Perfecting the Portal

Perfecting the Portal: Medicaid Seeks to Improve Provider Portal

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Tex Med. 2014;110(1):39-42.

By Amy Lynn Sorrel
Associate Editor

The web-based Medicaid provider portal is undergoing a facelift that could mean expanded access to Medicaid patients' health history so doctors can deliver more efficient, well-rounded care. But the execution will be tricky, which is why physicians want to see the changes carefully tested to make sure the new system not only promotes patient care, but also minimizes hassles for physicians in the already administratively frustrating Medicaid program. 

The portal, YourTexasBenefitsCard.com, allows physicians to verify patients' eligibility, set appointment reminders, and view limited information on patients' health status, namely their immunization history and dates of their last medical and dental checkups. Starting in February, the Texas Health and Human Services Commission (HHSC) plans to pilot-test enhancements that will allow doctors to get a more comprehensive view of Medicaid patients' health via an electronic health record (EHR). It will include additional information on patients' prescription history, lab tests, and visits and procedures. 

The Texas Medical Association participates in the Medicaid workgroup overseeing the project. At press time, the association was helping recruit physician practices to participate in a three-month pilot and working with Medicaid to develop a user-friendly portal before it goes live.

The legislature ordered the expansion in 2009. But the initiative was slow-going due in large part to legal and regulatory barriers that HHSC still must balance, namely making sure sensitive patient information such as mental health history remains protected from inappropriate access, while at the same time giving doctors easy access to the information they need to appropriately treat their patients.

Until more comprehensive health information exchanges (HIE) are up and running statewide (see "Vital Connections," October 2012 Texas Medicine, pages 43-48), the enhanced portal could prove an important stopgap and "provide valuable information that has been difficult to get. So we applaud Medicaid on their hard work in making this available," said Dallas pediatrician Joseph Schneider, MD. He spoke to Texas Medicine as chair of TMA's Ad Hoc Committee on Health Information Technology. He also chairs Medicaid's Electronic Health Information Exchange System Advisory Committee. 

At the same time, he said, the Medicaid portal "needs to be looked at with the same caution that a physician would look at a portal offered by a private insurer in that it may be incomplete. And from an office productivity standpoint, the mechanics of how the portal will actually work are important. Like all new things, it's easy to criticize, and we can't let the perfect be the enemy of the good. We need to carefully pilot this." 

Privacy a Priority

In an effort to improve quality, safety, and efficiency in Medicaid, the 2009 Texas Legislature, under House Bill 1218, told HHSC to develop a Medicaid HIE system. Part of that mandate included creating a web-based portal for Medicaid patients, which, in addition to the current immunization records and checkup reminders, would include new information on:   

  • Health events: a record of each patient visit to a health care provider, including the provider's name and address, dates of service, standard diagnosis codes and descriptions, and procedure codes and descriptions;
  • Prescription history: the medication name, quantity, last fill date, and number of refills for the prescription; and
  • Lab tests: the date of service, a description of the test, and test results. 

Medicaid & CHIP Health IT Policy Advisor Sylvia Kauffman says the new portal will provide three years of patients' health history in those categories using Medicaid claims data. If a patient visits several different providers, Medicaid would merge those claims into a diagnosis and treatment summary physicians can access in one place.

One of Medicaid's main tasks now is figuring out how to include and yet protect what is considered "ultrasensitive" personal health information without running afoul of state and federal privacy laws. 

"That's the challenge: We have to make sure patients' health information is protected and make [the portal] as user-friendly as possible for providers," Ms. Kauffman said.

HIPAA, for example, allows the state to display patients' general health information through the web portal without patient authorization for treatment and payment purposes. But Ms. Kauffman says sharing more sensitive facts may require "extra review" and written patient consent. Specifically, that could include data related to:  

  • Sexual assault,
  • Genetics,
  • Family planning,
  • Mental health,
  • Communicable disease,
  • Psychotherapy notes,
  • Domestic violence,
  • Substance abuse,
  • HIV/AIDS,
  • Treatment of a minor, and
  • Intellectual disability. 

"We need to make sure the [portal] system knows how to treat this data based on what the law says: Each claim has to be reviewed to find out if any of this type of data is in it; how we display it; does it require patient consent; and do we need to provide a disclosure to the provider that we have revealed certain information," Ms. Kauffman said. 

To find that balance, HHSC formed a workgroup that, at least in the initial phases of the new portal implementation, recommended allowing patients to opt out of electronically sharing their Medicaid health information at any time. If patients opt out, the system would not display any of their health data. If they don't opt out and by default agree to share their history, physicians would have to get written patient consent at the point of care and attest electronically that they received it in order to view both the general and sensitive health data through the portal. There are exceptions for emergencies. Physicians also would have to keep the consent form on file for seven years, according to a draft version of the portal's Terms of Use Agreement.

Ms. Kauffman called the proposed up-front patient consent a "short-term strategy to get this data out as quickly as we can into providers' hands," saying eventually the Medicaid portal will link to local HIEs. But for now, "we are asking them to incorporate this consent into what they are already doing, so we hope it's not additional work."

Because the portal would display only high-level diagnosis and procedure codes for any sensitive health information, as opposed to detailed chart notes, for instance, state officials hope most patients will agree to share the information. In turn, they hope the enhancements will encourage physicians to use the tool more widely and continue to seek physician input on the consent process and through the pilots before launching the portal statewide.

"On the forefront of this whole discussion is making sure this is not a burden to providers," Ms. Kauffman said. "We are very excited about being able to provide this information to clinicians, and we think it has great potential to improve the quality of care for our [Medicaid] clients."

Eliminating Hassles

TMA leaders say the portal could give physicians at least some helpful health information on Medicaid patients, particularly when actual medical records are unavailable. But they also encourage HHSC to continue to fine-tune the portal to make it as user-friendly as possible, including improving the consent process. Association staff caution, too, that due to antitrust concerns, physicians and physician groups must independently decide whether to participate in the portal, which is voluntary.

"Having documentation of a patient's health history is critically important to providing the right care at the right time," said Keller pediatrician Jason V. Terk, MD, a member of TMA's Select Committee on Medicaid, CHIP, and the Uninsured and Council on Legislation. He added that it's not uncommon for physicians to have to treat Medicaid patients in the emergency department, in an urgent care facility, or at first-time office visits without access to their past medical history. 

For patients consistently on Medicaid, the new portal also could be what Dr. Schneider called a "very valuable" source of information that now only Medicaid possesses. Because many patients go on and off Medicaid, however, it may provide only a portion of their health history and could be missing important information. "Since it is initially claims-based, there may be timing issues where recent information that could change the care needed by the patient may not be available."

Nor is it clear how practices can easily sift through the large amounts of data on complex patients that will likely accumulate. Administrative inefficiencies such as separate logins for separate tasks, for example, threaten to interrupt workflow and take extra time away from patient care, Dr. Schneider added.

But it's the proposed requirement for physicians to obtain and keep patient consent, he says, that could pose the more significant administrative burden for practices if not done right. TMA also raised concerns about potential liability risks for physicians if they are unable to comply with the consent process. In late October, TMA asked HHSC to clarify and simplify the process — in particular the draft electronic Terms of Use Agreement and consent attestation forms doctors would have to agree to before accessing the portal — to help participating physicians comply. 

At press time, HHSC had not finalized the consent process or the forms, and TMA was working with the agency to improve them. 

HHSC also indicated to TMA that physicians would not be required to establish a Medicaid-specific consent process, and physicians could obtain consent from Medicaid patients the same way they do for all other patients without any new forms.

Dr. Terk says the state has a long history of prioritizing patient privacy, and physicians share those concerns. 

"Certainly, a person's medical history is sensitive and private information, and providing access to it raises concerns that are indeed valid. Breaches of sensitive online data happen all too commonly, and people are harmed by that. But if the burden to access the information is too high, then the [portal] will not be used by enough physicians to make a significant difference in the care provided to Medicaid enrollees," he said. 

Dr. Schneider added that the state pilot is critical to sort out these issues before the new portal goes live statewide. "Assuming that the pilot is successful, it could be made more widely available," he said.

TMA advised the state to make sure the pilot included a representative sample of physicians based in various settings, including offices, clinics, children's hospitals, and inpatient and emergency settings; and a good mix of patients, including newborns, adolescents, those who are transient, and patients with complex conditions. 

TMA also requested that HHSC allow the association's Select Committee on Medicaid, CHIP, and the Uninsured to review the pilot results before the program expands.

Amy Lynn Sorrel can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.   



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