I love the thermometer Ted posted about Access–it is a reminder that one can be surprised to know who has access to email. 

I am the physician advisor for a project in which homeless teens are working with a theater group to produce a play about homelessness and their experiences.   Who could be more disenfranchised than homeless youth?  But guess what?  Denver’s Gay and Lesbian Community Center has a program called Rainbow Alley for teens who identify as LGBT or who are questioning their sexual orientation or gender identity, and they provide computer access for these kids.  Since more than 40% of homeless youth are LGBT, and the Center does not do a litmus test anyway, this means that potentially all these kids could have access to the internet.  And of course, there are other places as well–libraries, or as Ted posted earlier, even Burger King can provide access.

 For the moment, this doesn’t help me–you have to be a Kaiser Permanente member to get health care from us, which includes emailing doctors.  So these kids with no resources or insurance can’t email me.  But can you imagine how a charity or public health system with online access could use this to make health care and advice available to people who have no permanent address or even phone?

The expression of happiness in the title is a reflection of the milestone that this was in this journey. It was the first time that we went to the Gemba (”the factory floor”) with health plan leaders and delivery system leaders together, to talk about patient centered health information technology.

We were guided by Urban Health Plan’s inspiring CEO and Chief Medical Officer Paloma Hernandez and Samuel De Leon, MD, who allowed us to observe the process of care at their Bronx, NY-based care system. Invited guests included Susan Beane, MD, the Chief Medical Officer, and Linda Erlanger, the Director of E-Commerce, from Affinity Health Plan, which, “..for 18 years, has been operating managed care programs designed to address the needs of low-income populations. We are a mission-driven organization, striving to achieve positive change in the lives of the families and communities they serve.”

The goal was to do something we had not done before, bring stakeholders together to see the the actual place where the facts of health care impact the patient (for a nice description of the philosophy behind this, based on work done at Toyota Motor, see this post).

First, some photographs. Click on any to see full size.

Asthma, an Epidemic in this Community

I shadowed Mayra Nadal, MD, who is a pediatrician, and like all of the other physicians at Urban Health Plan, are using a fully functional electronic health record, manufactured by eClinicalWorks.

After a few visits, I noticed that several of her patients had severe asthma, and were being treated very intensively. One patient, a young boy, was on multiple ambulatory medications yet he was still not able to breathe normally.

I learned from Mayra that this is a sad reality for this community - this population is at exceptionally high risk for being affected by asthma. This is well known in the community. What I saw in the exam room were the best attempts of this care system to blunt the impact of this disease (and Urban Health Plan has distinguished itself nationally as a leader in managing chronic illness). Mayra showed me that they had taken extra care in the build of the EHR to include standard asthma histories and tracking of asthma plans because of the prevalence. The tools looked very complete; at the same time, they are the tools an informaticist wish they didn’t have to build. It doesn’t seem right that children in the Bronx community should grow up without an expectation to breathe normally.

Mayra was very facile with the EHR, and like me, prefers the use of an EHR because she can type faster than she writes. When I asked about online access to health information to patients, she was receptive to the idea that patients’ families would have access to ordered tests, if they had Internet access. This might be useful for things like newborn screens and other screening exams.

Overall, the impression I got from observing physicians here was one of competence using a state of the art EHR in practice. It is also worth noting that Samuel De Leon, MD also provided a very visible optimistic brand of leadership throughout this part of our experience.

On creating a prepared, proactive care system

(more…)

We just love Susannah Fox’s thermometer analogy for Internet access. It’s no longer an on/off switch. Here are the latest ones, to assist understanding of access in various populations. My conclusion is that Internet access is relatively robust across the population spectrum, at least from the perspective of making patients’ own health information available to them online.

For a full explanation, please head over to e-patients.net, where Susannah explains this better.

Josh spotted these and asked me to snap a photo or two. We noticed these at multiple Burger King restaurants in New York City.

Yet another place for patients to gain access to their health care information - if it is made available to them. And that’s beginning to happen here.

It was a great several days re-visiting several innovative organizations in this city. Watch for upcoming blog posts…

Our trip to New York City has left me full of anticipation about the launch of electronic patient portals for safety-net populations. Two networks of community health centers–the Institute for Family Health and Urban Health Plan–that have reach a stable point in their EHR operations are gearing up for the launch of their accompanying patient portals. In addition, we had the opportunity to meet collaboratively with Urban and Affinity Health Plan (one of the largest New York Medicaid managed care organizations) to discuss ways that they can mutually support each other’s patient-centered care objectives.

The Institute for Family Health, led by the pioneering physician & CEO Neil Calman, has been live with an Epic EHR for 5-6 years. In just over a week, Adam Szerencsy will go live with Epic’s PHR function for the Urban Horizons clinic for which Adam serves as Medical Director. In the two months that follow, IFH intends to roll out portal access to the rest of its community health center clinics around New York City.

We discussed several technical and strategic issues around the PHR roll-out, such as the most efficient and secure verification process, the timing of releasing lab data, and what diagnoses(if any) to exclude from the patient’s version of the record. The bigger issues appeared to be around how to best understand the impact of the transition on both clinicians and patients.

It became clear that turning on the patient portal clearly brings some new opportunities. Clinicians will have an opportunity to witness what the impact and value that patient access to their records has for the consumer. Physicians will see that having the patient in the room with the clinician while he or she is documenting the visit will create a more accurate records in more understandable language–thus leading to a better tool for guiding future care planning between patient and clinician. Drs. Calman and Szerencsy–as well as IFH’s technical guru, Jonah Piascik–were strategizing about ways to maximize PHR usage among their population, including the use of cell phone ticklers to alert their patients about new information available in their PHR.

At Urban Health Plan’s flagship health center in the South Bronx, I shadowed Dr. Claude Parola–an internist who heads their adult medicine clinic–who has been serving a diverse range of patients there since he finished his infectious diseases fellowship nearly 10 years ago. A native of Haiti, Dr. Parola seems to speak as comfortably in English and Spanish as he does in French and Creole–important given that he said that more than 90% of his patients were primarily Spanish speakers.

In his encounters with patients, Dr. Parola was totally comfortable using his EHR, an eClinical Works system, to provide efficient guidance in helping him to manage his patient encounters. Particularly because he was in the walk-in clinic that day (and therefore mostly seeing patients for whom he was not their primary care physician), eCW served his needs in most ways because he was able to make sense out of what the patient’s needs were. The exceptions were two patients who had recently been discharged from short stays in New York hospitals, for which all he had was a single nebulous piece of paper that provided little useful information about what transpired in that patient’s inpatient stay.

Dr. Parola was excited by the prospect of being able to establish asynchronous communication with his patients. He seemed perturbed by the belief that his patient population would not be able to communicate with him electronically. Based on his own experience, Dr. Parola believed that most of his patients (or, in some cases, their caregivers) would be able to communicate with him through eCW’s secure messaging functionality. Dr. Parola looked forward to much more efficient communication for him and his patients, as both parties spend a lot of time playing phone tag, remaining on hold, and not being able to communicate as efficiently as they would like. Dr. Parola also looked forward to making greater use out of eCW’s after-visit summary and patient education components as his patients became engaged with the online tools.

For Affinity, Chief Medical Officer Susan Beane told us that their most important member-centered objective is to know how each member feels. What is each member’s functional status, quality of life and experience with the health care delivery system? Affinity has been using the SF-12 to measure members’ functional status, and they would like to find ways to gather even more information to help them know whether the health plan and its contracting providers are optimizing members’ potential for healthy living.

Urban’s visionary CEO, Paloma Hernandez, has been pressing forward with e-health applications. She is excited about the upcoming launch of the eClinical Works patient portal, but she does have concerns. Under the current model of reimbursement, she is well aware that if many of Dr. Parola’s patients can address a certain number of their needs via secure messaging, thus substantially reducing their need to cross through the clinic’s doors, Urban will not have the revenue it needs to survive.

That provides providers and health plans with an opportunity to think about new models of reimbursement–such as the patient-centered medical home–that could help us reward clinicians for true value and patient-centered care. When we create these reimbursement models, it’s important that we make sure that we really are ensuring that these models focus on value to the patients we all are trying to serve.

A little bit behind on blogging this week, and a little out of order because we’re back in New York City, working with some of the stars we began our journey with.

The quote comes from a conversation I had with one of those individuals, Sal Volpe, MD, who now as part of his process of care, regularly prints his full progress notes and gives them to every single patient. Sal’s board certified in Internal Medicine, Pediatrics, and Geriatrics, and is running the eClinicalWorks EHR in tandem with its patient portal. And this is how we got connected.

When I knew we were coming up, I learned from fellow blogger (on here) Melinda Jenkins, that there was a physician who had the eCW portal up and running. I of course asked if I could visit, meet, or talk to them, and Sal is him. His practice is located in Staten Island, New York.

Sal has about 50 patients up on the patient portal, out of a panel of about 1,700, so he’s just starting out. But he’s not worried about it - he would be happy with 1,000 patients online. He’s currently running a half-time practice, and prior to his work on the eClinicalWorks project, he’s had experience across a breadth of health plan administration and other physician leadership roles. He’s got a blog (of course), which is at http://ehrphrpatientportal.blogspot.com/.

So I asked him about the case for an EHR, and the case for a patient portal. He talks to a lot of medical groups about this. Given his health plan experience, he has a good understanding of how the benefits accrue in terms of quality, billing, and service, and he’s got optimism for the future.

The quote above says something about small practices’ ability to innovate. Sal told me that he can use the tool of the transparent progress note to communicate about needed prevention or testing not just to the patient but to their families. He knows I’m going to blog about this because I think it is a big deal.

We continue to find a lot of good things happening in New York around health information technology and patient access. More posts on the way…..

Sites visited

• Individuals from various health plan organizations

The persona of a typical health plan has been challenging to discern in the first 90 days.

The integrated health plan / delivery system organizations Kaiser Permanente and Group Health are discussed within the integrated delivery system persona.

A Key Stakeholder

Conversations with health plan representatives and with others about their experiences with health plans around PHRs raised many questions about the health plan role in advancing PHRs. As the image above shows, health plans sit at a cross-road of data.

Health plans theoretically stand to benefit substantially from more efficient use of delivery system resources and greater consumer engagement in care management. Questions emerged around PHR ownership, and on whether widespread adoption via the health plan is possible (see Health Plan Perspective). We were not able to get information across a breadth of business units which limits the generalizability of this assessment at this time. Given equal effort, we were less successful in arranging contact with health plan organizations relative to delivery of care organizations.

The unclear role of this stakeholder is reflected in the literature. First, in the writing of national PHR leaders:

Because health care payers and purchasers are the primary beneficiaries, they should probably be the primary ones who bear the cost of PHRs. However, the evidence supporting the rationale for payers to provide PHRs is not mature, and they may be reluctant to do so.

(see: Tang PC, Ash JS, Bates DW, Overhage JM, Sands DZ. Personal Health Records: Definitions, Benefits, and Strategies for Overcoming Barriers to Adoption. J Am Med Inform Assoc 2006;13:121-6.)

Second, in the opinions of consumers using a PHR for diabetes care, when asked what they are willing to pay for a PHR:

There are several reasons that may account for these attitudes toward user fees. First, the group discussions may have influenced the participants’ attitudes. For example, in one of the focus group sessions, a participant pointed out that if the portal succeeds in helping patients manage their diabetes, it may decrease the number of diabetes-related hospitalizations and thereby prove to be a cost-saving measure for the health system. At the end of the same session, only one participant in the group thought that a user fee might be acceptable.

(see: Hess R, Bryce CL, McTigue K, et al. The Diabetes Patient Portal: Patient Perspectives on Structure and Delivery. Diabetes Spectr 2006;19:106-10.)

The PHR opportunity that health plans have is that they have access to a wide range of data that could populate their members’ PHRs. If they create an effective infrastructure to manage and integrate those data, they can offer their members a useful tool. According to one large health plan executive, “Our role in the HIT space is leveraging that infrastructure to be the conduit between clinical and administrative data; we can facilitate important data connections.”

Health plan executives also recognize that the biggest opportunity to make effective use of PHRs for better care management and increased cost-effectiveness is for their members with chronic conditions. For this large health plan, although its overall PHR adoption rate is only 10% to 15%, its adoption rate among those actively managing chronic conditions that it targets is between 30% and 40%.

Once the health plan creates the data infrastructure, the keys are figuring out how to present the data in a context-relevant manner, how to align incentives for both clinicians and members, and how to proactively deliver timely, relevant, tailored messages to members that make the data meaningful to the individual. The other big challenge that health plans face in that respect is that—due to lag time in administrative data processing—they often don’t have access to “timely” data, making it difficult to target their messaging to particular moments in care.

It is understood that several pilot programs to support personal health records or components thereof are under way in the regions we visited (see A Virtual Reality). Plans also appear to be active in other areas to promote quality of care, such as in supporting disease management and lifestyle programs. Transparency initiatives underway include improved availability of cost, quality, and outcomes data. (see U.S. healthcare payers to limit IT investments in 2008).

In the practice settings we visited, we detected an ambiguous message from health plans about the value of personal health records in care. The experience at the practice level may not represent that at the strategic and marketing levels of plans. This is similar to the issue of having “Vision from the board room to the bedside,” (see: Patient-Centered Care, What Does it Take?) that many delivery systems face internally already, and therefore not specific to health plans.

It is noted by others that in health plan environments, “consumers have not raced to adopt them (PHRs).” Again, this is in comparison to environments where PHRs are unambiguously promoted and are showing strong demand from patients.

Unresolved Issues

• Overall health plan intent with regard to PHR adoption is not understood based on our experience to date
• For health plans actively engaged in PHR promotion, where is the best locus of control (patient, provider, plan) for successful PHR implementation and what should the role of the health plan be?
• Health plans are trying to figure out how to effectively integrate clinical and administrative data, and how to overcome administrative data processing lag time in order to ensure that PHR data are populated in a timely manner.

Countermeasures

Data about customer experience with health plans (see: Forrester Research: Customer Experience Index Snapshot: Health Plans, as well as the impact of PHRs on affordability (see: Zhou Y, Garrido T, Chin H, Wiesenthal A, Liang L. Patient Access to an Electronic Health Record With Secure Messaging: Impact on Primary Care Utilization. Am J Manag Care 2007;13:418. are supportive of a strong role for health plans in this ecosystem. We would therefore like to continue to engage in this area next.

We are also working to communicate with national innovators in health plan environments, as opposed to health plans in the markets we have visited.

We are also scheduled to engage in a co-shadowing experience with health plan executives this month (February, 2008).

Ways to Engage

• Identify innovators as a starting point
• Bringing the patient experience forward - co-shadowing, interaction with consumer groups

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

Use of online banking is a good proxy for patient access to their electronic health record because it requires a combination of convenience and confidence to make it compelling. The Pew Internet & American Life Project just released another excellent report on Online Shopping that includes data about this. Incidentally, 49 % have purchased a product online. Is that number higher or lower than you thought?

In my work, I use the online banking figures because even when the overall penetration was 18 % in 2002, providing these services was felt to be very compelling to the populations I worked with. That is now the number for the populations reporting the lowest household income in this survey.

Peter Stalberg et al., “E-mail Access and Improved Communication Between Patient and Surgeon,” Arch Surg 143, no. 2 (February 1, 2008): 164-168

This is really a post about three items, a study, a critique, and a blog response, which addresses the issue of patient-physian e-mail exchange with data, attitudes, and approach to behavior change.

1. Peter Stalberg et al., “E-mail Access and Improved Communication Between Patient and Surgeon,” Arch Surg 143, no. 2 (February 1, 2008): 164-168.
2. David S. Mulder, “E-mail Access and Improved Communication Between Patient and Surgeon–Invited Critique,” Arch Surg 143, no. 2 (February 1, 2008): 168-169.
3. “The Doctor Is Online - Well - Tara Parker-Pope - Health - New York Times Blog,”.

The first item is a prospective study performed by endocrine surgeons in Australia who asked, “What would happen if we encouraged patients to contact us via e-mail about their upcoming endocrine surgery?” They randomized a group of 100 patients, half of whom were explicitly told to access their surgeon via e-mail and half who were not told this, but given the information in associated materials.

It is great to see a study like this performed in a surgical population, and confirm many of the findings we’ve seen in practice for some time: Physician recommendation makes a significant difference. Information needs of patients are often not met in the face-to-face interaction. Patients’ families and communities have information needs too (9 % of e-mails were sent by family members). That’s the study (Item #1).

The critique attached appears to reluctantly state that this type of communication will “become an important part of any future electronic medical record.” It perpetuates myths about Internet access, such as the percent penetration (it’s actually now 76 % among all Americans over 60 % in households with incomes less than $40,000). Initiatives like this can support better understanding of that issue. The value of our surgical partners having his conversation is great, regardless. That’s the critique (Item #2)

The blog item is a review posted by Tara Parker-Pope, who’s very enthusiastic about the report and the value of the communication. The interesting part (as in many blogs) is in the comments, back and forth. This is where behavior change potentially comes in to play, as people sort out concerns as part of the process (”before you change your behavior, you have to change your mind.”) I notice that Ms. Parker-Pope refutes or adds to some of the comments in a way that is interesting - she puts them in between the person’s note and their signature. Some of the comments are of the ad hominem variety. The discussion seems to get off the track of patient-centered care.

I think this speaks to the emotionally-laden nature of this discussion. As I have often said (see “Pushback,” from the DailyKaizen blog), part of this process is to listen with respect, know “why?” we want something to happen, and allow people to understand what that “why?” is. If we are not sure what it is, then we risk misunderstanding. I think this is the challenge in the way the blog is constructed and the discussion being led. The goal of a LEAN/Toyota inspired approach to improving health care is based on respect for the customer (the patient) and those who care for them. We will definitely get there. That’s the blog post (Item #3).

Item #4 is your comments. Post away!

Sites Visited

• Kaiser Permanente (Oakland Medical Center, Oakland, CA, West End Medical Center, Washington, DC)

Benchmarks in incentive alignment and scale

Kaiser Permanente, and organizations like it, are in many ways a benchmark for patient centered health information technology. They have the highest EHR and PHR penetration in health care. Kaiser Permanente currently has 1.7 million of its members using its PHR, and relaunched in November, 2007 as “My Health Manager.” Group Health Cooperative of Washington State is currently at 46 % of enrolled adults with verified access to the MyGroupHealth web site.

MyGroupHealth (ghc.org) adoption curve, 2002-present

The alignment of incentives is reflected in the slope of adoption by patients. The adoption curve for Group Health patients is significantly steeper than comparable organizations (see: Halamka JD, Mandl KD, Tang PC. Early Experiences with Personal Health Records. J Am Med Inform Assoc 2008;15:1-7.)

The work of these organizations is critical in demonstrating that patient centered health information technology can be a reality for all of health care. As we observed, they are post-implementation and involved in relaunch and refinements of their PHRs to support both patient workflow, and the workflow of staff who serve patients in medical centers.

If there are challenges in these organizations, it is that their work requires scalability beyond the typical physician practice, so there is always a risk that innovative ideas may be harder to implement. They are able to work around some of these limitations by supporting regions with higher levels of innovation (for example, the Colorado Region of Kaiser Permanente is a pioneer in teen-physician electronic messaging, see iHealthBeat: Kaiser Colorado Lets Teenagers E-Mail Doctors, Check EHRs).

In my visits to these organizations as a Permanente physician myself, followed by visits to other organizations described here, I noted an gap in knowledge about the potential of PHRs - an understanding of the benefits of PHRs of involving patients and their families in their care has been built up through experience among Permanente physicians that does not yet exist in other parts of health care. In addition, there is no official policy for knowledge transfer that I noticed. Group Health Cooperative generally shares knowledge in the interest of promoting patient empowerment. Kaiser Permanente is embarking on a significant initiative to share its experiences as well. In a session hosted at the California Healthcare Foundation, Holly Potter, Director of National Communications for Kaiser Permanente HealthConnect indicated to the group that, “We don’t have that option anymore” (see: Presentation: Blogs in Health Care) when it comes to delaying or restricting communication about its efforts to the community.

Unresolved issues

• Person to person knowledge transfer (attitudes, technical, workflow) to non-integrated care systems
• Risk of reduced innovation due to high expectations for consistent service across large populations

Countermeasures

Doug VanZoeren, MD, Mark Snyder, MD, and Ted Eytan, MD, bring leaders from the Office of the National Coordinator to Kaiser Permanente West End Medical Center, Washington, DC

This initiative represents a portion of the effort that Kaiser Permanente and Group Health Cooperative are making to provide knowledge to the entire industry. Other efforts include participation in national standards bodies, commissioning high quality research studies, and providing access to its operations (see: Office of the National Coordinator Visits Kaiser Permanente West End Medical Center). One of the most important efforts I have been engaging in throughout is to bring technical and execution expertise to organizations who are implementing PHRs. This will continue throughout the initiative.

It might be useful in the future for these organizations to put together a publicly available “toolkit” for PHR implementation, which would include everything from tested organizational policies, communication collateral, and staff and patient adoption techniques. Currently, this information is being transferred one to one by individuals within the organization. Perhaps a repository of experiential knowledge of basic items such authentication procedures could be made available for other organizations.

Group Health Cooperative has previously released its “Clinical Information System Rollout Toolkit” to the health care community for unrestricted use. We did not create a companion “PHR Toolkit,” however as a part of this work, I recently put together a basic PHR Toolkit that was forwarded to the Institute for Family Health, to assist in their implementation efforts.

Ways to Engage

Victor Silvestre, MD, Kaiser Permanente Oakland Medical Center

Kaiser Permanente is engaged at many levels to promote PHRs, including in the establishment of standards and sharing information, including on this blog.

Several staff members in these organizations are active in public conversations, such as on standards bodies, and are an excellent way to support involvement and knowledge transfer. In addition, given current initiatives to demonstrate the value of their care models, both organizations’ Communications departments will be useful in arranging for access to practices and Permanente physicians who can demonstrate the value of PHR-enabled practices.