Proposal for Demonstration Project


Dynamic, interactive patient education plays a critical role in improving patient safety, ensuring quality of care, and ultimately reducing costs. This document suggests changes to CMS meaningful use (MU) requirements for patient education that will help ensure that patients are provided timely, useful education and that outcomes can be tracked and reported effectively. First, patient education delivery and usage reporting should be done outside of EMR systems. Secondly, MU incentives should be based on percentage of patients who receive education and report positive outcomes, as opposed to meeting minimum requirements for distribution. This proposal discusses the reasons for these two changes and how they can help move meaningful use from process measures to outcome measures.


Today all of us have access to secure, easy-to-use technology that allows us to effortlessly book an international trip, check in online for a flight, talk to anyone around the world in real time, and keep track of our to-do lists. The same level of convenience and ease of use has not been realized in technologies used to deliver patient education. This is in no small part due to the regulations put in place for meaningful use. The focus of meaningful use on measuring technology adoption levels instead of patient outcomes has had unintended consequences for patient education. Because providers are required to provide patient education via the EMR, providers are not motivated to thoughtfully prescribe patient education based on their patients’ needs; instead, they end up “checking the box” to indicate that education has been delivered. Additionally, there are technology restrictions inherent in EMRs that make it difficult to deliver quality patient education materials.

Providing education via the EMR workflow often means that providing the suggested education is prioritized over providing the right information at the right time. This issue is one that we have encountered as we have talked with our clients about delivering patient education. The following example illustrates the application of MU resulting in illogical conformity.

An 86-year-old man in the hospital was being discharged. During the discharge process the EMR searched relevant keywords and coding and found pediatric content relevant for the 86-year-old. The nurse found the error and did not want to give the content to the patient, preferring to search for relevant educational content separately, but the patient education director stated that because it was the first item that populated in the EMR workflow, it was required by MU to be attached to the patient chart. The nurse attached the information to the chart for regulation. However, because the nurse cared for the patient, she threw away the paper printed from the EMR and printed a relevant article for the patient that could not be documented. This is only one example of the unintended focus on compliance as opposed to patient outcomes.

Furthermore, because meaningful use incentives require EMRs to suggest and track delivery of patient education, the quality of the education suffers. This requirement for delivery means that content must be fit into the specification provided by EMR vendors. The formats that can be used to deliver patient education in EMRs are limited to rich text file (RTF) format with little to no graphics or even basic formatting to aid in patient comprehension. The RTF format originated in the 1980s. There is some talk from major vendors about upgrading support to HTML 1.0 from the 1990s. This a far cry from today’s available technology that can easily offer personalized, interactive multimedia with real-time reminders and tracking and monitoring. We have listed specific technology issues and the adverse impact on patient education quality in appendix A.

Our experience working with over 2000 hospitals has validated these concerns: our clients are dissatisfied with the patient education that is delivered via EMRs, but EMR vendors are not motivated to work with patient education vendors to improve delivery of patient education, as this area is outside their core competencies. Providers are frustrated that they don’t have a simple way to provide truly meaningful education to their patients without the spectre of MU incentives overshadowing their desire to do what’s right for their patients. Our proposal can solve both of these problems.


We understand CMS has a significant challenge in creating incentives for providers to improve patient education. We propose the following framework to help align incentives between patients, patient education, and providers.

  1. Suggested Patient Education based on Problem list: Allow patient education vendors to suggest content for patient education from the problem list.
  2. Delivery and Reporting: Allow patient education vendors to report directly to CMS on patient education usefulness and outcomes from patients.
  3. Grading: Grade providers based on a curve instead of minimum threshold.


Suggested Patient Education based on EHR Problem list

We propose that CMS allow patient education vendors to pull the problem list from EHRs, suggest available patient education, and record the patient education sent to the patient. Many EHRs use very basic keyword and coding based searches to suggest content that does not match the patient’s need. Furthermore integrated content in EHRs do not have access to available multimedia educational components. By allowing patient education vendors to suggest content based on the problem list from EHRs we enable smart algorithms that match the best available to content to patients.

Delivery and Reporting

We propose that hospitals continue to prescribe patient education from within the EMR workflow, but allow management of patient education content and usage reporting outside of the EMR. The InfoButton standard is a great example that is already implemented. However, InfoButton does not meet MU requirements and hence cannot be utilized by clinicians for patient education.  By allowing providers to manage content and report on delivered materials via approved patient education vendors instead of EMRs, the quality and usability of the materials will be improved: patient education vendors will be encouraged to innovate and compete on delivering the best education possible without the technology constraints of the EMR. In addition, the tracking and reporting of patient education dissemination will be more robust.

Patient education vendor software can easily accumulate patient feedback and usage analytics for hospitals to meet regulatory requirements, and make it available to CMS in various formats.

Beyond just reporting the data points used today, we would like to work with CMS to research and propose a new set of data points for CMS to measure usefulness of patient education. Below is a list of data points that may be considered for further evaluation:

  • System Outcomes
    • Readmissions
    • Hospital Acquired Conditions
  • Patient Reported Outcomes and Measures
    • Patient Feedback on usefulness
  • Use:
    • # of patient education requests from EMR (info button or other digital requests)*
    • # of patients sent digital patient education*
    • # of patients given only printed patient education*
    • # of patients that acknowledged receiving information
    • # of patients that shared education with caregiver
    • Time spent by patient on sent patient education
    • % of patients and families that reported patient education was not helpful, helpful, very helpful

* Can be done with InfoButton technology available in EMRs and patient education vendors today. We note that it is possible for patient education vendors to get MU certified for related modules and submit reports but this is impractical because the numerator (# of patients) is only controlled by the EMRs


To receive MU incentives today, hospitals and EMR vendors focus on meeting the minimum requirements for patient education MU measures. Instead of setting a minimum goal, we propose grading providers on a curve. The industry has the technology to enable curve-based grading that will push competition and innovation. Imagine if grading was based on % of patients who received print education, received digital education, and the follow-up patient responses. Providers and vendors would be motivated to offer engaging solutions to improve their scores compared to other hospitals in their region. We suggest offering bonus points for showing continued growth YOY till 100% of all patients report the patient education delivered to them was useful.

Next Steps

  1. We propose a demonstration project to allow 5-10 healthcare systems to work with patient education vendors for one year to test this new reporting framework.
  2. We propose that CMS request feedback to define patient education metrics that can be reported independently of the EMR.

About the Authors

StayWell has been a leading provider of patient education for over 30 years. StayWell’s Krames patient education is currently being used by over 2000 hospitals nationwide, and is integrated into leading EMRs, including EPIC, Cerner, Meditech, and others.

Doctella is a startup co-founded by world-leading scientists: Dr. Peter Pronovost, a leading safety and quality researcher from Johns Hopkins; Dr. Adil Haider, a leading patient-centered outcomes researcher from Harvard; and Amer Haider, a Silicon Valley entrepreneur and security expert. Doctella has a know-how license from Johns Hopkins and Johns Hopkins is an equity partner in the company.

StayWell and Doctella have partnered together to provide the Krames Health Engagement Platform, a dynamic platform that delivers interactive and doctor-specific patient education. The platform uses an open framework that provides interactive reminders and real-time feedback from patients and caregivers–all while maintaining health literacy principles critical to ensure patient understanding.

Contact Information

Nicole Latimer, President of Staywell, LLC

Amer Haider, CEO of by Patient Doctor Technologies, Inc.


Appendix A

Below are some technical limitations on patient education imposed by EMRs using RTF text format .


Due to limitations in available EMR storage formats, patient education is typically stored in simple formats like plain text, HTML 1.0 or RTF. These formats cannot render rich formatting created by the publisher of patient education. This is a loss for patients because readability and comprehension of the content suffers greatly.


Each EMR decides how to present content using demographics.

Example:   Cerner does not filter on age and gender, so the system will suggest educational content that is not suited to a patient’s gender or age.

Types of content

RTF does not allow for hyperlinks. This limits the ability to use animation, deep links, video, and other rich media types. In some cases, patient education can be sent to the patient portal where links to rich media type can be linked. However, there is typically not a push mechanism in patient portals so patients need to find the information by logging in on their own.

Latest version

Cerner, Epic, and Meditech provide quarterly updates to their customers.  On the provider side, updating integrated patient education content in EMRs can take up to 20 hours of IT resources and is a low priority.  Moreover, the process to download the latest content is time-consuming for the hospital’s Patient Education Coordinator.

Custom Content

Hospitals have content they have created and they would like to customize patient education materials provided by a vendor. This is not possible when delivering content via the EMR.

Tracking and Analytics

Because content is delivered only in print format, there is no way to track patient consumption of education and measure/correlate ROI and benefits.

Multi-EMR environment support

Environments with multiple best-of-breed EMRs with separate portals cannot offer a single source of truth for patients online.