As part of our work to promote more effective preventive care and health promotion, we are experimenting with various ways to best leverage information therapy. One idea centers on the systematic use of behavioral change “prescriptions” (ie. exercise and nurtition) to activate patients. Exercise prescriptions have been well-described in the literature and an early example of customized patient centered information therapy.

The Rx format elevate the importance of lifestyle changes for both the provider and the patient. Since the instructions are patient specific and customized to a patient’s interests & motivational stage, they could be a useful tool for clinicians to activate patients more effectively. Operationally, since prescriptions are a part of a typical visit workflow, writing exercise prescriptions can help integrate exercise/nutrition counseling into the usual flow of the visit.

One of the challenges of behavior change prescriptions is how best to support them within our EMR system. Inclusion of these non-pharmaceuticals as prescriptions can lead to unintended downstream consequences - like cluttering medication lists used in SmartText. Conversely, having these as prescriptions may reinforce regular review of patient lifestyle and piggybacks on existing medication reconciliation systems. Medications can also be reviewed on the MyChart patient portal. Finally, having exercise/nutrition Rx does allow us to centrally track specific actions around exercise and nutritional support for patients (ie how many patients with BMI > 30 received an exercise Rx in 12m).

As we consider how to pilot the use of these prescriptions, we continue to search for operational and IT alternatives. We have considered embedding them into our After-Visit-Summaries, yet concerned that it perhaps loses some of its “influence” when not in the expected Rx format. Any suggestions would be welcome!

Joe

My colleague and fellow PCHIT advocate and blog co-author, Joe Kimura, MD, of Atrius Health / Harvard Vanguard Medical Associates steered me to this article and asked me to take a look, which I am happy to do here for PCHIT readers:

Zickmund S, Hess R, Bryce C, et al. Interest in the Use of Computerized Patient Portals: Role of the Provider–Patient Relationship. Journal of General Internal Medicine 2008;23:20-6.

I’m reviewing the article through the lens of my own experience using a version of the same patient portal product that UPMC is using, MyChart, produced by Epic Systems, Inc., although the paper does not explicitly mention what product they are using. I think this makes a difference in the interpretation.

The other thing that makes a critical difference in interpretation is the environment in which the product is being rolled out. I will get to that later.

The study encompasses the performance of ten focus groups involving a total of 39 diabetic patients who were portal naive and then portal experienced, as the groups were performed in two waves. This is excellent - a view onto the experience of a patient portal experienced patient is needed in the literature.

The other excellent thing in my mind is the voice of the patient throughout. I wish that the medical publishing industry would become Web2.0 savvy and allow authors to post video vignettes of the patients’ voices on YouTube or something similar. I give a presentation from some of Group Health’s focus group work, and the video is very powerful.

Think of this example:

When I start talking nutrition [with the provider]…it’s almost like I’m not saying anything r I’m just saying ‘blah, blah, blah.’ It’s like she’s not even listening at that point.

(more…)

Once again, our advisory group generated several valuable insights that will help us refine our thinking. In this case, they had the opportunity to respond to the draft interim report we generated based on the first half of the PCHIT Initiative. What is especially valuable is placing the findings from our research in the context of their extensive and diverse experiences.

What follows is some of the feedback we received that complemented and/or reinforced our preliminary findings in each of the areas that we addressed.

Safety-Net Providers

• We need to think creatively about how we make people aware of the PHR concept.
• An open question remains: How much of a prerequisite is an EHR for implementing a PHR? Can safety-net providers develop a concurrent roll-out strategy for EHR/PHRs?
• There might be opportunities to take the models of safety-net leadership in places like New York City and translate them to other urban settings.
• In order to get broad-scale safety-net engagement, a series of pressure points need to be applied simultaneously.
• Are there parallels that can be drawn between the role that libraries have played for low-access (to the Internet) populations and the opportunity that safety-net clinics can play for underserved populations? According to a Pew Internet Project study, libraries poured resources into digital connection, and it has helped them to maintain their relevance in the 21st century.

Small Physician Practices

• More needs to be done in the health care industry to lay out multiple pathways for small practices to engage with their patients electronically.
• Attention to the challenges that small practices have in creating common data (vis-a-vis PHRs and physicians’ records) are important to practice efficiency and, ultimately, quality care.
• Some of what’s been learned about community health center PCHIT engagement may apply to small practices as well.

Multispecialty Groups and Integrated Delivery Systems (IDSs)

• While IDSs have a clear economic incentive to implement PCHIT applications, the lack of a clear business case for multispecialty groups creates major obstacles to adoption.
• Multispecialty groups need to pay more attention to hand-offs in terms of personal health information as it pertains to issues of identity and security–again, this is not a big issue for IDSs.
• When we think about PHR or PCHIT “adoption,” we should focus–at least in part–on the number of practices that are engaging electronically with patients about their care, not just the number of validated users of the applications.

Health Plans (non-integrated systems)

• There are different perspectives on the role of health plans vis-a-vis PHR promotion.
• Some people view the health plan as potential rich data repository, but a significant portion of consumers do not view their health plans as care partners.
• Some people believe that the health plans’ biggest PHR opportunity is to be proactive via benefit design and financial incentives for provider and consumer technology adoption.
• In order to address the role of health plans, we need to address the role of purchasers/employers.
• To adequately address the role of health insurers, we need to address government-funded coverage as well.

Community Profiles

• It’s important to clarify that differences among communities are a combination of public policy and market dynamics.
• More explicit statements should be made about the need for public policy direction, in terms of funding, regulation of data, expectations regarding the pace of HIT implementation, etc.
• Differences among the communities also involve leadership at multiple levels.

Underserved Populations

• The term “digital divide” does not adequately describe issues related to access to electronic communication tools.
• Connectivity is more a matter of degree; access is a more of a “dimmer switch” than an “on/off switch.”
• The biggest determinants of access to the Internet are age and education level.

Latinos Online: Summary chart, Pew Internet & American Life Project

We held a successful Advisory Group Meeting of the PCHIT initiative yesterday (and will post about that shortly), and one of the many pearls we received was from Susannah Fox, regarding the characterization of Internet access among populations. Through her research, she characterizes Internet access as a “dimmer” rather than an “on/off” switch.

She presented a visual example to us in a “thermometer” diagram that she created as part of her report on Latinos Online, published in March, 2007. She is planning to produce similar data on Internet access as characterized by device (e.g. cell phone) as well. She’s given us permission to reproduce the visual here.

Ending the use of the term “Digital Divide”

The approach of the Pew Internet and American Life Project seems useful moving forward as we think about bringing patients and their families of all backgrounds into the care experience. With that in mind, I am going to discontinue the use of the term “Digital Divide.” I don’t think it accurately describes Internet access across populations in the United States.

Your comments on this are welcome, of course!

Today is the second meeting of the PCHIT Advisory Group (Click here to see their picture and biographies). We have nearly 100 % participation, with the exception of Chuck Milligan, who is out of state right now.

This blog is as much about PCHIT as it is about working on PCHIT, and the Advisory Group component has been very important. Our meetings have created opportunities to stop and ask “Why?” for everything we are doing.

This particular meeting has a defined purpose, which is to assist Josh and I finalize a piece of work we are putting together for this effort, called “PCHIT Personas” (And maybe the group will help us if the name isn’t quite right, either). This borrows from a concept of user-centered design where professionals create personas around the individuals they are designing for. Our personas are not people, but entities, such as safety net providers, health plans, multispecialty groups, and integrated delivery systems. We want to assemble our experience so we can know what each entity is about and what their influencers are. We are also learning about what our influencers are, as well. We then want to take that information to frame our next three months in terms of what we will “do” to support PCHIT, since this is about doing, after all (within the framework of PDCA though….).

Reflection is great. And to have help from experienced and bright individuals like this makes it even better. We’ll post the outcome of our discussion, happening at the Center for Information Therapy World Headquarters in Bethesda, tomorrow. Wish us luck!

I reconnected with Bev Johnson and Marie Abraham this week, from the Institute for Family Centered Care, in Bethesda, MD. They are embarking on some exciting projects (in my opinion), which includes supporting the implementation of a patient Web portal at Medical College of Georgia, an institution that has been well described in the patient-centered care literature.

As Bev and Marie asked me about experiences with patient portals, they asked me to provide them with a workflow I use to bring in patients’ families into care, using the After Visit Summary. I thought I’d just write about it here, so everyone can see it.

One of the things I have noticed in the era of the EHR/PHR is that there is always someone else or others supporting patients that are not with them physically. This part isn’t new, but my ability to support that vital group (families and community) is.

What I do, then, is use the After Visit Summary to compose a letter to that person or people, with the patient helping me write it. The “letter” is printed out on the hard copy, and then permanently stored for viewing on the PHR of course.

I start by asking, “who is at home or in your life who assists you with your health?” This can be a mother, father, brother, sister, son, daughter, friend, etc. I ask what their name is. For this example, let’s say the patient is a 65 year old female and the someone is her son. It goes something like this:

Dear Mr. Smith,

I saw your mother, Karen, today at the Capitol Hill Medical Center, who came in to see me about her cough. Today, I listened to her lungs, her heart, looked in her throat, checked her ears and her nose, and checked her stomach. She has a normal temperature today and her lungs sounded normal. I didn’t see any signs of a serious infection today, so I think this will improve in the next 1-2 weeks.

In the meantime, I think it’s fine to use a mild cough suppressant, to take at night, which I prescribed, and okay to eat and drink normally. It is fine to continue the aspirin she is taking once a day for her heart as well.

If she has a temperature over 100 degrees, the cough gets worse, she has trouble breathing, or you are worried at all, please call our office our consulting nurse line on the phone. If there isn’t an immediate concern, then feel free to send a secure e-mail about this or any other issue.

It is good to get things like this checked out. I appreciate the visit and we’re here to help you get well.

Regards,

Ted Eytan, MD

This is a general approximation. The key elements of this workflow are:

1. Engaging the patient to learn about their support system and their interest in a communication directed that way.
2. Typing the letter with the patient, to confirm the history and plan. This is a time when very useful questions come up, like “is it okay to eat a regular diet?” or “when should I stop taking that medication?” The patient is very helpful in making sure that what I say makes sense to them! I actually practice slowing down during this time. I get to do necessary documentation work with the patient as a partner, and make sure that our concerns are appropriately felt about what is going on.
3. Providing the patient with an explanation they can take to the person(s) in their life, who have questions of their own, such as, “Did you tell the doctor about symptom X?” and generally want to know more than “The doctor said everything’s okay.”

All of these elements generate very important conversations in my mind, about what is most important for healing in the moment, and over time. It doesn’t really take any extra time to do this. In fact, I’ll say that it takes the same or less time to do this if you factor in what I see a lot of, which is many clarifying questions at the end of the visit. This allows some time for those to come naturally, and be answered in writing.

The piece of this that I most enjoy is that the patient helped me write the story of the visit, and later imagining that their loved one can see that they were thought of during the care experience.

So…to the health care provders out there - what do you think? Want to give it a try? Have you given this a try?

To the patients out there - what do you think? What if your doctor did this for you? Would you think about asking them to give it a try?

I finally got email from one of my teen patients! It was from a 16year old, and concerned refilling a medication for asthma. Pretty straightforward, really, but it was exciting to have a teen email me. It got me thinking about why we have heard from so few teens.

This particular patient is actually pretty unusual in my practice–a teen who is taking (and whose parents have given) responsibility for managing her own medications. The reality of the matter is that in most families, even with older teens, it is the parents who are in charge of medication refills, getting immuniztion records, and so on. So in most cases, it might be the parents who email for a refill. I can live with that–it still makes life easier for everyone to have such a convenient way of taking care of non-urgent medical needs when your own schedule permits.

But I am not hearing much from parents of teens either. I have been mulling that over–it seemed like such an obvious win for the parents! I think the issue is that it all seems too complicated, so my colleagues and I aren’t taking the time to promote it as much as we might, and the teens and their parents are put off by the steps needed to get it all working. I am speculating, but I think this is the case. I know I sometimes consciously decide not to talk about online access for a teen and their parent when I am running behind, because confidentiality is not easy to explain, nor is the way we had to adapt our online system to conform to confidentiality rules. If it is too hard for me, what about all my colleagues?

It also takes a number of steps to get it all going in our system–the teen has to create their own account on our website (kp.org), then the parent has to fill out a paper request to gain access, then this takes time to create . . . Why bother when you know from your other web experience that folks can create an account in a matter of minutes online to many sites. Those sites generally don’t contain personal health information, but they are the standard people judge by.

So what are we going to do? I don’t know yet. I am working with some communication experts to try to distill the explanation down to a few golden points without dumbing down the idea of confidentiality. I am also thinking about how we might do more of the process right in our office while the teen and parents are there. This would simplify things, and it would also make it a lot clearer that we think it is a cool tool to have for our patients. More to come . . .

Example paper self-management tool, New York City

2008 will be an exciting year of increasing EHR use in NYC! Along with the EHR will come consumer access to the PHR that is tethered to the eClinicalWorks (eCW) software that more and more of our primary care providers will use.

eCW has a patient portal (http://www.eclinicalworks.com/webportal.php) that we will be testing and modifying to better support consumer self management. It provides essential functions, such as the ability to fill in demographics and health history, view medications, lab results, and bills, send and receive messages, and view educational materials. We will design special additional functions to build upon previous development of paper self management tools, such as the colorful one shown here.

Our special challenge is to design a PHR for the culturally and linguistically diverse Medicaid population in NYC. We are not sure how many have access to personal computers and the internet. We may experiment with kiosks in primary care waiting rooms to provide access and personal support for people to get started using the PHR. David Lobach is using kiosks after investigating internet use and PHR interest through a telephone survey of 31 Medicaid beneficiaries in North Carolina; only 52% had high-speed internet connections (http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1839688). Another recent study compiled focus group reactions of medically underserved African Americans and Latinos in New Jersey to PHRs (http://www.mathematica-mpr.com/publications/pdfs/phrissuebr.pdf). Findings from these preliminary studies that I take to heart are: 1) most consumers want access to some basic personal health information, 2) many people think data should be entered by health personnel, but 3) people distrust the privacy and security of keeping their personal health information online and they want to be able to control access to the record and audit who views it and why. This tells me that our tethered eCW PHR may be the best place to start with our NYC Medicaid folks. Perhaps, if using the PHR actually improves control over serious health problems, more consumers will take the plunge and try it.

This year, we will have the opportunity to coordinate with other areas of the NYC Department of Health and Mental Hygiene (DOHMH) to decrease the rate of high blood pressure among city residents. Providers will be supplying Medicaid patients with BP monitoring equipment and our PHR may be one place where people can track and manage their own BP. It will add to the tools that consumers can find on helpful websites, such as information under “Healthy Heart” on: http://www.nyc.gov/html/doh/html/diabetes/diabetes-pub.shtml. Another DOHMH website with consumer BP resources is: http://www.nyc.gov/html/doh/html/cardio/cardio-pressure.shtml.

It is very exciting to coordinate public health and informatics programs to improve health with the large population we have in NYC!

One of the challenges we have faced in the PCHIT Initiative is the best role for health plans to play in promoting personal health records (PHRs) and other HIT applications for their members when the plan is distinct from the providers (as opposed to integrated delivery systems like Kaiser Permanente, Group Health, etc.).

Some health plans have made investments in portals that provide their members with access to health content, tools, claims/benefits summaries, and PHRs. Part of the challenge relates to whether the health plan can provide valuable enough information in its PHR (largely generated through claims data) to make it worthwhile for its members to use it.

I decided to log onto my own health plan PHR at myuhc.com (I remembered having done it once before and not going back, but it was worth another test drive to better figure out why). After I went through the exercise of logging in (which required several steps since I can never remember my usernames and passwords if my standards aren’t allowed or are taken), I came to a waiver I had to sign. I wasn’t too crazy about it because it didn’t (as best I could tell) seem to create any firewalls between my PHR and the health plan’s data collection for business purposes. Recalling the valuable insight shared with us by Deven McGraw about a different health plan’s PHR, I therefore thought it best to think carefully about how I shared my personal health information (PHI).

Having no choice but to “agree” in order to even see what I had access to, I checked the box and proceeded to find out what I could access. What I found was somewhat disappointing: a couple of office visit claims (well-care visit from September and a visit to an orthopedist 18 months ago for a nagging running injury that has since mostly subsided); a TB test from December (that I got for the PCHIT Initiative shadowing I’m doing); and a few lab tests (e.g., cholesterol panel). There was no valuable information stored here from those visits (I probably spent 30 minutes with my primary care physician–it was a new patient visit–and I barely remember what we discussed), and no lab values were associated with the lab tests, so there’s no way that I can use that data for historical comparison or any useful purpose, except the date it was done.

I could theoretically self-populate the myuhc PHR with PHI that I provide. That might help UHC to send me targeted health content (I don’t know if they have built that kind of Ix functionality), but I have to make the calculation as to whether it’s worth it without my knowing what they’re going to do with that data. Moreover, it’s a lot of work on my end–do I really want to invest that much time up front without having some sense of what I’ll get returned?

I look forward to learning from other health plans how they are making their PHRs more intrinsically useful to their members and/or supporting their network of providers to adopt them.

In a new report from the Pew Internet & American Life Project, Internet access for individuals with lower household income and educational attainment is in the range of 61 percent. It’s interesting to note that until recently, this was the overall Internet penetration rate for all Americans (it’s now at 76 percent). The former percentage for all Americans (63 percent) was enough for many health care organizations to pursue connectivity with patients in higher education and income brackets. Now that everyone has reached this plateau, perhaps this access should be universal across health care.

The report also includes useful insights into the role of libraries in our communities. There is a great opportunity to integrate libraries into our health care system as a key agent of Information Therapy applications.

The low-access (no access or Dial-up only) group is potentially a core group of customers for the nation’s public libraries. Although they are less likely in general to use the the library than the high-access group (39 percent vs. 61 percent), those with low-access are equally likely to turn to the library for help with their problems (health care, paying for health care, and government benefits).

Prior to my move to Washington, DC, I did some work with Seattle Public Libraries (see A Dialogue at the Public Library about Internet-enabled Care). The ground is fertile for this collaboration.