The reason it is a “series” and not “a front end” is because this system actually has brands that are specific to the specialties and care that it supports. Here’s a picture from a computer screen that shows them:

We’ll post a link to the new blog here, and then automatically redirect all traffic to the new site.

This blog was started along with the initiative in October, 2007, and will, as planned, move to a site hosted by the Center for Information Therapy. Josh and the IxCenter will maintain things there, including the 141 posts and 155 comments that resulted from this effort.

The new blog will continue to discuss important developments at the intersection of HIT and patient-centered care and build on related work going on at the IxCenter.

Ted will continue to write about his own experiences in health information technology, patient empowerment, reducing disparities, and physician (and patient!) leadership at http://www.tedeytan.com/.

We learned so much from the committed organizations we visited, all of which involve practitioners dedicated to promoting patient-centered care. We also learned, as one medical director colleague once said, that we are living in a hailstorm of innovation. We thank all of the organizations and the people who support them, for their time and interest in their patients and communities.

We also thank the supporters of this work

Images, click any to see larger

I have actually never had a patient demonstrate their own access to the electronic health record to me. This was the first time in my career. I am so used to doing the demos and describing what patients want, and this was so different because it included the things that worked best, but also the hopes and dreams for using this tool to be involved in care. Christine not only did the demonstration for me, but also 3 Medical College of Georgia Students, and part of the research team on a funded project to introduce patient access into hypertension care.

In the hopes and dreams part, Christine talked about uses of the system that we might consider concerning as medical professionals, such as writing messages that conveyed a significant level of concern about her condition (she lives with MS), but when she explained it, it made sense, and it became not so concerning.

This was a theme throughout the visit – the normalcy of patient and family involvement in care. This was very evident in the 3W Neurosciences unit and Ambulatory clinic. Countertops are reduced or eliminated. The layout is open. There is no such thing as “visiting hours.” Signage is welcoming and participation is encouraged. There are alcoves for family conferences, and even computers set up for families to use. There is guest wireless throughout the hospital.

As you watch the Remaking of American Medicine show and look at the data associated with this tranformation, it’s very clear this is not only good for families and patients (and society), it’s good for business. Quality is up, mortality is down, patient satisfaction is up, profits are up – all the right trends for a hospital serving a vital population like this.

This organization of course is part of a health care system with many challenges – physicians and nurses have significant time challenges, and even the physicians in training here are at risk in terms of their future enjoyment of the profession. I casually ran my idea of a 4th year rotation on patient-centered care (which would include elements of LEAN such as process flow, physician leadership, and service and access methods) with our student hosts, and they provided a little balance to the concept and assistance with messaging. Matt, Kim, and Brandi reminded me about the immediate needs of physicians in training and the way that they learn about and commit to new training experiences. I’d therefore like to propose a rotation on success in practice beyond the diagnosis – enjoying work, life, and balancing both successfully. Being patient centered guarantees that this is the outcome for any physician, in my opinion.

The thing I am super interested whenever I meet people who have done exceptional things is, “Why?” I noticed that in the PBS show, Medical College of Georgia was an institution in which their transformation was not set off by a patient tragedy. So I asked Pat about this and here’s what she said:

What started this and kept it going and I may have told you this in a way is that we developed a value around the inclusion of the patients voice in our work from the beginning of the design process for the new childrens hospital. I personally was a senior executive back then and I was utterly transformed by the power of the patient’s (in this case, parents and children) perspective on what mattered most in care and I could see that this was a strength that we were denying ourselves as executive leadership. We also had very good mentors way back then in Bev Johnson and the Institute for Family Centered Care and I think we were just open to learning. Because I became so committed and over time could show the hard results in terms of outcomes so did the rest of our leadership. I think it is really that simple….just persistence over many years, Ted.

I think this is very remarkable – Pat and the Medical College of Georgia did not wait for a patient to be hurt to transform their system. I keep reading and hearing about organizations that transform only after a tragedy. We’re health care, we cannot wait for a tragedy, right?

When we were touring 3West, Pat, Roslyn, and Bernard showed me a plaque, signed by every staff member that represents their commitment to patient and family centered care. The first thing I did was look at the date that it was first signed, and of course wondered if it was up to date. As I did that Roslyn said, “Whenever we get new staff, they add their signatures, too. We haven’t had new staff in a long time, though, because people stay here.”

I can’t wait to see the innovation that will come from Medical College of Georgia in the launch of their patient access system. This will take Patient and Family Centered Care beyond their physical buildings and wherever patients and families live, work, and play.

With thanks again to the patients, families, staff, physician and leadership at MCG for being great teachers, so that every patient and family can be involved in their care, whether or not they are fortunate to be supported by the MCG Health System.

And, I am not going to consider patient access to their medical record successful until a patient does the demo.

Images: Click on any to see larger

Just as with several other organizations I have visited, I did not imagine that I would be heading to Augusta, Georgia to learn about how to involve patients and families in their care, but I’m glad I did. This is a place where so many things that are seen as abnormal in the rest of health care, are normal (see this paper for a description of patient centered care, with a focus on MCG). In an environment like this, it’s okay to ask “why?” when it comes to issues of involving patients and families in their care.

The occasion of my visit is related to a grant that Medical College of Georgia has received to study the use of a personal health record to improve hypertension care. With respect to the idea that being as close to the patient as possible is important, Ms. Pat Sodomka, Senior Vice President of Patient and Family Centered Care, hosted my visit on behalf of the organization.

Part of my study included watching the excellent program, The Remaking of American Medicine, which featured Medical College of Georgia in its last hour, and it was amazing to see how much has been accomplished both in involving patients and their families, and in transforming the organization.

Today, I’ll post about what I saw clinically. Tomorrow, I will post about what I saw systematically in this leading edge care system.

I began in Family Medicine and Internal Medicine, where practitioners and patients are both busy, and integrating one or two electronic health records in the care that they use. This is what I observed when shadowing family medicine specialist Bill Phillips, MD.

Besides data from their own organization, they need to integrate the needs of patients working to stay healthy in a system with an affordability crisis. In my own practice, I had not had to think about which big box retailer offers which drugs for $4 , or even free, as a loss leader. However, this is a big issue for patients. I reviewed the formulary for Wal-Mart’s $4 program – it’s extensive.

I was able to shadow the Director of the Osteopathic Medicine Program, Julie Dahl-Smith, DO, who is also board certified in Family Medicine, as she performed a manipulation visit and acupuncture visit for a family. This made me think about the value of patient involvement through a personal health record. The treatments that Dr. Dahl-Smith provides are distinct from the allopathic treatments that I have been trained to do. There’s an opportunity for patients to become more knowledgeable about the treatments that work best for them through patient access.

I spent time with Shilpa Brown, MD, who manages her own faculty practice as well as a residency practice and extensive student teaching. Patients in each have distinct needs. I also observed some key differences in workflow between private practice and academic practice. Faculty are ultimately accountable for 1, 2, 3 or more residents’ care, whether that care is provided in person or virtually. There is much that MCG will contribute in this area as an innovative academic medical center.

In between, I visited with the Neurosciences Interdisciplinary Rounding Team, which includes nurses, pharmacists, students, residents and attendings, led by Dr. David Hess. This is a unit, 3W (which I will talk more about tomorrow) that serves patients and families not just locally but regionally. What would it be like if a family member who is based far away from Augusta could connect with their family’s care team electronically? The team was open to this idea.

This organization is unique in my travels because it is a full academic medical center with many top notch training programs, which include a family medicine residency and an osteopathic residency. It is also special in the way it involves patients and families in the care, through its advisor program. The program reaches all the way into undergraduate medical education, and every new program seeks involvement. Patient advisors are free to visit MCG facilities and talk to patients and families about their care.

As I was being guided to the Internal Medicine clinic by Bernard Roberson, Director of Family Services Development, we passed by one of the “commons” (a different way of thinking about a waiting room that’s more patient centered) and a patient waiting to be seen said to us, “Tell me more about patient and family centered care.” It turned out it was one of MCG’s Patient Advisors, and I think we both saw it as a welcome sight. That’s how things are different here.

Tomorrow, a post about the system-ness of Patient and Family Centered Care at Medical College of Georgia.

Pictures, click on any to see full size

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?

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.

In Augusta, Georgia, a national epicenter for Patient and Family Centered Care, as featured on “The Remaking of American Medicine.” It’s a really impressive place. I’ll be blogging more about it soon. Nothing provides more energy than patient empowerment.

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.

Mark was demonstrating the After Visit Summary, in this case, to a group of leaders from the District of Columbia Primary Care Association, which is currently undertaking an impressive program to implement health information technology in safety net medical centers in Washington. Senior Project Specialist Lauren Mardirosian was in attendance, along with Tracy Knight, NW Social Services Director from Bread for the City, and Deborah Parris, Health Information Manager from Family and Medical Counseling Services.

I set up the visit, with Kaiser Permanente’s help, because I am excited by the fact that our members’ experience can help patients in every care system, locally and nationally. It’s a virtuous circle – sharing our experience brings other experience back that we can use to do even better, and the cycle continues. I have really learned the reinforcing power of sharing in this journey. It’s even more enjoyable when I get to work with colleagues like Mark and Medical Center Chief Doug VanZoeren, MD, who willingly give their time alongside me.

What about the After Visit Summary? Mark showed that by involving the patient in its development, he makes the creation as important as the delivery in achieving its goals – involving patients and families in their care. In an era where we talk about Web2.0, Health2.0, and focus on user generated content, I think this is a great example – we create the record of what happened today, together.

DCPCA is implementing a modern electronic health record system, manufactured by eClinicalWorks, that has this capability. A care system that I visited in Sonoma, California, is already generating these for patients. Sometimes a piece of paper (albeit one that is also available on the Web in real time, on Kaiser Permanente’s personal health record, kp.org) can be as revolutionary as the people who put it together.

Thanks again to DCPCA, Mark, Doug, and Kaiser Permanente North Capitol Medical Center members and staff for their interest in helping patients everywhere.

Pictures: Click on any to see larger. Note: The patient displayed is a test patient. No actual patient information was demonstrated during the visit.

A lot.

There’s an interesting discussion underway at e-paients.net, about a recent case in Minnesota, which I was asked to (and did) comment on.

(e-patient) Dave brought up an important point, which concerns holding people accountable. Is it for the error, or knowing that the potential for error exists, or both?

I remembered this excellent paper from my files about this, and fortunately it is public domain, since it has been funded by our tax dollars. It’s useful to review the principles contained in it, which include supporting accountability and learning at the same time. Interesting that a lot of smart people have already done the thinking. Now we need to operationalize it.

With regard to the discussion on e-patients, I also remembered something about me. Whenever I walk into one of my organization’s medical centers, I assume that I am 100 % accountable for everything that is happening there. As I walk by the pharmacy, the lab, and head up to primary care, I imagine that my role is to protect every patient receiving care in all of those areas, whether or not I am directly involved in providing that care.

Now, imagine that every physician, staff member, patient, patient’s family, community member, carried themselves that way in every hospital and medical center. What would health care be like?

This cannot happen unless we support the idea that everyone on the care team, patient included, deserves access to all of the information about their care.

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.

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:

Every community has patients that depend on community supported care, in systems that may or may not have robust HIT infrastructures.

In many communities, EHRs are being implemented, in some cases with patient access over the Web. I am not sure that MiVia would necessarily replace a proprietary EHR patient access system; however, it could very much complement it.

What I have learned from my experience is that health care, and the health information associated with it, should be wherever the patient is. It sounds obvious, but what can happen is that a patient can be admitted to a hospital, where a medical record is created in one electronic system. The patient can then be discharged and then another medical record is created in the outpatient setting, which is counter to the idea of medical information following the patient. What if the person and family are not regular users of these settings? Who will put their medical story together?

Putting those ideas together, imagine an employer of farm workers or underinsured or uninsured individuals wanted to do what they could to keep employees well, even if they did not sponsor health insurance. Imagine a community that had a solid strategy for implementing an EHR and even a personal health record in the safety net, but there are still individuals who do not get care in even that safety net. Could a product like this be the “glue” that allows every patient to have access to their own information? Could the idea of a “Promotores de Salud” program be part of every community health system’s benefit program such that all patients have electronic access to their own clinical information? I am used to the idea of charity care being “all of the emergency room visits for which we were unreimbursed.” What if we turn that around and say, it’s “care that we provide in the community to prevent emergency room visits?”

Going back to the story at the beginning of yesterday’s post – what if you did see that doctor who may not speak your language, or you wondered if anyone knew if you needed preventive care. If you could give them a card that said, “It’s all here,” maybe providing for yourself and your family might be a little less scary both for you, and for the health care professionals that want to keep you well.

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….

The mobile clinic itself is very modern, with an Internet connection via satellite, and with exam rooms and a small laboratory. The clinic is supported by the St. Joseph Health System of Sonoma County as part of their Community Benefit program. MiVia is used as the electronic health record as well as the personal health record for these patients. Providers do their documentation right into MiVia. I did not shadow a patient visit, unfortunately, due to a desire to maximize the privacy of patients in this particular environment.

Jessica next gave us a tour of the mobile dental unit, at a different location. Jose Fernandez was the Promotore supporting dental care at this facility. MiVia is a personal health record for comprehensive health – oral health included. This is the first PHR system I have seen that does this. In some ways, this system is more comprehensive than what are offered to patients in the most advanced health systems. I spoke with Chris Tomaszewski, DDS, the dentist, and Susanne Hansen about their provision of dental care. Chris said that she’s very comfortable with mobile dentistry, as she formerly practiced for the Navy, and both Chris and Susanne seemed to echo the feeling I got from all of the providers that they really enjoy what they are doing. As with the mobile medical unit, this appeared state of the art to me. Chris does the data entry into MiVia so that patients’ oral health issues are present in their record wherever they go. In addition, the comprehensiveness of the record allows the dental team access to the medical history of the patient.

Both the Promotores and the mobile health units are funded out of the Community Benefit office of St. Josephs. What impressed me about this was that the Community Benefit was applied proactively in this community to reach a group where they are, as opposed to reactively, by providing care in the emergency room / tertiary care setting.

Right now, there are about 5,000 patients’ records in the secure MiVia system. Tomorrow, I will post on the features of the system, which include patient control and access, and even temporary access on demand.

I think this work is very important in the transformation of a health system to become accountable and accessible to patients. The MiVia team are serving a group of patients that would otherwise not be served by health information technology efforts in the community, and in many ways, their service is better than their insured counterparts. Heidi and Christine estimate that there are 15,000 farm workers eligible to be a part of this system, and are working to fund the system to provide that care. If I think about the fact that every community has a population like the one that MiVia serves, and will not be served by other systems implementing HIT, this could be a key piece of ensuring that every patient in every care system has access to, and is empowered by, their own clinical information. MiVia is being designed for interoperability (more on that tomorrow, as well).

My question to the people I met was, “why did you decide to do this?” and the answers remind me why people that go into healthcare are exceptional. I think what is special about this provider group is that they get to see the impact of what they do for the community, and of the many things about this work that can be applied to all of health care, it is helping every piece of work be tied to the impact that it makes for a patient and their family.

With thanks to Heidi, Christine, Jessica, Chris, Susanne, Jackie, Jose, and the MiVia and SJHS Community Health Clinics Teams for their time and inspiration.

Tomorrow I will post a virtual tour of MiVia, including the features that make the scenario described at the top of this post not so scary for this population, because they deserve not to be scared.

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

Jason is interested in changing that, and bringing more providers into the world of the EHR. He showed me the work he is doing to support management of his panel’s quality goals, with an interest to do this community wide. There is a plan to bring patient access to this system later this year, once the first three medical centers go live. We spoke a little bit about this – the medical home model, as described in presentations like this speaks about the MA-physician teamlet. In the care system I come from, the patient is part of the team, via access to their own health information online and print (e.g. the after visit summary). We have found that this is a critical part of the medical home – because a patient’s medical home is really where they live and work. This can be done with RCHC’s system, and I think RCHC’s efforts plus the efforts of MiVia (see tomorrow’s post), plus other local providers’ work could result in an entire community with access to their own clinical information.

I think it’s an important distinction that Jason is moving ahead to make an ideal care system work first compared to other places that look at structural issues first in deciding to innovate. I think think this is a great place for physicians to be leaders, as Jason is – to show how things should be for patients so that a system can then support it.

I remember a comment I heard at a meeting about primary care last year that, “medical students deciding to go into primary care are good at reading balance sheets.” I remember feeling uncomfortable with that idea in my own experience. I knew how to read a balance sheet in medical school, but I also knew how to read the face of a person (a patient) who is helped to achieve their life goals through good health. I think both of us shared this same experience in choosing family medicine. Jason and I both agree that in the work we do, every patient deserves to have the best of every system out there, not just the best of whatever system they receive care. My time in Sebastopol reminded me of something I have mentioned several times on this and other blogs: people who choose to go into health care are exceptional people, because they have to be. While we respond to incentives like most humans do, we also respond to the calling that got us here. Great things can happen even when they aren’t supposed to. After they happen, a system should be supportive of them still happening.

My only regret about coming to Sebastopol was that I did not observe the process of care with real patients, as I have done with other sites I have visited. My sense is that a lot of innovation is happening here and the work of Redwood Community Health Coalition has the potential to be the model for other safety net systems, or systems in general, to excel in primary care. Thanks again, Jason, and the entire team a Sebastopol Community Health Center for being gracious hosts!

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:

We began our shadowing experience with Huy Ho, MD supported Mara, in the Internal Medicine section. Sharp uses an electronic health record manufactured by Allscripts, Inc. , as well as companion applications such as PACS, which allows for quick access to radiologic images. Each exam room is equipped with flat panel displays. Currently, documentation and order entry occur on paper, which is scheduled to change. From that perspective, several of the processes I observed were very similar to what I used to use before the era of the EHR in my organization. There are challenges around filling out forms, and completing documentation, which may be either dictated or on paper. Huy enjoys the rapport with patients that he can create as a primary care provider in this system.

We also spoke with John Pauls, MD, Ph.D., a specialist in Asthma, Allergy & Clinical Immunology, who has been with Rees-Stealy for about a year and enjoys his practice greatly, especially considering past experience in private practice, and experience in the Canadian medical system. He’s very supportive of the technology that Sharp uses to connect its group practice, and the opportunities it provides to improve the overall quality of care for all practitioners. Unfortunately, we missed his last consult of the morning so were unable to observe him in a clinical interaction. We spoke some about some of the challenges of electronic health records in general providing for patient needs, with one example being the ability to prescribe and/or add useful interventions like saline irrigation tools to the patient’s health record. This has been a challenge in many EHR systems – to record all of the things patients do, whether or not they are physician-prescribed activities.

We met Randy Hawkins, MD, who’s the Chief Information Officer for the group and a practicing Neurologist. He’s concerned with supporting the entire medical group in moving forward on all technology fronts. We looked at the features of the electronic health record in use and upcoming improvement work slated to occur, specifically on order entry and documentation. Randy has a very rich fund of knowledge regarding health information technology and awareness of the current systems’ capabilities. The real and reasonable question arises on where to put patient access into that plan.

We spoke some about the population served by this campus, which is felt to have good access to the Internet. At the same time, this is still an abstract concept for the group, since they are early in their planning. It was intentional that we interact with this group, and I know from experience that this transition requires a lot of shared information and discussion. I spoke with Randy’s Medical Assistant, Nancy, a bit about provider-patient e-mail and I appreciated her response to the question about her interest in doing this with patients. She said, “I would have to see how it works.” I think that is a great approach, because my experience so far is that everyone wants to do what works for patients.

The Rees-Stealy Medical Group is the first multispecialty group we have visited on this journey that does not currently have an operational patient-access system to their electronic health record (consistent with the majority of medical groups in the United States), so it was a unique experience. The physicians and staff here are obviously committed to a quality care experience and have the results to show it. From that perspective, I think they would be successful in working with patients this way. Sharp is fortunate that they have several medical groups to gain expertise from as they move ahead, and I think they could be a model for other multi-specialty groups and their community when they succeed.

Josh will also post his experiences here. In the meantime, here’s a picture of him on one of the reactor panels.

Josh and I are in San Diego this week for the Health 2.0 Conference, and to interact with innovative California health care organizations. I think we are two of the few people in the U.S. that did not attend HIMSS last week. However, we are two of the few people in the U.S. who are attending Health 2.0.

The quote in the title was from my table at the “Unconference” which was facilitated by Enoch Choi, MD, from the Palo Alto Medical Foundation. It refers to the difference between web services offered by physician groups and what could be offered.

In the kinds of conferences I go to, attended mostly by medical professionals (and in many parts of my medical group itself), I typically feel like “year ahead of my time guy.” (This post from my blog, using a cute Apple commercial, I think illustrates the dilemma well). In this group, though, I feel like “year behind everyone else guy (person)” and that’s pressure that I like. The current state of the art of patient access to their care team(s) is one to one, and in the next step should be many to many. I gave the example of a patient electing to have a surgical procedure. What might be one of the first questions they would ask. How about, “Can I talk to other patients who have had this procedure? And who have had it performed by you?”

We had a discussion about creating change and where that might happen – from within the (medical) profession or outside of it. Keith Schorsch, the CEO of Seattle-based Trusera offered the idea of the “enlightened” provider. I asked if there was a registry where we could all sign up. I was kidding though, because in my (our) travels so far, I find that all physicians/providers are enlightened, when we support them in being so. And that comes from thinking about the patient at the center.

The Kaiser Permanente Effect

Something I noticed that I need to watch out for, more carefully than I did on day 1, is the impact of being in a room of innovators as a representative of a large medical group / health plan. I say “Kaiser Permanente” effect even though I am not a Kaiser Permanante employee, but the thought/idea that permeates an audience sometimes when I/we represent ourselves and our work is the one that goes something like, “Only Kaiser Permanente/Group Health can do that kind of innovation.” That statement can be taken two ways – it can mean, “We aren’t going to do anything innovative because we aren’t structured like that.” I think in this audience, my concern is that it can be taken as, “We don’t have the ability to overcome inertia outside of a Kaiser Permanente/Group Health system.”

I think the statement in general is incorrect, and that’s good news. As I sometimes say, I am going to spend the day watching myself and listening 51 % of the time. There are a lot of smart people here working very hard to stimulate improvement in the health care system we all use; they are thinking of innovation 24/7 and I want to help make their ideas count. And pick up some new ones along the way.

Speaking of Innovation

One of the reasons we are here is to visit and shadow providers at Sharp Health Care. As you can tell from the image above, they are a leader in health care and interested in providing patient-centered health information technology. Josh and I presented our work to the group and it was well received. We’ll be shadowing in one of their medical facilities in the next two days.

Legal and Policy Analysis: Personal Health Records: Why Many PHRs Threaten Privacy, World Privacy Forum

2008 Survey of Health Care Consumers, Deloitte Center for Health Solutions

Actually we do want access to our own health information. The title is a reference to three things:

1. Personal Health Records, why PHRs May Threaten Privacy, published by the World Privacy Forum.

I think this is less about not using a Personal Health Record (PHR) and more about understanding HIPAA, and its useful. The paper states clearly that the discussion is a different one for HIPAA-covered entities (such as Kaiser Permanente and Group Health). I would recommend that people review the information or at least the summary document to be familiar with what an organization can or can’t legally do with personal health information. I think that’s the key – even if an organization states it is not going to do something, there may be no legal protection if they change their mind.

So could a personal health record threaten privacy? Sure. Is it a reason not to use one? That’s a personal decision of benefits vs risks. I think it would be a challenging statement to say that these concerns should keep all Americans from having access to their own health information, and certainly the situation is different for HIPAA-covered entities, where there is both access and legal protections. I also think that we should not rely on information technology to create trust for us using software, or the system we have long been waiting for will never arrive.

2. Deloitte’s 2008 Survey of Health Care Consumers, published by the Deloitte Center for Health Solutions

This is a very well done representative survey sample of Americans with regard to health care with a focus on online access an alternative treatments. The conclusion is very clear: consumers want access to information created by themselves with their physicians, hospitals and health plans. And only 6 percent have this access. So, a huge discrepancy between what people want and what they are getting.

I keyed in on some very important statements, that buttress a fact from my travels, that “uninsured does not mean uninformed”:

The attitudes and preferences of the uninsured mirror those of the insured

Interest in online appointment scheduling, e-mail access, and online access to medical records and test results is equally high in the uninsured and insured groups.

There was a similar attempt at creating “personas” of the various consumer groups in this paper, much as we did here, for the stakeholders we are working with. I would say that the technique is less effective in this report because the personas aren’t based on standard terms and are likely to be forgotten. In the health system world, it seems easier to segment by known groups, like Gen X, Gen Y, baby boomer, or by insurance status or by care system.

One other item of note is that 60% of respondents state that they are on medications. That’s an impressive number, especially when I think about the power of the compounds that we prescribe today. Having access to one’s information is more than a convenience. I wrote about a real-life example that I encountered recently, on my blog.

3. Google. See for yourself. I think this ties together a lot of the ideas above. John Halamka makes some comments about HIPAA and the Google product based on his experience being on the Google Health Advisory board. I think patient-centeredness may become mainstream. Comments are welcome of course.