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Electronic Capabilities for Patient Engagement among U.S. Non-Federal Acute Care Hospitals: 2012-2015

ONC Data Brief 38 | September, 2016

JaWanna Henry, MPH; Yuriy Pylypchuk, PhD; Vaishali Patel, PhD MPH

Providing patients with the ability to engage with their health care provider electronically can lead to better communication, care, and outcomes for patients as well as lower costs (1). Federal programs, plans, and tools are available to guide health care clinicians and patients toward greater patient engagement (2) (3). The Shared Nationwide Interoperability Roadmap calls on health care providers to enable patients to electronically view, download, and transmit their health information to a destination of the patient's choice (4). The Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs required participating hospitals and health care professionals to enable patients with online access to view, download, and transmit their health information (5). This brief describes trends in hospitals' capability to engage patients with their health information electronically from 2012 to 2015.

Highlights
The percent of hospitals that enable patients to electronically view, download, and transmit their health information grew almost 7-fold between 2013 and 2015

Figure 1: Percent of non-federal acute care hospitals that provide patients with the capability to electronically view, download, and transmit their health information, 2012-2015

This figure contains a bar chart that represents the percent of non-federal acute care hospitals that provide patients with the capability to electronically view, download, and transmit their health information for 2012, 2013, 2014, and 2015.  View has 24% for 2012, 40% for 2013 (a significant difference from 2012), 91% for 2014 (a significant difference from 2013), and 95% for 2015 (a significant difference from 2014).  Download has 14% for 2012, 28% for 2013 (a significant difference from 2012), 82% for 2014 (a significant difference from 2013), and 87% for 2015 (a significant difference from 2014). Transmit has 12% for 2013, 66% for 2014 (a significant difference from 2013), and 71% for 2015 (a significant difference from 2014). View, download, and transmit has 10% for 2013, 64% for 2014 (a significant difference from 2013), and 69% for 2015 (a significant difference from 2014).

NOTES: *Significantly different from previous year (p < 0.05). Data regarding "Transmit" and "View, Download, and Transmit" were not collected in 2012.

SOURCE: ONC/American Hospital Association (AHA), AHA Annual Survey Information Technology Supplement: 2012 - 2015.

Critical Access, medium, and small hospitals lag behind large hospitals in possessing electronic view, download, and transmit capabilities for their patients

Figure 2: Percent of non-federal acute care hospitals that provide their patients with the ability to electronically view, download, and transmit their health information by hospital type, 2015

This figure is a horizontal bar chart that represents the percent of non-federal acute care hospitals that provide their patients with the ability to electronically view, download, and transmit their health information by hospital type for 2015.  The capability to view, download, and transmit is 61% for Critical Access Hospitals, 65% for small hospitals, 71% for medium hospitals, and 78% for large hospitals.  Critical Access, small and medium hospitals were significantly different from large hospitals.  The capability to transmit is 65% for Critical Access Hospitals, 68% for small hospitals, 74% for medium hospitals, and 79% for large hospitals.  Critical Access, small and medium hospitals were significantly different from large hospitals.  The capability to download is 83% for Critical Access Hospitals, 84% for small hospitals, 89% for medium hospitals, and 92% for large hospitals.  Critical Access and small hospitals were significantly different from large hospitals.  The capability to view is 93% for Critical Access Hospitals, 93% for small hospitals, 97% for medium hospitals, and 98% for large hospitals.  Critical Access and small hospitals were significantly different from large hospitals.

NOTES: *Significantly different from large hospitals (p < 0.05). Hospital size is based on the number of beds: large=400 or more; medium=between 399 and 100; and small=less than 100. Critical Access is a special designation for certain small hospitals by the CMS.

SOURCE: ONC/American Hospital Association (AHA), AHA Annual Survey Information Technology Supplement: 2012 - 2015.

Since 2013, the number of states where a majority of hospitals possess view, download, and transmit capabilities dramatically increased

Figure 3: State percent of non-federal acute care hospitals with the capability for their patients to view, download, and transmit their health information, 2013 and 2015

This figure contains two heat maps of the United states: one for 2013 and 2015. Each describes the state percent of non-federal acute care hospitals with the capability for their patients to view, download, and transmit their health information. The legend ranges include "Not Reliable Estimate," "0-19%", "20-39," "40-59%," "60-79%," and 80-100%." The maps show drastic increases in the capabilities by state from 2013 to 2015.

2013

2015

NOTES: Estimates for states shaded gray did not meet the standards for reliability (NR=not reliable). See Appendix Table A for a complete list of this measure by each State for years 2013 and 2015.

SOURCE: ONC/American Hospital Association (AHA), AHA Annual Survey Information Technology Supplement: 2012 - 2015.

The percent of hospitals offering additional types of patient engagement capabilities increased significantly between 2014 and 2015

Figure 4: Electronic capabilities offered by non-federal acute care hospitals to their patients (excluding view, download, and transmit), 2013-2015

This figures is a horizontal bar chart that represents electronic capabilities offered by non-federal acute care hospitals to their patients (excluding view, download, and transmit) for 2013-2015.  Send or receive secure messages had 51% for 2014 and 63% for 2015, a significant difference from 2014.  Submit patient-generated data had 13% for 2013, 32% for 2014 (a significant difference from 2013), and 37% for 2015 (a significant difference from 2014).  Pay bills had 55% for 2013, 67% for 2014 (a significant difference from 2013), and 74% for 2015 (a significant difference from 2014).  Schedule appointments had 29% for 2013, 41% for 2014 (a significant difference from 2013), and 44% for 2015 (a significant difference from 2014).  Request refills had 27% for 2013, 39% for 2014 (a significant difference from 2013), and 42% for 2015 (a significant difference from 2014).  Request amendments had 33% for 2013, 72% for 2014 (a significant difference from 2013), and 77% for 2015 (a significant difference from 2014).

NOTES: Questions regarding secure messaging were not asked in 2013. *Significantly different from previous year (p < 0.05).

SOURCE: ONC/American Hospital Association (AHA), AHA Annual Survey Information Technology Supplement: 2012 - 2015.

Nine in ten hospitals possess four or more electronic patient engagement capabilities

Figure 5: Number of patient engagement capabilities adopted by non-federal acute care hospitals, 2014-2015

This is a vertical bar graph that represents the number of patient engagement capabilities adopted by non-federal acute care hospitals for 2014-2015.  In 2014, 20% of hospitals adopted 0-3 patient engagement functionalities.  In 2015, 14% of hospitals adopted 0-3 patient engagement functionalities, which is significantly different from 2014.  In 2014, 41% of hospitals adopted 4-6 patient engagement functionalities. In 2015, 43% of hospitals adopted 4-6 patient engagement functionalities.  In 2014, 38% of hospitals adopted 7-9 patient engagement functionalities. In 2015, 43% of hospitals adopted 7-9 patient engagement functionalities, which is significantly different from 2014.

NOTES: Patient engagement activities include: view, download, transmit, request amend, request refill, schedule appointment, pay bills, submit patient data, and send secure messages. *Significantly different from previous year (p < 0.05).

SOURCE: ONC/American Hospital Association (AHA), AHA Annual Survey Information Technology Supplement: 2012 - 2015.

Summary

Hospitals significantly increased their adoption of key patient engagement functionalities between 2012 and 2015. There was a seven-fold increase in the percent of hospitals that provided patients with the capability to electronically view, download, and transmit their health information from 2013 to 2015. The tremendous growth in hospitals' adoption of view, download, and transmit capabilities in a relatively short period of time points to the potential impact of the Medicare and Medicaid EHR Incentive Programs, and specifically to the measures related to view, download, and transmit that were required for Stage 2 of the program. In 2015, almost all hospitals (95%) offered patients the ability to electronically view their health information. Almost 9 in 10 hospitals enabled patients to download their health information. A lower percentage of hospitals–about 7 in 10–offered patients the ability to electronically transmit their health information. However, this capability also grew significantly between 2014 and 2015. The potential impact of the Medicare and Medicaid EHR Incentive Programs is also demonstrated through significant increases in hospitals' adoption of other program requirements; such as the ability of patients to electronically send or receive secure messages from their health care provider.

There is evidence of both growth and variation in hospital adoption of view, download, and transmit capabilities. In 2013, no states had 40% or more of their hospitals with these three electronic capabilities; whereas by 2015, all states had 40% or more of their hospitals with these three capabilities. Hospitals' adoption of view, download, and transmit capabilities varies by type of hospital. Large hospitals provide view, download, and transmit capabilities to patients at higher rates compared to CAHs and medium to small size hospitals. Almost 8 in 10 large hospitals have all 3 capabilities while only about 6 in 10 CAHs have all 3 capabilities.

Overall, hospitals have increased their adoption of other patient engagement functionalities. In 2015, there was a significant decrease in the percent of hospitals adopting 3 or less patient engagement functionalities while there was a corresponding significant increase in hospitals adopting 7 or more of these functionalities. However, certain "convenience" functions that enable patients to schedule appointments or refill their medications electronically lagged behind in adoption compared to those that relate to the Medicare and Medicaid EHR Incentive Programs, Health Insurance Portability and Accountability Act (HIPAA) regulations, or billing. For example, only about 4 in 10 hospitals offer patients the ability to schedule appointments or refill medications in contrast to about 3 in 4 hospitals that enable patients to electronically request amendments to their medical record or pay their bills online.

Overall, the data indicate that the adoption of patient engagement functionalities has been increasing nationwide. However, disparities exist in hospitals' adoption of such functionalities. The Office of the National Coordinator for Health Information Technology (ONC) has prioritized changing the culture around patients' access to electronic health information to advance person-centered and self-managed care (6). ONC's efforts, such as new requirements for application programming interfaces (APIs) under the ONC Health Information Technology Certification Program and the Blue Button Initiative, are designed to foster patient engagement and access to health information by providing novel avenues for reaching patients. APIs, for example, will allow patients to access their health information in user-friendly ways, such as through "apps" on their mobile devices. Moreover, APIs can be applied to different technology platforms and are not limited to personal computers; thus, providing additional means of reaching patients that might not have access to computers. Future research that investigates divergent trends in hospital adoption of patient engagement functionalities will provide important insights on how to ensure that all patients have access to their health information and are actively engaged with their health care provider.

Definitions

Non-federal acute care hospital: Includes acute care general medical and surgical, general children's, and cancer hospitals owned by private/not-for-profit, investor-owned/for-profit, or state/local government and located within the 50 states and District of Columbia. The inclusion of children's general and cancer hospitals makes this definition different from previous peer-reviewed research. However, it is more consistent with the population of hospitals eligible for federal health IT adoption incentives.

Interoperability: The ability of a system to exchange electronic health information with and use electronic health information from other systems without special effort on the part of the user (2). This brief further specifies interoperability as the ability for health systems to electronically send, receive, find, and use health information with other electronic systems outside their organization.

Small hospital: Non-federal acute care hospitals of bed sizes of 100 or less.

Large hospital: Non-federal acute care hospitals of bed sizes of 400 or more.

Rural hospital: Located in a non-metropolitan statistical area.

Critical Access hospital: Less than 25 beds and at least 35 miles away from another general or Critical Access Hospital.

Data Source and Methods

Data are from the American Hospital Association (AHA) Information Technology (IT) Supplement to the AHA Annual Survey. Since 2008, ONC has partnered with the AHA to measure the adoption and use of health IT in U.S. hospitals. ONC funded the 2014 AHA IT Supplement to track hospital adoption and use of EHRs and the exchange of clinical data.

The chief executive officer of each U.S. hospital was invited to participate in the survey regardless of AHA membership status. The person most knowledgeable about the hospital's health IT (typically the chief information officer) was requested to provide the information via a mail survey or secure online site. Non-respondents received follow-up mailings and phone calls to encourage response.

The survey was fielded from October 2015 to the end of February 2016. The response rate for non-federal acute care hospitals was 56.15%. A logistic regression model was used to predict the propensity of survey response as a function of hospital characteristics, including size, ownership, teaching status, system membership, availability of a cardiac intensive care unit, urban status, and region. Hospital-level weights were derived by the inverse of the predicted propensity.

Estimates considered unreliable had a relative standard error adjusted for finite populations greater than 0.49. Responses with missing values were assigned zero values. Significant differences were tested using p < 0.05 as the threshold.

References

1. Health Affairs. (2013). Health Policy Brief: Patient Engagement. Accessed August 1, 2016 at: http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_86.pdf.

2. Consumer Health Data Aggregator. (2016). ONC announces Phase 1 winners of Consumer Health Data Aggregator and Provider User Experience Challenges. Accessed August 5, 2016 at: http://www.hhs.gov/about/news/2016/07/18/onc-announces-phase-1-winners-consumer-health-data-aggregator-and-provider-user-experience.html#.

3. The Office of the National Coordinator for Health Information Technology. (2016). Patient Engagement Playbook. Accessed August 31, 2016 at: https://www.healthit.gov/playbook/pe/.

4. The Office of the National Coordinator for Health Information Technology. (2015). Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap version 1.0. Accessed June 1, 2015 at: http://www.healthit.gov/sites/default/files/nationwide-interoperability-roadmap-draft-version-1.0.pdf.

5. Centers for Medicare & Medicaid Services. Medicare and Medicaid EHR Incentive Programs. Available from: https://www.cms.gov/ehrincentiveprograms.

6. The Office of the National Coordinator for Health Information Technology. (2015). Federal Health IT Strategic Plan: 2015 - 2020. Accessed August 31, 2016 at: https://www.healthit.gov/policy-researchers-implementers/health-it-strategic-planning.

Acknowledgements

The authors are with the Office of the National Coordinator for Health Information Technology, Office of Planning, Evaluation, and Analysis. The data brief was completed under the direction of Seth Pazinski, Director of the Office of Planning, Evaluation, and Analysis and Talisha Searcy, Director of Research and Evaluation for the Office of Planning, Evaluation, and Analysis. Other staff that contributed to this document include: Lana Moriarty, Office of Programs and Engagement and Lauren Wu, Office of Standards and Technology.

Suggested Citation

Henry, J., Pylypchuk, Y., Searcy T. & Patel V. (September 2016). Electronic Capabilities for Patients among U.S. Non-Federal Acute Care Hospitals: 2012-2015. ONC Data Brief, no.38. Office of the National Coordinator for Health Information Technology: Washington DC.

Appendix

Appendix Table A: Percent of non-federal acute care hospitals that provide electronic capability to view, download, and transmit heath information by U.S. State, 2013 and 2015

NOTES: n=survey respondents; N=hospitals surveyed. NR=estimate does not meet standards for reliability (not reliable).

SOURCE: ONC/AHA, AHA Annual Survey Information Technology Supplement: 2013-2015.

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Appendix Table B: Survey questions assessing hospitals' patient engagement activity

Survey Question: Are patients treated in your hospital able to do the following? (Yes/No/Do Not Know):

EHR Functionality
View their health/medical information online
Download information from their health/medical record
Electronically transmit (send) transmission of care/referral summaries to a third party
Request an amendment to change/update their health/medical record
Request refills for prescriptions online
Schedule appointments online
Pay bills online
Submit patient-generated data (e.g., blood glucose, weight)
Secure messaging with providers