Efforts to advance patient-centered health information technology (PCHIT) initiatives have been shaped by the environments that exist in each individual state or community. Environmental factors can be shaped by: specific regional quality improvement (QI) or health information technology (HIT) initiatives; local or state government interventions; the dynamics of that particular competitive marketplace; and historical evolution of local health care delivery.

We have compiled key developments that have specifically had an impact on PCHIT evolution (or have the strong potential to do so) in the regions were we have been operating.

California

Some of the most advanced EHR and PHR innovation has transpired in California in different types of practice models. For example, California has many large, multispecialty medical groups, and Palo Alto Medical Foundation (PAMF) was one of the first medical groups in the country to provide its patients with access to a PHR with functionality to access a wide range of clinical information. In addition, PAMF has made efforts to connect its PHR to health content in an effort to maximize the utility of the PHR for patient-centered care. Some other large medical groups have implemented PHRs or other patient-centered HIT tools for their patients, but they remain a minority. A recent survey of California’s primary care physicians suggested that although 19% say they often or sometimes communicate with their patients by email, only 4% of patients reported that they have communicated electronically with their physicians.

Some of California�s health plans also have taken an active role in advancing PCHIT applications. Kaiser Permanente�which serves about 20% of the state�s population�now has more than 1.7 million members signed up to use its PHR (approximately 20% of all members). It has developed a variety of tools to help its members use PCHIT tools to better manage their health. Functions include: access to clinical health records; secure messaging with clinicians; access to all lab data; ability to review and renew prescription medications; appointment requesting; links from personal health information to educational content; and linkages between various self-management tools and personal clinical data.

California also has big gaps in HIT evolution, most notably among the FQHCs and other safety-net providers, where fewer than 5% of more than 500 clinics use electronic systems to manage clinical information (see Health Care Foundations Announce $4.5 Million Program to Speed Adoption of Electronic Records in Community Clinics). State and local government efforts to drive HIT adoption among safety-net providers have been limited. To fill this gap, the California Endowment launched the Community Clinics Initiative (CCI) in 1999. Over the last several years, several of CCI�s grants have been directed to HIT investment, though little of that effort has been focused on patient-facing applications. The California HealthCare Foundation, CCI (now a joint project of Tides and the California Endowment), and the Blue Shield of California Foundation launched the California Network Electronic Health Record Adoption to implement EHR systems among safety-net providers in the state. The project announced that it will build EHR support hubs that will provide technology, technical support, vendor management and other services that community clinics often cannot afford. CCI has provided $41 million to assist 163 clinic and 15 regional associations. From RWJF’s Health Information Technology in the United States:

Each year, CCI and its external evaluator, Blueprint Research and Design Inc., have administered a written survey to these clinics, titled �The Clinic Information Management Assessment Survey.� Surveys collected

in the fall of 2002 yielded an 80 percent response rate from executive directors and 84 percent from medical directors. CCI�s 2003 Information Technology Fact Book reported that 5 percent of medical clinics had EHRs and 3 percent of dental clinics; in addition, about 23 percent of medical clinics and 9 percent of dental clinics had established EHR implementation planning committees.

In comparison, Group Health Cooperative has widely reported that its Statewide Clinical Information Project, which implemented and EHR and PHR in 25 medical centers, cost $42 million.

Massachusetts

By objective measures of quality and performance, Boston health plans are the best in the country. The region�s largest plans�Harvard Pilgrim Health Care (HPHC), Tufts, and Blue Cross and Blue Shield of Massachusetts (BCBS MA)�are the three >highest-quality health plans in the country (see Best Commercial Health Plans 2007, USNews & World Report), according to the National Committee for Quality Assurance (NCQA) and US News rankings. New England�s decade-long focus on comparative performance measurement through a variety of regional quality initiatives has created a competitive market for quality rankings; in fact, US News places 15 of the top 20 health plans from New England.The combination of the focus on quality and the major impact of Boston�s large teaching institutions have spurred considerable adoption of HIT in large practices. In addition to large practices, small practices are increasingly getting wired due to pressure from larger providers. For example, Partners Health Care, Inc. (PCHI) recently mandated that all of its network of small and medium-sized physician practices connect to the PCHI EHR network by January 1, 2009 or be dropped from the network (see Boston Health Network Requires All Physicians to Adopt EHRs by 2009).

Although many clinicians have access to EHRs�one estimate suggested that 84% of physicians could document visits via EHRs –only 29% of the state�s physicians reported that they have adopted EHRs. In order to tackle the interoperability problem of health information exchange (HIE), several organizations in the state have worked to drive forward a �virtual RHIO.� Massachusetts Health Data Consortium (MHDC) has been driving forward health care information transfer for nearly 30 years. A decade ago, MHDC helped to launch the New England Healthcare Electronic Data Interchange Network, which now provides a lot of the administrative interconnectivity necessary for HIE. MHDC also operates MA-SHARE to provide a clinical �grid� to support communities in clinical data exchange. In December 2004, the state government lauched the Massachusetts eHealth Collaborative (MAeHC) with the goal of actually wiring that HIE into the providers� offices.

Consumer access to personal health data somewhat mirrors provider access in that theoretical access exists for many consumers, but few are making use of that functionality. Many of Boston�s large providers have also launched personal health record (PHR) corollaries to their EHRs. However, among the practice settings studied, adoption among consumers remains under 10% of the eligible population. The first and most active PHR, CareGroup’s PatientSite, currently has approximately 35,000 active consumer users, according to a recent JAMIA study. Penetration is difficult to judge because the study does not indicate the potential eligible patient population. (see: Early Experiences with Personal Health Records)

New state government initiatives may also spur PHR adoption. Governor Deval Patrick announced in December 2007 a new �compact� on health, with the goal of devising a comprehensive approach to tackling the state�s entrenched health care problems. It is unclear at this juncture whether consumer engagement via HIT will be a significant component of this new initiative.

New York

New York has taken a leadership role in HIT adoption, and there is great potential to advanced patient-centered HIT in the state. However, experts remain concerned that despite a demonstrated financial commitment to HIT advancement, few policy leaders have yet articulated a strong policy position regarding the need for consumer access and engagement with regard to HIT adoption.

Both the public and private sector have recently infused significant capital resources into New York�s HIT efforts. In 2004, the state government passed the Health Care Efficiency and Affordability Law for New Yorkers Capital Grant Program (HEAL NY) to invest up to $1 billion over four years to improve care and efficiency. One of HEAL NY�s two primary objectives is capital investment in HIT and health information exchange (HIE). In HEAL NY Phase 5, one of the five main components of the envisioned future New York HIT infrastructure is, �Medical information follows the consumer so they are at the center of their care� (see HEAL NY - Phase 5 Health Information Technology Grants: Advancing Interoperability and Community-wide EHR Adoption). In addition, they have also developed a specific consumer use case that is aligned with the American Health Information Community consumer engagement use case. The goal is to structure the requirements in such a way as to ensure that they are integrated into the policy and technical design.

With the encouragement of state and federal funding, many RHIOs have formed in New York�several in the New York City area as well as local RHIOs in different communities across the state. In addition to the state government activity, New York City�s Department of Health has launched the Primary Care Information Project (PCIP) with a particularly emphasis on helping to wire the city�s federally qualified health centers (FQHCs) and other safety-net providers. The PCIP goals focus in significant part in advancing better chronic care self-management. Therefore, PCIP wants to advance the personal health applications of HIT tools, though the first priority is enabling provider HIT adoption.

Some FQHCs, such as those that are part of the Institute for Family Health (IFH) already have fully functional EHRs. IFH is preparing to launch the PHR component of that system and intends to begin implementation planning in early 2008. Most FQHCs, however, are in more preliminary stages of EHR and PHR development.

In order to spur HIT adoption among private medical groups, the state�s quality improvement organization, IPRO, is providing free assistance through the national Doctor Office Quality Information Technology (DOQ-IT) project. IPRO helps 350 individual adult primary care practices select, implement, and optimize HIT systems. Although consumer access to information is not an explicit objective of DOQ-IT, this infrastructure may provide a better platform for consumer access to their own health information.

In order to provide a more cohesive strategy to these various efforts to spur HIT adoption and HIE, public and private partners formed the New York eHealth Collaborative (NYeC) to build consensus on state HIT policy priorities and collaborate on HIT implementation efforts. NYeC has established four initial goals to “galvanize health care systems improvement by promoting broad use of HIT through a comprehensive and coordinated state policy agenda that:

1. Stimulates coordinated and collaborative efforts among health care stakeholders to identify and overcome barriers to widespread HIT adoption and use to enhance evidence-based practice by clinicians, as well as consumer engagement in health maintenance and management;

2. Advances health care performance measurement, public reporting and improvement supported by HIT;

3. Improves public health through effective prevention and management of chronic disease, as well as stronger public health surveillance and emergency response capabilities; and

4. Ensures accountability by measuring and evaluating HIT impact on health care systems, payers, providers, and consumers.

More detail regarding their strategy and key activities can be found in the NYeC Overview Document.

Unresolved Issues

• Geographic regions vary substantially, leading to different challenges. In more wired communities–such as Boston–the foundation has been set for EHR adoption (though fully functional EHRs may not be integrated into smaller practices for two or more years) and larger systems have developed feasible PHR platforms. In those locales, the step-wise approach means the timing suggests that their biggest challenge is encouraging clinicians to engage electronically with their patients.
• In contrast, other geographic settings that do not have a consistently evolved EHR infrastructure, the unresolved question is whether to take the traditional step-wise approach to HIT adoption or consider building patient-centered HIT applications into the roll-out of their EHRs. Conversations with HIT leaders in many of these organizations suggests a desire to consider the latter tactic but a concern that it will be difficult to bring all the necessary HIT and clinical leaders on board for such a dramatic “big bang” (turning on all functionality at once), such as was done at places like Group Health Cooperative in Seattle.
• The role of integrated delivery systems such as Group Health brings up another important unresolved issue: What should the role of IPA-/network-model health plans be in driving PCHIT adoptions? Many of the group-model plans have made major strides in PCHIT advancement not only because the economic imperative is clear (in the long-term, better care management and member engagement is a “win” for everybody), but also because–as integrated systems–there’s no question that they should be directly investing in building systems for their members.
• In constrast, the IPA-model health plans face a challenge in determining their most appropriate role in the promotion of PHRs.If they go down the PHR development role on their own, they likely will primarily be populating their members’ PHRs with administrative data–and, in many cases, with data that comes with a significant time delay that renders it less meaningful. However, working with the providers with whom they contract to generate clinical data-oriented PHRs for their members may not be feasible.
• Policy leaders need to create explicit goals around consumer access and engagement to ensure that the intense policy efforts around HIT adoption specifically address the needs of patients and their families.

Countermeasures

One option available to grantmakers and policymakers is to tie HIT funding to this strategy. Options include “patient-centered mandates” and/or a patient-centered technical support strategy. In the former, those who hold the purse strings basically require that HIT applications include tools for both clinicians and patients in order to receive funding assistance. In the latter, those with funding authority create a technical support infrastructure to chart paths toward the more holistic HIT adoption approach and support progressive organizations with technical assistance to make it feasible to undertake the more ambitious, patient-centered approach.

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