Yesterday was the final day of the Kaiser Permanente HealthConnect Online Leadership discussion, which carried themes over from the previous day around making a Personal Health Record work for members. Of note:

• Improving the ways members achieve secure access to the PHR. During the recent natural disasters in Southern California, Kaiser Permanente established a telephone-based process for members to verify their identity to use the PHR, for people who no longer had access to basic items like mailboxes and reliable computer access. This allowed them to continue to manage their health during difficult times. The system will eventually be expanded to include all members across the nation, with an online version that can provide secure identity verification.
• Helping the industry to define the ideal PHR based on working models. Jan Oldenberg, from the Kaiser Permanente Internet Services Group, is bringing the experience of the organization to the public as it creates definitions and requirements for what a PHR should be. In this way, communities do not have to guess at the services and features that are most useful to patients as they ask for these services. Of note, Jan and the group are engaged in the HL7 PHR Standards Definition, which is currently accepting public comment until tomorrow. We (and all of you) are reminded to review these and provide input. When standards are agreed upon, we can all move forward quickly.
• Customer Service Support. A PHR brings support needs with it, and Kaiser Permanente logs in the neighborhood of 40-50,000 calls a month, tied predictably to new feature rollouts, but also to issues that can be resolved by listening to members. I was personally delighted to hear that since Northern California began automatically sharing lab results in August, 2007, call volume for lab results has remained flat, despite larger volumes of information being shared with members. From my own work with PHR’s, I know that it is never too early to involve customer service support professionals in implementation. Going even further, it is never a bad time to sit with customer service professionals in person as they support members on the phone, in person. I’ve done this and it’s an incredible learning experience.

And the end of two days, I learned a lot, even as a pioneer in the PHR space myself. Here is an organization that is up and running in a big way, and they are beyond asking “should we do this?” They are saying, “We are doing this for our patients. Now, how do we do this better?”

There were no blanket statements, like, “we should do it this way.” Instead, I heard a lot of, “what do we know about what members need, and what works for them?” and “As a member, how would I feel about this or that approach?” - Many times.

Thanks again to Kaiser Permanente, and especially Judy Derman, Senior Practice Leader, Internet Services Group, and Kate Christensen, MD, Medical Director, Internet Services Group, for letting me sit in, and letting me share what I saw here. I think it’s useful to have this snapshot out there for leaders who are moving the practice of medicine forward in a patient/person/family-centered way.

PCHIT links for November 26th through November 28th:

• Are Your Patients Ready for Electronic Communication? - October 2007 - Family Practice Management - Nice story about a practice that learns its patients are ready. Helpful survey included
• The Digital Office - Special edition on PHR’s, from HIMSS
• Society for Adolescent Medicine: Advocacy/Policy - Position paper on confidentiality / privacy for teens
• Pacific Business Group on Health - Page on Building Healthcare Value - nice summary from the purchaser perspective

Kate Christensen, MD, Medical Director, kp.org, with Paulanne Balch, MD, Physician Lead for HealthConnect Online, Colorado Region

Greetings from Oakland, where I have been graciously invited to attend a get together of Kaiser Permanente’s clinical and business leadership for HealthConnect Online, which serves the personal health record connected to the electronic health record, HealthConnect, and accessible through kp.org.

I will say that even in the absence of the PCHIT work, I would want to be here. Why? Because I have always thought that the most innovative staff within Kaiser Permanente support the HealthConnect project, and the most innovative of that group support HealthConnect Online.

This was the first such meeting with every Kaiser Permanente region now fully live with the PHR, with Ohio up now for 30 days. And from my perspective, the news is good. As each region of the system discussed their current and future plans for the PHR, commentary focused on value of each feature for the members. I really liked what Gail Sands, Director of Innovative Projects for the Ohio region said: “This is the patient’s chart. They should know what’s inside.”

Strides in Transparency

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PCHIT links for November 15th through November 21st:

• Healthy San Francisco: - San Francisco starts a Medical Home program
• Nurture by Steelcase > Home - Work by Steelcase for a supportive health care environment
• EHRs Lack Features To Boost Patient Care, New York City Official Says -

I recently received my first email directly from one of my teen patients. I was thrilled! It was a long wait for us to get messaging up for parents of kids in our practice, as well as the teens themselves. The message was straightforward–a young woman I take care of needed a refill fo some of her asthma medications before leaving on a sports-related trip. She got her medicines, of course!

This is still the only message I have received from a teen in 5 months. So I did a quick check with my colleagues, and the experience is the same–we built it, but not very many teens have used messaging yet. I wonder why?

We knew from pre-HIPAA experience in California that when email access to an adolescent specialist was offered to parents and their teens, the parents accounted for 95% of emails, so I did not expect huge volumes of messages. But I think it also has something to do with how complicated it can all seem. Teen confidentiality rules are not easy to explain in 2 sentences or less, and it is even harder to quickly explain how our computers respect those rules. I think this makes it hard for physicians and other providers to enthusiastically promote email access in the exam room. Since providers are the single most effective sales force for email, that limits our success. I have to admit that even I, who ought to be our biggest champion for teen access, sometimes run out of time and energy to promote it with my teen patients.

I also think the teens are wary of a system in which their parents can read the secure email they send and receive. This is separate from the teen’s yahoo account, and is behind a secure firewall, but if their parents have access, both the teen and the parent can see the same emails. We have been very transparent about this, and have been very clear that email is not meant for confidential topics. But I think many teens still find this threatening.

Our software vendor (Epic) does have some major improvements in the confidentiality feature coming in a future release, so I hope that concern will go away for the teens soon. In the meantime, I am trying to figure out how to distill an explanation of what the teens can see, what the parents can see, and why into something that is short and easy for everyone to use. Tall order!

In the meantime, I am left with an email I got this morning from the mother of a child I take care of with autism. He is doing extremely well, thanks to endless energy from his parents and good early intervention. It was very easy for this mom to send me a message to update me, say thanks, and wish me happy holidays. I am not sure it would have happened if she had to leave a phone message. It is a wonderful start to the holidays for me, and reinforces why it is still worth spending time making access easy and safe for teens and their parents.

Site 3, after New York and Boston will be California. Josh and I will be spending time with Partners Kaiser Permanente and California Healthcare Foundation, as well as several care providers in a shadowing capacity.

Speaking of New York, Josh, Dorothy, and I joined Neil Calman, MD, on the monthly Ix Insights Webinar, where Neil we talked about the first visit to New York, and Neil’s work to support patient centered primary care in a large community clinic system. You can review the whole thing on the Center for Information Therapy web site.

As the subject of the post states, these awards, what some consider the Oscars of e-Health, have been published.

In the interest of creating the best person/user/patient/consumer experiences, the awardees listed provide a nice reference point for those looking to talk with organizations who serve their customers well online.

Three of the partners of the PCHIT Initiative, Group Health Cooperative, Kaiser Permanente, and California Healthcare Foundation were distinguished with Platinum and Gold Awards in several categories.

I know that both organizations spend a considerable amount of effort in involving their members in the usability of their web sites, and caring that they are usable. Maureena Moran is the Executive Director of Web Services and Enterprise Information Management at Group Health Cooperative, and she allowed me to share the kudos she gave teams at Group Health:

Kudos to the entire web team, including Web Services and ISD’s Web Development and Systems Integration Groups, in particular, for their undying commitment to defining, designing, and developing the best online services for Group Health’s customers!

We also won the top design award — Best Site Design — for a Medical Practice/Clinic. Kudos to Judy Hucka and her team, including our lead web designer Stacy McCauslin, and the entire User Experience team for their commitment to using the best internet design standards for ease-of-use and simple navigation.

I think having a web services team of any size is one of the most potent drivers of patient-centered care processes across all aspects of a practice. The skill and talent they bring to understanding what patients want when they are physically present as well as when they are not is priceless.

Center for Practice Innovation: Clinical Metrics show improvement

Information Therapy: No co-pay or formulary check required.

This was a big “a ha” for me while in attendance of the American College of Physisicans’ Center for Practice Innovations November Conference.

The title of the conference as “Focus on the Practice- Challenges, Choices and Change.” In complete honesty, my assumption was that I was going to learn about the challenges and difficulties of smaller practices in supporting the most current models of care. I did learn about some of that; however, my assumption was proven mostly faulty after seeing the presentations. What I learned about was about how smaller practices are actually not only getting there, but shining a light onto the rest of medical care through innovation.

I saw multiple examples of practices examining their care processes carefully and making improvements in the flow of information (even using LEAN-Toyota Management-waste reduction techniques).

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My name is Mark Groshek. I am a pediatrician with Kaiser Permanente in Colorado, and I am the lead physician in our organization for eHealth. Like all the Kaiser Permanente regions, KP Colorado uses an electronic health record from Epic Systems. In May of 2006, we launched on-line access for our adult members to much of their charts, including Email My Doctor, My Test Results, My Allergies, My Immunizations, and My Ongoing Health Conditions. I even sent the first email as a patient to find out when my next checkup was due!

As a pediatrician, it was painful for me that we didn’t have the functionality to be able to let parents use these features for their kids when we launched. So June 26 of 2007 was a banner day for us–we launched these features for parents of kids, and for parents of teens. And we launched direct access for teenagers.

One of the best things about my job is that I split my time between my pediatric practice and eHealth. That means that I get to use the tools I help launch to care for my own patients. I have a baby girl in my practice who had already been hospitalized twice with respiratory problems and an oxygen requirement by the time she was 2 years old. Her mother was not able to care for her, so her grandmother, who is single, was the primary caretaker for her and her older brother, and holding down a full time job as well. She had a lot of trouble getting her referral appointments scheduled at our local Children’s Hospital. So this little girl’s grandmother emailed me the first day. It was so much easier for her to use email to work through the problems with the referrals, and questions about how to adjust her oxygen, and still keep the rest of her life together. I am happy to say things are much better for this little girl a few months and several consultants later. Better yet, we were able to take care of a lot of issues without making her sit on the phone, or have to take time to come to the clinic. She has told me many times (in email!) how helpful this has been to her.

In medical care today, much of the care our patients need is asynchronous–they need information or advice, but it doesn’t have to happen on the spot. Telephone systems are not always very efficient, and can require people to stay on hold. Office visits are terribly time inefficient for our patients–a 10-20 minute doctor visit often involves half a day for our patients. When we need to communicate, but we don’t need to be face to face, email is tremendously helpful. I haven’t really used email with people I don’t know yet, and I think it is likely to be far more helpful when patients and their doctors already have a relationship. But I know from my experience how much it helps my patients, and I love it!

In future posts I will be sharing what we are learning from giving direct access to our teen agers, as well as to their parents.

Our first new Co-Author is Mark Groshek, MD, from Kaiser Permanente, Colorado. He’s a leader nationally in tackling one of the most interesting issues in PCHIT, adolescent care. His first post follows this one and he will be a regular contributor about his experiences.

This blog is an experiment. It’s the chronicle of a journey of discovery around patient centered health information technology. Josh Seidman and I have been witnessing experiences at the practice level in health care organizations and talking about them here. This blog is not about Josh and Ted’s journey, alone, though.

What we also wanted to do was have the organizations themselves talk about their own experiences over time, with us. Therefore, as I have gone to each site, I have asked for a volunteer leader from each to blog with us. The leader can be a physician, nurse, any care provider. It can be a patient. This is a person that would talk about their experiences supporting patient-centered health information technology - including Personal Health Records and Information Therapy - the good times, the we wish things were better times, and the “what do we do now?” times. This is the benefit of the blog platform - it is not good at describing perfection - it’s great at describing a little bit of improvement every day.

Why do this?

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