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.

These were the words I heard overhead while I was having dinner with a friend recently. Within minutes I was ushered into a back room and encountered a true medical emergency, with confused and concerned bystanders. They ultimately showed excellent judgement by activating the emergency medical system and reaching out for help locally in the interim.

I have answered several public calls for a physician in the past few years, and each situation makes my heart sink out of compassion for both the unwilling patient and the people around them, who want to do whatever they can to help.

As it so happens, my friend found me as I was pondering the situation. He asked, “Ted, how would a patient having their medical records accessible to them on the Internet make a difference here?”

I didn’t have well formed answer then, but I do now. It could have made a big difference, and not because we would bring up a web browser and start surfing.

A physician who practices with the knowledge that their patient is a partner and will see everything they do is more likely to produce records that are (a) accurate (b) involve the patient in treatment planning (c) at the patient’s health literacy level (d) involve family members in assisting in ongoing care needs. Patients can carry accurate diagnosis and medical lists and learn more about how treatment impacts their daily living.

So it’s not about the web site, it’s about the way we respect patients when we involve them and their families in care. When I think about the types of very powerful compounds we prescribe patients and the amount of information we give them (in one study, only 62% of prescriptions were fully explained to patients, 26% of the time even the name of the drug was not told to patients), it is possible to think about how many of our friends or family could be in a situation like this against their will. Prepared, knowledgeable, patients may be less likely to have emergencies in the first place. I know for certain that this was the cause of one of the emergencies I responded to about a year ago. No one leaves their home in the morning hoping to ride in an ambulance later in the day.

As my friend and I parted for the night, it seemed that the story had a happy ending as the patient received the help they needed and life went on in the environment we were in. But just like the physician in “A Fortunate Man,” even if everything turned out just fine, I would still be sad.

Each time this happens I can’t help asking the question, “Why did this happen? And why didn’t the health system prevent it?” When I think about the answers, I become just a little bit more restless to change things.

• 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?