Empowering Neurological Patients Through Digital Portals and EHR Enhancements

For years the healthcare community has been hearing about consumer-driven healthcare and the rise of empowered patients, yet the journey patients follow in the real world too often hasn’t kept pace with that rhetoric. In the past few years, however, advances in digital technology — and the electronic health record (EHR) in particular — have enabled the notion of “the empowered patient” to take on a new reality.

Cleveland Clinic’s Neurological Institute has observed this change as it has made enhancements to its Epic EHR and the associated EHR-integrated MyChart® online health management platform for patients. This article profiles some of those enhancements and what they have meant for patients, providers and neurological care delivery overall.

Greater access and responsiveness through MyChart refinements

No portion of the Neurological Institute has been impacted by changes to MyChart and the EHR more than the Section of Headache and Facial Pain. Several years ago, the section had challenges scheduling patient appointments in a timely way and managing the high volume of MyChart messages received from patients. The challenges stemmed from the large number of patients managed by the section each year —20,000 to 25,000 — and the often years-long duration of management needed for chronic headache.

“Too many patients had to wait more than a month or two for an open appointment, and our providers were scrambling to keep up with patients’ MyChart messages,” says Emad Estemalik, MD, Section Head of Headache and Facial Pain.

In addition to introducing and expanding virtual visits for headache patients — including an online intensive interdisciplinary program for those with chronic headache launched in mid-2018 — the section turned to two fundamental MyChart refinements to try to meet these challenges.

One was a process change adopted in mid-2019 — specifically, optimizing the process for triaging MyChart messages. The new triage system involves initial review of messages by administrative assistants to address any purely administrative inquiries and to direct other messages based on their underlying complexity. For instance, inquiries such as medication refill requests go to advanced practice providers for handling, whereas clinical questions go to the section’s nursing team, which escalates them to the section’s physicians as needed based on complexity and acuity.

More notable was a refinement that addresses both of the above challenges at once: MyChart was enhanced to enable established patients to do direct scheduling of virtual or in-person appointments within the MyChart platform itself, without need for a phone call. That refinement was implemented in tandem with the hiring of specialized advance practice providers dedicated to seeing headache patients via virtual visits.

“Now, if a MyChart message makes clear a patient needs a timely clinical assessment or response, they can be invited to make a virtual appointment right away,” notes Dr. Estemalik. “Sometimes a patient will send a MyChart message in the morning and be able to directly schedule a virtual visit for that afternoon. Patients avoid waiting on the phone, and it’s more efficient for our office as well.”

The result has been a “tremendous difference” in scheduling capacity, he says, along with increased patient satisfaction arising from much greater responsiveness to their requests and needs.

Other enhancements to the patient journey

Additional centers within the Neurological Institute have now adopted or are exploring direct scheduling via MyChart for established patients. As centers embrace direct scheduling, they can dedicate blocks of schedule time to patients who meet specific criteria in order to determine the level of provider who will see patients at that time.

Meanwhile, other MyChart capabilities and refinements are increasingly used across the Neurological Institute, including:

• Family virtual visits. This feature of MyChart Video Visits allows a patient to invite family members from remote locations to join in on a virtual visit with their clinician. “Many providers feel this is very valuable, particularly for some patients who may not communicate details of their care plan effectively to their own family or caregivers in another part of the country,” says Matt Stanton, Executive Director of Digital Health at Cleveland Clinic.
• Image upload. Patients are provided a link in their MyChart visit instructions at which they can upload photos or imaging studies from another institution for seamless transfer to the patient’s EHR, where they are available for review by the patient’s clinician at their next visit.

The latter capability is particularly valuable for presurgical consults, which are increasingly offered via virtual visits. “If a patient has one or more appointments with medical staff in our Neurological Institute for evaluation purposes, and the evaluation prompts consideration of surgery, a virtual presurgical consult might be welcome, especially if the patient had to travel far,” Dr. Estemalik notes. “While some patients really value in-person interaction with a surgeon before surgery, others prefer the convenience of virtual. Patients want options.”

New frontier in patient-entered data

Over the past year the Neurological Institute has also adopted widespread use of MyChart to capture patient-entered data on an unprecedented scale and at a high level of specificity. Although these changes may not impact patients’ care journeys as directly as the MyChart refinements above, they substantially shape care. “The patient-entered data we now collect through MyChart is crucial to patient monitoring and our clinical decision-making,” says Dr. Estemalik. “It’s a crucial component in enhancing value-based care and population health management.”

Before each appointment, patients are prompted via MyChart to complete a questionnaire highly specific to their condition and the nature of their visit. Administration via MyChart lends itself to completion at home, although patients can also complete their questionnaire on a tablet provided in a waiting room before in-person visits. Because of MyChart’s integration with the EHR, data are immediately available during the visit to inform decision-making.

While the Neurological Institute has been collecting comprehensive patient-entered data in conjunction with appointments for years, the new MyChart initiative has prioritized efficiency and relevance of data collection. Each center develops its own questionnaires tailored to the conditions it treats — for example, the movement disorders team administers different sets of questions for dystonia, Parkinson disease, essential tremor, etc. Questions vary by type of visit as well —initial visit versus follow-up visit versus surgical consult, etc. — but administration continues at all visits to allow longitudinal tracking of patient-reported outcomes.

“Our section revamped our patient-entered data questions upon moving the questionnaires to MyChart,” says Dr. Estemalik. “We were able to eliminate about 50% of the questions that weren’t crucial to what we needed, so we made things more efficient for patients and more focused on clinical relevance.”

Indeed, a premium is put on patient convenience, with questionnaires generally limited to 60 questions or less except for a handful of conditions, such as amyotrophic lateral sclerosis (ALS), where patients understand that greater detail may be imperative. Instruments widely used across neurologic subspecialties, such as the PHQ-9 and the PROMIS Global-10, are shared seamlessly through the EHR to avoid repeat administration by multiple centers.

The Neurological Institute began offering questionnaires via MyChart in early 2020. By late summer, 30% to 40% of patients were supplying patient-entered data that way, with the percentage rising steadily throughout 2020. “That level of patient adoption is ahead of the curve among U.S. health systems,” says Neal Jordan, a consultant with the healthcare software company Epic who has been working with the Neurological Institute on its patient-entered data initiative. Participation varies by clinical area, with headache patients being most engaged — roughly 60% of them consistently complete questionnaires via MyChart.

Another point of distinction for the Neurological Institute, according to Jordan, is the specificity of its patient-entered data capture. “For example,” he says, “the Neuromuscular Center alone is offering five specific questionnaires — one each for ALS, myasthenia gravis, neuropathy and autonomic disorders, plus a final generalized set of questions for patients with other conditions. That level of specificity is unique among healthcare organizations.”

Enhancements to EHR data entry too

The past year has seen changes in EHR data entry on the provider side as well, again under the guidance of Jordan and with important implications for patient care. “We have worked extensively to improve EHR note documentation across the Neurological Institute,” Jordan says.

He explains that the improvements have centered on standardization of note entry in two major regards. One involves standardizing the location of specific types of data to promote efficiency in finding and entering information. The other involves evidence-based standardization, to provide prompts that ensure all essential clinical considerations for the management of a particular condition are being addressed.

In addition to promoting time savings through more efficient documentation, these efforts have supported standardization of letters to referring physicians to ensure uniform coverage of essential issues. They also result in standardization of instructions provided to patients in their MyChart after-visit summaries. “The result is better, clearer and more complete communication to both referring providers and patients,” Jordan says.

The documentation improvements have yielded at least two additional benefits. First, they are a valuable teaching tool, as the evidence-based standardization walks residents and fellows through a set of essential items to be tracked or considered for a particular condition, and why they matter. Even more valuable is the resulting ability to track patients’ data over time, which is useful both for guiding patient management and for aggregation (in de-identified form) for research purposes.

“Over the past year we have created about 3,000 new EHR data points for the Neurological Institute that are now trendable and trackable, from reviews of systems to elements of the physical exam to questionnaire responses,” says Jordan. “This is a level of granularity that I’m not aware of anywhere else.”

All about openness to change

As Cleveland Clinic continues to extend these EHR and MyChart improvements across its Neurological Institute, those involved in the effort have advice for other health systems contemplating similar changes.

For Dr. Estemalik, key steps include fostering a culture of willingness to move beyond normal comfort zones and keeping an open mind about innovation. “There’s much to be learned from the initial widespread adoption of EHRs 10 or 12 years ago,” he said. “To many, shifting from traditional paper records at first seemed like more trouble than it was worth, but the increased efficiency of the EHR soon became clear to everyone.”

He adds that it’s also crucial to really know your patient population and roll out patient-empowering features accordingly. “At Cleveland Clinic, our headache team has been in the forefront of these efforts because our patients — many of whom are women in their 20s to 40s — are generally technologically savvy and eager to embrace digital platforms,” he says. “That’s been a good place to start and learn lessons that can be tailored to other populations.”

Stanton, who oversees digital health initiatives across all of Cleveland Clinic, says the Neurological Institute has met particular success because of a distinctive cultural attitude toward digital tools. “Many teams will approach a new tool by saying, ‘Let’s see how this tool can fit into our current workflow and practice,’” he says. “In contrast, the Neurological Institute tends to say, ‘Here’s this impressive new tool. Let’s take a look at how we can change our workflow because there’s likely a better way to do it with the new tool.’ That openness to a new way of practicing can really be key to making the most of digital technologies.”