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.

Dr. Jonathan Wald and myself spent another morning shadowing at Brigham and Women’s Hospital, which is a teaching affiliate of Harvard Medical School. It was a personal honor for me to be paired with David Bates, MD, MSc, whose work I have admired, respected, and used to inform how I serve patients for a long time, in the field of Informatics, Quality and Patient Safety. On this day, David was seeing patients from his own panel, in the capacity of general internist.

Before we started the day, though, Jonathan took me through the halls of the hospital, where there was an exquisite display of portraits of pioneers in the medical field, including Dr. Helen Brook Taussig, the founder of pediatric cardiology, and Dr. Paul Dudley White, who co-described Wolff-Parkinson-White syndrome, a staple of every medical student’s education. I think Jonathan and I are of the same mind in thinking that it’s important to reflect on where we came from as we do this work. Before Dr’s Taussig and White, we didn’t know how to manage congenital heart abnormalities or how electricity traveled through the heart, and now we do, because they said, “We don’t know how to do this, yet.” We’ll say the same thing in the application of technology to make care more patient-centered.

After spending time at BWH, I went to East Boston, to visit Frances Kuebler, MD, who is President of the Medical Staff and Physician Champion for East Boston Neighborhood Health Center’s EpicCare installation. EBNHC is an important part of the East Boston community, and serves a broad diversity of people who rely on the health center almost exclusively. This neighborhood health center is also state of the art technologically, one of the reasons I wanted to visit. I shadowed Stephen Simon, MD, in his practice.

Part I: The Pictures, Part II: The Practices (next post)

In the last post, I described my day at two different care organizations; Partners, and East Boston Neighborhood Health Center.

Continuing, a summary of….

The Practices:

Brigham and Women’s Hospital, Dr. David Bates: I shadowed David for several patients who are on his panel and well known to him. David uses the Longitudinal Medical Record produced by Partners Health Care, integrated with Patient Gateway. Jonathan Wald, MD, the Physician Lead, was next door working with a colleague to talk about Patient Gateway in practice. I think there were a ha’s for all of us about how to use a resource like this, including how to bridge the world of regular electronic mail and the PHR. David visibly practiced Information Therapy in front of me, when he printed out a document to describe a condition for a patient he was treating. The LMR as I understand it, does not automatically produce an after visit summary. I didn’t see David use Patient Gateway features during our visit, but we did have some time to talk about PHRs and the interest in supporting good research for the production of good outcomes knowledge about how to use them in practice. Jonathan is working on the issue of patient adoption, which he may comment about separately

East Boston Neighborhood Medical Center, Dr. Stephen Simon: EBNHC uses EpicCare, and has used it since 1998. Physicians have been documenting and ordering using the system for about 4 years. Their urgent care is also on the system. In shadowing, I was able to observe the first visit in this experience in Spanish, which was important for me to see. In the exam rooms at EBNHC, screens are pointed toward the exam table, where physicians can review data with their patients together, and I saw this happen in the visit(s). Stephen was very facile with EpicCare and has taken the time to customize it for best use. EBNHC does not yet have a PHR active for its patients.

One thing that was really important for me to see was a difference in focus. During my time at EBNHC, the staff was applied to recent health care reform policies that have gone into effect in Massachusetts, which affect everything from co-pays to drug formularies. It was impressive to note how much this was on the minds of the staff here, to support a transition that is successful for their patients. This issue did not come up in conversation at the other medical centers - different populations, different needs. I honestly know very little about this initiative as I don’t live in this community, but it’s clear that it should be understood as a modulator of capabilities. At the same time, EBNHC is also pioneering electronic prescription transmission from its EpicCare system.

The PHRs:

Partners, as I mentioned earlier is positioned for adoption, and are making plans to integrate the Patient Gateway into practices more. The system has good functionality and can provide staff experience in using technology to reach patients wherever and whenever they need to.

EBNHC, in contrast, does not yet have a PHR online. The considerations here are the impact of system upgrades, which must be done accurately, and continued optimization of portions of their system. Much like the Institute for Family Medicine in New York, they maintain a very robust EHR with a smaller staff pool. It’s actually very impressive. In fact, during my time there. Dr. Kuebler was updating parts of the system based on requests for her peers, like in near real time. That’s nimble! This can also make readiness for the jump to PHR more challenging at the same time. One key issue for this population is the need for a multi-lingual PHR. Coming to East Boston really brings home the fact that the time now upon us to address disparities in the way systems are designed so that they are accessible by the same population that accesses the health system. It felt very real when I was there.

Of course, Josh and I would like to follow both organizations as they continue on their journey to support their communities in the distinct ways that they do. I think both will contribute to the conversation significantly.

With thanks again to Drs. Wald, Bates, Kuebler, and Simon, and the staff and patients at Brigham and Women’s Hospital and East Boston Neighborhood Health Center for the gift of their time.