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The American Journal of Managed Care November 2016
Referrals and the PCMH: How Well Do We Know Our Neighborhood?
Andrew Schreiner, MD; Patrick Mauldin, PhD, Jingwen Zhang, MS; Justin Marsden, BS; and William Moran, MD, MS
Does Medicare Advantage Enrollment Affect Home Healthcare Use?
Daniel A. Waxman, MD, PhD; Lillian Min, MD, MSHS; Claude M. Setodji, PhD; Mark Hanson, PhD; Neil S. Wenger, MD, MPH; and David A. Ganz, MD, PhD
A New Chapter in Health Reform
Michael E. Chernew, PhD, and A. Mark Fendrick, MD
Prescribers' Perceptions of Medication Discontinuation: Survey Instrument Development and Validation
Amy Linsky, MD, MSc; Steven R. Simon, MD, MPH; Kelly Stolzmann, MS; Barbara G. Bokhour, PhD; and Mark Meterko, PhD
Currently Reading
Enhancing Patient and Family Engagement Through Meaningful Use Stage 3: Opportunities and Barriers to Implementation
Jaclyn Rappaport, MPP, MBA; Sara Galantowicz, MPH; Andrea Hassol, MSPH; Anisha Illa, BS; Sid Thornton, PhD; Shan He, PhD; Jean Adams, RN, ACIO; and Charlie Sawyer, MD, FACP
Reconsidering the Economic Value of Multiple Sclerosis Therapies
Tiffany Shih, PhD; Craig Wakeford, MA; Dennis Meletiche, PharmD; Jesse Sussell, PhD; Adrienne Chung, PhD; Yanmei Liu, MS; Jin Joo Shim, MS; and Darius Lakdawalla, PhD
Health Systems Tackling Social Determinants of Health: Promises, Pitfalls, and Opportunities of Current Policies
Krisda H. Chaiyachati, MD, MPH; David T. Grande, MD, MPA; and Jaya Aysola, MD, DTMH, MPH
Maternal Mental Health and Infant Mortality for Healthy-Weight Infants
Susan E. White, PhD, RHIA, CHDA, and Robert W. Gladden, MA, BS
The Role of Internal Medicine Subspecialists in Patient Care Management
Jonathan L. Vandergrift, MS; Bradley M. Gray, PhD; James D. Reschovsky, PhD; Eric S. Holmboe, MD; and Rebecca S. Lipner, PhD
Medical Home Transformation and Breast Cancer Screening
Amy W. Baughman, MD, MPH; Phyllis Brawarsky, MPH; Tracy Onega, PhD, MS; Tor D. Tosteson, ScD; Qianfei Wang, MS; Anna N.A. Tosteson, ScD; and Jennifer S. Haas, MD, MSc

Enhancing Patient and Family Engagement Through Meaningful Use Stage 3: Opportunities and Barriers to Implementation

Jaclyn Rappaport, MPP, MBA; Sara Galantowicz, MPH; Andrea Hassol, MSPH; Anisha Illa, BS; Sid Thornton, PhD; Shan He, PhD; Jean Adams, RN, ACIO; and Charlie Sawyer, MD, FACP
Two leading US health systems attempted to implement 4 draft objectives for Meaningful Use Stage 3 within their health IT infrastructure to provide feedback on needed enhancements to the policy.

The proposed Patient and Family Engagement objectives for Meaningful Use Stage 3 (MU3) seek to provide patients with increased access to, and control over, the content and dissemination of their electronic health record (EHR) information.

Study Design: Implementation study conducted from 2013-2014.

Methods: In this study, 2 leading US health systems attempted to implement 4 draft MU3 objectives within their current EHR system. Senior staff provided qualitative feedback on their implementation experience; researchers used content analysis to identify major themes and implementation challenges.

Results: We found that the draft objectives would support the MU3 Patient and Family Engagement goals, but that all objectives would benefit from the following: changes in policy language to promote flexibility in implementation; training and workflow adaptions, as well as patient education, by healthcare organizations; and new EHR functionalities.

Conclusions: In the short term, a semi-automated approach is likely necessary to support MU3 objective implementation. These challenges are not unique to MU3 and underscore gaps in the current health information infrastructure.

Am J Manag Care. 2016;22(11):733-738
Take-Away Points

Meeting the technical and operational requirements of Meaningful Use Stage 3 (MU3) patient engagement objectives will be difficult to do in a fully automated fashion.
  • Electronic health platforms still need to evolve to provide a basic level of functionality for providers and patients to access and transmit health information online to meet the standards described in the MU3 proposed objectives.
  • The pilot implementation experience of 2 advanced healthcare systems suggests that a semi-automated approach to information exchange—where some information is reviewed and sent out by a human rather than automatically by a system—may be necessary until functionality evolves.
The adoption and use of health information technology (IT) can improve the quality, coordination, and efficiency of healthcare delivery.1-4 Health IT can also promote patient involvement by providing patients with electronic access to their own healthcare information and providers5-10—something that research suggests that patients want, along with some control over sharing this information with others.6,8,11-14 Facilitating this access can allow patients and family members to coordinate across the care team, communicate electronically with providers, and engage in self-management of their own health conditions.8 Yet, most electronic health information (EHI) systems have not yet achieved the higher-level patient-centered functionalities7 that could truly support informed patient engagement.11,15

Promoting patient and family engagement is one of the aims of the Meaningful Use (MU) initiative within the Medicare and Medicaid EHR Incentive Program under the Health Information Technology for Economic and Clinical Health (HITECH) Act.16 Patient engagement EHR functionality was a new requirement in MU Stage 2 (MU2).10 The draft objectives first proposed for MU Stage 3 (MU3) in 2013 increased expectations about patients’ ability to access and control the content and dissemination of their EHR information.17 However, there are technical and resource limitations to realizing the potential of EHR technology for engaging patients,6,18,19 including a lack of patient awareness and tools for accessing information,20-22 and a still-evolving technology and information infrastructure.

The early publication of draft MU3 Patient and Family Engagement objectives by the Health Information Technology Policy Committee (HITPC) provided researchers with an opportunity to evaluate implementation barriers and recommend improvements to the objectives prior to the publication of draft or final regulations.3,20 The challenges of MU Stage 1 (MU1) and MU2,13 including limited availability and suitability of certified products,23 underscored the importance of such input to policymaking. When the draft MU3 objectives were published, many healthcare providers were still working on MU1 and others were awaiting new releases from their EHR vendors to begin work on MU2. The Agency for Healthcare Research and Quality (AHRQ) sought input from the field concerning objective feasibility, required EHR enhancements, and how the proposed objectives could help improve care delivery. In this evaluation—which was funded by AHRQ—health systems attempted to implement the draft Patient and Family Engagement MU3 objectives. Researchers followed their progress to evaluate the feasibility of implementation within the health systems’ existing EHRs.


Two leading health systems, Intermountain Healthcare and Geisinger Health System, attempted to implement up to 4 of the MU3 draft objectives for Eligible Hospitals in the Patient and Family Engagement domain (listed in the Table). The objective language presented in this paper reflects the most up-to-date versions of the objectives that were implemented in the study sites, representing an amalgam of language used in 3 draft MU3 language iterations. Geisinger and Intermountain were selected due to their use of enterprise EHR systems—used across inpatient and outpatient settings—as well as their history of using health IT to promote patient and family engagement, and their experience customizing commercial EHR systems.24-28 Each system also had administrators and programmers on staff with the ability to design custom programming to write the objectives’ functionality into their EHRs with little to no support from EHR vendors; some functionality had been built prior to the evaluation as part of previous system-specific enhancements.

From September 2013 to May 2014, each organization began, continued, or accelerated their implementation efforts for all or a subset of the 4 objectives in their organization’s EHR. Two senior health IT officials from each health system provided qualitative feedback on a biweekly basis during semi-structured 90-minute telephone interviews that took place over the course of 5 months. The interviews focused on their implementation experience, including the feasibility of programming the objectives given their EHR’s capacity, limitations in exchanging and collecting information, and any workarounds explored. An interviewer coded each of the interview transcripts (with 2 researchers coding initial interviews to ensure consistency) and synthesized findings into a thematic framework. The framework, which lists major themes and implementation challenges, was reviewed by our implementation sites to ensure they represented the correct themes discussed. All 4 senior health IT officials reviewed the cumulative findings summarized in a final report released by AHRQ in May 2014.29

Because Intermountain Healthcare and Geisinger Health System have comparatively advanced health IT infrastructures that enabled them to implement certain proposed MU3 objectives, researchers also solicited input from a panel of senior health IT professionals from hospitals and healthcare systems working on MU1 and MU2 that relied on commercial EHR products; this panel met 1 time by teleconference. Additionally, we conducted a focused literature review on patient engagement and EHI-sharing to evaluate the face validity of our findings. This review comprised a key word search and synthesis of recent research findings and analyses.

Subsequent to our evaluation, in March 2015, the “Notice of Proposed Rule-Making” (NPRM) for the MU3 objectives was published and included 2 objectives in the Patient and Family Engagement domain.30 Therefore, we reviewed the NPRM’s patient engagement objectives and noted where the new language affected the applicability of our original findings.


Below, we detail the essential functionalities we believe will be necessary for any health system’s IT infrastructure to support the MU3 objectives based on the findings reported by Intermountain and Geisinger. Then, based on the most salient findings from the implementation experience across both organizations, we briefly outline how each of the draft MU3 objectives evaluated in our study could be enhanced to allow patients and their families to more meaningfully use their EHI and how policy makers and healthcare organizations can best support the implementation of MU3. Despite the restructuring in the March 2015 NPRM, our underlying findings still apply, particularly regarding the need to supplement automated solutions with manual processes and oversight of data exchange from designated data entry staff (a “semi-automated” solution).

Essential Functionalities

The MU3 patient engagement aims depend on a few basic functionalities, namely the ability to accurately identify patients and their clinicians, distinguish data entered by providers and patients, attest to treatment relationships, and confirm authorization for sharing EHI. The implementation pilot underscored gaps in these functionalities that have limited the first 2 MU stages and that will continue to challenge MU3.

Identifying the intended patient and clinician. Verifying a patient’s identity is critical to ensure that information entered into or extracted from the EHR is associated with the correct person and to share patient-generated data securely (eg, logging into remote access points). Positive identification supports modifying EHR content and providing educational materials based on patient preferences and healthcare conditions. Determining to whom patient-directed information should be sent and who will be responsible for acknowledging, reviewing, and responding to this information requires accurate provider identification. The lack of a national patient identifier makes it difficult to identify patients with certainty for secure access and information sharing.19 The absence of a national provider directory with accurate, secure provider e-mail addresses makes it difficult to electronically locate a recipient and promote care coordination through data sharing. Despite robust health information exchanges (HIEs) in some communities, all healthcare organizations eventually encounter external partners with whom information cannot be shared because providers’ secure e-mail addresses are incomplete or incorrect. They also run the risk of creating duplicate patient records or inadvertently merging records from distinct patients because they lack a communitywide master patient index. Healthcare organizations are forced to create customized, sometimes labor-intensive, solutions to these identification challenges.

Both Intermountain and Geisinger maintain master patient indexes and use matching algorithms to verify patient identity; however, these are not always sufficient to identify duplicates and reconcile identity information. These healthcare organizations rely on manual processes to find, update, and reconcile provider Internet addresses, and must manage substantial error logs. The “Direct” secure e-mail or another sponsored system could serve as a national provider directory, but will require maintenance as providers relocate and change affiliations and e-mail addresses. Otherwise, every organization will need to maintain an internal directory and ensure correct addresses for communicating with clinicians outside its network.

Defining patient–clinician relationships and authorizing information sharing. Sharing information requires declaring a treatment relationship between a patient and an individual clinician or group of clinicians (and ending the relationship when a patient changes providers or moves). Patients must authorize sharing their health information, when and with whom; these authorizations must be managed for accuracy. For patients to control communication with their providers, they need flexibility in defining the patient–provider relationship for a given encounter or care episode. EHRs or other data-sharing platforms should facilitate patient selection of providers as EHI recipients and update these relationships over time. Currently, there are no standard methods for recording and retrieving patient authorization to share EHI, querying this information, or managing authorization changes. Geisinger and Intermountain were managing these processes manually.

Varying state regulations complicate sharing of records. Recording patient authorizations, often with signatures, is a manual process; maintaining a current list for each patient is a substantial challenge. Verifying authorization for sharing can be semi-automated, but although some EHRs and HIEs have this functionality, others do not. Currently, in most healthcare organizations, patients are asked to authorize information sharing (or not) for any and all providers—they cannot specify which providers should be able to view their information or which specific types of information each may access.

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