“If you don’t like the news, go out and make some of your own” - this was the theme of the presentations given by safety net organizations who are innovating by providing patient online access to their personal health information. It’s now possible to talk to safety net providers who have the technology and the skill to provide this type of access for their communities. This is great news.

Hilary Worthen, MD, visited us in person in Oakland, when we had this discussion , to describe Harvard-Affiliated Cambridge Health Alliance’s patient portal. CHA is using the MyChart patient access system, produced by Epic Systems, Inc. Here are his slides. Comments welcome.

Sites visited

Union Square Family Health Center, Somerville, MA

• Institute for Family Health (New York)
• East Boston Neighborhood Health Center (Massachusetts)
• Cambridge Health Alliance (Massachusetts)
• La Clinica de La Raza (California)
• District of Columbia Primary Care Association (District of Columbia)
• Lifelong Medical Care (California)
• Queens Health Network (New York)
• Unite HERE! (New York)
• Urban Health Plan (New York)
• Baltimore Medical System (Maryland)

An Emphasis of PCHIT

As others studying health information technology adoption have pointed out, the populations served by these providers are of concern, and are being emphasized in this initiative. There is a focused description of the populations we are interested in and disparities in this report (see Persona: Vulnerable population).

There are multiple ways of identifying safety net providers (see Electronic Health Records Still Not Routine Part of Medial Practice, Robert Wood Johnson Foundation). Our work focused primarily on community health centers, which are estimated to serve about one in eight uninsured patients. Within CHC’s themselves, about 75 percent of patients are uninsured or on Medicaid.

EHR Adoption Among U.S. Physicians and Health Centers, from Health Information Technology in the United States: The Information Base for Progress: Robert Wood Johnson Foundation; 2006

In terms of adoption of EHRs, there is comparability to physicians in general, with a trend toward lower adoption for physicians with a higher percentage of medicaid patients. There is no comparable data for PHR implementation, unfortunately.

Resilient and Creative

Each safety net provider we visited, sometimes on the same day we visited a non-safety net provider, showed a different light onto health care. This was especially true for a physician accustomed to leading in a multispecialty group with commercial contracts (Ted).

The expectation might have been extreme resource constraint without ability to innovate in health information technology. However, we found organizations that are as technologically savvvy as their non-safety net peers, in an environment where 92% of community health centers nationally do not have electronic health records. This group has access to novel ways of financing improvement (in particular, a limited supply of grants, depending on the region, see Remarks to the National Association of Community Health Centers, HRSA Administrator Elizabeth M. Duke) and many that we visited have state of the art electronic health record systems.

However, few of the organizations above have implemented a personal health record yet. Cambridge Health Alliance was in the process of implementing theirs when I visited in November and has begun a pilot since. Institute for Family Health is about to begin its pilot in New York. At the same time, in conversation with providers and in some cases, patients at these locations, there was a general welcoming of the concept of patient access to the electronic health record, even in a multi-lingual care environment.

Dr.’s Davis and Isles, Belair-Edison Clinic, Baltimore Medical System

We learned about the financing model of safety-net providers that makes them ideal care providers in the communities they serve. Specifically, rates of reimbursement for in-person visits may be higher for federally qualified health centers. This environment is changing though, based on health reform efforts underway in states like Massachusetts.

At the same time, current models focus care provision on a physical visit. At La Clinica de La Raza, for example, I attended a celebration of the achievement of a milestone in number of encounters in a particular month. The celebration was a testament to the hard work and will of staff to support the organization’s viability. At the same time, there will be challenges to introduce non-visit based care if the unit of reimbursement is the in person visit.

“Uninsured” does not equal “Uninformed”

An impressive and reassuring finding in observations was that patients receiving care in these environments are getting informed about their care via various means, including the Internet, and are open to connecting with their providers this way. As a patient at Berkeley Primary Care told me, “I want my doctors to meet me half way.” Seeking care among multiple providers in the community with disjointed communication between them is perceptible information gaps for patients who have reduced abilities to tolerate fragmented care.

These information gaps are being addressed by consulting with others in the community, or by becoming disempowered in the care relationship. We saw examples of both, which were displeasing to both physician and patient. In these situations, patients may not be discussing these feelings with their providers in the exam room unless asked, which I also observed.

A recent study measured oncologists’ recognition of empathetic opportunities and found response to these to be low (22 percent with “continuer” statements) (see Pollak KI, Arnold RM, Jeffreys AS, et al. Oncologist Communication About Emotion During Visits With Patients With Advanced Cancer. J Clin Oncol 2007;25:5748-52). This finding, among a group of terminally ill patients, may be as relevant for members of vulnerable populations who provide empathetic opportunities to their care system to “meet them half way” through improved interaction and information about their care.

EHR deployments are without PHR deployments

A concerning trend we noticed was the assumption that an EHR deployment in this context should not include patient access or patient-centric health information tool deployment.

More than one individual in safety net environments expressed the following sentiment in our travels: “PHRs won’t work for this population, because of inaccessibility to computers/the Internet.” However, the data behind this assessment was hard to come by. The impact of statements like this, made in some cases from vendors of EHRs supporting these organizations, is that PHR deployment is not included in implementation plans. This is the case even when it is in other organizations’ rollout for the same product.

Our concern is that this is a significant missed opportunity and may result in the hastening of an exacerbation of differential HIT adoption and ultimately health disparities.

Observations and discussion with support staff again showed that there is more potential internet use and uptake than commonly believed. At a recent discussion hosted by the District of Columbia Primary Care Association, one clinic administrator said, “Whenever I walk into the waiting room, there is always someone using the computer (referring to a community-wide program to make computers available in local clinics),” and “we’ll never know if people will use this if we don’t set it up.”

No EHR deployments are planned in some, impact on physician recruitment?

Several safety net providers we visited have no EHR deployments planned at all, and I (Ted) witness varying degrees of discomfort with this situation, based on previous use of EHRs by staff physicians. Those that had direct use of EHRs in their past appeared more eager to adopt the technology. Bina Patel, MD, at La Clinic de La Raza lamented that when she chose to move to California to practice in a CHC, she interviewed at 7 different organizations only to find that she would have to practice on paper at each of them. A situation like this has the potential to impact future recruitment of young physicians to these environments. There are California CHCs that are implementing EHRs, such as Redwood Community Health Coalition (see Network of Community Health Centers Utilizes Electronic Medical Records System, Patient Portal and Electronic Health eXchange to Improve Patient Care).

An EHR is not a prerequisite, though

We discovered that having an EHR is not a prerequisite for using Patient Centered Health Information Technology. Prior to rollout of its EHR, pharmacists at Whitman Walker Clinic in Washington, DC are using freely available web tools such as MedactionPlan.com to prepare visual medication regimens for their patients. It is therefore possible to begin using tools that inform and activate patients in their care, very economically, and at a level comparable to EHR-equipped institutions.

Queens Health Network in New York City also demonstrates this idea through the use of smart cards, that patients can carry to providers without EHR’s, but with an inexpensive card reader that plugs into any PC.

Unresolved Issues

• Impact of reimbursement model on forward movement
• Awareness of digital divide issues
• Place of PHR deployment alongside EHR deployment - disparities in implementation plans between safety net and non-safety net providers is of concern
• Impact of disparities in technology use on recruitment of physicians in these environments
• Opportunities to implement patient-accessible HIT outside of an EHR implementation

Countermeasures

Provider collaborating using a state of the art electronic health record, East Boston Neighborhood Health Center, Boston,MAk

We plan to continue a focus on these organizations in 2008. Our next site, Urban Health Plan, in New York City, has a functioning EHR and is planning to rollout an associated PHR. We are working to arrange co-visitation with its payer, to explore financing models “on the shop floor.” In addition, we are separately preparing information about digital disparities, and are actively engaging with safety-net organizations that are implementing EHR’s now (see DC Primary Care Association - Improving Access and Quality using health information technology) or are about to implement PHR’s (Institute for Family Health) in the interest of changing perceptions in this community of care organizations.

Ways to Engage

At the current time, there are several organizations with active EHR programs with an interest in PHR deployment, and we will continue to work with them (Institute for Family Health, Urban Health Plan, Cambridge Health Alliance). It seems most appropriate to spend time studying their experience and generalizing to other similar providers. Conversations with payers as part of this engagement would also be useful.

PDF: 7 years and 140,000 patients later

While at Cambridge Health Alliance, I gave the attached presentation about Group Health Cooperative’s work to transform care through the use of technology. One of the organization’s leaders asked if I could forward a copy of the slides, or would they just be able to download them off of this blog.

Since this is information that our organization has provided in many other forums, the blog idea sounds ideal, so here it is. These are just the slides, without any narration; however, they may give you a feeling of our journey to support our members’ care. The narrated version is available from myself or one of my Group Health colleagues, feel free to contact us.

If I were to characterize the most important points:

1. Group Health Cooperative launched the personal health record in tandem with the ambulatory EHR, with great results for patients and their care providers.
2. The focus is on the member experience and their ability to enjoy unparalleled access and transparency through the use of these services.
3. Group Health is a pioneer in Information Therapy, and includes Ix prominently in its work
4. Thanks to the electronic Health Profile, patients and physicians can now work together to achieve life goals through optimal health, before illness strikes. The future is here, and it’s bright!

These accomplishments come from a team of individuals within the organization committed to a patient-centered care for Group Health members, and every patient in every care system. This is the basis for the open sharing of this information.

Update, November 14, 2007 An excellent descriptive paper of Group Health’s work was published in JAMIA this week. Congratulations to James Ralston, MD, from the Group Health Center for Health Studies. This paper helps answer questions about “stickiness,” adoption, and overall patient satisfaction (hint: it’s high).

Ralston JD, Carrell D, Reid R, Anderson M, Moran M, Hereford J. Patient Web Services Integrated with a Shared Medical Record: Patient Use and Satisfaction. J Am Med Inform Assoc 2007:M2302.

Enjoy!

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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