Problem Addressed

• E-mail communication with providers is rare, despite consumer interest: According to a recent study, only 24 percent of physicians used e-mail to communicate with patients in 2004 to 2005.¹ However, a Harris Interactive poll conducted in 2002 found that 90 percent of U.S. consumers with Internet access would like to be able to communicate with their providers via e-mail.²
• Access to online medical records is even rarer: One survey found that up to 96 percent of the population does not have online access to their medical records.³

Description of the Innovative Activity

• Enrollee use: The system is available to all Group Health Cooperative enrollees seeing providers at Group Health–owned facilities. Patients access the shared health record through MyGroupHealth, Group Health Cooperative's Web site (http://www.ghc.org). Two-part authentication (via a password and a separate one-time verification code) is required to access the health record and other services on the portal. The shared health record is heavily promoted by the health plan and providers, with information about it placed prominently on the Group Health Cooperative Web site and in examination rooms and member publications.
• Secure messaging: Secure e-mails can be sent between patients and physicians and between patients and Group Health Cooperative's consulting nurse service. All e-mails are included in the patient’s medical record for patient and provider review.
• Online medical record: Enrollees can view nearly all aspects of their medical record, including:
  • After-visit summary: The after-visit summary provides a user-friendly summary of the visit and summarizes physician recommendations.
  • Immunization history: The immunization history allows enrollees to check which immunizations they have received and when; information about various vaccines is also provided.
  • Current health conditions: Enrollees can access a "problem list," a brief summary of the patient's chronic conditions. Conditions are also linked to online educational resources.
• Laboratory and other test results: Enrollees can access laboratory, radiology, and pathology test results through the online system. Results are sent electronically to the patient and provider. Except for a few sensitive tests, patients are notified at the same time the physician is notified when results are normal; when results are abnormal, patients are notified within 1 business day after physicians are notified, giving physicians the opportunity to followup with patients first without disrupting their normal workflow.
• Medication management: Patients can access a list of all medications filled at a Group Health Cooperative pharmacy in the last 12 months; patients can also request a medication refill online. Medications can either be picked up at a Group Health Cooperative pharmacy or can be shipped to the patient's home at no charge.
• Benefit review: All members can review their coverage agreement, summary of benefits, and explanation of benefit forms.
• Appointment request: Patients may access a list of currently scheduled appointments, cancel an appointment, or schedule a new appointment online with any Group Health Cooperative provider seen in the past 3 years; patients can select an appointment date and time and then receive an e-mail confirming the appointment.
• Health resources: The Health and Wellness Resources section offers indepth articles, interactive tools, videos, information about classes, and other resources to help members and patients stay healthy and manage their health conditions. The section includes content on major diseases and conditions, as well as adult health, teen and child health, nutrition and fitness, and health care decisionmaking. It also includes the Healthwise^® Knowledgebase health encyclopedia, which covers more than 5,000 topics and is updated quarterly.
• Electronic health risk assessment: All Group Health Cooperative members have access to an online electronic health risk assessment; enrollees are reminded by their employers and in after-visit summaries to complete the electronic health risk assessment at least once a year. The electronic health risk assessment is also highlighted on the Group Health Cooperative Web site and in new member materials, newsletters, posters, and pamphlets. Key elements of the electronic health risk assessment include the following:
  • Patient input: Patients answer questions about their medical history, family medical history, and lifestyle habits (including physical activity, drinking behavior, tobacco use, and sexual practices).
  • Patient reports: Patients receive personalized reports with recommendations for health improvements based on Group Health Cooperative evidence-based guidelines that are developed by the Department of Clinical Improvement and Prevention. Recommendations relate to preventive screenings, chronic disease management, behavior change, and general wellness.
  • EMR input: Electronic health risk assessment data are integrated into the EMR in both summary form and with discrete data elements in the record; health concerns are flagged so that the clinician can follow up with the patient and integrate care for these conditions into the general care plan for the patient. For patients who are not using a Group Health Cooperative facility for primary care, care management staff at Group Health receive an alert to contact the patient’s physician for followup care.
• Decisionmaking support: To reduce unwarranted variation in use of elective procedures, Group Health has made high-quality decision aids from HealthDialog available to enrollees for 12 preference-sensitive health conditions related to elective surgical procedures.
• Mobile phone applications: Information provided in February 2012 indicates that in July 2011, Group Health launched its first suite of mobile services for the iPhone. The "Group Health App" offers users the ability to view their medical record, securely e-mail their care team, call or e-mail the 24-hour Consulting Nurse Service, check symptoms and receive recommendations for care based on those symptoms, find the nearest Group Health Medical Center, and check lab and pharmacy wait times at the Medical Centers. The Android version launched in September 2011; in December, the ability to order medications and view a child's medical record (ages 0 to 12) was added.

References/Related Articles

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Results

• Heavy penetration of the shared health record, leading to fewer visits and phone calls: Approximately 54.8 percent of eligible adults currently use the shared health record. In addition, approximately 30 percent of laboratory studies ordered by medical group members are reviewed by patients online; in certain medical centers, this number is as high as 50 percent. Approximately 23 percent of encounters now occur via secure messaging. A survey of users found that the secure e-mail function replaces more time-consuming access methods, including office visits (27 percent of the time) and telephone contact (66 percent of the time).
• Identification and addressing of health needs through the electronic health risk assessment: The electronic health risk assessment has provided customized education and information and has identified health issues for thousands of Group Health Cooperative enrollees, many of who intend to do something to address these issues:
  • Behavioral change needs: Of 12,200 enrollees who took the electronic health risk assessment in 2007, 66 percent were identified as overweight or obese, 25 percent were found to be physically inactive, 6 percent engaged in risky drinking behavior, 11 percent used tobacco, and 13 percent engaged in risky sexual practices.
  • Preventive care needs: In the analysis mentioned above, 1,478 members were identified as needing a pneumonia vaccine and 2,577 as being overdue for colorectal cancer screening; in total, 34,970 tailored recommendations for preventive care were made, an average of 2.8 per person.
  • Chronic disease management needs: The electronic health risk assessment measures the degree to which six common illnesses—diabetes, depression, chronic obstructive pulmonary disease, asthma, high blood pressure, and heart failure—are well managed. The proportion of members with these conditions that the electronic health risk assessment assessed as being in good control ranged from 47 percent (diabetes) to 78 percent (asthma). (Data allowing comparison with nonusers are unavailable.) Enrollees determined to be in poor control of their chronic conditions were provided with individual recommendations for practical steps to improve control and long-term outcomes; this information was also provided to their care teams.
  • Greater understanding of health conditions: A survey found that 91 percent of those using MyGroupHealth found that it improved their understanding of a health condition, with 27.8 percent finding the information extremely valuable, 21.3 percent very valuable, and 22 percent fairly valuable.
  • High intent to address identified issues: A survey of electronic health risk assessment users found that more than 66 percent found it to be extremely helpful or very helpful in helping them understand their health status and risk for future illness, almost 75 percent said they would take action to improve their health because of the assessment, and 81 percent said they planned to retake it to track their progress.
• Higher enrollee satisfaction and retention: An analysis of satisfaction surveys found that, compared with nonusers, shared health records and secure-messaging users felt they received more attention from their practitioner (60 vs. 50 percent); had more opportunities to ask questions (60 vs. 51 percent); received more thorough care (56 vs. 49 percent); believed that their practitioner was more prepared (46 vs. 40 percent), and received a better explanation of care from the practitioner (53 vs. 44 percent). The enrollee retention rate is 6.5 percent higher for shared health record users than for nonusers.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Transition to application-based Web site: At the end of 1999, Group Health Cooperative leaders decided to transition its Web site from an information- and marketing-oriented site to a transactions-oriented, application-rich site.
• Development and rollout of applications: Group Health Cooperative began by redesigning the site, adding a personal health record with patient-entered data, and building a secure messaging system that allowed patients to communicate with physicians and nurses online, along with an online appointment request function. These functions were rolled out, beginning in late 2000, over a 12-month period to give physicians and staff time to acclimate to the system. The entire suite of services was named "MyGroupHealth."
• Previews and pilot demonstration to obtain physician support: Physician support was obtained through involvement of physician users in the application development, preview meetings, and a pilot demonstration test with a small group of physician practices. To alleviate concerns as the rollout was expanded, Group Health Cooperative shared feedback and best practices from early physician and patient adopters of the system.
• EMR enhancements: In 2001, informatics staff began working with a software vendor to replace its existing EMR product. The new system, launched in 2003, included the shared health record and replaced the homegrown secure messaging system with a new secure messaging function.
• Shared health record usability testing: Group Health Cooperative conducted usability testing with members to ensure the system's user-friendliness and to solicit suggestions for how to improve the system.
• Provider EMR training: Group Health Cooperative provided significant Web-based and classroom training to physician practices before going live with the EMR and placed trained support staff within each medical center after going live.
• Electronic health risk assessment launch: The electronic health risk assessment was launched in 2006. Group Health Cooperative physicians were heavily involved in designing the categories tracked by the electronic health risk assessment and the recommendations the system generates for each health risk.
• Mobile application launch:  Information provided in February 2012 indicates that the Group Health Mobile application launched in July 2011.

Resources Used and Skills Needed

• Staffing: The program requires significant staff from Group Health Cooperative's internal informatics department. The MyGroupHealth team began with 10 people in 2000 and, according to information provided in February 2012, now includes approximately 15 to 20 people supporting the electronic health risk assessment and shared health record components. Physician time is also required to verify the accuracy of the site and the electronic health risk assessment and to make sure that the algorithm embedded in the assessment that generates recommendations based on health risks is working correctly.
• Costs: No cost estimates are available.

Funding Sources

Getting Started with This Innovation

• Ensure senior leadership buy-in: Senior leader awareness and commitment is critical to the success of information-based strategies that focus on enhancing quality, access, and patient-centeredness.
• Make patient-centeredness an organization principle: Make decisions based on the best solution for the patient or member. If possible, include a patient on the team at key decision points.
• Enlist physician participation: Physicians should develop and review system content, participate in designing application workflow, and test functionality.
• Consider financial relationship between physicians and sponsoring organization: It is easier to implement a shared messaging system when physicians are employed in practices owned and operated by the health system, because reimbursement issues that arise under fee-for-service payment (e.g., concerns about payment for time spent on secure e-mail) do not exist.
• Pay attention to provider workflow: Providers will resist adoption if the system prevents them from working efficiently. New systems often require providers to change how they work. For example, providers may need to educate patients about the purpose of a laboratory test in advance so patients are prepared to view the results directly via the online portal.
• Leverage electronic systems by developing linkages: For example, many organizations have created health risk appraisals, but few have integrated the resulting data into the EMR, which makes the tool more valuable for both providers and patients.
• Make system user friendly: A site with many fragmented applications will not be viewed favorably by users. The site should be organized, coordinated, and easy to use (as evidenced by usability testing, not staff opinion).

Sustaining This Innovation

• Monitor health content: Review health content within designated time periods to ensure the accuracy of clinical information.
• Solicit and incorporate user feedback: Periodically survey physicians and enrollees/patients to learn about their perceptions and solicit suggestions for program improvement and expansion. As resources allow, incorporate these suggestions into online offerings. At Group Health, for example, the chief of radiology recently requested that images be made available to members online.