2020 MIPS IA_BE_14: Engage patients and families to guide improvement in the system of care

Activity ID

Activity Weighting

Subcategory Name

Beneficiary Engagement

Activity Description

Engage patients and families to guide improvement in the system of care by leveraging digital tools for ongoing guidance and assessments outside the encounter, including the collection and use of patient data for return-to-work and patient quality of life improvement. Platforms and devices that collect patient-generated health data (PGHD) must do so with an active feedback loop, either providing PGHD in real or near-real time to the care team, or generating clinically endorsed real or near-real time automated feedback to the patient, including patient reported outcomes (PROs). Examples include patient engagement and outcomes tracking platforms, cellular or web-enabled bi-directional systems, and other devices that transmit clinically valid objective and subjective data back to care teams. Because many consumer- grade devices capture PGHD (for example, wellness devices), platforms or devices eligible for this improvement activity must be, at a minimum, endorsed and offered clinically by care teams to patients to automatically send ongoing guidance (one way). Platforms and devices that additionally collect PGHD must do so with an active feedback loop, either providing PGHD in real or near- real time to the care team, or generating clinically endorsed real or near-real time automated feedback to the patient (e.g. automated patient-facing instructions based on glucometer readings). Therefore, unlike passive platforms or devices that may collect but do not transmit PGHD in real or near-real time to clinical care teams, active devices and platforms can inform the patient or the clinical care team in a timely manner of important parameters regarding a patient's status, adherence, comprehension, and indicators of clinical concern.

Validation

Functionality of methods to engage patients and families, which may include patients and families that need additional support due to disability, in improving the system of care by leveraging digital tools for ongoing guidance and assessments outside the encounter and with the use of active feedback loops

Suggested Documentation

1) Documentation showing patient and family engagement using digital collection and use of patient data, which may include patients and families that need additional support due to disability, for return-to-work and patient quality of life improvement; and
2) Documentation of PGHD in real or near-real time to the care team, or generating clinically endorsed real or near-real time automated feedback to the patient, including patient reported outcomes (PROs), (e.g., meeting agendas and summaries where patients families have been engaged, survey results from patients and/or families; and improvements made in the system of care; surveys should be administered by a third party survey administrator/vendor to the best extent possible).

Examples of Additional Activities that Qualify for Attestation

Completing these alternate activities can fulfill the requirements of this Improvement Activity; and Notes

Sub-IA-1: Engage in Non-face-to-face chronic care management using remote monitoring and/or telehealth technology;
Sub-IA-2: Leverage digital tools for ongoing guidance/assessments outside the encounter;
Sub-IA-3: Implement Manage My Surgery ™  (MMS);
Sub-IA-4: Report Patient Reported Outcomes Also known as Patient Reported Outcome Measures (PROMs);
Sub-IA-5: Utilize mobile remote monitoring to facilitate CHF management;
Sub-IA-6: Send medication reminders through mobile phones for hypertension medication adherence; which may include collection and use of patient data for return-to-work and patient quality of life improvement;
Sub-IA-7: Conduct non-face-to-face chronic care management using remote monitoring and/or telehealth technology;
Sub-IA-8: Implement Sonar MD;
Sub-IA-9: Conduct remote monitoring of empaneled chronic care management patients