Charles Milligan, Jr., is the Executive director of the Center for Health Program Development and Management, University of Maryland, Baltimore County. I have to insert here that Chuck is also an alum of the University of Calfiornia, Berkeley School of Public Health…

The Center’s Mission is “…to work with public agencies and nonprofit community-based agencies in Maryland and elsewhere to improve the health and social outcomes of vulnerable populations in a manner that maximizes the impact of available resources,” and Chuck brings his experience here as well as experience supporting diverse populations in California in the areas of health care law and policy.

Chuck stimulated a very key conversation that resulted from a little confusion of my part (as I have now surmised). We talked about “PDCA cycles” and the idea that in the Toyota Motor Company, 80% of time is spent on planning, 20% on execution, the opposite of some American Companies. In our discussion these concepts seemed at odds, because as Chuck pointed out, policy makers benefit from quick movement from planning to execution so that they have something concrete to work off of.

Chuck also provided guidance on consumer involvement, that as we look to readily available sources of input, we should also look for not-so-readily available sources of input, because community boards and the like may not be truly representative in every case.

As Maryland’s leading public applied research organization for Medicaid Managed care, the Center is working on appropriately adjusted outcomes measurements that support reimbursements, or as Chuck stated, “report cards that are fair.” His group is also working on an electronic health risk appraisal and the impact on utilization before and after.

With UMBC itself, Chuck alerted us to a forum on behavioral health issues on campus, that will touch on issues of confidentiality and safety, which will happen on November, 27.

The Adjust: I couldn’t wait to resolve the issue regarding “P” from PDCA and “Planning,” and referred that question out to some experts in the LEAN world, which is detailed on the DailyKaizen blog in this post. The adjust, therefore, is in my opinion to keep going by rapidly improving what we do, and the 80% time planning spent happens in the P, C, and the A parts of the cycle. In that respect, Josh and I are doing regular checks on what we are doing. I am also working on setting up a visual system for the work (I will post the picture here, of course).

Chuck is one of the experts on our group regarding reimbursement and care of vulnerable populations, so as with other members of the group, we would like to check on what is happening in this arena. We are already doing that a bit based on the guidance by working to arrange discussions with payers in communities we are visiting. We did this in Boston, and are working to do this in California, our next stop.

In the PCHIT initiative, our primary point of contact for shadowing clinician-patient interaction has been the clinician and has taken place in clinics. However, we know that very few people–even those with chronic conditions unless they have serious acute events–spend more than 1% of their time in traditional clinical settings (think about how many hours out of hte 8,760 hours in a a year you spend in the doctor’s office or hospital).

For that reason, it’s equally important for us to spend time shadowing consumers accessing health information and health care from their homes, workplaces and elsewhere. While on our recent trip to practices in Boston, I had the opportunity to visit with two consumers, and learned about their recent experiences accessing new personal health records (PHRs).

These two people are older, well-educated adults, but both are fully “wired” seniors.  They recently were informed that they had access to their own personal health information (PHI) via a secure portal from their health plan. However, they weren’t given much guidance on what was available and how to make the most use of it. Moreover, they had access to very little PHI aside from medications (there does appear to be a function for renewing prescriptions). There was no access to lab values or other tests, and no link to content that would provide context on how the limited PHI that was available related to their health.

Interestingly, that health plan also seems to be involved in a PHR/health risk assessment (HRA) pilot project with the CDC using a separate platform. One of them received an email from his health plan a couple weeks ago asking if he wanted to participate, and he responded to a survey–basically an HRA. That ultimately led to the generation of an information prescription reminding him to get his flu shot. The reminder–and a second one to reinforce the message–made use of fancy graphics and mapping software to impart the flu shot recommendation. However, the glitzy mapping and graphics were, more or less, irrelevant to the message, and there was no content in the message that explained the health rationale behind why a senior with diabetes could benefit from an influenza vaccination (many people don’t think of the flu as being a serious illness despite the fact that it is responsible for 200,000 hospitalizations and 36,000 deaths every year in the US, and people with chronic conditions are at greatest risk for serious complications). Given the information he was prescribed, this person’s logical reaction to the email he got was: What’s the point of this map and why should I care about this message? 

This reinforces how important it is that we not assume that “If we build it, they will come.” Our PHR “Field of Dreams” requires that we are thoughtful in how we connect PHI to health content. PHI data points and informational messages need to include a health context so that the information has clear meaning to the individual and effectively communicates the health rationale for desired behaviors or informed decisions.

PCHIT links for November 9th through November 13th:

• JAMA: Soliciting the Patient’s Agenda: Have We Improved?, January 20, 1999, Marvel et al. 281 (3): 283 - Data often cited and here’s the source: patients redirected an average of 23 seconds while providing their history.
• The Center For Health Design Research - Pebble Project - Center for Health Design supports evidence based design of health environments. Have they done work in PHR/EHR enabled institutions?
• Life as a Healthcare CIO: Personal Health Records - John Halamka, MD, supports the idea that PHR adoption is not a technology issue. Consistent with my findings on our recent trip to Boston.
• A Model for Health Care That Pays for Quality - New York Times - NYT Reports on Patient Centered Primary Care Model promoted by ACP, IBM, and others
• E.H.R. Home - HL7 announces balloting for PHR standards

Deven McGraw is the Chief Operating Officer of the National Partnership for Women and Families and brought terrific community-centric perspectives to the discussion, through her work with the Partnership and also through her expertise on health information technology issues.

She serves on the Privacy, Confidentiality, Security Workgroup of the American Health Information Community and is our link to that organization. She is working on defining what the best privacy and security protections are for consumers. She is also active in policy issues and specifically empowering consumer groups to impact ways that systems are shaped. This includes access, and also beyond access to issues related to the quality of care once access is achieved. New developments for her work include work to provide technical assistance to state-based organization.

The Adjust: Deven talked with us about creating “workable models in a community where people enjoy what they have.” This was key in that the measure of success will come from the people who are being served rather than the care providers, and this is what a federal system can point to and scale. With this in mind, we are going to gather information about community and consumer involvement as we work with organizations. As we just got back from Boston, we already started bringing this into the conversation. It is critical because when adoption of PCHIT by patients is at issue, it is relevant to look at their involvement. Another adjust at this point is to think about how this work will support policy activities - we really have not defined that at this point (and purposefully, from my perspective, to get experience at the practice level). From here, though, we should begin investing in awareness of the work of the National Partnership and other policy experts to shape this work for that audience.

Continuing where I left off last week, with feedback and adjustments from members of the PCHIT Advisory Group:

Susannah Fox is an Associate Director at the Pew Internet & American Life Project, whose work has been very influential in describing people’s use of the Internet.

Susannah just published a report on patients with a Disability or Chronic Disease that we mentioned here previously.

Upcoming work that we will take note of includes work around PHR’s and EHR’s (Susannah is currently a contributor to e-patients.net), and a research agenda that will go beyond measuring simple Internet use. She describes this as “Attitude, Actions, Assets” and is looking at information ecosystems and people. Within these reviews, she will focus on 2 key populations: Latinos, and Teens. Within the teens group, she will be taking a look at gaming, and teens and writing.

It goes without saying that we follow Susannah’s work in a very dedicated fashion. I have been subscribing to the RSS Feeds offered by their site since I started using RSS. The forthcoming reports will offer an important view on PCHIT, especially now that I have returned from Boston and was able to observe care given in leading edge medical centers serving Latino patients, among others.

Key health care leaders are saying the time for PHRs are now. Based on the Boston visit, I am saying the time for multilingual and culturally relevant PHRs is now. We’ll be therefore eagerly awaiting these two new reports on the Pew web site.

Speaking of the Pew web site, Susannah is also managing its redesign, to make the information more modular and accessible, while incorporating the latest Web 2.0 feature. At least that’s our expectation. Given Pew’s current work in informing builders of Internet services for patients, we’ll look forward in how they inform the builders of the communication tools of those builders.

PDF: 7 years and 140,000 patients later

While at Cambridge Health Alliance, I gave the attached presentation about Group Health Cooperative’s work to transform care through the use of technology. One of the organization’s leaders asked if I could forward a copy of the slides, or would they just be able to download them off of this blog.

Since this is information that our organization has provided in many other forums, the blog idea sounds ideal, so here it is. These are just the slides, without any narration; however, they may give you a feeling of our journey to support our members’ care. The narrated version is available from myself or one of my Group Health colleagues, feel free to contact us.

If I were to characterize the most important points:

1. Group Health Cooperative launched the personal health record in tandem with the ambulatory EHR, with great results for patients and their care providers.
2. The focus is on the member experience and their ability to enjoy unparalleled access and transparency through the use of these services.
3. Group Health is a pioneer in Information Therapy, and includes Ix prominently in its work
4. Thanks to the electronic Health Profile, patients and physicians can now work together to achieve life goals through optimal health, before illness strikes. The future is here, and it’s bright!

These accomplishments come from a team of individuals within the organization committed to a patient-centered care for Group Health members, and every patient in every care system. This is the basis for the open sharing of this information.

Update, November 14, 2007 An excellent descriptive paper of Group Health’s work was published in JAMIA this week. Congratulations to James Ralston, MD, from the Group Health Center for Health Studies. This paper helps answer questions about “stickiness,” adoption, and overall patient satisfaction (hint: it’s high).

Ralston JD, Carrell D, Reid R, Anderson M, Moran M, Hereford J. Patient Web Services Integrated with a Shared Medical Record: Patient Use and Satisfaction. J Am Med Inform Assoc 2007:M2302.

Enjoy!

My journey in Boston was completed with a visit to one of the large health insurers in the region, and to Cambridge Health Alliance, which serves Cambridge, Somerville, and Boston’s metro-north communities.

While in the area, I did manage to make a visit to the LEAN Enterprise Institute, where I was thrilled to meet James Womack, the author of several works that have shaped much of the work underway at Group Health and other health institutions. While at LEI, we talked about the penetration of LEAN into the health care space. Organizations in Boston are lucky to have access to this teaching and research resource so close by.

Health Plan Perspective: I visited with a physician in one of the region’s largest health insurers to learn more about the financing environment and its relationship to patient centered HIT work. As people in the field are aware, Massachusetts is home to the nationally recognized eHealth Collaborative, which is bringing 34 member organizations and pilot communities to support adoption of EHRs statewide. As the MAeHC web site, states, this is a $500 million proposition. In the discussion I participated in, two key questions arose from the plan perspective: 1. Who owns the personal health record? and 2. How and if will it be adopted? These are very helpful questions to keep in mind as we talk about innovations that require participation from a whole system (providers, patients, financing) to be successful. As I come from an environment where all are aligned within the same organization, it’s good to know what the key issues are. There will tension between interventions where ownership has been reasonably well established, such as disease management, and for which outcomes can be measured. Everyone wants to make investments that directly support beneficiaries. A recent article I read pointed out that there is much experimentation going in in the health plan sphere. The challenge, therefore, may be around focusing strategy toward PCHIT. The key questions mentioned may need to be answered to get us there, which is helpful to know.

Cambridge Health Alliance: The practice: My guide on my visit was Hilary Worthen, MD, Director of Medical Information Systems for CHA, and primary care practitioner for 25 years. Hilary and I did the thing I enjoy so much - walking through the community to understand it better, which brought us to Union Square Family Health and its Medical Director, Rachel Wheeler, MD. Cambridge Health Alliance, like East Boston Neighborhood Health Center, is fully electronic, using the EpicCare electronic health record.

The pictures (click on any to see full size):

(more…)

Dr. Jonathan Wald and myself spent another morning shadowing at Brigham and Women’s Hospital, which is a teaching affiliate of Harvard Medical School. It was a personal honor for me to be paired with David Bates, MD, MSc, whose work I have admired, respected, and used to inform how I serve patients for a long time, in the field of Informatics, Quality and Patient Safety. On this day, David was seeing patients from his own panel, in the capacity of general internist.

Before we started the day, though, Jonathan took me through the halls of the hospital, where there was an exquisite display of portraits of pioneers in the medical field, including Dr. Helen Brook Taussig, the founder of pediatric cardiology, and Dr. Paul Dudley White, who co-described Wolff-Parkinson-White syndrome, a staple of every medical student’s education. I think Jonathan and I are of the same mind in thinking that it’s important to reflect on where we came from as we do this work. Before Dr’s Taussig and White, we didn’t know how to manage congenital heart abnormalities or how electricity traveled through the heart, and now we do, because they said, “We don’t know how to do this, yet.” We’ll say the same thing in the application of technology to make care more patient-centered.

After spending time at BWH, I went to East Boston, to visit Frances Kuebler, MD, who is President of the Medical Staff and Physician Champion for East Boston Neighborhood Health Center’s EpicCare installation. EBNHC is an important part of the East Boston community, and serves a broad diversity of people who rely on the health center almost exclusively. This neighborhood health center is also state of the art technologically, one of the reasons I wanted to visit. I shadowed Stephen Simon, MD, in his practice.

Part I: The Pictures, Part II: The Practices (next post)

In the last post, I described my day at two different care organizations; Partners, and East Boston Neighborhood Health Center.

Continuing, a summary of….

The Practices:

Brigham and Women’s Hospital, Dr. David Bates: I shadowed David for several patients who are on his panel and well known to him. David uses the Longitudinal Medical Record produced by Partners Health Care, integrated with Patient Gateway. Jonathan Wald, MD, the Physician Lead, was next door working with a colleague to talk about Patient Gateway in practice. I think there were a ha’s for all of us about how to use a resource like this, including how to bridge the world of regular electronic mail and the PHR. David visibly practiced Information Therapy in front of me, when he printed out a document to describe a condition for a patient he was treating. The LMR as I understand it, does not automatically produce an after visit summary. I didn’t see David use Patient Gateway features during our visit, but we did have some time to talk about PHRs and the interest in supporting good research for the production of good outcomes knowledge about how to use them in practice. Jonathan is working on the issue of patient adoption, which he may comment about separately

East Boston Neighborhood Medical Center, Dr. Stephen Simon: EBNHC uses EpicCare, and has used it since 1998. Physicians have been documenting and ordering using the system for about 4 years. Their urgent care is also on the system. In shadowing, I was able to observe the first visit in this experience in Spanish, which was important for me to see. In the exam rooms at EBNHC, screens are pointed toward the exam table, where physicians can review data with their patients together, and I saw this happen in the visit(s). Stephen was very facile with EpicCare and has taken the time to customize it for best use. EBNHC does not yet have a PHR active for its patients.

One thing that was really important for me to see was a difference in focus. During my time at EBNHC, the staff was applied to recent health care reform policies that have gone into effect in Massachusetts, which affect everything from co-pays to drug formularies. It was impressive to note how much this was on the minds of the staff here, to support a transition that is successful for their patients. This issue did not come up in conversation at the other medical centers - different populations, different needs. I honestly know very little about this initiative as I don’t live in this community, but it’s clear that it should be understood as a modulator of capabilities. At the same time, EBNHC is also pioneering electronic prescription transmission from its EpicCare system.

The PHRs:

Partners, as I mentioned earlier is positioned for adoption, and are making plans to integrate the Patient Gateway into practices more. The system has good functionality and can provide staff experience in using technology to reach patients wherever and whenever they need to.

EBNHC, in contrast, does not yet have a PHR online. The considerations here are the impact of system upgrades, which must be done accurately, and continued optimization of portions of their system. Much like the Institute for Family Medicine in New York, they maintain a very robust EHR with a smaller staff pool. It’s actually very impressive. In fact, during my time there. Dr. Kuebler was updating parts of the system based on requests for her peers, like in near real time. That’s nimble! This can also make readiness for the jump to PHR more challenging at the same time. One key issue for this population is the need for a multi-lingual PHR. Coming to East Boston really brings home the fact that the time now upon us to address disparities in the way systems are designed so that they are accessible by the same population that accesses the health system. It felt very real when I was there.

Of course, Josh and I would like to follow both organizations as they continue on their journey to support their communities in the distinct ways that they do. I think both will contribute to the conversation significantly.

With thanks again to Drs. Wald, Bates, Kuebler, and Simon, and the staff and patients at Brigham and Women’s Hospital and East Boston Neighborhood Health Center for the gift of their time.

Patient Education Center, Bulfinch Medical Group

Immediately as we entered Bulfinch Medical Group (BMG), an outpatient practice affiliated with Massachusetts General Hospital (part of Partners Healthcare), we saw a fantastic educational resource center for BMG patients. It was integrated well both physically and functionally to fully support clinician-prescribed Ix. 

As you enter through the door to the practice, the resource center is immediately on the right, staffed by a welcoming and knowledgeable health educator, who can guide users to the right electronic and print materials (I think there were three computer work stations for patients…or, I suppose, family members waiting there during the appointment, wondering about their loved ones’ conditions—a clearly strong information-seeking space). What is particularly notable from multiple perspective—functional, aesthetic, and philosophical—is that it is separated by glass so that it can be a distinct, quiet setting and yet one that is central and visible to every person who enters the practice (you just can’t miss it!). In many clinics that have started down this road, they may have a small kiosk or computer station sitting in the waiting room that doesn’t particularly important or inviting. In larger clinics or community hospitals, they might have a separate resource center or patient library, but it often is not in a place that the average patient would notice.

It appears clear to me that this architecture was philosophically intentional and is fully supported by how the resource center is integrated into the clinical encounter. The office staff put an “Information Rx” prescription pad with a patient information sheet, making it a routine part of every clinical encounter. For example, when the nurse practitioner I shadowed was finishing up an appointment with a Brazilian nanny experiencing back pain and carpal tunnel syndrome, she complemented her oral care plan and next steps with the Ix to be filled in the resource center—noting that the content she had checked off from a list of several dozen options—needed to be provided in Portuguese. The nurse practitioner noted that it might take about a day for the resource center to fill that language-specific information prescription. The patient left the exam room with both her Rx (over-the-counter pain reliever and a muscle relaxant) and her Ix (to understand how to prevent and reduce back pain and physical therapy exercises to do on her own).

Marcy Bergeron, Director of Quality Innovation, described other Ix innovations that BMG has implemented, spearheaded in significant part by Marcy. Perhaps most impressive is how far BMG has advanced its pre-visit prep for annual physicals. The initial BMG initiative was (I think)launched soon after the 2004 Ix conference and was decidedly low-tech. Not wanting to be constrained at the pace of Ix implementation by technology integration limitations, BMG moved forward with a manual pre-visit prep Ix sent via regular US mail. Now, pre-visit Ix can be filled online through BMG’ online tools (http://www.massgeneral.org/bmg/forms.html).