The best way to understand the state of PCHIT has been the annual information therapy (Ix) conference, and the sixth annual edition was held earlier this week in Park City, Utah.

Target and Tailor and Engage, Oh My!

The 2007 Ix Conference Summary

Overview

There aren’t many health care conferences where you can jingle to Schoolhouse Rock and contemplate its impact on your medial prefrontal cortex in the same session.

Looking back to the first information therapy (Ix®) conference in 2002, it’s amazing how far Ix has advanced. In 48 hours, we learned that the state of the science behind targeting and tailoring of health information has grown dramatically. Equally important, innovators have now demonstrated successful strategies for engaging-even entertaining-people to activate them as partners in their care management.

For more detail on the state of PCHIT, see Summary of 6th Annual Ix Conference.

There was a long segment on National Public Radio’s Morning Edition (”Patients Turn to the Internet for Health Information“) this morning that started with the same Pew Internet Project data on Web usage by people with special health needsthat I referenced earlier in the week.

Among the many interesting points brought up is that, in the well-known CHESS (Comprehensive Health Enhancement Support System) study, people who had Internet access and were offered some guidance (i.e., information therapy or Ix) by clinicians did much better than those who just had open, unguided Web access. Researchers found that those who got Ix were better informed, more willing to ask questions of their doctors, and took more responsibility for their treatment choices.

I spent my last day in New York shadowing in one of Institute for Family Health’s smallest practices - two physicians and a nurse practitioner. Like the other practices in the system, this one is busy, taking scheduled patients and walk-ins. And like the others, it is fully enabled using an electronic health record. Pictures are below. Click on any to see full size.

I saw the art of family medicine here, which is that regardless of the time pressures always faced in medicine, physicians are able to focus and be there for their patients. The physician I saw practice on this day had a really nice rapport with her patients and I noticed was able to connect with them on topics important to them outside of health care - trips they might be taking, or significant family issues. This is always great to see in the context of an electronically enabled practice - doctors can still be doctors. The other significant thing for me was the kindness of the patients in their willingness to let me learn about their relationship with their doctor by watching the interaction. The several that I observed were welcoming after an informed consent was obtained by their physician.

Also, a new best practice for me (I think) - sitting while shadowing. I have traditionally stood in a corner to be as unobtrusive as possible, but it was brought to my attention that my height may be a little imposing in the exam room. I liked it - more at the level of the patient, and more blended in. With great thanks to the 13th street practice.

What about the PHR? I was informed that this practice is diligent about sending patients results and other important health information, which made me think about the value of a personal health record here. What if patients could retrieve their own information, accompanied by information about each test automatically (Information Therapy)? It was important for me to come visit and see that reality for this practice. I think there could be win here in physicians empowering patients to become informed about their own care on their own time. One issue this system will face is in their use of external ancillaries, such as lab and radiology. The PHR may force the issue of establishing a solid interface to both, and this is a good thing - the patients will expect their data to be available to them and to their provider. Everyone wins.

Later in the day, I met with Karen Nelson, MD, MPH, the CEO of Unite HERE Health Center. The facility is beautiful and modern (see pictures below), and also fully electronic, using the General Electric Centricity Product.

We talked about the history of UNITE HERE! and the patients seen here. They are doing a lot of work in Ambulatory ICU and serve a distinct group of special patients in the city. I would very much like to come visit on my return, and had the idea that I would not only like to shadow a provider, but shadow a patient living with chronic disease, if this is possible.

October 8, 2007–I was interviewed Friday morning by John Gordon, a public radio reporter for “Future Tense” for a segment (podcast also available) airing today about new findings published by the Pew Internet Project. Pew always has made major contributions to our understanding of how consumers use the Internet for health–more than just a series of data points and demographic trends (although those data are valuable too), because Pew delves deeply into areas not studied in some other generic surveys.

Today’s study focused on how people with special health needs use the Internet. I won’t bother reporting on the study, but there are two points I emphasized to the reporter that I believe are particularly noteworthy.

“E-patients with special needs have mostly positive things to say about their online health searches, but they are more likely than others to report frustration as well.”

Those with special needs are more likely than other e-patients to report that their online searches affected treatment decisions, their interactions with their doctors, their ability to cope with their condition, and their dieting and fitness regimen.”

With respect to the latter, there were 2 questions (one about affecting decisions and the other about changing their overall approach to care) that had different responses—and there was a statistically significance difference between special-needs vs. other e-patients—that I found somewhat surprising. What would cause there to be a difference in how the Internet affected their decisions vs. the impact on their overall approach to care.

Both of these findings emphasize the need for information therapy (Ix) for online consumers with special needs even more so than for the general population. Because this population’s health needs are greater, their information needs are greater. That’s why whatever information they can find has such a big impact on their decision making, their clinician-patient communication, ability to cope, and their wellness, yet they have trouble getting the info they need. All of that concern is just magnified by the data on them not checking sources. That’s hardly their fault; there’s just not much decent guidance to go by out there for sifting through Web site info quality (one of the main points of my own dissertation research–for a summary see, The Mysterious Maze of the World Wide Web: What Makes Internet Health Information High Quality? available at The Center for Information Therapy: Whitepapers).

Given all that, the promise of patient-centered HIT applications for people with special needs is enormous–just imagine if this population could have access to just the information they need when and how they need it. By creating ways to maximize the potential of the Internet and other electronic tools with the support, guidance and coaching that clinicians can provide, we can empower this population to improve their own health.

On this day, I visited the Institute’s Walton Family Health Center in Bronx, New York. Due to a time constraint on my part, I did not get to shadow providers caring for patients, but I did attend a CME in the morning and then walked around the facility with it’s Medical Director. Pictures are below, click on any to see it in gallery format.

The facility is about 10 years old, and to my eyes, it seems very well designed, as well designed as any outpatient medical center I have seen. This is a medical center that has transitioned to the EHR that the rest of the Institute uses, so they have experienced the return of space back to the practice now that paper charts are gone. You can see a scanning station in one of the images - this is where the medical records room used to be.

This medical center is interesting in that it also houses a dental practice, which coexists well according to the Medical Director. It was pointed out to me that the dental exam rooms have no doors, to promote team efficiency. The dental practice also uses a dental-specific EHR, that in this case does not communicate with the medical EHR. I have long been fascinated with dental practices, because I believe that they have done a lot of work to maximize workflow in the era of electronic records that allopathic medicine could learn from. I have seen that dentists do a great job of involving care team members in the use of the EHR and in producing documentation, and this was the case here, when I asked how documentation was supported.

You’ll note the picture of the flourescent viewbox - physicians are forgetting how to use this in the area of digital radiology, and that’s the case here. There are challenges in this medical center in not having on site radiology, though. Radiology services can be challenging to arrange, and retrieval of exam data that goes with it can be equally challenging. This has implications for a personal health record and patients’ desire to have complete results available to them.

I was also able to talk with Paloma Hernandez, CEO of Urban Health Plan of Bronx, NY, and her Medical Director, Samuel De Leon, MD, about visiting this organization as one of our future sites. I got the sense of their innovation by the fact that they are now piloting iris scanners for patient identification, linked to their EHR system. It looks like they are doing outstanding work, as is the Institute.

As has been rumored for some time, Microsoft Corporation has jumped into the PHR arena, with HealthVault, which seeks to consolodate needed health information for patients. It looks to have a facebook-like integration quality, with developers able to add applications that users can subscribe to.

Microsoft Introduces No-Cost, Online Personal Health Record - iHealthBeat

More diversity in the field is welcome. The PCHIT project is really about understanding things at the health system level, to allow projects like this to flourish - whatever it takes to empower patients in their care.

Yesterday, Neil Calman brought me to meet with the Primary Care Information Project Group to follow-up on work his team has been doing to leverage the Institute’s EHR to support public health. I was only briefly introduced to the work they are doing, but I will of course want to learn more. A Personal Health Record system is part of their plans. I was given a nifty Electronic Health Records Action Kit by the group, which puts together the rationale for going electronic very nicely.

There is not yet a personal health records action kit that I can see, but judging from the quality of the EHR kit, I think they’ll do a good job with this one when it’s produced. The team was very welcoming of new ideas and I was also impressed at their interest in understanding the EHR and how to leverage it to maximize the community’s health. It seems like a very nice partnership.

First site! Institute for Family Health, based in New York City.

I spent my first day at Sidney Hilman Family Practice Center, shadowing 3 clinicians and flow staff. Pictures are below, click on any to see as a photo album.

I started the day shadowing flow staff (medical assistants) to see how patients are roomed and brought into the practice. They do something I have not seen in my practice, which is assess patient’s learning ability for every new patient, prior to the provider entering the room. They do this via a template that they fill out with the patient. Something I heard a medical assistant tell a patient that I really liked: “Have a nice visit…” - this seemed to be nice stage setting for a good interaction.

(more…)