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.

In yesterday’s post, I talked about my day shadowing with Dr. Pete Lovett, who’s the Medical Director of Berkeley Primary Care, which is part of LifeLong Medical Care. Today, a few more observations based on my time with his other patients, plus my time with Frances Herb, MD, Berkeley Primary Care’s HIV Specialist.

Other patient perspectives

As I mentioned yesterday, I learned that “uninsured” does not mean “uninformed.” Another of Pete’s patients indicated that he was very actively using the Internet to learn more about his condition. He was very interested in complementary healing remedies and satisfied with the results he had achieved so far. As with other patients, there was a challenge here in terms of integrating information from other specialty care providers in the visit. There was not ready access to treatment information. And as with the other patients, this one had a good fund of knowledge about his care in other venues. I asked about this patients’ support system and he indicated that he did share information about his health with a colleague, over the Internet. He also indicated an interest in gaining assistance from his physicians about information he was seeing online about treatment options.

Other connectivity issues

For the rest of my afternoon, I was able to shadow Frances Herb, MD, who is a general internist and specialist in HIV care. I asked Frances what made her decide to practice medicine in this medical center. She told me that she remembers being in the same situation (being uninsured) that many of her patients are in now and wanted to support those that came after her. As with the rest of the Medical Center, charts are primarily on paper. She introduced me to a few of her patients, and noted in each case that she had a written record of their care back 10-13 years. It was an impressive show of continuity.

(side comment: One of the most enjoyable parts of using the paper chart when we had it at Group Health was visiting a member who had been with the organization since 1947 - reviewing their paper chart was like looking at an encapsulated version of the history of medical care. No EHR can duplicate the social experience of paper…)

In HIV care, there is an exception with regard to charting - there is a functional EHR that is interconnected with other medical centers in the area, thanks to Ryan White funding. But only in these patients. As far as I could tell, there is no PHR attached to this record. However, I did see Frances print laboratory values, chart them, and give them to patients - Information Therapy.

At one point I asked Frances how she would feel about securely e-mailing her patients. She said, “Secure e-mail to my patients? I would love to be able to securely e-mail other physicians about my patients’ care.” Good response.

Watching myself

LifeLong Medical Care is the fifth safety net care provider I have visited so far in this project. In true LEAN tradition, I can’t help but reflect (through a process known as hansei) on how I got here. My past experience involved rotation in residency at the Country Doctor Community Health Center in Seattle, Washington, which is not in the Country (it is right around the corner from one of Group Health’s largest medical centers) but does have great doctors. I haven’t been in a safety net medical center since, and I realize that I have lost touch with the disparities in technology that are now existing in modern medical care. This doesn’t mean that I have come to a conclusion that a PHR doesn’t make sense here - just the opposite actually. I can see an even greater benefit here, and maybe more than the EHR itself (or at least as powerful). Now that I have been involved with an ideal care system with the ability to transform, I want to think about ways to support LifeLong Medical Care and organizations like it - I think they are ready and their patients will benefit.

Today, I am going to visit a Kaiser Permanente Medical Center in Oakland, California, a medical center at John Muir Mount Diablo Health System in Walnut Creek, and tomorrow, La Clinica de La Raza, also in Oakland.

Lifelong Medical Care, Berkeley Primary Care, Berkeley, California

These were the words of a young man who stayed for a few minutes after his primary care visit at Downtown Berkeley Primary Care, to talk to me about his care experience. In fact, this was a new experience for me, too, because it was the first time that a physician whom I was shadowing asked me to do more than observe the visit. Pete Lovett, MD, is the Associate Medical Director of the Berkeley Primary Care Clinic and my guide during the visit.

A little background, first, and a good illustration of why there is more to an organization than their Web site. I am going to break this description into 2 posts for readability.

I was connected to Lifelong Medical via the California Healthcare Foundation, which has a strong interest in supporting the safety net medical providers in the communities it serves. On lifelongmedical.org, it says, “LifeLong is known as the primary “safety net” provider of medical services to the uninsured and those with complex health needs in Berkeley, North Oakland, Albany and Emeryville. In 2004, LifeLong provided approximately 101,000 primary care visits to over 17,000 people, nearly half of whom were uninsured.” I knew prior to visiting that LifeLong does most of its charting on paper, and does not have an online personal health record for its patients. My presumption then, was that I would be here as a comparison for other safety net medical centers I am working with on the East Coast, many of whom I am working with because they have full EHRs or who are in the process of getting them.

Pete is a family physician trained in the National Health Service in the United Kingdom, with experience as Family Practice Faculty at University of California, San Francisco. As a physician in the NHS, he has experience with paperless practices, and in fact told me that his work in the United States has meant a return to less developed ways of moving information around. It turns out that LifeLong Medical does have experience with an EHR that it uses exclusively for its HIV patients.

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