The quote is from Abigail Chen, MD, who I shadowed yesterday as I was shown UNITE HERE’s implementation of the Ambulatory ICU (you can read more about the A-ICU concept here). Before I get to that though, I arrived in the morning with my usual level of interest in both seeing how patients benefit from health information technology and integrating into the flow of the medical center as unobtrusively as possible.

Fortunately, Andrew Tzellas, MD, quickly slowed down my CPU and invited me into his team’s huddle for the morning. I was invited to have a seat next to Palmeras and Nancy, team experts on chronic disease management and coverage, and then joined by Jenny, the clinic coordinator, Andrew, and his medical assistant. As they started the huddle, Nancy printed off the day’s schedule and gave them to me so I knew what general issues the team was working on. Each patient in this ambulatory clinic was reviewed by the team across the spectrum - health status, disease management, social and coverage issues. A green tracking slip was pre-filled by Palmeras for each patient and added information about due health maintenance. Andrew and Jenny, each viewing the electronic health record, worked with the team to create the day’s plan. While this was happening, walkie talkies would announce patients’ arrival (I wasn’t paying attention to this, but Jenny pointed out that the whole team was). At one point, as Andrew was talking about the guidance for a particular patient, he said, “I can inform them about my, I mean, our feeling about this issue.” The transition from individual planning to group planning of care was apparent.

I sat in on the next huddle as well, this time for Abigail Chen, MD. Same flow. It reminded me a bit of being a third year medical student on my first rotation in medical school, when I walked into a functioning team (my first rotation was trauma surgery - that requires functioning!) and I was impressed with the cadence and “beat” of the group (or as they say in Japanese, takt). I could tell the teams had spent quite a bit of time forming the approach here.

UNITE HERE serves a very special population. From their web site:

UNITE (formerly the Union of Needletrades, Industrial and Textile Employees) and HERE (Hotel Employees and Restaurant Employees International Union) merged on July 8, 2004 forming UNITE HERE. The union represents more than 450,000 active members and more than 400,000 retirees throughout North America.

 

UNITE HERE boasts a diverse membership, comprised largely of immigrants and including high percentages of African-American, Latino, and Asian-American workers. The majority of UNITE HERE members are women.

The Health Center itself is gorgeous, but it wasn’t so very recently. As I talked to staff, I learned about the transformation that has happened in the last 7 years, from a health center that sometimes served 100 patients on a Saturday with wait times several hours long, to a health center where customer service training is the norm, innovative approaches to chronic disease care are standard, and patients are treated with respect. I was told that staff were even trained using callers who role-played actual patients to ensure that each patient was treated with courtesy. That’s an impressive commitment.

A few pictures (click on any to see full size). I have to admit I got caught up in learning about the team care concept and didn’t get as many photos as I wanted to. Next time!

I was able to shadow a patient of Abigail’s, where she of course used the Health Center’s state of the art electronic health record, (Centricity, manufactured by General Electric). In the course of the visit, Abigail ordered some screening lab tests for the patient and took the time to explain the purpose of each, in Spanish, the patient’s native language. The patient was immediately referred at the end of the visit for teaching about pre-diabetes, which was performed by medical assistants, all specially trained in a variety of health topics. Great care was placed in involving the entire team in the care, as the quote at the top of the post states, and from my observation, this busy medical center had a more relaxed feel, or at least a feel that everyone was accountable to each patient together. This coordination did not come overnight - it came with support from leaders who encouraged innovation, and in my view of outcomes in the waiting room (where are were publicly posted), it’s working.

In the background of all of this, where does patient centered health information technology fit in? UNITE HERE has a state of the art electronic health record. They are preparing to launch a patient portal which will include staff messaging and other features that are being developed now. Unlike Urban Health Plan, there is not a big pediatric population, and there is a clear emphasis on chronic disease management, team care, and a further emphasis on diabetes. The Health Center is already innovating to provide patient-centered care, which is a prerequisite for success in implementing patient-centered health information technology. One of the tenets is “from the board room to the bedside.” In this health center, the board room is just around the corner, so it’s easy to cycle through improvements rapidly. This is the advantage of the small practice over the integrated delivery system - the risk of ideas not counting (or worse, being wasted) is less.

I have not previously seen a patient portal launched off of a Centricity system, so this experience should be valuable both in the population being served and the technology being used. For a health system working to attract Union members across industries and across the geography of New York City, this will add another great reason to choose this team.

This brings the number of patient accessible EHRs coming on line in New York City to three - Institute for Family Health, Urban Health Plan (Part of the Primary Care Information Project), and now UNITE HERE. All will add significant information to the conversation about patient access in a diversity of populations. This is the real thing, and they are all going to do an excellent job, and we’ll be helping along the way. Congratulations to all of the patients in these three leading health systems.

Thank you again to Karen Nelson, MD, MPH, the patients, staff, and physicians at UNITE HERE for the gift of their time and (some of) their knowledge. There is a lot to learn here.

Addition 2/29/08: One thing I forgot to mention that’s really important is the fact that I only shadowed one patient. The reason why is because the team appropriately asked for explicit consent from other patients who stated their preference to not have an observed visit. This is a marker of respect for the patient, because the consent is asked as a question, and the answer is listened to. I don’t think it’s a coincidence that at every site we have visited, at least one patient declines having an observer. What that says to me is that we are at a place where the patient is at the center of care.

PCHIT links for February 26th through February 27th:

• Life as a Healthcare CIO: Dispatch from HIMSS - Related to what I saw at Queens Health Network, a portable personal health record managed by a patient can make interoperability go faster.
• Are Consumers Interested in Having Online Access to Their Medical Records and Test Results? - iHealthBeat - Patient access to EHR’s IS compelling. Low adoption rates mean something else is going on.

Note: This post was previously published, but is being reposted today to tie together the special report, which is now published on this site in its entirety. To see all of the parts together, click on this link.

Welcome

Tyriece, Lisa, and Ted Eytan, MD, Belair-Edison Clinic, Baltimore Medical System

This is a compendium of personas in our health care delivery system. It’s designed to inform individuals and organizations interested in increasing patient and family involvement in all aspects of care, and has been specifically commissioned by the funders of PCHIT.

At the current time, it is estimated that between 3 and 10 % of Americans have access to their care teams through personal health records (PHR). Also at the current time, there are a host of organizations and individuals working to increase this percentage.

Besides being a compendium of organizational personas, Profiles is also an interim status report on the PCHIT initiative. As such, it has a PDCA format.

Plan

PCHIT starts at the level of the patient-physician relationship and moves outward

A way to visually consider where PCHIT is focusing its efforts is through adaptation of the “Sequence of HIT Adoption” model proposed by the Robert Wood Johnson Foundation (see Electronic Health Records Still Not Routine Part of Medial Practice, Robert Wood Johnson Foundation).

Our plan was to spend time in a cross section of health care, observing the patient-physician interaction. PCHIT was designed to look at factors present in different care environments at the level of the patient-physician interaction. This is based on the concept of Genchi-Genbutsu. This concept is so central to the design of this initiative that we are including an explanation of it here:

First of all, gen means actuality or reality. When we look at the word gen-ba, it means the actual place. In the terms of manufacturing, we can loosely translate this to mean where the work is done. Why is this meaningful? It is not until we understand the other gen words that this begins to make sense.

Second is gen-butsu. Butsu means, the condition of the thing. In terms of manufacturing and considering the word gen-ba, we ask ourselves, �what are the conditions of things in the workplace, where the work is actually done?� The things we are looking for? The condition of the design, the quality, the process, the people, the methods, the equipment, etc. When we think of genba and genbutsu, we are looking to see if the conditions of our standards are deviating in the workplace. This forms the basis for standardization of all aspects in the business.

Third is gen-jitsu. The actual situation. We are looking for facts so that we may understand the gap between reality and standard. We are not looking for what it should be, we know that. We are looking for actual situations, or the facts. This helps us begin to dig for the actual root cause.

If we only consider the standards we tend to sit in a meeting room wondering why the equipment, the people, the materials and processes don�t meet standards. The only way to truly know, is to go to the actual workplace, observe the actual conditions and collect the facts. This leads to true understanding of reality. Otherwise our solutions we invent in the meeting room are for problems that are not really happening in the workplace. This is the reason why problem solving begins with the saying, �go and see for yourself, in the workplace where the work is actually happening.�

We weighted our interest toward organizations with emerging health information technology initiatives, as opposed to mature, or no health information technology initiatives.

We weighted our interest toward organizations serving diverse populations, including under-insured, safety-net, and minority populations (inclusive of federal protected classes as well as gay, lesbian, bisexual, and transgender individuals).

We weighted our interest toward organizations situated geographically in areas served by our sponsors, including New York, California, and District of Columbia.

Kaiser Permanente, a sponsor of this effort, is used here as a benchmark, given its maturity in patient centered health informaiton technology. The same is true for Group Health Cooperative.

Do

Over the next several days, we’ll publish our “Persona” description for key stakeholders in the implementation of patient centered health information technology.

We chose to use the persona concept, established in user interface enginering - you can read a little bit about it here.

Comments are Welcome

Your additional experience, expressed by adding comments on each page of interest, are welcomed

Efforts to advance patient-centered health information technology (PCHIT) initiatives have been shaped by the environments that exist in each individual state or community. Environmental factors can be shaped by: specific regional quality improvement (QI) or health information technology (HIT) initiatives; local or state government interventions; the dynamics of that particular competitive marketplace; and historical evolution of local health care delivery.

We have compiled key developments that have specifically had an impact on PCHIT evolution (or have the strong potential to do so) in the regions were we have been operating.

California

HIMSS gathers in Santa Clara, CA, to talk about PHRs

Some of the most advanced EHR and PHR innovation has transpired in California in different types of practice models. For example, California has many large, multispecialty medical groups, and Palo Alto Medical Foundation (PAMF) was one of the first medical groups in the country to provide its patients with access to a PHR with functionality to access a wide range of clinical information. In addition, PAMF has made efforts to connect its PHR to health content in an effort to maximize the utility of the PHR for patient-centered care. Some other large medical groups have implemented PHRs or other patient-centered HIT tools for their patients, but they remain a minority. A recent survey of California’s primary care physicians suggested that although 19% say they often or sometimes communicate with their patients by email, only 4% of patients reported that they have communicated electronically with their physicians.

Some of California�s health plans also have taken an active role in advancing PCHIT applications. Kaiser Permanente�which serves about 20% of the state�s population�now has more than 1.7 million members signed up to use its PHR (approximately 20% of all members). It has developed a variety of tools to help its members use PCHIT tools to better manage their health. Functions include: access to clinical health records; secure messaging with clinicians; access to all lab data; ability to review and renew prescription medications; appointment requesting; links from personal health information to educational content; and linkages between various self-management tools and personal clinical data.

Fruitvale, California

California also has big gaps in HIT evolution, most notably among the FQHCs and other safety-net providers, where fewer than 5% of more than 500 clinics use electronic systems to manage clinical information (see Health Care Foundations Announce $4.5 Million Program to Speed Adoption of Electronic Records in Community Clinics). State and local government efforts to drive HIT adoption among safety-net providers have been limited. To fill this gap, the California Endowment launched the Community Clinics Initiative (CCI) in 1999. Over the last several years, several of CCI�s grants have been directed to HIT investment, though little of that effort has been focused on patient-facing applications. The California HealthCare Foundation, CCI (now a joint project of Tides and the California Endowment), and the Blue Shield of California Foundation launched the California Network Electronic Health Record Adoption to implement EHR systems among safety-net providers in the state. The project announced that it will build EHR support hubs that will provide technology, technical support, vendor management and other services that community clinics often cannot afford. CCI has provided $41 million to assist 163 clinic and 15 regional associations. From RWJF’s Health Information Technology in the United States:

Each year, CCI and its external evaluator, Blueprint Research and Design Inc., have administered a written survey to these clinics, titled �The Clinic Information Management Assessment Survey.� Surveys collected

in the fall of 2002 yielded an 80 percent response rate from executive directors and 84 percent from medical directors. CCI�s 2003 Information Technology Fact Book reported that 5 percent of medical clinics had EHRs and 3 percent of dental clinics; in addition, about 23 percent of medical clinics and 9 percent of dental clinics had established EHR implementation planning committees.

In comparison, Group Health Cooperative has widely reported that its Statewide Clinical Information Project, which implemented and EHR and PHR in 25 medical centers, cost $42 million.

Massachusetts

By objective measures of quality and performance, Boston health plans are the best in the country. The region�s largest plans�Harvard Pilgrim Health Care (HPHC), Tufts, and Blue Cross and Blue Shield of Massachusetts (BCBS MA)�are the three >highest-quality health plans in the country (see Best Commercial Health Plans 2007, USNews & World Report), according to the National Committee for Quality Assurance (NCQA) and US News rankings. New England�s decade-long focus on comparative performance measurement through a variety of regional quality initiatives has created a competitive market for quality rankings; in fact, US News places 15 of the top 20 health plans from New England.The combination of the focus on quality and the major impact of Boston�s large teaching institutions have spurred considerable adoption of HIT in large practices. In addition to large practices, small practices are increasingly getting wired due to pressure from larger providers. For example, Partners Health Care, Inc. (PCHI) recently mandated that all of its network of small and medium-sized physician practices connect to the PCHI EHR network by January 1, 2009 or be dropped from the network (see Boston Health Network Requires All Physicians to Adopt EHRs by 2009).

Longwood, Boston, MA

Although many clinicians have access to EHRs�one estimate suggested that 84% of physicians could document visits via EHRs –only 29% of the state�s physicians reported that they have adopted EHRs. In order to tackle the interoperability problem of health information exchange (HIE), several organizations in the state have worked to drive forward a �virtual RHIO.� Massachusetts Health Data Consortium (MHDC) has been driving forward health care information transfer for nearly 30 years. A decade ago, MHDC helped to launch the New England Healthcare Electronic Data Interchange Network, which now provides a lot of the administrative interconnectivity necessary for HIE. MHDC also operates MA-SHARE to provide a clinical �grid� to support communities in clinical data exchange. In December 2004, the state government lauched the Massachusetts eHealth Collaborative (MAeHC) with the goal of actually wiring that HIE into the providers� offices.

Consumer access to personal health data somewhat mirrors provider access in that theoretical access exists for many consumers, but few are making use of that functionality. Many of Boston�s large providers have also launched personal health record (PHR) corollaries to their EHRs. However, among the practice settings studied, adoption among consumers remains under 10% of the eligible population. The first and most active PHR, CareGroup’s PatientSite, currently has approximately 35,000 active consumer users, according to a recent JAMIA study. Penetration is difficult to judge because the study does not indicate the potential eligible patient population. (see: Early Experiences with Personal Health Records)

New state government initiatives may also spur PHR adoption. Governor Deval Patrick announced in December 2007 a new �compact� on health, with the goal of devising a comprehensive approach to tackling the state�s entrenched health care problems. It is unclear at this juncture whether consumer engagement via HIT will be a significant component of this new initiative.

New York

New York has taken a leadership role in HIT adoption, and there is great potential to advanced patient-centered HIT in the state. However, experts remain concerned that despite a demonstrated financial commitment to HIT advancement, few policy leaders have yet articulated a strong policy position regarding the need for consumer access and engagement with regard to HIT adoption.

Both the public and private sector have recently infused significant capital resources into New York�s HIT efforts. In 2004, the state government passed the Health Care Efficiency and Affordability Law for New Yorkers Capital Grant Program (HEAL NY) to invest up to $1 billion over four years to improve care and efficiency. One of HEAL NY�s two primary objectives is capital investment in HIT and health information exchange (HIE). In HEAL NY Phase 5, one of the five main components of the envisioned future New York HIT infrastructure is, �Medical information follows the consumer so they are at the center of their care� (see HEAL NY - Phase 5 Health Information Technology Grants: Advancing Interoperability and Community-wide EHR Adoption). In addition, they have also developed a specific consumer use case that is aligned with the American Health Information Community consumer engagement use case. The goal is to structure the requirements in such a way as to ensure that they are integrated into the policy and technical design.

Primary Care Information Project, New York City

With the encouragement of state and federal funding, many RHIOs have formed in New York�several in the New York City area as well as local RHIOs in different communities across the state. In addition to the state government activity, New York City�s Department of Health has launched the Primary Care Information Project (PCIP) with a particularly emphasis on helping to wire the city�s federally qualified health centers (FQHCs) and other safety-net providers. The PCIP goals focus in significant part in advancing better chronic care self-management. Therefore, PCIP wants to advance the personal health applications of HIT tools, though the first priority is enabling provider HIT adoption.

Some FQHCs, such as those that are part of the Institute for Family Health (IFH) already have fully functional EHRs. IFH is preparing to launch the PHR component of that system and intends to begin implementation planning in early 2008. Most FQHCs, however, are in more preliminary stages of EHR and PHR development.

In order to spur HIT adoption among private medical groups, the state�s quality improvement organization, IPRO, is providing free assistance through the national Doctor Office Quality Information Technology (DOQ-IT) project. IPRO helps 350 individual adult primary care practices select, implement, and optimize HIT systems. Although consumer access to information is not an explicit objective of DOQ-IT, this infrastructure may provide a better platform for consumer access to their own health information.

New York City, October, 2007

In order to provide a more cohesive strategy to these various efforts to spur HIT adoption and HIE, public and private partners formed the New York eHealth Collaborative (NYeC) to build consensus on state HIT policy priorities and collaborate on HIT implementation efforts. NYeC has established four initial goals to “galvanize health care systems improvement by promoting broad use of HIT through a comprehensive and coordinated state policy agenda that:

1. Stimulates coordinated and collaborative efforts among health care stakeholders to identify and overcome barriers to widespread HIT adoption and use to enhance evidence-based practice by clinicians, as well as consumer engagement in health maintenance and management;

2. Advances health care performance measurement, public reporting and improvement supported by HIT;

3. Improves public health through effective prevention and management of chronic disease, as well as stronger public health surveillance and emergency response capabilities; and

4. Ensures accountability by measuring and evaluating HIT impact on health care systems, payers, providers, and consumers.

More detail regarding their strategy and key activities can be found in the NYeC Overview Document.

Unresolved Issues

• Geographic regions vary substantially, leading to different challenges. In more wired communities–such as Boston–the foundation has been set for EHR adoption (though fully functional EHRs may not be integrated into smaller practices for two or more years) and larger systems have developed feasible PHR platforms. In those locales, the step-wise approach means the timing suggests that their biggest challenge is encouraging clinicians to engage electronically with their patients.
• In contrast, other geographic settings that do not have a consistently evolved EHR infrastructure, the unresolved question is whether to take the traditional step-wise approach to HIT adoption or consider building patient-centered HIT applications into the roll-out of their EHRs. Conversations with HIT leaders in many of these organizations suggests a desire to consider the latter tactic but a concern that it will be difficult to bring all the necessary HIT and clinical leaders on board for such a dramatic “big bang” (turning on all functionality at once), such as was done at places like Group Health Cooperative in Seattle.
• The role of integrated delivery systems such as Group Health brings up another important unresolved issue: What should the role of IPA-/network-model health plans be in driving PCHIT adoptions? Many of the group-model plans have made major strides in PCHIT advancement not only because the economic imperative is clear (in the long-term, better care management and member engagement is a “win” for everybody), but also because–as integrated systems–there’s no question that they should be directly investing in building systems for their members.
• In constrast, the IPA-model health plans face a challenge in determining their most appropriate role in the promotion of PHRs.If they go down the PHR development role on their own, they likely will primarily be populating their members’ PHRs with administrative data–and, in many cases, with data that comes with a significant time delay that renders it less meaningful. However, working with the providers with whom they contract to generate clinical data-oriented PHRs for their members may not be feasible.
• Policy leaders need to create explicit goals around consumer access and engagement to ensure that the intense policy efforts around HIT adoption specifically address the needs of patients and their families.

Countermeasures

One option available to grantmakers and policymakers is to tie HIT funding to this strategy. Options include “patient-centered mandates” and/or a patient-centered technical support strategy. In the former, those who hold the purse strings basically require that HIT applications include tools for both clinicians and patients in order to receive funding assistance. In the latter, those with funding authority create a technical support infrastructure to chart paths toward the more holistic HIT adoption approach and support progressive organizations with technical assistance to make it feasible to undertake the more ambitious, patient-centered approach.

In many, if not all, of the sites we visited, the question of disparate access to PCHIT was raised. The same question has been raised with regard to EHR’s as well. In its report, the Expert Consensus Panel (see Electronic Health Records Still Not Routine Part of Medial Practice, Robert Wood Johnson Foundation, 3:27):

(The Expert Consensus Panel) has identified racial and ethnic minority patients and low-income or publicly insured patients as the two highest priority patient populations

The PCHIT Initiative broadens this view of vulnerable populations to include those with documented disparities including but not limited to individuals who are lesbian, gay, bisexual, and transgender. An additional vulnerable population of interest are returning soldiers (see: Longitudinal Assessment of Mental Health Problems Among Active and Reserve Component Soldiers Returning From the Iraq War).

Available data about Internet access contradicts conventional wisdom

Charts: Click on any to see full size (Sources: Benchmarking Digital Inclusion, ITIF, and Estabrook L, Witt E, Rainie L. Information Searches that solve problems. Washington, DC: Pew Internet & American Life Project; 2007)

In a review of the literature related to Internet use among vulnerable populations, we discovered that commonly held beliefs about use and access are not true. Even at the lowest educational and income levels, Internet use approaches 60 %, where it was only 10-30 % in 2001.

The following studies shed additional light on this issue:

• Estabrook L, Witt E, Rainie L. Information Searches that solve problems. Washington, DC: Pew Internet & American Life Project; 2007. A random sample survey performed between June and September, 2007 shows gains in Internet access and explores type of access - “High” for broadband at home or work, “Low” for no access or Dial-up only
• McNeill HL, Puleo E, Bennett GG, Emmons MK. Exploring Social Contextual Correlates of Computer Ownership and Frequency of Use Among Urban, Low-Income, Public Housing Adult Residents. J Med Internet Res 2007;9:e35. - In Boston public housing, 51 % of adults own and 42 % of adults regularly use computers, and those reporting feeling “safe” in their neighborhoods have a greater likelihood (76 % higher association) of using a computer regularly.
• Beckjord BE, Finney Rutten JL, Squiers L, et al. 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). J Med Internet Res 2007;9:e20 - “In 2003, Internet users with high levels of education were more likely to have communicated online with an health care provider, consistent with previous studies. That education was nonsignificant in 2005 may suggest that health care consumers� level of education is less of a barrier to communicating online with health care providers as the prevalence of online patient-provider communication increases.” and “We did not observe associations between online communication with health care providers and characteristics such as race/ethnicity or annual income that have been documented in other studies as evidence of a �digital divide�”
• Carroll AE, Zimmerman FJ, Rivara FP, Ebel BE, Christakis DA. Perceptions about computers and the internet in a pediatric clinic population. Ambul Pediatr 2005;5:122-6. - “Most families like using computers and feel comfortable using the Internet regardless of socioeconomic status. Fears about the digital divide’s impact on the attitudes of parents toward computers or their comfort using the Internet should not be seen as a barrier to developing Internet-based health interventions for a pediatric clinic population.”

A more sensitive indicator of patient access to electronic health records is likely to be online banking (see this post on that topic), because online banking requires confidence and convenience as well as access to be successful.

Online banking use and income level, from Online Shopping, Pew Internet & American Life Project, 2008

East Boston Community

Patient-centered HIT applications do not necessarily require use of a computer on the consumer’s end. For example, a mobile phone may be the most effective vehicle for certain populations, whether the information coming to them is in the form of an automated phone call (which can be delivered in multiple languages), a text message (such as for medication reminders), or a more sophisticated combination of audio, graphics and video. A variety of strategies are profiled in a recent report published by the Georgetown Health Policy Institute’s Center for Children and Families (see Health Information Technology: Innovative Applications for Medicaid).

Outside of patient access to computers or the Internet, there are opportunities

Some analysts shortchange vulnerable populations by suggesting that language barriers, the digital divide, or health literacy pose insurmountable obstacles to effective PHR adoption. Perhaps no population faces a greater panoply of barriers–including Spanish as primary language, health literacy, access to computers and the Internet, geographic challenges, and a lack of care continuity–than migrant farm workers. The tool, MiVia, has demonstrated that PHRs can be effective tools when appropriate accommodations are made, such as using community health workers to help facilitate PHR adoption.

As we consider patient-centered health information technology, the definition should be broadened beyond personal health records, to any technology that provides the benefits and impacts of patient access. These impacts accrue whenever the health system is accountable to those it serves, by providing them the information they generate about them, whether in paper, computer or smart card form.

Unresolved issues

• It is unclear how pervasive the conventional wisdom of the “digital divide” is, and if there are related factors that would bias toward inaction even if the data were better understood for populations studied (ethnicity, income, education)
• For populations that are less well studied (e.g. lesbian, gay, bisexual, transgender, returning soldiers), the impact of provision of access to PCHIT in safety net environments is also unknown. With limited funding available to study sexual minority populations, for example, disparities may only be exacerbated in an environment of HIT without PCHIT.

Countermeasures

In 2008, we are emphasizing safety net providers and vulnerable populations in PCHIT work. We are providing the technical assistance of a knowledgeable medical informaticist and patient empowerment advocate to demonstrate the impact of PCHIT in a vulnerable population. We would also like to spend some effort in packaging this data and presenting it in leadership forums. Ted Eytan did this recently for the District of Columbia Primary Care Association, where it was well received (see Presentation to DCPCA, December 18, 2007), as well as on a recent event at Urban Health Plan, in Bronx, New York (see: “We did it! Thanks Affinity Health Plan and Urban Health Plan!“)

Ways to Engage

In addition to working with health care and IT leadership on promoting PCHIT as part of HIT, it would be valuable to engage with patients themselves. In 2008, we are hoping to shadow a patient who is part of a vulnerable population as they manage chronic disease. This will most likely happen on our trip to Sonoma, California, in March, 2008.

Sites visited

Union Square Family Health Center, Somerville, MA

• Institute for Family Health (New York)
• East Boston Neighborhood Health Center (Massachusetts)
• Cambridge Health Alliance (Massachusetts)
• La Clinica de La Raza (California)
• District of Columbia Primary Care Association (District of Columbia)
• Lifelong Medical Care (California)
• Queens Health Network (New York)
• Unite HERE! (New York)
• Urban Health Plan (New York)
• Baltimore Medical System (Maryland)

An Emphasis of PCHIT

As others studying health information technology adoption have pointed out, the populations served by these providers are of concern, and are being emphasized in this initiative. There is a focused description of the populations we are interested in and disparities in this report (see Persona: Vulnerable population).

There are multiple ways of identifying safety net providers (see Electronic Health Records Still Not Routine Part of Medial Practice, Robert Wood Johnson Foundation). Our work focused primarily on community health centers, which are estimated to serve about one in eight uninsured patients. Within CHC’s themselves, about 75 percent of patients are uninsured or on Medicaid.

EHR Adoption Among U.S. Physicians and Health Centers, from Health Information Technology in the United States: The Information Base for Progress: Robert Wood Johnson Foundation; 2006

In terms of adoption of EHRs, there is comparability to physicians in general, with a trend toward lower adoption for physicians with a higher percentage of medicaid patients. There is no comparable data for PHR implementation, unfortunately.

Resilient and Creative

Each safety net provider we visited, sometimes on the same day we visited a non-safety net provider, showed a different light onto health care. This was especially true for a physician accustomed to leading in a multispecialty group with commercial contracts (Ted).

The expectation might have been extreme resource constraint without ability to innovate in health information technology. However, we found organizations that are as technologically savvvy as their non-safety net peers, in an environment where 92% of community health centers nationally do not have electronic health records. This group has access to novel ways of financing improvement (in particular, a limited supply of grants, depending on the region, see Remarks to the National Association of Community Health Centers, HRSA Administrator Elizabeth M. Duke) and many that we visited have state of the art electronic health record systems.

However, few of the organizations above have implemented a personal health record yet. Cambridge Health Alliance was in the process of implementing theirs when I visited in November and has begun a pilot since. Institute for Family Health is about to begin its pilot in New York. At the same time, in conversation with providers and in some cases, patients at these locations, there was a general welcoming of the concept of patient access to the electronic health record, even in a multi-lingual care environment.

Dr.’s Davis and Isles, Belair-Edison Clinic, Baltimore Medical System

We learned about the financing model of safety-net providers that makes them ideal care providers in the communities they serve. Specifically, rates of reimbursement for in-person visits may be higher for federally qualified health centers. This environment is changing though, based on health reform efforts underway in states like Massachusetts.

At the same time, current models focus care provision on a physical visit. At La Clinica de La Raza, for example, I attended a celebration of the achievement of a milestone in number of encounters in a particular month. The celebration was a testament to the hard work and will of staff to support the organization’s viability. At the same time, there will be challenges to introduce non-visit based care if the unit of reimbursement is the in person visit.

“Uninsured” does not equal “Uninformed”

An impressive and reassuring finding in observations was that patients receiving care in these environments are getting informed about their care via various means, including the Internet, and are open to connecting with their providers this way. As a patient at Berkeley Primary Care told me, “I want my doctors to meet me half way.” Seeking care among multiple providers in the community with disjointed communication between them is perceptible information gaps for patients who have reduced abilities to tolerate fragmented care.

These information gaps are being addressed by consulting with others in the community, or by becoming disempowered in the care relationship. We saw examples of both, which were displeasing to both physician and patient. In these situations, patients may not be discussing these feelings with their providers in the exam room unless asked, which I also observed.

A recent study measured oncologists’ recognition of empathetic opportunities and found response to these to be low (22 percent with “continuer” statements) (see Pollak KI, Arnold RM, Jeffreys AS, et al. Oncologist Communication About Emotion During Visits With Patients With Advanced Cancer. J Clin Oncol 2007;25:5748-52). This finding, among a group of terminally ill patients, may be as relevant for members of vulnerable populations who provide empathetic opportunities to their care system to “meet them half way” through improved interaction and information about their care.

EHR deployments are without PHR deployments

A concerning trend we noticed was the assumption that an EHR deployment in this context should not include patient access or patient-centric health information tool deployment.

More than one individual in safety net environments expressed the following sentiment in our travels: “PHRs won’t work for this population, because of inaccessibility to computers/the Internet.” However, the data behind this assessment was hard to come by. The impact of statements like this, made in some cases from vendors of EHRs supporting these organizations, is that PHR deployment is not included in implementation plans. This is the case even when it is in other organizations’ rollout for the same product.

Our concern is that this is a significant missed opportunity and may result in the hastening of an exacerbation of differential HIT adoption and ultimately health disparities.

Observations and discussion with support staff again showed that there is more potential internet use and uptake than commonly believed. At a recent discussion hosted by the District of Columbia Primary Care Association, one clinic administrator said, “Whenever I walk into the waiting room, there is always someone using the computer (referring to a community-wide program to make computers available in local clinics),” and “we’ll never know if people will use this if we don’t set it up.”

No EHR deployments are planned in some, impact on physician recruitment?

Several safety net providers we visited have no EHR deployments planned at all, and I (Ted) witness varying degrees of discomfort with this situation, based on previous use of EHRs by staff physicians. Those that had direct use of EHRs in their past appeared more eager to adopt the technology. Bina Patel, MD, at La Clinic de La Raza lamented that when she chose to move to California to practice in a CHC, she interviewed at 7 different organizations only to find that she would have to practice on paper at each of them. A situation like this has the potential to impact future recruitment of young physicians to these environments. There are California CHCs that are implementing EHRs, such as Redwood Community Health Coalition (see Network of Community Health Centers Utilizes Electronic Medical Records System, Patient Portal and Electronic Health eXchange to Improve Patient Care).

An EHR is not a prerequisite, though

We discovered that having an EHR is not a prerequisite for using Patient Centered Health Information Technology. Prior to rollout of its EHR, pharmacists at Whitman Walker Clinic in Washington, DC are using freely available web tools such as MedactionPlan.com to prepare visual medication regimens for their patients. It is therefore possible to begin using tools that inform and activate patients in their care, very economically, and at a level comparable to EHR-equipped institutions.

Queens Health Network in New York City also demonstrates this idea through the use of smart cards, that patients can carry to providers without EHR’s, but with an inexpensive card reader that plugs into any PC.

Unresolved Issues

• Impact of reimbursement model on forward movement
• Awareness of digital divide issues
• Place of PHR deployment alongside EHR deployment - disparities in implementation plans between safety net and non-safety net providers is of concern
• Impact of disparities in technology use on recruitment of physicians in these environments
• Opportunities to implement patient-accessible HIT outside of an EHR implementation

Countermeasures

Provider collaborating using a state of the art electronic health record, East Boston Neighborhood Health Center, Boston,MAk

We plan to continue a focus on these organizations in 2008. Our next site, Urban Health Plan, in New York City, has a functioning EHR and is planning to rollout an associated PHR. We are working to arrange co-visitation with its payer, to explore financing models “on the shop floor.” In addition, we are separately preparing information about digital disparities, and are actively engaging with safety-net organizations that are implementing EHR’s now (see DC Primary Care Association - Improving Access and Quality using health information technology) or are about to implement PHR’s (Institute for Family Health) in the interest of changing perceptions in this community of care organizations.

Ways to Engage

At the current time, there are several organizations with active EHR programs with an interest in PHR deployment, and we will continue to work with them (Institute for Family Health, Urban Health Plan, Cambridge Health Alliance). It seems most appropriate to spend time studying their experience and generalizing to other similar providers. Conversations with payers as part of this engagement would also be useful.

As I mentioned in my previous post, I was beckoned to the borough Queens, NY, shortly after my presentation at the United Hospital Fund. Despite the snow, the trip wasn’t that difficult (in fact, Rachel’s advice to stop and get shoe covers made all the difference in the world).

It was, of course, well worth the trip. I came to Elmhurst Hospital Center, part of Queens Health Network, where they have been using smart card technology to enable better patient care.

First, pictures (click on any to see full size):

As the images show, patient ID cards for the network have embedded smart chips in them that store 64K worth of information, in read-only format. A new version is being rolled out that will store 128K worth of information and be read-write. Given that 22 different languages are spoken by the borough’s 3 million residents, it is easy to see that having a portable version of a medically-understandable health record could be useful. The Network has outfitted local emergency rooms with card readers.

In an innovative program with the Queens Library, patients will be able to access card readers there to see what is on their smart card. What I was shown was a concise clinical summary of health care activity, that included medications, recent tests, and ongoing medical conditions. I could imagine how this could reduce the stress of relaying a person’s medical history to a new doctor or a doctor in an emergency situation. Within the hospital, the patients’ records are available on a state of the art electronic health record; the card is just for portability. Outside of the emergency room environment, a PIN code is used to access the data.

The commitment is there to make this work. Clinics have machines that generate the special ID cards. Card readers are attached at key points in the clinical workflow to ensure updating of the latest information from the EHR. Challenges remain, including making sure that updating of the card occurs at every visit. We did not discuss in detail the impact of a read/write card, and how that would bring data back to the Health and Hospitals’ Corporation electronic health record.

During my visit I was also shown Queens Health Network’s work to improve chronic disease care using registry systems linked to their electronic health record, by Rand David, MD. They have made significant gains in the last 5 years in both process and outcome measures for diabetes, which is what I was shown. Alfred Marino, Glenn Martin, MD, and Amelia Shapiro, are the team working on the smart card piece, in addition to several operations leaders who are integrating this into the workflow. Besides the interest in the technology, they have an interest in the distinct attributes of the population they are working to serve, which came across very clearly to me.

What strikes me as very interesting about this idea is that it supports a simple and “interoperable” health record that is under patients’ physical control. In my own work, I had not considered the value of a smart card linked to our electronic health record, but why not? If it improves the comfort with which a patient is able to seek care, especially in a multicultural community, I think this could fill an important niche.

There are definitely challenges regarding workflow and community support of this program, which are both being actively worked on. The work of Queens Health is a very nice demonstration that patient access to their own health information is not just about having Web or Internet access, and it can make a difference in supporting good health care.

United Hospital Fund, Empire State Building, New York City

On our last day in New York City, Rachel and the United Hospital Fund arranged for a presentation on patient-centered health information technology to the New York Business Group on Health, at UHF-NYC headquarters in the Empire State Building.

As I do with most presentations, I started with a thought provoking question, and this day’s was “When was the last time you looked at your medical record?” The responses, as expected, were extremely varied. Most had never seen their medical record, or seen it in disconnected parts. There were some answers that went like this: “I have seen my claims data in a PHR, but not my medical record.” I thought it was interesting that people were able to differentiate between claims data and a medical record.

At the same time I said, “I wouldn’t be here talking about this if I didn’t think you could do it,” and I meant it. As I posted previously, New York is having great success implementing EHR’s through their PCIP project, and are about to add patient access to these systems. A strong purchaser community can bring the next level of integration - that of a wellness ecosystem.

Several audience members pointed out, accurately, that there are things that can be done in an integrated health system that cannot be done in a dis-integrated one. At the same time, there was sharing of some innovative projects that are happening in the health plan community as well as the purchaser community. I left as impressed with the possibilities as I was when I came.

When I looked out the window at the brewing snowstorm at the end of my talk, Rachel reminded me, “You’re still going to Queens.” Of course I was, and I’m glad I did. More on that in the next post.

• Center for Health System Change - Physicians Moving to larger practices - Important to know about shifts in physician practice makeup in terms of targeting patient access.
• Whose Data Is It Anyway? Expanding Consumer Control over Personal Health Information - CHCF.org -
• L.I. Hospital Scrutinized After Deaths of Patients - New York Times - This very sad story brings up the issue of patient safety as a function of providing patient access. Is it possible that a patient might identify correctly that the specimen tested was in error if they looked at the report also?

As part of our visit last week, Josh and I made sure to stop in at New York City’s Primary Care Information Project. As today’s press release indicates, PCIP is demonstrating success in promoting electronic health record use among New York City physicians.

There is a component of this work that involves implementation of the personal health record, and we spent time with Melinda Jenkins, Ph.D., FNP, and Joslyn Levy, RN, to learn more about this part of the project. We were given a demonstration of the patient portal that comes bundled with the eClinicalWorks product. As I have seen at the installation in Washington, DC, eCW has relatively robust integration within the EHR for patient access. I have not yet seen this in action personally, but I did speak with Sal Volpe, MD, a user of both the eCW EHR and PHR (see this post for that conversation).

The success that PCIP has achieved has come from focusing on the build for the provider side of the system. We learned that the patient access component is coming with the “Cycle 2″ portion of the project, which was scheduled to be kicked off the day after we visited (good timing!). In the meantime, Melinda and the team have been working on improvements to the out-of-the-box portal to promote self-management and longitudinal care.

Since Melinda is a contributor to this blog (see her posts here), we’ll let her continue to fill in the readership on her work. So far, the news is good from New York that health information technology can be implemented in our care system, even for the most vulnerable populations.

We stopped in to say hi to Mat Kendall, MPH, PCIP’s Director of Operations, and second to none (even including myself, I think) in the optimism department. Mat is a pro at creating visual systems in his office, which he graciously allowed me to photograph and display here, as great examples. Students of the Toyota Management System will appreciate the impact of keeping this work visible. Keep up the great work, New York!

Click on any image to see it full size