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2021 MIPS IA_BE_14: Engage Patients and Families to Guide Improvement in the System of Care

Activity ID

IA_BE_14

Activity Weighting

High

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.

Objective

Use active devices and platforms to allow the patient and the clinical care team to share information on a patient's status, adherence, comprehension, and indicators of clinical concern in a timely manner.

Suggested Documentation

Evidence of engagement with patients and families by using digital tools for ongoing guidance and assessments outside the encounter. Include both of the following elements:

1) Use of digital tool or platform – Documentation of the practice’s adoption of an endorsed clinical tool or platform for digital collection and use of patient data that can create an active feedback loop between patient and clinical care team (e.g., license for tool/platform); AND
2) Collection of patient-generated health data (PGHD) and participation in active feedback loop with patients – Documentation of PGHD submission in real-or near-real-time to the care team, or reports generating clinically endorsed real-or near-real-time automated feedback to the patient, including patient reported outcomes (PROs); may be used for patients and families who need additional support because of disability or plans to improve their quality of life or return to work.

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