While at Massachusetts General Hospital last week, as a guest of The Stoeckle Center for Primary Care Improvement, I was invited to meet the team at the Laboratory of Computer Science based at MGH. The Lab of Computer Science produces the OnCall series of clinical web portals, which are a front end to the Computer Stored Ambulatory Record medical record system.

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:

This week’s photograph is of myself, with Susan Edgman-Levitan, PA, Executive Director of the John D. Stoeckle Center for Primary Care Innovation. Susan invited me as a guest to the Center to learn about the primary care practice of the future being envisioned at Massachusetts General Hospital, as well as the work under way at the famous Lab of Computer Science.

I enjoy working with Susan because she knows how to laugh. And in advocating for patients in her friendly style, she’s kind of like this…

I am posting this presentation that I created, commissioned by the California Healthcare Foundation, and supported by the Center for Information Therapy and indirectly, Group Health Cooperative.

It is the presentation that created the need for me to define Health 2.0. It is also the last presentation I will give as as a Group Health employee, and the only time I will be able to give it, due to my my career change.

It’s in slide show format, so feel free to click on any of the images and page through. I had a lot of fun putting it together because it allowed me to reflect on what I learned and how much I have changed in my thinking in just the past year. May the same trend continue.

I would like to extend special thanks to Crosskeys Media, producers of the excellent show “Remaking of American Medicine,” for allowing me to use portions of the content in the interest of supporting patient centered care. I encourage anyone interested in this topic to view or purchase the show. There is an educational license available that allows for use in teaching (as a whole piece, not intended for editing by users). It’s worth it.

Feedback and comments welcomed.

Sites Visited

• Harvard Vanguard Medical Associates
• Partners Health Care
• John Muir Physician Organization

Challenges with Patient Adoption

This seemed to be the hallmark of the multispecialty groups we visited, all with different organizational structures. Harvard Vanguard is a private multispecialty group, has an existing patient portal, MyHealth Online, as does Partners Health Care, in Patient Gateway. John Muir Physicians have chosen the RelayHealth platform, but have not yet implemented it across all care sites.

In observations at the practice level, we noticed an enthusiasm for PHRs in both HVMA and Partners, and both organizations are putting some effort toward promoting adoption. For example, brochures at nurses stations.

At the same time, the messages at times seemed ambiguous at the level of the patient. For examples, physicians in practices served by Patient Gateway are communicating with patients outside of the Patient Gateway environment, using electronic mail. Partners has a Physician Leader accountable for Patient Gateway’s success. Harvard Vanguard Medical Associates does not. There was not a consistent approach among physicians at sites we visited (both Boston organizations) with regard to explaining the benefits of these tools to patients. We also noticed signs like the one pictured here, which describe a workflow that makes less sense in the presence of a personal health record system.

Independent acts of adoption were visible, however, at several sites, such as Masschussetts General Beacon Hill Primary Care, where Administrative Manager Richard Perrotti has worked with medical staff to integrate Patient Gateway into the care experience. In addition, practices that we observed were interested in ideas to promote adoption from others engaged in PHR use in practice, which leads us to believe that there is receptivity to a consistent message about benefits.

Data in a recently published article demonstrates flat adoption curves (see: Halamka JD, Mandl KD, Tang PC. Early Experiences with Personal Health Records. J Am Med Inform Assoc 2008;15:1-7) for other institutions local to HVMA and Partners, most notably Beth Israel Deaconess Medical Center. This is despite the fact that these organizations do not charge additional fees for use of these services.

Internal, External, Technical Factors?

When on site in Boston, organizations we spoke with acknowledged that hurdles to promoting adoption originated in internal prioritization of multiple initiatives, as opposed to external factors. This may be prevent the application of resources to developing a coordinated approach to adoption.

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This blog post, by Andrew Dreyfus, the executive vice president for health care services at Blue Cross Blue Shield of Massachusetts and former president of the Blue Cross Blue Shield of Massachusetts Foundation, caught my eye.

Commonhealth » Blog Archive » A NEW AND DIFFERENT WAY TO PAY FOR CARE by Andrew Dreyfus

At the level the information is presented it sounds promising - that delivery systems might have more lattitude to use all of the tools available today to coordinate care (including patient access to their records online). The details are not listed, though. I wonder what about the plan would enable a more patient centered approach to implementing health information technology. Would a delivery system under this plan be spurred to promote personal health record adoption?

As we found when we visited Boston recently, adoption of relatively robust patient access systems has been less than desired, especially compared to systems where incentives are aligned. Maybe this might help?

I’m posting this as a trackback to the blog post to see if more information might be shared about this, either here or on the original blog. How does this new payment methodology stimulate patient access to health information technology and non-visit based care?

PCHIT links for December 26th through December 27th:

• Early Experiences with Personal Health Records — Halamka et al. 15 (1): 1 — Journal of the American Medical Informatics Association - As reviewed here: http://www.tedeytan.com/2007/12/27/242/
• Patient-centered Applications: Use of Information Technology to Promote Disease Management and Wellness. A White Paper by the AMIA Knowledge in Motion Working Group — Demiris et al. 15 (1): 8 — Journal of the American Medical Informatics Association - Nice description of what we know/don’t know about PCHIT. However, given that the rest of the world uses IT in a more customer centric way, are we going to wait for research?
• PHRs: From Evolution To Revolution by Liz Boehm - Forrester Research - Interesting commentary on health plans, PHRs, and adoption. Are health plans ready?

PCHIT links for December 18th:

• Electronic Health Information among Community Health Centers … - Penetration of EHR’s in Community Health Centers
• Electronic Health Information among Community Health Centers: Adoption and Barriers - Information about adoption of EHR’s in community health centers, 2006
• Remarks to the National Association of Community Health Centers - Information about HIT deployment in community health centers, including large grants this year
• Massachusetts (Mass) Health Policy Forum - Title - Comprehensive view on the Health IT Landscape in MA
• Perceptions about computers and the internet in a …[Ambul Pediatr. 2005 Mar-Apr] - PubMed Result - Study from University of Washington showing impressive use of the Internet
• Use of the Internet to Communicate with Health Care Providers in the United States: Estimates from the 2003 and 2005 Health Information National Trends Surveys (HINTS) | Beckjord | Journal of Medical Internet Research - 10% communicate with health care providers; no association with education level or income which is significant.

PCHIT links for November 9th through November 13th:

• JAMA: Soliciting the Patient’s Agenda: Have We Improved?, January 20, 1999, Marvel et al. 281 (3): 283 - Data often cited and here’s the source: patients redirected an average of 23 seconds while providing their history.
• The Center For Health Design Research - Pebble Project - Center for Health Design supports evidence based design of health environments. Have they done work in PHR/EHR enabled institutions?
• Life as a Healthcare CIO: Personal Health Records - John Halamka, MD, supports the idea that PHR adoption is not a technology issue. Consistent with my findings on our recent trip to Boston.
• A Model for Health Care That Pays for Quality - New York Times - NYT Reports on Patient Centered Primary Care Model promoted by ACP, IBM, and others
• E.H.R. Home - HL7 announces balloting for PHR standards

My journey in Boston was completed with a visit to one of the large health insurers in the region, and to Cambridge Health Alliance, which serves Cambridge, Somerville, and Boston’s metro-north communities.

While in the area, I did manage to make a visit to the LEAN Enterprise Institute, where I was thrilled to meet James Womack, the author of several works that have shaped much of the work underway at Group Health and other health institutions. While at LEI, we talked about the penetration of LEAN into the health care space. Organizations in Boston are lucky to have access to this teaching and research resource so close by.

Health Plan Perspective: I visited with a physician in one of the region’s largest health insurers to learn more about the financing environment and its relationship to patient centered HIT work. As people in the field are aware, Massachusetts is home to the nationally recognized eHealth Collaborative, which is bringing 34 member organizations and pilot communities to support adoption of EHRs statewide. As the MAeHC web site, states, this is a $500 million proposition. In the discussion I participated in, two key questions arose from the plan perspective: 1. Who owns the personal health record? and 2. How and if will it be adopted? These are very helpful questions to keep in mind as we talk about innovations that require participation from a whole system (providers, patients, financing) to be successful. As I come from an environment where all are aligned within the same organization, it’s good to know what the key issues are. There will tension between interventions where ownership has been reasonably well established, such as disease management, and for which outcomes can be measured. Everyone wants to make investments that directly support beneficiaries. A recent article I read pointed out that there is much experimentation going in in the health plan sphere. The challenge, therefore, may be around focusing strategy toward PCHIT. The key questions mentioned may need to be answered to get us there, which is helpful to know.

Cambridge Health Alliance: The practice: My guide on my visit was Hilary Worthen, MD, Director of Medical Information Systems for CHA, and primary care practitioner for 25 years. Hilary and I did the thing I enjoy so much - walking through the community to understand it better, which brought us to Union Square Family Health and its Medical Director, Rachel Wheeler, MD. Cambridge Health Alliance, like East Boston Neighborhood Health Center, is fully electronic, using the EpicCare electronic health record.

The pictures (click on any to see full size):

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