Earlier in my journey, when I visited technologically enabled practices in New York and Washington, DC, I wondered aloud to my project officer, Veenu Aulakh, MPH, from the California Healthcare Foundation, if California would also show itself to be a leader in 21st century medicine enabled by technology. There’s no question that systems like Sutter Health, Kaiser Permanente, and Sharp are national leaders - we were looking for leaders in smaller practices, where 90 % of Americans receive their health care.

Then we discovered Sebastopol Community Health Center, part of the Redwood Community Health Coalition.

I got to visit with Jason Cunningham, DO, the Medical Director and full spectrum family medicine specialist, in March, 2008, but I did not get to shadow him providing care. I wanted to come back, and so I did, this time with Veenu. Coming with Veenu also satisfied my desire to do some shadowing with our funders, because they can see things from a unique perspective. I was able to do the same with our New York funders, when Rachel Block shadowed with us in March. Veenu has an industrial engineering background, so she is not a stranger to shadowing or process improvement.

Jason and the staff gave us a warm welcome, and again it was like walking into the 21st Century (instead of the 19th). Not a single paper chart in sight. There was now an automated vitals machine. Care team coordinators (the role assigned to medical assistants in this model) were now using tablet computers to room patients. Jason and the team were further developing their electronic health record, manufactured by eClinicalWorks, to support a medical home practice.

First photographs - click on any to see larger size

To show the possibilities of collaboration in this new world, Jason informed us that he’s going to install the special build of the product known as “Take Care New York,” or TCNY, tuned for population management and with the experience of the entire Primary Care Information Project in New York city. In other words, California patients are going to benefit from an EHR that includes the experience of New York patients, seamlessly.

Proving the viability of a medical home, even in (especially in) the safety net

As space age as this practice looks, it is not funded predominantly through commercial insurance. Sebastopol Community Health Center is a Federally Qualified Health Center, with a funding stream tied strongly to in person visits. Despite this potential limitation, this health center is working to support visit-based AND non-visit based population care in a financially viable way. They are doing this by maintaining visit density, keeping overhead low, and providing team care coordinators with non-direct-patient care time to co-manage panels, assisted by an introspective EHR. Jason showed us how he can query his panel quickly to build exception reports and understand their health, right within the electronic health record. No separate registry is being used here, which means no interfacing and no double-entry of data.

The shadowing experience

We started the day with the team huddle, which was as futuristic as one would hope - each practitioner with a portable version of the electronic health record, reviewing the patients of the day and preparing for each individualized care experience. By now, Jason has discovered the best approach to using an electronic device in the exam room. Even though this site is described as an “alpha alpha” site, the technology seemed to melt into the background of the green rolling hills during the visit. This could be because the team are using low footprint tablet PCs in exam rooms. It’s also because the devices are used strategically for new vs. follow-up visits. The device is always positioned in patient view, with provider facing the patient.

I could also tell that in true continuous improvement fashion, little things have been changed and improved in the system over time. A new field here, a new way of communicating between the team about something here, an idea to use an exam room one way or another with the computers.

In between patients, I had a great conversation with Jenny, the Center’s Family Nurse Practitioner. She asked for my advice on how to document parts of the patient experience in the health record, and my best answer was to think about where the patient would expect it to be, every time, and put it there. We both agreed, I think, that one of the best things we can do as care providers is to treat a patients’ story with respect by recording it accurately, and making sure it is safely kept where it can be used to support ongoing care by anyone on the team, with all of the appropriate security controls, of course.

Teaching, for a lifetime

Because this medical center is prototyping the future workflow of the rest of the Coalition medical centers, there is always teaching going on of other providers. On this particular day, Harriett, the Care Team Coordinator (a Medical Assistant) was training a fellow Care Team Coordinator on the use of the system.

At one point during the day, Harriett came in for a short break during a very busy morning. I mentioned to her that I noticed that she has a very supportive teaching style. When there was a question, she would make sure that her student learned by doing - she was very good at not taking over the use of the computer, essentially empowering others to learn. A commitment to being an experimental medical center means a commitment to always teaching. I asked about this - how would it feel to be teaching every day for the next few years as the system rolled out, I asked? Her answer was, “This is for a lifetime.”

Fortunately for the Medical Center and her patients, Harriet has been accepted into the Physician Assistant program at University of California, Davis, and Jason has agreed to be her preceptor during her practical work.

I’m Still a Fan

Jason and his colleagues are pouring themselves into to this work, for the benefit of their patients and their community. As I said in March, I am hugely impressed with the initiative to provide the right care first and foremost, with an eye to finances, not the other way around.

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If you are interested in innovation, I think this is a good podcast worth listening to - and the actual audio is more useful than the printed version.

I listened to it the day before I attended the latest Patient Centered Primary Care Collaborative, in Washington, DC. At the meeting, I was fortunate to run into one of my role models, Susan Edgman-Levitan, PA, and we talked about the idea that the Medical Home is about improving the care of patients where they spend most of their time - where they live, work, and play. We can help patient-centered care flourish by including ideas from everyone involved in the care, including nurses, doctors, allied health practitioners, eye care, oral health care, behavioral health care, just to name a few.

I liked what Jack said in the podcast, that in a company, there has to be

a sense that in every soul of the company, the idea that everybody innovates.

Toward the end of the podcast, Jack gets quite fired up about the idea that innovation can’t be regulated to the chosen few. My experience reinforces this. In the area of health information technology, this is critical. When most people think about implementing HIT, they think about the implementation period. The most powerful part of HIT is what happens after implementation, and using a management system like the one developed by Toyota Motor Company (as we are) can allow an organization to turn HIT into an organization wide innovation engine - if they capture all of the ideas of everyone involved in providing care and put them to use. To not do so is to waste one of the most valuable raw materials for growth - ideas and time (and most importantly our patients’ time).

One other conversation that has come up in the last several days is about generational changes in approach. Many of the Generation X and Generation Y colleagues I have been talking with were raised in a professional environment where we were not going to have all the answers, and we are uncomfortable being accountable for them. We want to share the power of coming up with the answers with our provider colleagues and our patients. This is not to say that our baby boomer colleagues don’t have this desire, too. I think we are stimulating each other to do what they’ve always wanted to do, and involving patients, their families, and all practitioners, all specialties and roles, is really going to make a person’s medical home special.

Feel free to take a listen and let me know what you think:

Finding Innovation Where It Lives

The quote is from Abigail Chen, MD, who I shadowed yesterday as I was shown UNITE HERE’s implementation of the Ambulatory ICU (you can read more about the A-ICU concept here). Before I get to that though, I arrived in the morning with my usual level of interest in both seeing how patients benefit from health information technology and integrating into the flow of the medical center as unobtrusively as possible.

A few pictures (click on any to see full size). I have to admit I got caught up in learning about the team care concept and didn’t get as many photos as I wanted to. Next time!

Fortunately, Andrew Tzellas, MD, quickly slowed down my CPU and invited me into his team’s huddle for the morning. I was invited to have a seat next to Palmeras and Nancy, team experts on chronic disease management and coverage, and then joined by Jenny, the clinic coordinator, Andrew, and his medical assistant. As they started the huddle, Nancy printed off the day’s schedule and gave them to me so I knew what general issues the team was working on. Each patient in this ambulatory clinic was reviewed by the team across the spectrum - health status, disease management, social and coverage issues. A green tracking slip was pre-filled by Palmeras for each patient and added information about due health maintenance. Andrew and Jenny, each viewing the electronic health record, worked with the team to create the day’s plan. While this was happening, walkie talkies would announce patients’ arrival (I wasn’t paying attention to this, but Jenny pointed out that the whole team was). At one point, as Andrew was talking about the guidance for a particular patient, he said, “I can inform them about my, I mean, our feeling about this issue.” The transition from individual planning to group planning of care was apparent.

I sat in on the next huddle as well, this time for Abigail Chen, MD. Same flow. It reminded me a bit of being a third year medical student on my first rotation in medical school, when I walked into a functioning team (my first rotation was trauma surgery - that requires functioning!) and I was impressed with the cadence and “beat” of the group (or as they say in Japanese, takt). I could tell the teams had spent quite a bit of time forming the approach here.

UNITE HERE serves a very special population. From their web site:

UNITE (formerly the Union of Needletrades, Industrial and Textile Employees) and HERE (Hotel Employees and Restaurant Employees International Union) merged on July 8, 2004 forming UNITE HERE. The union represents more than 450,000 active members and more than 400,000 retirees throughout North America.

 

UNITE HERE boasts a diverse membership, comprised largely of immigrants and including high percentages of African-American, Latino, and Asian-American workers. The majority of UNITE HERE members are women.

The Health Center itself is gorgeous, but it wasn’t so very recently. As I talked to staff, I learned about the transformation that has happened in the last 7 years, from a health center that sometimes served 100 patients on a Saturday with wait times several hours long, to a health center where customer service training is the norm, innovative approaches to chronic disease care are standard, and patients are treated with respect. I was told that staff were even trained using callers who role-played actual patients to ensure that each patient was treated with courtesy. That’s an impressive commitment.

I was able to shadow a patient of Abigail’s, where she of course used the Health Center’s state of the art electronic health record, (Centricity, manufactured by General Electric). In the course of the visit, Abigail ordered some screening lab tests for the patient and took the time to explain the purpose of each, in Spanish, the patient’s native language. The patient was immediately referred at the end of the visit for teaching about pre-diabetes, which was performed by medical assistants, all specially trained in a variety of health topics. Great care was placed in involving the entire team in the care, as the quote at the top of the post states, and from my observation, this busy medical center had a more relaxed feel, or at least a feel that everyone was accountable to each patient together. This coordination did not come overnight - it came with support from leaders who encouraged innovation, and in my view of outcomes in the waiting room (where are were publicly posted), it’s working.

In the background of all of this, where does patient centered health information technology fit in? UNITE HERE has a state of the art electronic health record. They are preparing to launch a patient portal which will include staff messaging and other features that are being developed now. Unlike Urban Health Plan, there is not a big pediatric population, and there is a clear emphasis on chronic disease management, team care, and a further emphasis on diabetes. The Health Center is already innovating to provide patient-centered care, which is a prerequisite for success in implementing patient-centered health information technology. One of the tenets is “from the board room to the bedside.” In this health center, the board room is just around the corner, so it’s easy to cycle through improvements rapidly. This is the advantage of the small practice over the integrated delivery system - the risk of ideas not counting (or worse, being wasted) is less.

I have not previously seen a patient portal launched off of a Centricity system, so this experience should be valuable both in the population being served and the technology being used. For a health system working to attract Union members across industries and across the geography of New York City, this will add another great reason to choose this team.

This brings the number of patient accessible EHRs coming on line in New York City to three - Institute for Family Health, Urban Health Plan (Part of the Primary Care Information Project), and now UNITE HERE. All will add significant information to the conversation about patient access in a diversity of populations. This is the real thing, and they are all going to do an excellent job, and we’ll be helping along the way. Congratulations to all of the patients in these three leading health systems.

Thank you again to Karen Nelson, MD, MPH, the patients, staff, and physicians at UNITE HERE for the gift of their time and (some of) their knowledge. There is a lot to learn here.

Addition 2/29/08: One thing I forgot to mention that’s really important is the fact that I only shadowed one patient. The reason why is because the team appropriately asked for explicit consent from other patients who stated their preference to not have an observed visit. This is a marker of respect for the patient, because the consent is asked as a question, and the answer is listened to. I don’t think it’s a coincidence that at every site we have visited, at least one patient declines having an observer. What that says to me is that we are at a place where the patient is at the center of care.

The expression of happiness in the title is a reflection of the milestone that this was in this journey. It was the first time that we went to the Gemba (”the factory floor”) with health plan leaders and delivery system leaders together, to talk about patient centered health information technology.

We were guided by Urban Health Plan’s inspiring CEO and Chief Medical Officer Paloma Hernandez and Samuel De Leon, MD, who allowed us to observe the process of care at their Bronx, NY-based care system. Invited guests included Susan Beane, MD, the Chief Medical Officer, and Linda Erlanger, the Director of E-Commerce, from Affinity Health Plan, which, “..for 18 years, has been operating managed care programs designed to address the needs of low-income populations. We are a mission-driven organization, striving to achieve positive change in the lives of the families and communities they serve.”

The goal was to do something we had not done before, bring stakeholders together to see the the actual place where the facts of health care impact the patient (for a nice description of the philosophy behind this, based on work done at Toyota Motor, see this post).

First, some photographs. Click on any to see full size.

Asthma, an Epidemic in this Community

I shadowed Mayra Nadal, MD, who is a pediatrician, and like all of the other physicians at Urban Health Plan, are using a fully functional electronic health record, manufactured by eClinicalWorks.

After a few visits, I noticed that several of her patients had severe asthma, and were being treated very intensively. One patient, a young boy, was on multiple ambulatory medications yet he was still not able to breathe normally.

I learned from Mayra that this is a sad reality for this community - this population is at exceptionally high risk for being affected by asthma. This is well known in the community. What I saw in the exam room were the best attempts of this care system to blunt the impact of this disease (and Urban Health Plan has distinguished itself nationally as a leader in managing chronic illness). Mayra showed me that they had taken extra care in the build of the EHR to include standard asthma histories and tracking of asthma plans because of the prevalence. The tools looked very complete; at the same time, they are the tools an informaticist wish they didn’t have to build. It doesn’t seem right that children in the Bronx community should grow up without an expectation to breathe normally.

Mayra was very facile with the EHR, and like me, prefers the use of an EHR because she can type faster than she writes. When I asked about online access to health information to patients, she was receptive to the idea that patients’ families would have access to ordered tests, if they had Internet access. This might be useful for things like newborn screens and other screening exams.

Overall, the impression I got from observing physicians here was one of competence using a state of the art EHR in practice. It is also worth noting that Samuel De Leon, MD also provided a very visible optimistic brand of leadership throughout this part of our experience.

On creating a prepared, proactive care system

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I was fortunate to speak recently with Paul Grundy, MD, MPH, the director of healthcare technology and strategic initiatives at IBM, about the work he is driving as the chair of the Patient Centered Primary Care Collaborative. Through the magic of Web2.0, I first picked up word of Paul’s work via this post on the IBM HealthNext blog, and since then have participated (in one meeting last summer) and watched as the movement has gained traction.

I chose Patient centered health information technology as manageable scope for a sabbatical; the ultimate goal for a career is patient centered care that respects patients, their communities, and those who serve them.

Paul sent along his thoughts on patient-centered primary care, and I am reposting them here, for others to read. As I have listened to Paul and his colleagues and compared it to my own experience studying Informatics and process improvement methodology, I have become acutely aware of not just the value stream within health care. I am aware of the value stream for a person in society, which is to achieve their life goals through optimal health.

When I wrote about my visits to work sites, like Genie Industries in Washington (see: “Overwhelmed with Possibility,” DailyKaizen Blog, July, 2006) and the NUMMI Plant in California (see: “NUMMI, Fremont California,” DailyKaizen Blog, August, 2007 ), it has become clear that our role is as the support system for these individuals, who are providing for themselves and their families, and finding fulfillment in their lives, through optimal health. The medical center is just a stop on the journey, not the destination. Employers add this perspective to our work and can assist in having our health system reflect this ideal design.

Paul’s words are below. As usual, your comments are welcome.

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