It’s interesting that it worked out the way it did, but the last organization I am visiting on my PCHIT journey is the organization I started at, Institute for Family Health. I didn’t plan it this way, it just happened. This time, though, things are different. IFH now has a physician champion for its online patient access to the medical record, Adam Szerency, DO, who is also the Medical Director of the Urban Horizons Medical Center in Bronx, NY.

I give the leadership of IFH credit - when I first met Neil Calman, MD, literally on the first day of my sabbatical, he said that they would be launching patient online access in Spring, 2008, and here it is, happening. Spring, 2008 seemed like a long time for patients to wait at the time.

In the interim period, I have worked with Neil and Adam and their superstar developer Jonah some, but they have done all of the work. My visit was a bit of a graduation day for me, and it was terrific. At the end of every patient visit, Adam excitedly told every patient that they, too, would be able to share in the access to their own medical records. I really loved the way he inquired, too. He would start with, “Do you have a computer at home?” Some patients said, “No,” but he did not stop there. He then asked, “Do you have access to the Internet?” And guess what, I think every answer to that question was a “Yes.” The best part for me was to watch Adam talk to patients about how he would be there for them in this new way.

As with every other innovative organization I have visited, I learned of a new application of the patient access system - in a community where primary care / specialty care communication is at a premium, Adam will use this system to support doc to doc communication, by keeping patients informed and involved in their care. They will have access to a secure web site with their medical information (using a system manufactured by Epic Systems, Inc.), and will be able to print or show this information to referral physicians. In a sense, they will become human information exchanges. It’s important to know that they are already serving in this role - this will add accuracy to it and empower patients with their own medical information.

One other little thing that I hadn’t considered that Adam pointed out to me was the work of documenting in English on the electronic health record at the same time he was having a spanish conversation with the patient. He has mastered this now, but it’s another consideration for our field (Informatics) to have as we support culturally competent care. The record is in English, the conversations are not. What’s best for our patients?

Pictures, click on any to see full size (coming shortly)

After shadowing Adam in his clinical morning, we had lunch at a local eatery in the Bronx, and talked about the future. Adam has done a lot of work to support his physician colleagues in adopting this technology and as an adopter himself, and the Medical Director of his medical center, I think he’s put together the winning recipe - enthusiasm, energy, accountability, leadership, for the patient and for the community. When Institute for Family Medicine is successful, they will have a wonderful story to tell health care about how every patient in every health care system deserves the best health care available anywhere.

After talking about our digital futures, I asked for the check, and it came as a reminder of the past - a written piece of paper. I took a picture of it for this blog and captioned it with Adam’s word when it was handed to us. He said, “Authentic.”

Moving to a new blog

This is the last post of my journey here with PCHIT. I’ll be continuing at http://www.tedeytan.com, as this blog moves over to the Center for Information Therapy. I’ll post more on that soon.

When I found out that Sal Volpe, MD, Mat Kendall, and the PCIP team were going to be talking about their work in the community where Sal practices, I knew I wanted to come and experience it.

We started with Sal allowing me to experience the trip from Manhattan to Staten Island, which can take up to 2 hours by car as it did this day. This says something about Sal’s commitment to this work. He makes this commute regularly to support New York in rolling out this program, at the same time he supports his family and Internal Medicine/Pediatrics/Geriatrics practice on Staten Island. On the way over, he told me how the electronic health record has changed things for him. Prior to having an EHR, he used to take his sons for a walk to his office, where he would catch up on charts for a bit, and then walk with them home. Since that time, they don’t have to stop at the office anymore - they just walk longer together. This is not to say that the EHR has reduced the workload, it has allowed Sal to integrate it better with his family.We arrived at Richmond University Medical Center and began with an overview of the PCIP program by Mat Kendall, the Director of Operations. It really is impressive to think that here is a Department of Health actively engaged and interested in community providers having better tools to take care of patients first.

Sal then came on and presented his experience, and I think his experience is important, given that he manages his own practice and accepts the risk of the business decisions he makes. With the data showing that EHR’s are more prevalent in group practices, Sal’s story is important in the conversation. He included his experience with the patient portal that comes with the system he uses, which is manufactured by eClinicalWorks. He then spoke about the fact that since he turned on the system, he has given every patient a copy of his physician’s progress note. When asked about this, he said, “What’s wrong with giving them a copy?” I thought that was a great question to ask of all physicians everywhere.I was given a ride back by Mat Kendall and the rest of the PCIP team. Spending time with Mat reassures me that optimism is infectious - usually I am the most optimistic person in the room but when I am around Mat, this is not the case. It’s always nice for me to have optimism radiated in my direction. We had a nice conversation about the future of the program and of the patient portal in it. Mat has 4 years’ worth of experience managing a Federally Qualified Health Center, so he has a good idea about how to be successful with patient access, and I believe him. Despite the challenges of a visit-based reimbursement model, there’s the idea that patient access will improve access to good health care and promote better use of the system among patients who do not know their risks. Mat also points out that the data to date about visit reduction comes from commercial health plan settings. The PCIP team is well aware of data about Internet use in the population it serves and the potential benefit from giving them access to data contained in EHR systems. Right on.I left the conversation and the evening as optimistic as I ever have about patient access to health information technology. Before I started this journey, I didn’t forsee that one of the most innovative practices I would discover would be in Staten Island, NY, or that a Department of Health could steward health information technology adoption for a whole community. I did and they are.

New York Times Company : Press : Press Release : The New York Times Company Announces Ten Semifinalists for the Second Annual Nonprofit Excellence Awards

The Institute for Family Health - dedicated to the development of innovative ways to provide primary health care services to underserved urban populations based on the family practice model of care.

We held our third PCHIT Advisory Group meeting today, and had great input from our insightful advisors. Rather than trying to summarize the meeting, I’m focusing on a particular PCHIT-related communication that came up and how it ties into some other recent thinking.

We have been using patient-centered health information technology (PCHIT) since the start of the initiative in part because the focus on personal health records (PHRs) is too narrow. We are interested in all vehicles that help facilitate “patient access to understandable clinical information,” as CHCF’s Veenu Aulakh put it. We also recognize that this phrase may not roll off the tongue, so we need to think creatively about how to communicate it to lay audiences.

Advisory Group member Susannah Fox inspired many concise insights of “seven-word wisdom” at the Health 2.0 conference in San Diego earlier this month. On the IxAction Alliance’s IxInsights webinar yesterday, she, Health 2.0 guru Scott Shreeve, and I each offered up seven-word wisdom related to the intersection of Health 2.0 and information therapy (Ix).

• Fox: “Engage consumers. Practice participatory medicine. Eliminate guesswork.”
• Seidman: “Tailored information. Integrated into care. Every encounter.”
• Shreeve: “Equitable, efficient, effective. Technology enabled reform. Thrive.”

The Advisory Group agrees that communicating what we mean and what we hope to achieve for consumers with the intersection of patient-centered care and HIT will take some creative semantic brainstorming. To get us started, I�ll get the ball rolling building off of Veenu�s PCHIT definition: �Patient access. User-centered design. Clear information.”

Hopefully, my colleagues–and others!–will chime in on how best to communicate what we want to achieve.

I had the opportunity yesterday to present findings from the PCHIT Initiative to the Institute of Medicine (IOM) Roundtable on Health Literacy (slides will be available to the public there soon). Yesterday’s forum was titled a “Workshop on Health Literacy, eHealth & Communication: Putting the Patient First.” Although I have been reflecting quite a bit on PCHIT findings over the last month, this was an opportunity to focus in more specifically on health literacy issues.

There’s no doubt that PCHIT has demonstrated that great opportunities exist for improving health literacy by implementing PCHIT applications. That can be done in two ways–either by using PCHIT applications for skill-building or by deploying new technologies that allow for effective communication without improving “health literacy”–at least defined in its traditional way (ability to understand written health information).

In order to do either of these, we do need to ensure that PCHIT implementation addresses two strategic and operational issues. First, more effort needs to be invested in connecting personal health information (PHI–an individual’s clinical data) to health content that can contextualize data points for the individual. Second, those organizations that implement PCHIT need to develop a concerted strategy for driving adoption of those tools by working with the clinicians to gain comfort in using the tools with their patients.

The biggest health literacy challenges that I saw in shadowing clinicians and patients were not related to race, ethnicity or education, but cognitive function. Particularly for patients with severe mental illness or developmental disabilities, PCHIT applications need to engage effectively with some ancillary caregiver, and those community hand-offs often were not smoothly handled. Language barriers sometimes were a health literacy challenge as well–though not for as much for Spanish (the encounters I observed with Spanish-speaking patients in safety-net and commercial settings were conducted in Spanish though they did not always have Spanish health content available to prescribe as follow-up) as for other languages.

Some of my comments also mirrored insights of others. For example, Ruth Parker from Emory University described health literacy as the ultimate patient-centered care. That is, there’s nothing that more addresses the on-the-ground, day-to-day needs of individuals than whether they can really understand the health information that they need to live healthy lives. Dawn Gauthier talked about Peace Health’s approach to PHR development that started with the premise that, “patient-centered care = user-centered design” and then proceeded to talk to patients, observe them, and listen to them tell their stories. Also, the importance of tailoring content came up–recognizing that health literacy, behavior change, and other critical health issues require a personalized approach to health information and health care. Finally, Cynthia Solomon from MiVia explained how PCHIT tools can serve as a “bridge” between disparate parts of the delivery system, much as the IxCenter has described the role of Ix as offering the consumer a bridge between encounters with different providers.

Chuck Friedman, Deputy Director of the Office of the National Coordinator for HIT also gave a glimpse into ONC’s soon-to-be-released strategic plan. It will center around “person-focused health care and improved population health enabled by IT.” That sounds a lot like “patient-centered HIT” to me.

Yesterday, I wrote a post about my visit to Sonoma, California, and the health care that MiVia is enabling. Heidi Stovall then gave me a tour of the application, and allowed me to take screen shots of it to post here. All of the information in the screen shots are not from real patients, so there is no personal health information being displayed.

Let’s take these one by one. And here are the images that go with the tour. Click on any to see full size.

1. This is the patient login, and includes their identification screen. Notice the LAC. That’s a “Limited Access Code” and allows a selected person access to the information, for example a care provider in an emergency.
2. A chart note. This allows a provider to document right into the patient’s personal health record. An interesting paradigm - the customer of this system is the patient, not the provider (sort of how I think these systems should be designed). Important to remember that these patients typically do not have medical records in other EHRs.
3. The printable ID card. I mentioned yesterday that this is not an actual ID, but to the users, it signifies “belonging” to something. At the same time, it can be given to a provider to signify that “there is a place you can go to learn about my medical and dental history.” It’s worth noting that my health plan offers this, but via a telephone service, not through the Web (I can access my own information, but I do not have an access code I can give to someone to do it for me).
4. A medical summary report. A easy place to find out about a person’s medical and dental conditions.
5. Sharing preferences. The patient can automatically add their record to the roster of a participating provider. If they do not add this, the provider can also add the patient by getting access code information. Again, the heritage of a patient-centered application is apparent. I think this looks very simple and understandable.
6. Pain and symptom diary. What’s significant here is that the patient-centered nature of this record means that patients can document in it as much as providers can. It’s a basic interface to be sure, but physicians know that a cornerstone of pain management is for patients to document what they are feeling.
7. Dental Records. Again, a basic interface, but it’s a bit of a breakthrough in my experience to combine oral health and general health in one place. From the patient perspective this makes total sense. From the physician perspective, we are used to segregating “medical” and “dental.” Why? Tradition? Because we went to different professional schools? I think the patient’s way is the best way.
8. CCR Export. I think this is one of the most promising features. It’s clear that this is a group of patients that are unlikely to be served by a health system with a tethered PHR, and one of our findings is that a tethered PHR is not the only way to serve patients. What if this subset of the community could upload their record to a tethered system, for example, if they receive care in a tertiary care hospital, or if they obtain a specialty consult in a system that has an EHR? In this case, they will still use MiVia as their portal. The idea is that the specialty care provider could either document here (copy their note), or send a CCR export to MiVia.

Here are some thoughts:

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Imagine that you were working internationally and had a serious stomach ache and needed to see a doctor. When you went into the medical clinic, the doctor asked you what medicines you were taking and what the status of your medical conditions were. What if you didn’t know or couldn’t tell them because you were in so much pain or you had seen a doctor but they didn’t give you a copy of your medical record. What if you lived in that same community for 5 years, but weren’t sure if you needed any medicine or treatment to prevent illness, and no one was keeping track. What if it felt like you didn’t belong….

While in California, I was honored to be invited to visit with the principals of MiVia, based in Sonoma, California. Here’s a short history of the system

 

MiVIA� (My Way) was designed as a collaborative effort of Vineyard Worker Services, St. Joseph Health System- Sonoma County and Community Health Resource & Development Center in 2002. Since then, these community based organizations have worked closely to help improve the quality of life and health conditions of farm workers living and working in the Sonoma Valley and beyond.

Today I will post about my experience with the health care associated with MiVia. Tomorrow, I’ll post a virtual tour of the system.

I arrived at the MiVia headquarters in Sonoma, a humbly-appointed, former OB-Gyn practice, where I was greeted by Cynthia Solomon and Heidi Stovall. Heidi offered me the choice of an overview of the work before heading over to the mobile health units. Of course I chose to go to where the work happens, and Heidi told me the story along the way. During our ride, I learned that MiVia was born out of a personal family need for members with significant health conditions to have their medical information available at all times. Then, in looking at the community, for them to have this access as well. What Cynthia and Heidi did was take their experience managing private medical practices, and apply it to community clinic settings, and ultimately in the care of this population (farm workers without ready access to care), and I am so glad I got to see it from this perspective.

We arrived at La Luz Community Center, where the St. Joseph’s Mobile Medical Clinic was parked, and I was introduced to Jessica Alcantar, one of the “Promotores de Salud,” and Jackie Williams, the Supervisor of the Clinic. Jessica showed me how she brought families into the care system by signing them up for MiVia first. The Promotores program is an innovation of this health system, and is essential to the use of the personal health record system. It allows anyone to have access to MiVia, and the team also does educational sessions about the use of the Internet for this population. Jessica told me that as an exercise, she taught the use of Google Earth to show people how they could find their nearest library. I asked about the value of the Internet in this population, and Jessica said, “They know the advantage of being able to connect with people back home.” A great demonstration of the shattering of conventional wisdom that the Internet is only useful for some and not all.

MiVia was developed in collaboration with the people it serves, and one of the unanticipated “wins” of the system was the MiVia ID card (see pictures). These can be printed on demand off of the Web, and are also issued to members as laminated card. For the people being served, this is often the only identification they have, their only tangible “belonging” to this community. The card is not just identification…more on that tomorrow.

In La Luz, a healthy cooking class was taking place as patients were being seen in the mobile clinic.

Here are my pictures from the visit, click on any to see full size, and then the “continue” link below to read on….

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While in the Bay Area, I had the opportunity to visit with Jason Cunningham, DO, at the Sebastopol Community Health Center in Sonoma, California. The Sebastopol Community Health Center is part of the Redwood Community Health Coalition, which is embarking on an ambitious electronic health record project, using the eClinicalWorks application.

Jason is a Board Certified Family Medicine specialist practicing a full spectrum of the specialty, including OB, pediatrics, and inpatient care. Unfortunately, I came to see the Center after he had finished seeing patients for the day, so I was unable to shadow. However, Jason embraced the idea of a walking meeting, so I could say I shadowed in the community as opposed to the medical office as we put steps on the pedometer.

Jason’s health center is designed to pilot an advanced medical home model, facilitated with a complete electronic health record. There are less patients receiving care at this brand new center while different approaches to care are tested in the practice. Specifically, there is more involvement of support staff in panel management, and a focus on excellent primary care provision, with a goal of creating a sustainable approach across the community. What I was really impressed by is the fact that this work is being done with the current reimbursement system as it is; in other words, the team is working to demonstrate better outcomes and affordable care through a focus on comprehensive primary care, within a safety-net, federally qualified health center system that emphasizes in-person visits. They are not waiting for a change in reimbursement approach to do this work.

In terms of the layout of the medical center itself, you can see from the images below that there is a focus on bringing the patient into the care experience. The patient sits across from the physician, and the computer, a tablet PC, is arranged so that both physician and patient have access to the information being used. Jason is also using after visit summaries with his patients, as shown in the image (test data shown), so that they leave with a written description of the visit and next steps. I of course think this is a key part of patient centered health information technology.

The surrounding community is both beautiful and also working diligently to provide access to regular, quality, primary care across the population.

Images, click on any to see full size

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Our week in California was a very productive one, in addition to our time at the Health2.0 Conference, because we visited several innovative practices in San Diego and the Bay Area.

One of those is Sharp HealthCare, which bills itself with the following (impressive) credentials:

Sharp HealthCare is San Diego’s health care leader with seven hospitals, three affiliated medical groups and a health plan. We are a 2007 Malcolm Baldrige National Quality Award recipient thanks to our doctors, nurses and 14,000 employees. Sharp is a not-for-profit and relies on philanthropy.

We spent our time with the Rees-Stealy Medical Group, at their downtown campus.

Sharp is a local and national leader in quality and a star in achieving goals as part of pay for performance programs.

First, the pictures, click on any to see full size:

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Almost exactly three months ago, Ted and I had the pleasure of visiting Dr. Mike Schierman, a primary care physician in Danville, California, practicing with two other part-time physicians. They are part of the John Muir IPA.

At that time, he had just begun implementing an EHR and many of our initial reactions are in a previous post. Although the sheer volume of work to convert a private practice to fully digital is daunting and remains a challenge, it’s clear that the process is progressing well. Dr. Schierman appeared more comfortable in how he used the computer and the EHR in the exam room.

Perhaps what I found most interesting this time is that his patients are impressed with his EHR use. One patient expressed enthusiasm on her visit to Dr. Schierman since implementation began and noted that her kids’ pediatrician is now using a similar system. None of Dr. Schierman’s patients begrudged him for needing to work with the computer as well as interacting with them—they seem to understand the value of having the EHR, and they

When Dr. Schierman stepped out of the room to get something, one patient—a retired carpenter—queried me about what I did. I vaguely described the PCHIT project and he quickly and excitedly asked me, “Am I going to be able to access my health information online?”

For others, it clearly would be important to do more than just put personal health information like lab data online—it’s not that they wouldn’t want access to it, but just that they would want it to be connected to something that explained it to them. Dr. Schierman asked if one patient if she wanted a copy of her labs. At first, she wasn’t sure because, “I wouldn’t know what they mean if you didn’t go over them with you.” Dr. Schierman printed out the labs and went over them with her thoroughly, categorizing and explaining each set of them, which she clearly appreciated. She then took the printed copy home with her.

Perhaps the most frustrating piece of the EHR implementation has been with the e-prescribing module, which has been shut down for now. A lot of the prescriptions weren’t getting to the pharmacies, which resulted in the doctors’ office being inundated with phone calls from patients. They intend to try again in the summer, when the volume of prescriptions isn’t so high. However, Dr. Schierman continues to use his computer to transmit a fax prescription to each patient’s preferred pharmacy—something that still really impresses his patients.

That provides real value to them because it increases their convenience (“You mean that the prescriptions will be there when I go to pick them up at my regular pharmacy?”). Perhaps more importantly, they get a sense that Dr. Schierman is a progressive doctor—working hard to make his practice as efficient and modern as possible.

Dr. Schierman is mostly pleased with how the transition is going, but he did say, “There are so many moving parts… It’s hard to make sure everything is on track.” Unlike larger practices that may—for example—have a training budget, Dr. Schierman and his office staff have “learn as we go, just testing out things and seeing what works.” But clearly he is well on his way, and his patients are very appreciative of the progress.