PCHIT links for December 26th through December 27th:

• Early Experiences with Personal Health Records — Halamka et al. 15 (1): 1 — Journal of the American Medical Informatics Association - As reviewed here: http://www.pchit.org/2007/12/27/242/
• Patient-centered Applications: Use of Information Technology to Promote Disease Management and Wellness. A White Paper by the AMIA Knowledge in Motion Working Group — Demiris et al. 15 (1): 8 — Journal of the American Medical Informatics Association - Nice description of what we know/don’t know about PCHIT. However, given that the rest of the world uses IT in a more customer centric way, are we going to wait for research?
• PHRs: From Evolution To Revolution by Liz Boehm - Forrester Research - Interesting commentary on health plans, PHRs, and adoption. Are health plans ready?

There’s an excellent viewpoint paper published in this month’s issue of the Journal of the American Medical Informatics Association:

Halamka JD, Mandl KD, Tang PC. Early Experiences with Personal Health Records. J Am Med Inform Assoc 2008;15:1-7.

It is a nice supplment to the paper previously published by colleagues at Group Health Cooperative about their 7 year experience implementing and operating a PHR:

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.

There’s a link to this paper as well as a presentation I made about the Group Health Cooperative story here.

The paper adds very helpfully to the body of knowledge about how to operate a PHR specifically. Unfortunately, there is no guidebook on how to make medical record information transparent. Some points of interest and comparisons to what I know about Group Health and Kaiser Permanente’s PHR systems:

• There’s a nice overview of lab, problem list, and clinical data sharing policies. There’s a spectrum here. Kaiser Permanente so far is the most advanced in my opinion, with real-time sharing of lab results in several of its regions, including Northern California, which results 21,000,000 labs per year. BIDMC is sharing imaging and pathology results after a delay, which is the most advanced I have seen. These pieces of data are the next frontier in many organizations, including Group Health. I liked that at BIDMC, they have set up sharing to be reconciled as most the most transparent setting when there is a conflict between members of a patient’s care team. I might suggest that we apply the same rule nationally - let’s have the medical profession adopt the most transparent policy in use at any given institution. We (at Group Health) have found this to be the most empowering of our members.
• On the point above, there’s really no place to go to compare sharing policies and devise a new standard for our profession. At the current time, each medical group is deciding based on its own judgement. Some involve patients and consumers in this decision. Some do not. There’s no “toolkit.” The last time standards for electronic messaging were published by AMIA was in 1998, if I am not mistaken.
• Adoption by patients seems to be less robust in Massachussetts relative to other places. The adoption curve for PatientSite looks relatively flat. Curves for Group Health and Kaiser Permanente are more like hockey sticks. This is something Josh and I are trying to understand as we work with folks in Boston (Harvard Vanguard Medical Associates and Partners Health Care have similarly appearing trends). The conclusion I come to is that we should not believe that low adoption equals low interest by patients.
• It was interesting for me to note that in Massachussetts, medication data may not be shared from health plan databases, but it may be shared from provider or retail pharmacy databases. Does this hinder support for PHRs from the health plan sector?
• Children’s Hospital in Boston operates a more patient-centric system out of the box. I could not discern what the uptake has been of this system from the article. Does this point to a tension between system flexibility and scale as we move ahead? Does the tethered nature of the largest PHR systems (Kaiser Permanente, Group Health Cooperative, BIDMC, Partners, Geisinger) probably make them easier to promote and manage as part of the patient-physician relationship?

This paper is very timely and another demonstration that patient centered health information technology has a growing leadership base within the medical profession. Perhaps a great next step might be for the medical profession to take these experiences and innovate in care standards about what we share with patients (as much as possible) and what we deliver with each clinical interaction (information relevant to the moment of care during and after the visit).

Today’s links are representative of the fact that we aren’t doing observations right now. Instead, we are preparing our first 90 day interim report for our partners. This means looking back on the last 90 days, and putting together our impressions at the interface between patient and health system, along with relevant background and policy information. We’ll post that here, of course.

PCHIT links for December 24th through December 26th:

• U.S. healthcare payers to limit IT investments in 2008 -
• ACGroup, Inc. Whitepapers - Nice overviews of the EHR market and physician practices
• PHRs: From Evolution To Revolution by Liz Boehm - Forrester Research - Interesting commentary on health plans, PHRs, and adoption. Are health plans ready?

I was invited to the blog to tell about the exciting development I’m involved in with the Primary Care Information Project (PCIP) at the NYC Department of Health and Mental Hygiene. I began my position as Coordinator of Consumer Informatics in September. We are working with a vendor to customize their EHR and web portal to support self management. Our special focus is to use technology to improve the health of the public, especially the Medicaid and uninsured populations in NYC.

This is a wonderful opportunity for me to use all parts of my experience and education. I’ve been a family nurse practitioner (FNP) since 1982, and I’ve maintained at least a day or two a week practice, mostly in community health centers (CHC), ever since. At one CHC, I consulted in the development and implementation of a custom EHR. I have formal informatics post-doctoral education and experience working with Sue Bakken at Columbia University. We developed and implemented hand-held computerized encounter documentation system for the ~300 Columbia NP students. Prior to that, I directed the FNP program at the University of Pennsylvania School of Nursing. I am proud to say that many of those graduates are now working in CHCs. In NYC, 100% of the CHCs will participate with the PCIP. Our self management tools are being built on the published evidence base and on years of self management and clinical systems improvement done by our health department. Stay tuned, and I will tell you about it as it grows!

PCHIT links for December 24th:

• Life as a Healthcare CIO: Standards for Personal Health Records - To prove a point about portability, John Halamka, MD, posts his medical record on his blog, in unstructured and structured formats.
• Health Privacy - Health Privacy 101 - HPP Releases Best Practices for Employers Offering PHRs. A good primer on PHR practices for employers.

PCHIT links for December 19th through December 21st:

• RCHC Redwood Community Health Coalition chooses eClinicalWorks - A California Safety-Net system that is implementing an electronic health record.
• Racial Profiling: The Unintended Consequences of Coronary Artery Bypass Graft Report Cards — Werner et al. 111 (10): 1257 — Circulation - I am starting to dig a little into disparities research. The authors point out that the benefit of CABG is the same for diverse populations, yet the performance is not the same. Should we think of HIT in a similar way? I am worried about profiling in the
• How Do Physicians Use the Internet for Work-Related Activities? - iHealthBeat - 39 % say they e-mail online with patients, 20% in 2005, with NCI estimate at 10%.

PCHIT links for December 18th:

• Electronic Health Information among Community Health Centers … - Penetration of EHR’s in Community Health Centers
• Electronic Health Information among Community Health Centers: Adoption and Barriers - Information about adoption of EHR’s in community health centers, 2006
• Remarks to the National Association of Community Health Centers - Information about HIT deployment in community health centers, including large grants this year
• Massachusetts (Mass) Health Policy Forum - Title - Comprehensive view on the Health IT Landscape in MA
• Perceptions about computers and the internet in a …[Ambul Pediatr. 2005 Mar-Apr] - PubMed Result - Study from University of Washington showing impressive use of the Internet
• Use of the Internet to Communicate with Health Care Providers in the United States: Estimates from the 2003 and 2005 Health Information National Trends Surveys (HINTS) | Beckjord | Journal of Medical Internet Research - 10% communicate with health care providers; no association with education level or income which is significant.

Presentation: Patient Centered Health Information Technology, Ted Eytan, MD

As I mentioned previously, Josh and I are hoping to add sites local to the DC/Maryland/Virginia area to the PCHIT initiative. I visited Baltimore Medical System this week. I have also reached out to the District of Columbia Primary Care Association (DCPCA Blog: Click here).

I first heard of DCPCA’s work well in advance of the initiative starting, through articles in iHealthBeat that discussed a new city-wide EHR network. As I have learned more about the project (DCPCA is connected to New York’s PCIP as well) and Medical Homes DC which it falls under, I have found that it is very “real.” So real, in fact, that I was invited (and graciously accepted the invitation) to sit in with providers as they trained on the new system. It has gone live for practice management in the first medical center, and will go live for clinicals in early January.

I presented the attached presentation to the Early Adopter EHR Advisory Group, informing implementation at the first 6 sites. The group welcomed a discussion of patient empowerment features of an EHR and we discussed the capabilities of the system being installed, eClinicalWorks, which are present and include a patient portal as well as after visit summary features. All exciting to hear about.

An issue we spent some time on was regarding digital disparties. I presented information from the medical literature and some of my own experiences, which show that maybe there are disparities of perception of what patients have access to. Here is a link to the cloud of studies Josh and I have reviewed on the topic to date:

PCHIT’s links to studies on digital disparities

As we have learned that bypass procedures should be equally effective for all members of a community, similar data is emerging that may lead us to the same conclusion for personal health records - that every health system can empower its patients using them. This could provide fuel for safety-net organizations to think about innovating in this realm as they innovate with EHRs.

Like Balitmore Medical System, DCPCA-supported medical centers are not yet officially part of the initiative. I hope to spend more time with them and eventually encourage sharing of their experiences, and maybe even invite an innovative clinician or two to blog with me here. What I am seeing so far is a very strong effort with the potential to be a model for many other health systems in the nation in HIT innovation.

With great thanks to DCPCA and EHR early adopters for entertaining this conversation and all that they are doing to move into the future for their patients and their community. It is very impressive work.

PCHIT links for December 17th:

• Clinical Messaging Is Costly but Worth It, Says Vanderbilt Study ? Digital Healthcare and Productivity - Useful information when doing cost-utility analyses around messaging, perhaps.
• e-patients: Markle Foundation Policy Meeting 2007 - Notes from the meeting. What will be achieved, e-patients asks?
• Exploring Social Contextual Correlates of Computer Ownership and Frequency of Use Among Urban, Low-Income, Public Housing Adult Residents | McNeill | Journal of Medical Internet Research - A respectable 51% owns and 42% of adults in low income public housing uses computers, narrowing the disparity gap. Do they have internet access? Interesting correlates with neighborhood safety.

We are three months into the PCHIT initiative, and we would like to add additional sites that are local to the Center for Information Therapy, to establish a longitudinal relationship of proximity to care systems.

One such care system is the Baltimore Medical System, which I toured with Chief Medical Officer Kyu Rhee, MD yesterday. We went to the Belair-Edison site and the Middlesex site.

I have to say here that the day was a very interesting one for me, as I spent the morning at a Kaiser Permanente medical center in a nearby community, and the contrasts were very striking. Both organizations are working hard to improve their service in admirable ways, even if their service challenges are vastly different.

BMS is undergoing a significant transition, into the electronic age. It is also undergoing a leadership transition, with Kyu accepting a new position at the National Institutes of Health, where he will further pursue his interest in reducing disparities in health. Our tour was a little bittersweet because of this, as Kyu bonded with colleagues at the two medical centers we visited.

Kyu has been Chief Medical Officer of BMS for 2 years, with previous experience as a medical center Medical Director and internal medicine/pediatrics physician in a safety-net medical system in Washington, DC. BMS serves about 55,000 patients at 11 sites (as of 2006), and it funded acquisition of its EHR, manufactured by Misys, on its own, which is remarkable for an organization like this. As the data that Kyu pointed out, 8% of community health centers have EHRs. This puts BMS in the 92nd percentile. It also frames my work a bit, as I have been tending to visit the early adopters - having an EHR is far from being the norm.

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