Yesterday I had the privilege of speaking at the pre-course for Internal Medicine 2008, American College of Physicians annual conference, in Washington, DC. The topic of the pre-course was the focus on the individual practice, and was facilitated by the great team at the Center for Practice Innovation, including Michael Barr, MD, MBA, FACP, Paula Woodward, MPH, BSN, RN, and Maria Rudolph, MPH.

I really like working with this group first of all because Michael and Paula assemble entertaining and fun experts, like Gordon Moore, MD, Rodney Hornbake, MD, and Peter Basch, MD. All of these physicians, and fellow panelist, Maria Rudolph, are “current” in the field and honest and passionate about improving patient care, which includes being able to stage agreement and disagreement. It’s sort of East Coast, and I like it.

The second reason I like this group is because they represent the overwhelming majority of care environments for patients in the U.S. (over 90% get care from small practices). In terms of promoting patient-centered care for every patient in every system, these are the physicians who have both the ability to innovate and the fiduciary responsibility to make it work for their practice. Putting those two together makes for a perspective that is supportive of HIT and patient centered HIT (that’s what I observed) that succeeds for patients, and those who care for them. I think that’s what we want.

We were asked to provide some parting words for this group, and honestly, I feel a bit awkward being a teacher to this group of practitioners. In many ways they see a lot more of healthcare than I do. In any event, my parting words were that when it comes to HIT, they know more than they think they know, and are well suited to ask, “how will this work for my patient?” That and they should ask every patient if they access the Internet.

ACP enters the blogosphere this week with ACP Internist. A great move for this specialty society, in my opinion.

My visit was capped with a trip to see my colleague David Kauff, MD, from Group Health Cooperative. I have to say that I had to make my way through quite a bit of product placement (more than I would expect to see in 2008), and I wasn’t allowed to take pictures in the exhibit hall, but it was well worth the trip to meet up with one of my favorite internists.

April 1st through April 2nd:

• Pattern Recognition » Blog Archive » I really hate Zotero - Like the concept, wants to improve the implementation
• Medical Home | Solution to Chronic Care Management? | Health Care | Disruptive Innovation for a New Primary Care Model | Center for Health Solutions - Deloitte LLP - Very nice overview of Medical Home, particularly with the rundown of stakeholders in the back, plus the medical home cost model.
• WordPress ? Support » Tags Import As Numbers, Not Words - Importing issues Wordpress
• Web 2.0 Expo San Francisco 2008 ? Co-produced by TechWeb & O’Reilly Conferences, April 22 - 25, 2008, San Francisco, CA -
• Compare Accounts | YouSendIt - Store and forward service for the times when e-mail isn’t so efficient. I use XDrive.
• Convert Your Paper to iPaper | Scribd - An ambitious project to convert paper , no extra charge
• John Furrier Says Google?s CIO is Leaving for EMI - Interesting change of employer, could the same thing happen if a Google employee was recruited to run a health care organization?
• Twitter - A Teaching and Learning Tool | ICT in my Classroom - Nice discussion of the uses of Twitter in education
• VoiceThread - Group conversations around images, docs and videos - An interesting image, video, voice annotating service. What are the applicaitons in medical group training and patient involvement

I was fortunate to speak recently with Paul Grundy, MD, MPH, the director of healthcare technology and strategic initiatives at IBM, about the work he is driving as the chair of the Patient Centered Primary Care Collaborative. Through the magic of Web2.0, I first picked up word of Paul’s work via this post on the IBM HealthNext blog, and since then have participated (in one meeting last summer) and watched as the movement has gained traction.

I chose Patient centered health information technology as manageable scope for a sabbatical; the ultimate goal for a career is patient centered care that respects patients, their communities, and those who serve them.

Paul sent along his thoughts on patient-centered primary care, and I am reposting them here, for others to read. As I have listened to Paul and his colleagues and compared it to my own experience studying Informatics and process improvement methodology, I have become acutely aware of not just the value stream within health care. I am aware of the value stream for a person in society, which is to achieve their life goals through optimal health.

When I wrote about my visits to work sites, like Genie Industries in Washington (see: “Overwhelmed with Possibility,” DailyKaizen Blog, July, 2006) and the NUMMI Plant in California (see: “NUMMI, Fremont California,” DailyKaizen Blog, August, 2007 ), it has become clear that our role is as the support system for these individuals, who are providing for themselves and their families, and finding fulfillment in their lives, through optimal health. The medical center is just a stop on the journey, not the destination. Employers add this perspective to our work and can assist in having our health system reflect this ideal design.

Paul’s words are below. As usual, your comments are welcome.

Read the rest of this entry »

Sites Visited

• Blackhawk Medical Center (Danville, California)
• Center for Practice Innovation, American College of Physicians

Innovative, and Pressured

Blackhawk Medical Center:
New displacing Old

Small practices compose the bulk of physician organizations - 93 percent of US practices have less than 6 physicians, 96 percent have less than 10 physicians*. Percent penetration of “full” electronic health records in this population is still less than 10 percent, with up to 24 percent with some form of EHR (see Electronic Health Records Still Not Routine Part of Medial Practice, Robert Wood Johnson Foundation). This makes for a large potential market for vendors on the one hand, and a more costly sales proposition on the other hand. To quote the AC Group (White Paper on 2006 EHR/EMR Marketplace):

it appears that the adoption rate is increasing by only 32% per year. Therefore, if the current trend continues, the total adoption rate will only be around 52% by 2010. So what will it take to increase EHR adoption? The industry must create financial incentives for physician adoption. Without financial incentives, the US EHR market will never exceed 50%.

We witnessed this challenge at Blackhawk Medical Center, part of the John Muir Physician Network. The practice has purchased an EHR with its own funds, with plans to tie to the larger organization’s patient portal.

Implementing an EHR within a small practice places pressure on the practice itself to show return on investment in the long term, and in the short term, to justify the upheaval caused by this transformation. When we went to shadow Dr. Schierman in his office, he apologized for the appearance of medical charts on his desk, which he was methodically reviewing in preparation for scanning. This is balanced by the external pressure of competing group model practices in the area who generally have higher HIT adoption rates and richer support (financial, technical, legal). A survey performed by the California Medical Association in 2005 and reported by the California Healthcare Foundation found that the greatest barrier to EHR use among physicians was the expense to purchase them (see Electronic Health Records Still Not Routine Part of Medial Practice, Robert Wood Johnson Foundation, and “Snapshot: The State of Health Information Technology in California, 2008 - CHCF.org”).

At the same time, projects like the Center for Practice Innovation of the American College of Physicians, are bringing forward practitioners who illustrate an advantage of these practices (see Small Practices leading the way: ACP’s Center for Practice Innovation).

Because the locus of control is within the practice in terms of workflow and information technology, there is a greater capability to experiment. In addition, there is greater capability to experiment with lighter-weight systems, including systems that are subscription-based, to examine changes in care independent of the technology. At the CPI’s November meeting, I saw several presentations given by small practices about their use of subscription based messaging and patient-entered-data systems.

One interesting development I noticed was the Ideal Micropractice, where physicians have minimal to no support staff, and with it a much greater capability to experiment with patient-centered health care and technology in support of a different cost-model for medical care.

All of this said, we did not find deep understanding of the value of personal health records in these environments. I (Ted) found that there was ready uptake of the concepts when they were introduced in these groups. However, there was a noted tendency before the conversation started to have a bias toward inaction. At the Center for Practice Improvement’s November meeting bore this out. Prior to several presentations touching on patient-physician messaging, a question was asked of the audience about patient-physician e-mail, with an ambivalent response. Following the presentations however, several individuals appeared much more enthusiastic about this work.

Awareness-building is occurring on a national basis as well. In a 2007 article in Family Practice Management, “Are your Patients Ready for Electronic Communication?,” the authors come to a surprising conclusion about their practice:

Overall, we were pleased to learn that 88 percent of our patients are able to access the Internet or e-mail either at home, through a public facility, or through family or friends. We had anticipated a much lower number. We were also impressed that 78 percent of patients with Internet access (either at home or elsewhere) expressed interest in using some form of electronic communication either to contact our office or to receive health-related information from our office.

I experienced a similar finding within the practice at Blackhawk Medical Center, when Dr. Michael Schierman took the time to ask each of his patients that day how they would feel about patient-physician messaging. The answers to the question, once asked, and the response, were similar to what was written about in the article above.

Unresolved Issues

• Funding sources for small practices to adopt health information technology are less clear relative to safety net providers or larger practices
• Conventional wisdom about the value of patient access to their health information online may lend to inaction
• External environment/incentives send an ambiguous message regarding adoption of patient accesss in electronic health record implementation

Countermeasures

Charts, scanned, secured, and ready for permanent storage

We plan to continue following the John Muir experience, given the presence of a strategy to integrate a patient portal and an electronic health record, and the innovative nature of this practice to begin with. This may provide support for the idea of PHRs in other practices. We would also like to connect with payers who support small practices to examine the relative priority given to supporting technology and patient-centered care in payment policies.

Ways to Engage

• Connection with innovators in the field
• Connection with specialty societies and practice innovation centers
• Connection at the payer level

*A note about practice size

In reviewing data for this persona, we came across several different measures for practice size, including “Percent physicians practicing in a practice of a certain size” and “Percent of practices of a certain size.” In our travels, we have also witnessed the communication of this data differently. For the purposes of this special report, we prefer to report by “Percent practices of a certain size” since this represents the experience that a patient will see when they receive care, and since a practice is most likely the unit of adoption of HIT.

To see a list of links that display this data different ways, go to PCHIT Personas: Practice Size

PCHIT Advisory Group - Slides

This post is first in a series will summarize our status and input from our Advisory Group (Blogs are about a little information at a time). Both the Group and this audience are welcome to comment. Our goal is to make any adjustments necessary, now, and continually improve our process as we do this.

The summary comes in the form of an “A3″ document and a short set of slides. The slides are published here.

A reminder that an A3 document really just outlines a story. It’s probably best for this medium for me to discuss the work of each Advisory Group member (with the exception of Patricia Flatley Brennan, who could not be with us this first time) and the impact on adjusting our work.

To also keep this manageable, I’ll do it over the course of the week, one each day.

Michael Barr, MD, MBA, FACP: Michael, as Vice President of Practice Advisory and Improvement for the American College of Physicians, is leading the Medical Home work of the College. This includes establishing the “systemness” of the Medical Home, as well as understanding the economics of the Medical Home. He is working with payers to establish the benefit to patients and ability of Medical Home to address self-management goals. As currently devised, this model is most effective in practices where there are longitudinal relationships, such as primary care, but also in specialty care in certain circumstances. Several demonstration projects are set to begin in 2008. The College’s Center for Practice Innovation has been working with small practices to transform them, in line with Medical Home principles. The ACP is heavily involved in technology issues, at the level of some delivery systems. Finally, we are alerted to the publication of a white paper in the Annals of Internal Medicine on payment methodologies.

Adjustment: The impact of Medical Home discussions locally and nationally is very clear, and observations in PCHIT should be connected to Medical Home principles. Ted Eytan is presenting at the CPI conference in Washington, DC, on November 17 and will be spending time with CPI staff and practices as part of this involvement. The ACP white paper will be reviewed by us as well for implications for PCHIT.