Personiform whitepaper

SPECIAL REPORT

Table of Contents
About Personiform...............................................2

Personiform:
Introduction.........................................................4

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

The Case for a
Capturing New Revenue Through
More Efficient Office Visits..................................6

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

New Revenue for Electronic

Record
Communications...............................................10

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

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

Meaningful Use and
Necessary changes to the healthcare system
Patient Engagement..........................................16
will require new avenues of communication,
Conclusion........................................................18
novels ways to engage patients, and the
References.......................................................19
capture of patient-generated health data

“
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.

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

Introduction
Changes to the US healthcare In this paper we discuss the fundamental need for a new health information platform
system will require new to meet the challenges faced by the US healthcare system in the 21st century. We
approaches to communication, review evidence of the need for effective patient-provider communication systems,
patient engagement, and patient demand for online access to dynamic health information, and the value of real-
collection of patient-generated time provider feedback to patient engagement. We also acknowledge the limitations
health data 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,
“ 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,

and integrated care.
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


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
73% of patients caregivers.
said they wish to use
a secure online tool The healthcare system fails to meet patient demand for online tools
for communicating
with their physician. 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
“
Half said they would
consider switching
physicians to use such
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
a tool.
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

“ Only 6.7% of
office-based physicians
“ • 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
regularly email patients.
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
A social health record offers As CMS and private insurers introduce pay-for-performance initiatives, providers will
unique advantages to any face new evaluations of their performance based on patient satisfaction ratings. The
physician organization 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


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 Visits
A social health record can Both physicians and patients alike lament insufficient time together in the exam
increase provider revenue through room. Patients are unable to fully express themselves and their personal health story.
more efficient office visits and Physicians feel pressure from the volume-driven payment system, frustrating their
better documentation 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


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


Use of Personiform could
significantly improve a physician’s
bottom line

Capturing Lost Revenue for Care Plan
Oversight
Physicians and their staff spend Care plan oversight (CPO) reimbursement is another type of reimbursement
time coordinating with home health physicians often miss due to documentation challenges. It is available to physicians
and hospice facilities but miss out of Medicare patients receiving care from approved Home Health or Hospice providers.
on opportunities for reimbursement 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 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
Communications
Personiform enables physicians As discussed, despite patient demand, physicians are generally reluctant to use
to capture new reimbursement for email to communicate directly with their patients. There are data security concerns
electronic office visits 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
AAFP estimates that
only about 3% of its
members are currently
“ 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
performing E-Visits. 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


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.
At the Mayo Clinic,
if E-Consultations were Asynchronous communications between physicians, such as that supported by
ordered a modest two to Personiform’s data capture and messaging, could alleviate these problems. Online
three times monthly by interactions between specialists and referring physicians are increasingly known as
each provider, the system E-Consultations. E-Consultations can replace or supplement mechanisms clinicians
could avoid 1,800 currently use to communicate about patients. The Commonwealth Fund estimates
specialty consultations that reductions in specialist visits through the use of E-Consultation range from 8.9%

per year, reducing
direct costs by
“ to 51%, with the majority of estimated reductions around 30%.10

At the Mayo Clinic, researchers have extrapolated that if E-Consultations were

$450,000 annually. 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.


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
PERSONIFORM USER STORY: PAMELA intuitive platform that captures time
spent interacting with patients, other
members of the care team, and the
patient’s health data. Personiform
Challenge: allows providers to generate reports
Pamela faces the constant challenge of keeping in touch with patients. Currently she uses text detailing time spent interacting
messages to stay in touch with her patients, who are generally young women. Pamela is not too with a specific patient, evaluating
concerned about the security of SMS messaging but is more focused on her need to keep her recorded symptoms in Chronicles, and
colleagues up to date on her patients and aware of the messages that have been sent. generating a diagnosis.
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
Moving away from
standard messages that are based on the phase in the pregnancy or recovery and care of a
newborn infant.
fee-for-service
While the Personiform platform offers
Solution: immediate value to providers and
Pamela signs into her Personiform account on her computer and accesses the home page. For patients in our current health system,
a given patient, she can bring up an overview of her patient’s health history. She clicks on a link its strength will grow under future
to drill down into more details drawn from a Chronicle that was earlier created by her patient. payment scenarios. Exponentially
The patient shared the Chronicle with Pamela and other members of the patient’s Care Team rising health costs and the associated
that are involved with the pregnancy. She can review the patient’s symptoms and details from pressure on budgets have already
the last office visit with the patient. The symptoms tracked in the Chronicle are also converted spurred experimentation with new
into SNOMED and ICD-10 medical codes. Those codes have been recorded and stored in her models. Integrated delivery systems
practice’s electronic medical record system. are looking to take advantage of
opportunities to capture shared savings
Pamela clicks on a Consult request from another patient that requires her attention. She reviews as Accountable Care Organizations.
a list of frequently used responses that are appropriate to the patient, who is in the 34th week of Other networks of physicians and
her pregnancy. However, she sees that none of them matches the question her patient asked. facilities are considering forming new
Instead of using a template, Pamela writes a short message in response and includes a link to ACOs. Practices are considering
an information page that is relevant to the question. This link is to an article that was actually becoming patient-centered medical
written by her patient’s own OBGYN Doctor. The article also has additional resources to inform homes and may form the backbone of
the patient, including a video recorded by the same doctor. Pamela sends the message via future ACOs.
Personiform to her patient and encourages the patient set a follow-up reminder.
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


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

The Bundled Payments for Care Improvement Initiative
Episode-of-care payments The CMS Bundled Payments Initiative provides joint payments for hospitals,
are evolving to include more physicians, and other healthcare providers across an episode of a patient’s care. The
opportunities and incentives program gives flexibility to provider teams to design their own care bundles.
to bundle payments across
providers. 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.


The core requirements for being deemed a PCMH are:

“
• Access and communication
The AAFP, AAP, ACP, • Patient tracking and registry functions
and the AOA support the
Medical Home concept.
Together theyrepresent
“ • Care management
• Self-management support
• Advanced electronic communications
about 33,000
• Electronic prescribing
physicians. • Test tracking
• Referral tracking
• Performance reporting and improvement

The requirements for the Comprehensive Primary Care Initiative:
• Coordinating care with patients’ other health care providers
• Engaging patients and caregivers in managing their own care
• Providing individualized, enhanced care for patients living
with multiple chronic diseases and higher needs
• 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


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
Period
In addition to “carrot” incentives, Avoidable hospital readmissions are another massive avoidable cost to the healthcare
CMS is also using “stick” penalties system. Nearly one in every five Medicare patients discharged from the hospital is
to lower readmissions 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


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 Engagement
Personiform data and interactions A recent study of Meaningful Use Stage 1 requirements revealed that attesting
support the most challenging organizations often deferred the menu criteria related to patient engagement
and critical patient engagement and care coordination. Hospitals struggled with requirements directly related to
elements of the Meaningful Use sending and receiving information to patients. At least 62% of hospitals deferred
program 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.

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.


Conclusion
Changes 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.


References
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to Physicians. Retrieved at: http://about.intuit.com/about_intuit/press_room/press_release/articles/2011/
IntuitHealthSurveyAmericansWorriedAboutCostsWantGreaterAccesstoPhysicians.html

2. Center for Studying Health System Change. (2010, October). Physicians Slow to Routine Email with Patients. (Issue Brief No. 134). Retrieved
at: http://www.hschange.com/CONTENt/1156/1156.pdf

3. Bard M, Nugent M. Navigant Consulting, Inc. Accountable Care Organizations and Payment Reform: Setting a Course for Success. (2011)
Retrieved at: http://www.navigant.com/~/media/site/downloads/healthcare/acctcarewhitepaperbrochure_us_hc.ashx

4. Flocke, Susan A and Andrew Gottschalk. Time Spent in Face-to-Face Patient Care and Work Outside the Examination Room. Annals of
Family Medicine. 2005 3(6):488-493. Retrieved from: http://www.annfammed.org/content/3/6/488.full

5. MedicaLogic. (2000) Establishing a Business Case: Ambulatory EMR. Retrieved from: http://www.google.com/url?sa=t&rct=j&q=&esrc=s&sou
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6. King MS, Sharp L, Lipsky M. Accuracy of CPT evaluation and management coding by family physicians. J Am Board Fam Pract.
2001:14(3):184–192.

7. Hill, Emily. How to Get All the 99214s You Deserve. (2003). Family Practice Management. 10(9), 31-36. Retrieved from: http://www.aafp.org/
fpm/2003/1000/p31.html#fpm20031000p31-b1

8. Matthews, Anne Wildes. (2009, July 9). The Doctor Will Text You Now. The Wall Street Journal Retrieved from: http://online.wsj.com/article/SB
10001424052970203872404574257900513900382.html?mod=googlenews_wsj

9. Horner K, Tufano J, Wagner E. Electronic Consultations Between Primary and Specialty Care Clinicians:Early Insights. Commonwealth
Fund Issue Brief (October 2011). Retrieved at: http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2011/Oct/1554_
Horner_econsultations_primary_specialty_care_clinicians_ib.pdf

10. Ibid

11. Angstman KB Adamson SC, Furst JW et al., “Provider Satisfaction with Virtual Specialist Consultations in a Family Medicine Department,” The
Health Care Manager, Jan.–March 2009 28(1):14–18. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/19225331

12. Antonelli RC and DM. (2004). Providing a Medical Home: The Cost of Care Coordination Services in a Community-Based, General Pediatric
Practice. Pediatrics.113(5 Suppl):1522-8. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/15121921

13. Sidorov, Jaan. (2011, October 25). The Per Patient Monthly Cost of Care Coordination for Accountable Care Organizations (ACOs). Retrieved
from: http://diseasemanagementcareblog.blogspot.com/2011/10/per-patient-monthly-cost-of-care.html

14. Jencks SF, Williams MV, Coleman EA, Rehospitalizations among patients in the Medicare fee-for-service program, New Engl J Med,
2009;360(14):1418–1428. Retrieved at: http://www.nejm.org/doi/full/10.1056/NEJMsa0803563

15. Goldfield NI, McCullough EC, Hughes JS, et al., Identifying potentially preventable readmissions, Health Care Finance Review,
2008;30(1):75-91. Retrieved from: http://www.cmms.hhs.gov/Research-Statistics-Data-and-Systems/Research/HealthCareFinancingReview/
downloads/08Fallpg75.pdf

16. Reed, R Lawrence II; Luchette, Fred A.; Esposito, Thomas J.; Pyrz, Karen; Gamelli, Richard L. Medicare’s Global Terrorism: Where is the Pay
for Performance? Journal of Trauma-Injury Infection & Critical Care. 64(2):374-384, February 2008. Retrieved from: http://journals.lww.com/
jtrauma/toc/2008/02000#-1841273488

17. Chollet D, Barrett A, Lake T. Reducing hospital readmissions in New York State: a simulation analysis of alternative payment incentives.
Princeton, NJ: Mathematica Policy Research, September 2011. Retrieved from: http://nyshealthfoundation.org/uploads/resources/reducing-
hospital-readmissions-payment-incentives-september-2011.pdf


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