Note: This post was previously published, but is being reposted today to tie together the special report, which is now published on this site in its entirety. To see all of the parts together, click on this link.

Welcome

Tyriece, Lisa, and Ted Eytan, MD, Belair-Edison Clinic, Baltimore Medical System

This is a compendium of personas in our health care delivery system. It’s designed to inform individuals and organizations interested in increasing patient and family involvement in all aspects of care, and has been specifically commissioned by the funders of PCHIT.

At the current time, it is estimated that between 3 and 10 % of Americans have access to their care teams through personal health records (PHR). Also at the current time, there are a host of organizations and individuals working to increase this percentage.

Besides being a compendium of organizational personas, Profiles is also an interim status report on the PCHIT initiative. As such, it has a PDCA format.

Plan

PCHIT starts at the level of the patient-physician relationship and moves outward

A way to visually consider where PCHIT is focusing its efforts is through adaptation of the “Sequence of HIT Adoption” model proposed by the Robert Wood Johnson Foundation (see Electronic Health Records Still Not Routine Part of Medial Practice, Robert Wood Johnson Foundation).

Our plan was to spend time in a cross section of health care, observing the patient-physician interaction. PCHIT was designed to look at factors present in different care environments at the level of the patient-physician interaction. This is based on the concept of Genchi-Genbutsu. This concept is so central to the design of this initiative that we are including an explanation of it here:

First of all, gen means actuality or reality. When we look at the word gen-ba, it means the actual place. In the terms of manufacturing, we can loosely translate this to mean where the work is done. Why is this meaningful? It is not until we understand the other gen words that this begins to make sense.

Second is gen-butsu. Butsu means, the condition of the thing. In terms of manufacturing and considering the word gen-ba, we ask ourselves, “what are the conditions of things in the workplace, where the work is actually done?” The things we are looking for? The condition of the design, the quality, the process, the people, the methods, the equipment, etc. When we think of genba and genbutsu, we are looking to see if the conditions of our standards are deviating in the workplace. This forms the basis for standardization of all aspects in the business.

Third is gen-jitsu. The actual situation. We are looking for facts so that we may understand the gap between reality and standard. We are not looking for what it should be, we know that. We are looking for actual situations, or the facts. This helps us begin to dig for the actual root cause.

If we only consider the standards we tend to sit in a meeting room wondering why the equipment, the people, the materials and processes don’t meet standards. The only way to truly know, is to go to the actual workplace, observe the actual conditions and collect the facts. This leads to true understanding of reality. Otherwise our solutions we invent in the meeting room are for problems that are not really happening in the workplace. This is the reason why problem solving begins with the saying, “go and see for yourself, in the workplace where the work is actually happening.”

We weighted our interest toward organizations with emerging health information technology initiatives, as opposed to mature, or no health information technology initiatives.

We weighted our interest toward organizations serving diverse populations, including under-insured, safety-net, and minority populations (inclusive of federal protected classes as well as gay, lesbian, bisexual, and transgender individuals).

We weighted our interest toward organizations situated geographically in areas served by our sponsors, including New York, California, and District of Columbia.

Kaiser Permanente, a sponsor of this effort, is used here as a benchmark, given its maturity in patient centered health informaiton technology. The same is true for Group Health Cooperative.

Do

Over the next several days, we’ll publish our “Persona” description for key stakeholders in the implementation of patient centered health information technology.

We chose to use the persona concept, established in user interface enginering - you can read a little bit about it here.

Comments are Welcome

Your additional experience, expressed by adding comments on each page of interest, are welcomed

In many, if not all, of the sites we visited, the question of disparate access to PCHIT was raised. The same question has been raised with regard to EHR’s as well. In its report, the Expert Consensus Panel (see Electronic Health Records Still Not Routine Part of Medial Practice, Robert Wood Johnson Foundation, 3:27):

(The Expert Consensus Panel) has identified racial and ethnic minority patients and low-income or publicly insured patients as the two highest priority patient populations

The PCHIT Initiative broadens this view of vulnerable populations to include those with documented disparities including but not limited to individuals who are lesbian, gay, bisexual, and transgender. An additional vulnerable population of interest are returning soldiers (see: Longitudinal Assessment of Mental Health Problems Among Active and Reserve Component Soldiers Returning From the Iraq War).

Available data about Internet access contradicts conventional wisdom

Charts: Click on any to see full size (Sources: Benchmarking Digital Inclusion, ITIF, and Estabrook L, Witt E, Rainie L. Information Searches that solve problems. Washington, DC: Pew Internet & American Life Project; 2007)

In a review of the literature related to Internet use among vulnerable populations, we discovered that commonly held beliefs about use and access are not true. Even at the lowest educational and income levels, Internet use approaches 60 %, where it was only 10-30 % in 2001.

The following studies shed additional light on this issue:

• Estabrook L, Witt E, Rainie L. Information Searches that solve problems. Washington, DC: Pew Internet & American Life Project; 2007. A random sample survey performed between June and September, 2007 shows gains in Internet access and explores type of access - “High” for broadband at home or work, “Low” for no access or Dial-up only
• McNeill HL, Puleo E, Bennett GG, Emmons MK. Exploring Social Contextual Correlates of Computer Ownership and Frequency of Use Among Urban, Low-Income, Public Housing Adult Residents. J Med Internet Res 2007;9:e35. - In Boston public housing, 51 % of adults own and 42 % of adults regularly use computers, and those reporting feeling “safe” in their neighborhoods have a greater likelihood (76 % higher association) of using a computer regularly.
• Beckjord BE, Finney Rutten JL, Squiers L, et al. Use of the Internet to Communicate with Health Care Providers in the United States: Estimates from the 2003 and 2005 Health Information National Trends Surveys (HINTS). J Med Internet Res 2007;9:e20 - “In 2003, Internet users with high levels of education were more likely to have communicated online with an health care provider, consistent with previous studies. That education was nonsignificant in 2005 may suggest that health care consumers’ level of education is less of a barrier to communicating online with health care providers as the prevalence of online patient-provider communication increases.” and “We did not observe associations between online communication with health care providers and characteristics such as race/ethnicity or annual income that have been documented in other studies as evidence of a “digital divide””
• Carroll AE, Zimmerman FJ, Rivara FP, Ebel BE, Christakis DA. Perceptions about computers and the internet in a pediatric clinic population. Ambul Pediatr 2005;5:122-6. - “Most families like using computers and feel comfortable using the Internet regardless of socioeconomic status. Fears about the digital divide’s impact on the attitudes of parents toward computers or their comfort using the Internet should not be seen as a barrier to developing Internet-based health interventions for a pediatric clinic population.”

A more sensitive indicator of patient access to electronic health records is likely to be online banking (see this post on that topic), because online banking requires confidence and convenience as well as access to be successful.

Online banking use and income level, from Online Shopping, Pew Internet & American Life Project, 2008

East Boston Community

Patient-centered HIT applications do not necessarily require use of a computer on the consumer’s end. For example, a mobile phone may be the most effective vehicle for certain populations, whether the information coming to them is in the form of an automated phone call (which can be delivered in multiple languages), a text message (such as for medication reminders), or a more sophisticated combination of audio, graphics and video. A variety of strategies are profiled in a recent report published by the Georgetown Health Policy Institute’s Center for Children and Families (see Health Information Technology: Innovative Applications for Medicaid).

Outside of patient access to computers or the Internet, there are opportunities

Some analysts shortchange vulnerable populations by suggesting that language barriers, the digital divide, or health literacy pose insurmountable obstacles to effective PHR adoption. Perhaps no population faces a greater panoply of barriers–including Spanish as primary language, health literacy, access to computers and the Internet, geographic challenges, and a lack of care continuity–than migrant farm workers. The tool, MiVia, has demonstrated that PHRs can be effective tools when appropriate accommodations are made, such as using community health workers to help facilitate PHR adoption.

As we consider patient-centered health information technology, the definition should be broadened beyond personal health records, to any technology that provides the benefits and impacts of patient access. These impacts accrue whenever the health system is accountable to those it serves, by providing them the information they generate about them, whether in paper, computer or smart card form.

Unresolved issues

• It is unclear how pervasive the conventional wisdom of the “digital divide” is, and if there are related factors that would bias toward inaction even if the data were better understood for populations studied (ethnicity, income, education)
• For populations that are less well studied (e.g. lesbian, gay, bisexual, transgender, returning soldiers), the impact of provision of access to PCHIT in safety net environments is also unknown. With limited funding available to study sexual minority populations, for example, disparities may only be exacerbated in an environment of HIT without PCHIT.

Countermeasures

In 2008, we are emphasizing safety net providers and vulnerable populations in PCHIT work. We are providing the technical assistance of a knowledgeable medical informaticist and patient empowerment advocate to demonstrate the impact of PCHIT in a vulnerable population. We would also like to spend some effort in packaging this data and presenting it in leadership forums. Ted Eytan did this recently for the District of Columbia Primary Care Association, where it was well received (see Presentation to DCPCA, December 18, 2007), as well as on a recent event at Urban Health Plan, in Bronx, New York (see: “We did it! Thanks Affinity Health Plan and Urban Health Plan!“)

Ways to Engage

In addition to working with health care and IT leadership on promoting PCHIT as part of HIT, it would be valuable to engage with patients themselves. In 2008, we are hoping to shadow a patient who is part of a vulnerable population as they manage chronic disease. This will most likely happen on our trip to Sonoma, California, in March, 2008.

The Library of Congress, General view of one of the classification yards of the Chicago and Northwestern Railroad, Chicago, Ill. (LOC), January 1, 1940.

Sites visited

• Individuals from various health plan organizations

The persona of a typical health plan has been challenging to discern in the first 90 days.

The integrated health plan / delivery system organizations Kaiser Permanente and Group Health are discussed within the integrated delivery system persona.

A Key Stakeholder

Conversations with health plan representatives and with others about their experiences with health plans around PHRs raised many questions about the health plan role in advancing PHRs. As the image above shows, health plans sit at a cross-road of data.

Health plans theoretically stand to benefit substantially from more efficient use of delivery system resources and greater consumer engagement in care management. Questions emerged around PHR ownership, and on whether widespread adoption via the health plan is possible (see Health Plan Perspective). We were not able to get information across a breadth of business units which limits the generalizability of this assessment at this time. Given equal effort, we were less successful in arranging contact with health plan organizations relative to delivery of care organizations.

The unclear role of this stakeholder is reflected in the literature. First, in the writing of national PHR leaders:

Because health care payers and purchasers are the primary beneficiaries, they should probably be the primary ones who bear the cost of PHRs. However, the evidence supporting the rationale for payers to provide PHRs is not mature, and they may be reluctant to do so.

(see: Tang PC, Ash JS, Bates DW, Overhage JM, Sands DZ. Personal Health Records: Definitions, Benefits, and Strategies for Overcoming Barriers to Adoption. J Am Med Inform Assoc 2006;13:121-6.)

Second, in the opinions of consumers using a PHR for diabetes care, when asked what they are willing to pay for a PHR:

There are several reasons that may account for these attitudes toward user fees. First, the group discussions may have influenced the participants’ attitudes. For example, in one of the focus group sessions, a participant pointed out that if the portal succeeds in helping patients manage their diabetes, it may decrease the number of diabetes-related hospitalizations and thereby prove to be a cost-saving measure for the health system. At the end of the same session, only one participant in the group thought that a user fee might be acceptable.

(see: Hess R, Bryce CL, McTigue K, et al. The Diabetes Patient Portal: Patient Perspectives on Structure and Delivery. Diabetes Spectr 2006;19:106-10.)

The PHR opportunity that health plans have is that they have access to a wide range of data that could populate their members’ PHRs. If they create an effective infrastructure to manage and integrate those data, they can offer their members a useful tool. According to one large health plan executive, “Our role in the HIT space is leveraging that infrastructure to be the conduit between clinical and administrative data; we can facilitate important data connections.”
Health plan executives also recognize that the biggest opportunity to make effective use of PHRs for better care management and increased cost-effectiveness is for their members with chronic conditions. For this large health plan, although its overall PHR adoption rate is only 10% to 15%, its adoption rate among those actively managing chronic conditions that it targets is between 30% and 40%.

Once the health plan creates the data infrastructure, the keys are figuring out how to present the data in a context-relevant manner, how to align incentives for both clinicians and members, and how to proactively deliver timely, relevant, tailored messages to members that make the data meaningful to the individual. The other big challenge that health plans face in that respect is that—due to lag time in administrative data processing—they often don’t have access to “timely” data, making it difficult to target their messaging to particular moments in care.

It is understood that several pilot programs to support personal health records or components thereof are under way in the regions we visited (see A Virtual Reality). Plans also appear to be active in other areas to promote quality of care, such as in supporting disease management and lifestyle programs. Transparency initiatives underway include improved availability of cost, quality, and outcomes data. (see U.S. healthcare payers to limit IT investments in 2008).

In the practice settings we visited, we detected an ambiguous message from health plans about the value of personal health records in care. The experience at the practice level may not represent that at the strategic and marketing levels of plans. This is similar to the issue of having “Vision from the board room to the bedside,” (see: Patient-Centered Care, What Does it Take?) that many delivery systems face internally already, and therefore not specific to health plans.

It is noted by others that in health plan environments, “consumers have not raced to adopt them (PHRs).” Again, this is in comparison to environments where PHRs are unambiguously promoted and are showing strong demand from patients.

Unresolved Issues

• Overall health plan intent with regard to PHR adoption is not understood based on our experience to date
• For health plans actively engaged in PHR promotion, where is the best locus of control (patient, provider, plan) for successful PHR implementation and what should the role of the health plan be?
• Health plans are trying to figure out how to effectively integrate clinical and administrative data, and how to overcome administrative data processing lag time in order to ensure that PHR data are populated in a timely manner.

Countermeasures

Data about customer experience with health plans (see: Forrester Research: Customer Experience Index Snapshot: Health Plans, as well as the impact of PHRs on affordability (see: Zhou Y, Garrido T, Chin H, Wiesenthal A, Liang L. Patient Access to an Electronic Health Record With Secure Messaging: Impact on Primary Care Utilization. Am J Manag Care 2007;13:418. are supportive of a strong role for health plans in this ecosystem. We would therefore like to continue to engage in this area next.

We are also working to communicate with national innovators in health plan environments, as opposed to health plans in the markets we have visited.

We are also scheduled to engage in a co-shadowing experience with health plan executives this month (February, 2008).

Ways to Engage

• Identify innovators as a starting point
• Bringing the patient experience forward - co-shadowing, interaction with consumer groups

Sites Visited

• Kaiser Permanente (Oakland Medical Center, Oakland, CA, West End Medical Center, Washington, DC)

Benchmarks in incentive alignment and scale

Kaiser Permanente, and organizations like it, are in many ways a benchmark for patient centered health information technology. They have the highest EHR and PHR penetration in health care. Kaiser Permanente currently has 1.7 million of its members using its PHR, and relaunched in November, 2007 as “My Health Manager.” Group Health Cooperative of Washington State is currently at 46 % of enrolled adults with verified access to the MyGroupHealth web site.

MyGroupHealth (ghc.org) adoption curve, 2002-present

The alignment of incentives is reflected in the slope of adoption by patients. The adoption curve for Group Health patients is significantly steeper than comparable organizations (see: Halamka JD, Mandl KD, Tang PC. Early Experiences with Personal Health Records. J Am Med Inform Assoc 2008;15:1-7.)

The work of these organizations is critical in demonstrating that patient centered health information technology can be a reality for all of health care. As we observed, they are post-implementation and involved in relaunch and refinements of their PHRs to support both patient workflow, and the workflow of staff who serve patients in medical centers.

If there are challenges in these organizations, it is that their work requires scalability beyond the typical physician practice, so there is always a risk that innovative ideas may be harder to implement. They are able to work around some of these limitations by supporting regions with higher levels of innovation (for example, the Colorado Region of Kaiser Permanente is a pioneer in teen-physician electronic messaging, see iHealthBeat: Kaiser Colorado Lets Teenagers E-Mail Doctors, Check EHRs).

In my visits to these organizations as a Permanente physician myself, followed by visits to other organizations described here, I noted an gap in knowledge about the potential of PHRs - an understanding of the benefits of PHRs of involving patients and their families in their care has been built up through experience among Permanente physicians that does not yet exist in other parts of health care. In addition, there is no official policy for knowledge transfer that I noticed. Group Health Cooperative generally shares knowledge in the interest of promoting patient empowerment. Kaiser Permanente is embarking on a significant initiative to share its experiences as well. In a session hosted at the California Healthcare Foundation, Holly Potter, Director of National Communications for Kaiser Permanente HealthConnect indicated to the group that, “We don’t have that option anymore” (see: Presentation: Blogs in Health Care) when it comes to delaying or restricting communication about its efforts to the community.

Unresolved issues

• Person to person knowledge transfer (attitudes, technical, workflow) to non-integrated care systems
• Risk of reduced innovation due to high expectations for consistent service across large populations

Countermeasures

Doug VanZoeren, MD, Mark Snyder, MD, and Ted Eytan, MD, bring leaders from the Office of the National Coordinator to Kaiser Permanente West End Medical Center, Washington, DC

This initiative represents a portion of the effort that Kaiser Permanente and Group Health Cooperative are making to provide knowledge to the entire industry. Other efforts include participation in national standards bodies, commissioning high quality research studies, and providing access to its operations (see: Office of the National Coordinator Visits Kaiser Permanente West End Medical Center). One of the most important efforts I have been engaging in throughout is to bring technical and execution expertise to organizations who are implementing PHRs. This will continue throughout the initiative.

It might be useful in the future for these organizations to put together a publicly available “toolkit” for PHR implementation, which would include everything from tested organizational policies, communication collateral, and staff and patient adoption techniques. Currently, this information is being transferred one to one by individuals within the organization. Perhaps a repository of experiential knowledge of basic items such authentication procedures could be made available for other organizations.

Group Health Cooperative has previously released its “Clinical Information System Rollout Toolkit” to the health care community for unrestricted use. We did not create a companion “PHR Toolkit,” however as a part of this work, I recently put together a basic PHR Toolkit that was forwarded to the Institute for Family Health, to assist in their implementation efforts.

Ways to Engage

Victor Silvestre, MD, Kaiser Permanente Oakland Medical Center

Kaiser Permanente is engaged at many levels to promote PHRs, including in the establishment of standards and sharing information, including on this blog.

Several staff members in these organizations are active in public conversations, such as on standards bodies, and are an excellent way to support involvement and knowledge transfer. In addition, given current initiatives to demonstrate the value of their care models, both organizations’ Communications departments will be useful in arranging for access to practices and Permanente physicians who can demonstrate the value of PHR-enabled practices.

Sites Visited

• Harvard Vanguard Medical Associates
• Partners Health Care
• John Muir Physician Organization

Challenges with Patient Adoption

This seemed to be the hallmark of the multispecialty groups we visited, all with different organizational structures. Harvard Vanguard is a private multispecialty group, has an existing patient portal, MyHealth Online, as does Partners Health Care, in Patient Gateway. John Muir Physicians have chosen the RelayHealth platform, but have not yet implemented it across all care sites.

In observations at the practice level, we noticed an enthusiasm for PHRs in both HVMA and Partners, and both organizations are putting some effort toward promoting adoption. For example, brochures at nurses stations.

At the same time, the messages at times seemed ambiguous at the level of the patient. For examples, physicians in practices served by Patient Gateway are communicating with patients outside of the Patient Gateway environment, using electronic mail. Partners has a Physician Leader accountable for Patient Gateway’s success. Harvard Vanguard Medical Associates does not. There was not a consistent approach among physicians at sites we visited (both Boston organizations) with regard to explaining the benefits of these tools to patients. We also noticed signs like the one pictured here, which describe a workflow that makes less sense in the presence of a personal health record system.

Independent acts of adoption were visible, however, at several sites, such as Masschussetts General Beacon Hill Primary Care, where Administrative Manager Richard Perrotti has worked with medical staff to integrate Patient Gateway into the care experience. In addition, practices that we observed were interested in ideas to promote adoption from others engaged in PHR use in practice, which leads us to believe that there is receptivity to a consistent message about benefits.

Data in a recently published article demonstrates flat adoption curves (see: Halamka JD, Mandl KD, Tang PC. Early Experiences with Personal Health Records. J Am Med Inform Assoc 2008;15:1-7) for other institutions local to HVMA and Partners, most notably Beth Israel Deaconess Medical Center. This is despite the fact that these organizations do not charge additional fees for use of these services.

Internal, External, Technical Factors?

When on site in Boston, organizations we spoke with acknowledged that hurdles to promoting adoption originated in internal prioritization of multiple initiatives, as opposed to external factors. This may be prevent the application of resources to developing a coordinated approach to adoption.

Read the rest of this entry »

Sites Visited

• Blackhawk Medical Center (Danville, California)
• Center for Practice Innovation, American College of Physicians

Innovative, and Pressured

Blackhawk Medical Center:
New displacing Old

Small practices compose the bulk of physician organizations - 93 percent of US practices have less than 6 physicians, 96 percent have less than 10 physicians*. Percent penetration of “full” electronic health records in this population is still less than 10 percent, with up to 24 percent with some form of EHR (see Electronic Health Records Still Not Routine Part of Medial Practice, Robert Wood Johnson Foundation). This makes for a large potential market for vendors on the one hand, and a more costly sales proposition on the other hand. To quote the AC Group (White Paper on 2006 EHR/EMR Marketplace):

it appears that the adoption rate is increasing by only 32% per year. Therefore, if the current trend continues, the total adoption rate will only be around 52% by 2010. So what will it take to increase EHR adoption? The industry must create financial incentives for physician adoption. Without financial incentives, the US EHR market will never exceed 50%.

We witnessed this challenge at Blackhawk Medical Center, part of the John Muir Physician Network. The practice has purchased an EHR with its own funds, with plans to tie to the larger organization’s patient portal.

Implementing an EHR within a small practice places pressure on the practice itself to show return on investment in the long term, and in the short term, to justify the upheaval caused by this transformation. When we went to shadow Dr. Schierman in his office, he apologized for the appearance of medical charts on his desk, which he was methodically reviewing in preparation for scanning. This is balanced by the external pressure of competing group model practices in the area who generally have higher HIT adoption rates and richer support (financial, technical, legal). A survey performed by the California Medical Association in 2005 and reported by the California Healthcare Foundation found that the greatest barrier to EHR use among physicians was the expense to purchase them (see Electronic Health Records Still Not Routine Part of Medial Practice, Robert Wood Johnson Foundation, and “Snapshot: The State of Health Information Technology in California, 2008 - CHCF.org”).

At the same time, projects like the Center for Practice Innovation of the American College of Physicians, are bringing forward practitioners who illustrate an advantage of these practices (see Small Practices leading the way: ACP’s Center for Practice Innovation).

Because the locus of control is within the practice in terms of workflow and information technology, there is a greater capability to experiment. In addition, there is greater capability to experiment with lighter-weight systems, including systems that are subscription-based, to examine changes in care independent of the technology. At the CPI’s November meeting, I saw several presentations given by small practices about their use of subscription based messaging and patient-entered-data systems.

One interesting development I noticed was the Ideal Micropractice, where physicians have minimal to no support staff, and with it a much greater capability to experiment with patient-centered health care and technology in support of a different cost-model for medical care.

All of this said, we did not find deep understanding of the value of personal health records in these environments. I (Ted) found that there was ready uptake of the concepts when they were introduced in these groups. However, there was a noted tendency before the conversation started to have a bias toward inaction. At the Center for Practice Improvement’s November meeting bore this out. Prior to several presentations touching on patient-physician messaging, a question was asked of the audience about patient-physician e-mail, with an ambivalent response. Following the presentations however, several individuals appeared much more enthusiastic about this work.

Awareness-building is occurring on a national basis as well. In a 2007 article in Family Practice Management, “Are your Patients Ready for Electronic Communication?,” the authors come to a surprising conclusion about their practice:

Overall, we were pleased to learn that 88 percent of our patients are able to access the Internet or e-mail either at home, through a public facility, or through family or friends. We had anticipated a much lower number. We were also impressed that 78 percent of patients with Internet access (either at home or elsewhere) expressed interest in using some form of electronic communication either to contact our office or to receive health-related information from our office.

I experienced a similar finding within the practice at Blackhawk Medical Center, when Dr. Michael Schierman took the time to ask each of his patients that day how they would feel about patient-physician messaging. The answers to the question, once asked, and the response, were similar to what was written about in the article above.

Unresolved Issues

• Funding sources for small practices to adopt health information technology are less clear relative to safety net providers or larger practices
• Conventional wisdom about the value of patient access to their health information online may lend to inaction
• External environment/incentives send an ambiguous message regarding adoption of patient accesss in electronic health record implementation

Countermeasures

Charts, scanned, secured, and ready for permanent storage

We plan to continue following the John Muir experience, given the presence of a strategy to integrate a patient portal and an electronic health record, and the innovative nature of this practice to begin with. This may provide support for the idea of PHRs in other practices. We would also like to connect with payers who support small practices to examine the relative priority given to supporting technology and patient-centered care in payment policies.

Ways to Engage

• Connection with innovators in the field
• Connection with specialty societies and practice innovation centers
• Connection at the payer level

*A note about practice size

In reviewing data for this persona, we came across several different measures for practice size, including “Percent physicians practicing in a practice of a certain size” and “Percent of practices of a certain size.” In our travels, we have also witnessed the communication of this data differently. For the purposes of this special report, we prefer to report by “Percent practices of a certain size” since this represents the experience that a patient will see when they receive care, and since a practice is most likely the unit of adoption of HIT.

To see a list of links that display this data different ways, go to PCHIT Personas: Practice Size