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.

As I mentioned in my previous post, I was beckoned to the borough Queens, NY, shortly after my presentation at the United Hospital Fund. Despite the snow, the trip wasn’t that difficult (in fact, Rachel’s advice to stop and get shoe covers made all the difference in the world).

It was, of course, well worth the trip. I came to Elmhurst Hospital Center, part of Queens Health Network, where they have been using smart card technology to enable better patient care.

First, pictures (click on any to see full size):

As the images show, patient ID cards for the network have embedded smart chips in them that store 64K worth of information, in read-only format. A new version is being rolled out that will store 128K worth of information and be read-write. Given that 22 different languages are spoken by the borough’s 3 million residents, it is easy to see that having a portable version of a medically-understandable health record could be useful. The Network has outfitted local emergency rooms with card readers.

In an innovative program with the Queens Library, patients will be able to access card readers there to see what is on their smart card. What I was shown was a concise clinical summary of health care activity, that included medications, recent tests, and ongoing medical conditions. I could imagine how this could reduce the stress of relaying a person’s medical history to a new doctor or a doctor in an emergency situation. Within the hospital, the patients’ records are available on a state of the art electronic health record; the card is just for portability. Outside of the emergency room environment, a PIN code is used to access the data.

The commitment is there to make this work. Clinics have machines that generate the special ID cards. Card readers are attached at key points in the clinical workflow to ensure updating of the latest information from the EHR. Challenges remain, including making sure that updating of the card occurs at every visit. We did not discuss in detail the impact of a read/write card, and how that would bring data back to the Health and Hospitals’ Corporation electronic health record.

During my visit I was also shown Queens Health Network’s work to improve chronic disease care using registry systems linked to their electronic health record, by Rand David, MD. They have made significant gains in the last 5 years in both process and outcome measures for diabetes, which is what I was shown. Alfred Marino, Glenn Martin, MD, and Amelia Shapiro, are the team working on the smart card piece, in addition to several operations leaders who are integrating this into the workflow. Besides the interest in the technology, they have an interest in the distinct attributes of the population they are working to serve, which came across very clearly to me.

What strikes me as very interesting about this idea is that it supports a simple and “interoperable” health record that is under patients’ physical control. In my own work, I had not considered the value of a smart card linked to our electronic health record, but why not? If it improves the comfort with which a patient is able to seek care, especially in a multicultural community, I think this could fill an important niche.

There are definitely challenges regarding workflow and community support of this program, which are both being actively worked on. The work of Queens Health is a very nice demonstration that patient access to their own health information is not just about having Web or Internet access, and it can make a difference in supporting good health care.