection. Finally, the physician must document the interaction and include it in the patient’s health record.

Thus far, several major insurers, including Aetna, Cigna, and select BlueCross plans have agreed to reimburse physicians an average of $30 for E-Visits. A relatively small percentage of physicians have billed for E-Visits to date. Medicare has also created a CPT code (94444) for the E-Visit but has yet reimburse physicians for it. Several major physician and patient-advocacy groups, including the AAFP and ACP, are pushing for Medicare to reimburse for E-Visits. However, the AAFP estimates that only about 3% of its members are currently performing E-Visits.8

When the E-Visit is not covered by insurance, physicians have asked patients to pay between $20 and $35 out-of-pocket. Patients are often receptive to the convenience of interacting online and avoid the lost time and expense of traveling to an office and waiting. As a result, cash-only and “concierge” primary care practices have begun to offer the service.

Personiform could enable providers to easily facilitate E-Visits. Patients can request that their doctor review an existing Chronicle with a pattern of symptoms and even attach photos or video. Alternatively, a patient can securely message his

Personiform enables physicians to capture new reimbursement for

electronic office visits

AAFP estimates that only about 3% of its members are currently performing E-Visits. “ “


or her physician with a concern and the physician can request that they fill out a provider-generated form documenting the symptoms. Personiform will generate the appropriate codes to accompany the E-Visit and integrate them into the patient’s EMR.

Electronic referrals may be the next e-reimbursement trend

The lack of communication between primary care physicians (PCPs) and specialists contributes to unnecessary and poorly coordinated healthcare. Physicians consistently lament the lack of accountability in the referral process. At best, a specialist may receive unstructured clinical notes about the patient from the PCP. PCPs report rarely receiving follow-up on their patient’s experience with the specialist.

This lack of communication is costly to the health system. Estimates say up to 30% of specialist referrals could potentially be avoided if better communication channels existed between PCPs and specialists.9 While shared EMR systems can enable communication and information sharing, they rarely have the necessary level of functionality for facilitating and capturing detailed interactions between PCPs and specialists.

Asynchronous communications between physicians, such as that supported by Personiform’s data capture and messaging, could alleviate these problems. Online interactions between specialists and referring physicians are increasingly known as E-Consultations. E-Consultations can replace or supplement mechanisms clinicians currently use to communicate about patients. The Commonwealth Fund estimates that reductions in specialist visits through the use of E-Consultation range from 8.9% to 51%, with the majority of estimated reductions around 30%.10

At the Mayo Clinic, researchers have extrapolated that if E-Consultations were ordered only two to three times monthly by each provider, the system could avoid 1,800 specialty consultations per year, reducing direct costs by $450,000 annually.11 These benefits may also stretch beyond integrated care organizations to fee-for-service environments. Several pilot programs have reimbursed physicians directly for use of E-Consultations at an average of $50.

For example, a PCP could review data stored in a Personiform Chronicle by the patient. The patient has captured structured data on the condition, such as level of discomfort, location, and attached a photo. All of this stored data is used to support the initial consult with the PCP. When the PCP decides to refer the patient to a dermatologist, the Personiform data can be shared. These interactions are stored in Personiform, available to both physicians, and are searchable for future reference should a similar issue arise with the same patient.

Providers and patients that utilize Personiform will have a richer cache of data to draw from when communicating. The result should be better referrals for the right patients and proper documentation for incentives and payments.

At the Mayo Clinic, if E-Consultations were ordered a modest two to three times monthly by each provider, the system could avoid 1,800 specialty consultations per year, reducing direct costs by $450,000 annually.

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New Payment Mechanisms and Documentation Requirements

CMS and private payers continue to search for new ways to measure and compensate providers for better care and lower costs. Providers will increasingly need to show evidence of coordinated and personalized care outside of traditional office visits. This might create a documentation quagmire if every email and phone call were required to be captured manually for reimbursement.

This will necessitate a flexible and intuitive platform that captures time spent interacting with patients, other members of the care team, and the patient’s health data. Personiform allows providers to generate reports detailing time spent interacting with a specific patient, evaluating recorded symptoms in Chronicles, and generating a diagnosis.

Moving away from fee-for-serviceWhile the Personiform platform offers immediate value to providers and patients in our current health system, its strength will grow under future payment scenarios. Exponentially rising health costs and the associated pressure on budgets have already spurred experimentation with new models. Integrated delivery systems are looking to take advantage of opportunities to capture shared savings as Accountable Care Organizations. Other networks of physicians and facilities are considering forming new ACOs. Practices are considering becoming patient-centered medical homes and may form the backbone of future ACOs.

CMS is also piloting new forms of episode-based reimbursement models. These models will require new levels of

patient engagement, communication, health data, and coordination of care between providers.

Instead of simply supporting documentation and an avenue for reimbursement in the fee-for-service environment, Personiform’s social health record will be central to an IT

PERSONIFORM USER STORY: PAMELA

Challenge:Pamela faces the constant challenge of keeping in touch with patients. Currently she uses text messages to stay in touch with her patients, who are generally young women. Pamela is not too concerned about the security of SMS messaging but is more focused on her need to keep her colleagues up to date on her patients and aware of the messages that have been sent.The messages she sends to patients are a mixture of answering specific questions, referring to useful articles, and encouraging patients to set reminders. These messages are driven by the specific phase of the pregnancy of her patients. Pamela would like to be able to setup standard messages that are based on the phase in the pregnancy or recovery and care of a newborn infant.

Solution:Pamela signs into her Personiform account on her computer and accesses the home page. For a given patient, she can bring up an overview of her patient’s health history. She clicks on a link to drill down into more details drawn from a Chronicle that was earlier created by her patient. The patient shared the Chronicle with Pamela and other members of the patient’s Care Team that are involved with the pregnancy. She can review the patient’s symptoms and details from the last office visit with the patient. The symptoms tracked in the Chronicle are also converted into SNOMED and ICD-10 medical codes. Those codes have been recorded and stored in her practice’s electronic medical record system.

Pamela clicks on a Consult request from another patient that requires her attention. She reviews a list of frequently used responses that are appropriate to the patient, who is in the 34th week of her pregnancy. However, she sees that none of them matches the question her patient asked. Instead of using a template, Pamela writes a short message in response and includes a link to an information page that is relevant to the question. This link is to an article that was actually written by her patient’s own OBGYN Doctor. The article also has additional resources to inform the patient, including a video recorded by the same doctor. Pamela sends the message via Personiform to her patient and encourages the patient set a follow-up reminder.


strategy that lowers costs and unnecessary episodes, while delivering higher quality care.

The Bundled Payments for Care Improvement Initiative

The CMS Bundled Payments Initiative provides joint payments for hospitals, physicians, and other healthcare providers across an episode of a patient’s care. The program gives flexibility to provider teams to design their own care bundles.

However, three of the four payment models commit providers to a 30-day readmission risk. Providers thus have an incentive to lower the cost of post-acute care and prevent avoidable hospital readmissions. CMS is focusing on episodes with high rates of avoidable readmissions when reviewing program applications.

Personiform supports the coordination of this post-acute care period between providers, patients, and family members. Structured messaging and Chronicles enable patients and family members to track their recovery process and alert the provider team of any changes or new symptoms.

The Bundled Payments Initiative remains in its infancy as the first applications are still being accepted. If bundled payments evolve beyond the current trial program and into the mainstream, this should create new incentives for innovation in patient-provider interaction. Online interactions that increase efficiency and save both provider and patient time will become more attractive.

The Patient-Centered Medical Home and Comprehensive Care Initiative

The Patient-Centered Medical Home (PCMH) is a team-based model of care led by a PCP who provides coordinated care throughout a patient’s life to maximize health outcomes. A Medical Home practice is responsible for providing for all of a patient’s health care needs or appropriately arranging care with other qualified professionals. This includes the provision of preventive services, treatment of acute and chronic illness, and assistance with end-of-life issues.

Currently, the PCMH model is being tested in a number of pilots across the country as well as through the CMS Medical Home Demonstration project and Medicaid-Medicare Advanced Primary Care Demonstration Initiative. As of May 2012, 4,220 practices nationwide had achieved PCMH status. The four major primary care organizations support the PCMH. The American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), the American College of Physicians (ACP), and the American Osteopathic Association (AOA) together represent about 333,000 physicians.

Expanding on the PCMH concept, CMS also recently launched the Comprehensive Primary Care initiative. This four-year initiative builds on the momentum of the Medical Home movement. CMS will pay participating primary care practices a $20 per-patient monthly care management fee in seven markets. Forty-five private insurers have agreed to join the initiative alongside CMS. Participating practices will receive this fee in exchange for providing enhanced services to their patients with a focus on care coordination.

Episode-of-care payments are evolving to include more opportunities and incentives to bundle payments across

providers.


The core requirements for being deemed a PCMH are:• Accessandcommunication• Patienttrackingandregistryfunctions• Caremanagement• Self-managementsupport• Advancedelectroniccommunications• Electronic prescribing• Test tracking• Referral tracking• Performance reporting and improvement

The requirements for the Comprehensive Primary Care Initiative:

• Coordinatingcarewithpatients’otherhealthcareproviders• Engagingpatientsandcaregiversinmanagingtheirowncare• Providingindividualized,enhancedcareforpatientsliving

withmultiplechronicdiseasesandhigherneeds• Longer and more flexible hours• Using electronic medical records• Delivering preventive care

These primary care programs necessitate user-friendly and engaging platforms for physician-patient interactions. Personiform’s social health record offers providers, patients, and specialists an avenue through which to communicate and securely share health information.

Lowering The Costs of Care Coordination

Improved care coordination is at the center of these new programs and healthcare reform in general. A 2004 study in Pediatrics evaluated care coordination efforts for a small community-based pediatrics practice. They estimate that annual coordination costs ranged between $22,809 (at the 25th percentile) to $33,048 (at the 75th percentile).12 Any tool that can mitigate a practice cost of this magnitude will prove immensely valuable.

Another useful analysis estimates the per-patient costs of care coordination. It utilizes typical nurse-to-patient ratios in outpatient care coordination programs (between 1:750 and 1:1500) and the Bureau of Labor Statistics for the fully loaded cost of an RN in 2010. This yields $5.57 to $11.13 per patient while acknowledging that additional overhead and administrative costs of 50% would likely increase the cost range to $8.35 to $16.70. These estimates suggest the $20 per-patient fee offered under the Comprehensive Primary Care Initiative is reasonable and perhaps even offers some new margin for enterprising organizations.13

However, that margin can only be captured with more efficient coordination of care. The bulk of care coordination efforts, such as coordinating visits with consultants or information sharing among the medical team and family, require phone calls and

The AAFP, AAP, ACP, and the AOA support the Medical Home concept. Together theyrepresent about 33,000 physicians.

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other inefficient mediums of communication. Personiform can cut down on these inefficient forms of coordination by streamlining communications and capturing critical clinical information.

Avoidable Readmissions and the Global PeriodAvoidable hospital readmissions are another massive avoidable cost to the healthcare system. Nearly one in every five Medicare patients discharged from the hospital is readmitted within 30 days.14 Across all insured patients, the preventable readmission rate is 11%, while the rate for Medicare patients is significantly higher at 13.3%.15 Unsurprisingly, CMS is piloting programs to lower the rate of avoidable hospital readmissions amongst its population.

In 2013 CMS will start penalizing hospitals with above average risk-adjusted readmissions rates for cases of congestive heart failure, heart attack, and pneumonia. The penalty will be 1% of the hospital’s total Medicare payments in 2013 and eventually rises to 3%. It is unclear what other penalties CMS may introduce in coming years, but reducing avoidable hospital readmissions will remain a top priority for Medicare and other payers.

In addition, episode-based payments also create incentives to lower readmissions and provide efficient post-discharge care. Under the physician fee schedule a major surgery has a 90-day post-operative period in which E/M services are not separately reimbursed. A 2008 study found that 70% of 90-day global package procedures would have generated more revenue for the provider had the comprehensive daily office visits been billed individually instead of the operation.16 Providers face the dual challenge of lowering readmissions while limiting unreimbursed care during the global period.

However, targeted interventions to lower readmission rates are very expensive. Evidence suggests that discharge programs using specially trained nurse advocates can reduce 30-day readmissions by 30% to 35%.17 Nurses spend significant time educating and coaching the patient to manage his or her disease after discharge. However, the study also estimates that these interventions to create and sustain reductions in readmissions typically cost about $200 per discharge, depending on labor costs. Unsurprisingly, hospitals have been slow to adopt these best practices.

Successful interventions to avoid readmissions require the elements of effective discharge planning:

1. Coordination between the hospital-based and primary care physician

2. Better communication between the hospital-based physician and the patient

3. Better education and support for patients to manage their own condition

4. Reconciliation of medications at discharge or immediately afterward

Personiform supports more efficient post-discharge care. It offers a way to monitor

In addition to “carrot” incentives, CMS is also using “stick” penalties

to lower readmissions


patient status with fewer office visits and less expensive labor. For example, a recent surgical patient can share a Personiform Chronicle with record of recent symptoms as well as photos. The physician or nurse can then use Personiform to confirm whether or not there is risk of an infection, potentially avoiding an unnecessary office visit or preventing a readmission.

Meaningful Use and Patient EngagementA recent study of Meaningful Use Stage 1 requirements revealed that attesting organizations often deferred the menu criteria related to patient engagement and care coordination. Hospitals struggled with requirements directly related to sending and receiving information to patients. At least 62% of hospitals deferred the criteria for sending educational materials to 10% of patients. Hospitals cited challenges identifying populations of patients and matching them with the appropriate educational materials.

A searchable record of interactions and Chronicles in Personiform can help overcome this and identify the appropriate patient groups. For example, patients using Personiform will have a robust family history recorded as structured data (yet another Stage 2 requirement). Patients complete a comprehensive My Health Profile when joining and setting up their Personiform account. This prerequisite will allow providers to search for those with elevated risk for certain conditions and send relevant educational and screening materials.

While Personiform data and interactions can support the many Stage 2 core requirements (see chart), it is particularly useful for meeting those elements requiring patient engagement.

Personiform data and interactions support the most challenging

and critical patient engagement elements of the Meaningful Use

program

New Requirements for E-Communication Creates Need for a Captive Audience

Stage 2 also requires that 10% of the patients of Eligible Professionals use secure electronic messaging to send at least one message to their provider. Upon first glance, this may appear to be an achievable threshold. However, this represents a


significant challenge in terms of patient engagement. While EMR systems and health portals often enable messaging, it remains difficult to engage patients to be more than intermittent users.

Personiform users will be encouraged to share their own symptoms and self-management experiences with providers on a frequent basis. Electronic messaging will be integrated into patient use of Personiform.

More Robust Transitions of Care

The aforementioned study found that 93% of attesting hospitals in 2011 skipped the requirement to electronically transmit care summary records during transitions of care. Like the majority of menu requirements from Stage 1, this will become a core requirement under Stage 2. At least 65% of transitions of care must now have a care summary document and 10% of those must be sent electronically.

Personiform will capture the majority of the data fields required in the care summary document. This includes the past diagnoses, updated problem list, medication and drug allergy list, list of additional care team members, and other basic demographic data. This data can be imported into an EMR or another platform to efficiently and accurately generate continuity of care documentation. In addition, Personiform Chronicles and their data can be added to a care summary document.

Future Meaningful Use Requirements

In 2012 The Office of the National Coordinator for Health IT (ONC) convened several meetings on the future of patient-generated health data (PGHD) and its role in the Meaningful Use program. ONC also recently requested comments on how PGHD should be integrated into Stage 3 of the program. While many physicians currently integrate PGHD into paper charts or by hand using email and spreadsheets, very few have created standardized pathways for patients to enter data that can eventually be integrated into the EMR.

The proliferation of remote monitoring devices, mobile applications, and other networks are enabling massive growth of PGHD. Increasingly, PGHD will be created, recorded, and shared electronically. By providing a platform for capturing data and importing it into an EMR, Personiform’s social health record will put providers ahead of the curve.

In order to leverage it for clinical decision-making, PGHD can and should be captured in a structured way. All of the key elements of symptomatic data (timing, intensity, duration, triggers) can be recorded as structured data, using rating scales for the more subjective elements such as intensity. Personiform’s intuitive user interface easily enables patients to create structured symptomatic data in this way.

Further, Stage 3 will emphasize access to self-management tools for patients. Engaged users of Personiform will not only have access to new self-management tools and information, but they’ll also be more likely to use them. Personiform will also allow providers to identify populations that are not particularly active in their self-management, based on their Personiform usage data. This will enable physicians to identify subpopulations to target with extra messages, reminders, and tailored educational content.


ConclusionChanges are underway in the US healthcare system. CMS and payers have begun to scratch the surface of true reform by realigning incentives toward outcomes and lower costs. However, these changes also require a fundamental shift in the way actors within healthcare system share information and interact with patients. That shift has yet to occur using existing health IT tools.

Care must not be limited to short, fragmented bursts of time spent in the clinical delivery system. Instead, patients must have a role in improving their own health each and every day. Whether operating as part of a Medical Home, an ACO, a hospital experimenting with Bundled Payments, or simply responding to other new pay-for-performance incentives, physicians must engage with patients to improve outcomes and prevent unnecessary care.

Personiform’s social health record platform provides new points of contact outside of the exam room. Engaged patients will use the platform to provide a more structured health narrative for physicians, saving them time and effort. As risk and responsibility for patient outcomes shift toward providers, Personiform provides an avenue through which to educate patients and encourage treatment adherence.

In the near-term, Personiform’s open and intelligent exchange of information will enable providers to improve patient engagement and satisfaction, take advantage of new payment incentives, document care more efficiently, and comply with Meaningful Use regulations. Patients will have newfound access to information along with the ability to track their own health and wellness in coordination with loved ones and friends.

However, Personiform’s ultimate goal is broader than that. When we finally have a system based on wellness outcomes and not a system based on volume of medical intervention, Personiform will be part of a positive feedback loop of information, engagement, and adherence that puts the patient at the center of healthcare.


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