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.

This post is a continuation of my experience at La Clinica de La Raza in Oakland, California. As I mentioned previously, it was a great experience and I was welcomed by the staff and providers who serve this community.

I mentioned that most of the clinical work performed here uses a paper medical record. There is laboratory testing and medication look-up, as well as scheduling features. I asked both Steve Schiff, FNP, and Bina Patel, MD, their thoughts about going electronic, and even communicating with patients online. Because providers share a communal work space, I received additional perspectives. Patri Zayas, MD, the Medical Director, also stopped in to say hello and answer questions about the Medical Center.

Bina told me that when she looked to move to California, she interviewed at 7 safety-net medical organizations, and none of them had or were planning to get electronic health records. She hoped to use an EHR in her new clinical environment. I asked her about e-mailing with her patients. She said that she does some of this now, and would look forward to doing it more comprehensively. She trained in a location with an electronic health record and is very comfortable with the electronic tools she has access to here.

I also talked to Steve and his colleagues, and learned that many patients in this community don’t have good reading skills, and often, the individuals in the home that can read are children, and not at a level that is sufficient for translating health information. A real dilemma. It is not one PHR fits all. Many providers here do not have experience with electronic health records, except perhaps at patients at other systems, such as Kaiser Permanente. As I spoke with Patri, I understood that the clinicians here have a good sense of what the right clinical goals are for their patients, but it may be hard to conceptualize how to get there with an electronic health record right now. I felt the same way when we started our journey 5 years ago.

I was very kindly invited to the all staff meeting held on that day by Suzy Mejivar, the Manager of the Clinic, which was a celebration of a lot of hard work by the staff. La Clinica had passed a level of volume of encounters that had never been achieved before (and I recalled a comment made at another safety-net medcial centers that encounter numbers are essential in this environment to survival). Suzy individually thanked each staff group for all of their teamwork. She said, “Love each other, respect each other, and work together.” She even complimented one of her case managers when she said that she knew they were doing a good job because she was at her aunt’s house when her aunt received a call from La Clinica. This is a measure of the integration in the community that this organization has. Suzy did ask me to introduce myself to the group, which I did, and when I said, “Our practice has been fully electronic since 2004,” I got a sense of excitement from the staff present.

What next?
Read the rest of this entry »

These were the words of Bina Patel, MD, who introduced the new baby of one of her female patients to me in an exam room. To another family physician, these words are magical, and the way that Bina smiled when she said them was an instant reminder to me of why family medicine is so special. We live to take care of whole families and their communities, and a lot of pride comes from being able to be there for all of them.

This is part 1. Part 2 will be posted tomorrow, in the interest of readability.

From La Clínica’s Web site:

La Clínica has played an important role in the East Bay by offering low-cost quality health care services for multilingual and multicultural populations at 23 locations in three counties: Alameda, Contra Costa, and Solano counties, with many of our patients served in the City of Oakland. La Clínica’s comprehensive services include: pediatrics, family medicine, women’s health care, mental health services, dental and vision care, and health education. We offer these services regardless of people’s ability to pay or insurance coverage.

To most effectively serve the diverse community of the East Bay, La Clínica hires health practitioners who fluently speak Spanish, English, Chinese, as well as Hindi, Arabic, and Amharic. We also make a concerted effort to recruit doctors, nurses, health educators and other providers who come from the same cultures as our patients.

The commitment to supporting the community with providers that reflect its own culture was very evident when I was invited for a visit. What was also evident when I entered the facility was the amount of care that was being provided - a lot. There was what I would say was a level of activity I had not encountered at Kaiser Permanente or John Muir Health - a “buzz.” It was reflected all the way into provider workspaces, which are shared.

On the day I attended, there was a bit of what I called a “cake explosion,” with the staff celebrating a colleague’s birthday. I had to include pictures here, and especially one of the slice plated on a fraction of a plate - this organization is concerned with affordability all the way down to their celebrations! Kidding aside, the way the staff celebrated each other on the day I visited was impressive.

Pictures: Click on any to see full size

The practices

Read the rest of this entry »