These are Adam Szerencsy, MD and Neil Calman’s slides from the recent discussion in Oakland, “Patient Online Access in the Safety Net,” hosted by the California Healthcare Foundation.

Adam and Neil are from the Institute for Family Health, and as you can tell, have learned a lot in providing online access to their patients in New York City.

This presentation had special meaning for me for several reasons. The first is that Neil’s organization was the first to host me outside of my integrated health system environment, to learn about applying PHRs to the care of all patients. The second is that I got to watch Adam lead the rollout of IFH’s patient portal from the initial thinking through to watching him prepare his patients for its eventual rollout, when I got to watch him practice in Bronx, New York. You can read the story (and see the pictures at this link) about what that day was like. I still remember it as strong affirmation that there are really exceptional physician leaders among us, who with the right tools can be freed to do great things for their patients and their communities.

Continuing on, in the publication of the stories of some of our nation’s leading edge safety net organizations in the area of patient online access, these are the slides shared by James Kahn, MD, from the University of California, San Francisco Positive Health Program. I had previously blogged about their myHERO patient portal, which is helping patients with HIV/AIDS manage their health better. Note the work underway on leveraging cell phones. There is a lot of innovation going on in these settings, because innovation is required to connect with patients who want to be connected. That’s a great feedback loop.

“If you don’t like the news, go out and make some of your own” - this was the theme of the presentations given by safety net organizations who are innovating by providing patient online access to their personal health information. It’s now possible to talk to safety net providers who have the technology and the skill to provide this type of access for their communities. This is great news.

Hilary Worthen, MD, visited us in person in Oakland, when we had this discussion , to describe Harvard-Affiliated Cambridge Health Alliance’s patient portal. CHA is using the MyChart patient access system, produced by Epic Systems, Inc. Here are his slides. Comments welcome.

I am attaching the opening remarks that I made, alongside Veenu Aulakh, at the Patient Online Access in the Safety Net discussion, hosted by the California Healthcare Foundation. It describes the “why?” in the context of my journey of discovery. Click on any image to see full size, and comments are welcome.

Update: Incidentally, depending on the reviewer, I am either congratulated or questioned about my presentation style. I just ran across this very nice slideshare : Death by Powerpoint . See if the slides below are more similar to that ideal (I hope they are)

I admit, that maybe, once or twice in my past, I may have used convening and convener in less than flattering terms, much like I used to use “process” in unflattering terms. I learned through LEAN, though, that process isn’t bad, bad process is bad. And so I have learned the same thing about convening, now that I have done it a couple times this summer, with the California Healthcare Foundation.

The most recent time was yesterday, when Veenu Aulakh, MPH, and I brought together Safety Net health care organizations, and national experts in patient online access and social impact of the Internet to talk about (you can guess…) “Patient Online Access in the Safety Net.”

These being the first convenings I have co-led, rather than participated in, I have learned a ton, and have gotten a good understanding of doing this for a purpose, which both situations have had. In the event we hosted yesterday, in Oakland, I put together an A3 document before we invited anyone, which included the background, the goals, and most importantly, the “why?” we were doing this in the first place. It was really helpful to have created agreement around the “why?” - I referred to this many times in the planning.

At the event itself, I got a new perspective that I had not had as a participant previously. It was one of listener/observer - even when I was doing the talking, I was interested to see reactions and learn what people and organizations are capable of. It made me think that when I have been a participant in convenings in the past, this is what my hosts were doing - learning what myself or my organization was capable of doing to solve a problem, as much as they might have tapped me as an expert. Interesting to have this happening in my brain.

Sharing information happened, too, courtesy of some of the most innovative organizations in the U.S., including Cambridge Health Alliance, University of California, San Francisco’s Positive Health Program , New York’s Primary Care Information Project, Institute for Family Health, and Kaiser Permanente.

In addition to all of this, there were a few nice moments of recognition for people’s work, such as when Jim Kahn, MD, thanked Kate Christensen, MD, and her team at Kaiser Permanente for their support and assistance in the launch of the myHERO patient portal for HIV patients cared for at San Francisco General Hospital.

…and a little something for me, a follow-up conversation with Hilary Worthen, MD, from Cambridge Health Alliance, about his study and pathway to discover and implement LEAN in primary care at CHA. He told me that for him, this is a transition from thinking about exam rooms and staff to “work that you need to get done, defined by doctor and patient.” I love hearing about how people apply their creativity and copy the thinking of LEAN to do exceptional things for their patients.

This being the second time I have done this, I don’t know if it was perfect. We tried a lot of things I’ve not done in meetings before, and I am still working to integrate social media before, during, and after. I am definitely sold on my philosophy of supporting any and all technology use (”if you need or want to use your device, use it”) - I have not, in my conveningness, come around to the “turn your devices off” philosophy, as I have written about previously.

Oh, and I learned that a 60″ table seats 8 people.

Here are a few images from yesterday. I’ll follow up with my slides in a separate post. Click on any to see larger size.

Livingston, Gretchen, Susan Minushkin, and D’Vera Cohn. Pew Hispanic Center Report: Hispanics and Health Care in the United States: Access, Information and Knowledge. Pew Hispanic Center.

Tomorrow I will be in Oakland, California, along with health care leaders from the California Heatlhcare Foundation, California Safety Net Organizations, National Leaders in Patient Online Access in the Safety Net, and other national leaders in the social aspect of the Internet for Americans to talk about patient online access in the health safety net. It promises to be a very interesting day, which I’ll post about here.

The referenced report is one of two recent studies on the impact of the Internet among Latinos in the United States, and among all Californians (next post). They are both timely and useful as we answer the question that I was asked many times while visiting Safety Net medical centers: “Are our patients online?”

Pew Hispanic Center Report: Hispanics and Health Care in the United States: Access, Information and Knowledge

This report describes research performed jointly by the Pew Hispanic Center and Robert Wood Johnson Foundation, and consisted of a bilingual telephone survey of a nationally represented samle of 4,013 Hispanic adults conducted from July - September, 2007.

Highlights from my review

• 27 % of Latinos report having no usual care provider, the rate is 42 % for those without insurance.According to the CDC, the proportion among Hispanics is more than double that of non-Hispanic whites and non-Hispanic blacks.
• Language differences are significant: 24 % are English dominant, 35 % are bilingual, 41 % are Spanish-dominant. This has significance with regard to the Internet….only 17% of Spanish-dominant Latinos receive health information from the Internet, compared to 53 % of their English-dominant peers. Interestingly, those of South American descent report a 51 % figure, higher than the figure for Puerto Rican (49%) and Mexico (31%).
• Fleshing the language issue a bit more: 40 percent of those who get health information from the television get it from Spanish-language stations. For those getting information from radio, 47 % rely on Spanish language radio stations
• Youth is a factor: 42 % of those aged 18-29 get health information from the Internet.
• Overall, 35% of Hispanics get their health information from the Internet, far behind television (68%), radio (40%), or a doctor (72%)
• Also of interest to me is in the demographics of this population, younger than their non-Hispanic cohorts, and with lower rates of chronic disease today (20 % with high blood pressure, compared to 22.4 % Non-Hispanic White, 31.6 % Non-Hispanic Black)
• And….in terms of health seeking, 41% said the reason they did not have a regular health provider was because they are seldom sick. The impact? Only 62 % of these individuals have had their blood pressure checked in the last 2 years.

What impressed me overall was the impact of language - it reinforces what I saw from my observations way back in November 2007:

Key health care leaders are saying the time for PHRs are now. Based on the Boston visit, I am saying the time for multilingual and culturally relevant PHRs is now.

Obviously, I still believe that, and this is why I am especially excited that one of the organizations presenting to us today is Cambridge Health Alliance (see information about my visits with CHA here), who have launched their personal health record to a population that is predominanly portuguese-speaking.

Without parity in access to quality health information, the concern is that the dependence on the in-person interaction with the health provider is greater for Spanish-dominant individuals than for English-dominant, and therefore the risk is greater that needed preventive care will not happen if they do not have a usual health care provider. The data appear to bear this out. It is worth thinking - if you did not have your blood pressure checked in the last 2 years, how would you be able to reassure your family about your ability to provide for them with a healthy heart? Should these individuals wait for their organs to be damaged, or should they have an equal chance at providing for themselves and their families with healthy hearts, brains, and kidneys? Thank you to the Pew Hispanic Center and Robert Wood Johnson Foundation for informing these questions.

• The problem for people who have no health insurance is…they’re uninsured - "An emergency room is hardly the medical home of choice for an American citizen" - Jane Srasohn-Kahn. Adds good information & support for providing people with understandable information about their care.

Jonah Froelich, MPH, California Healthcare Foundation’s resident expert on health information technology sent this along to me and I wanted to post it. It shows the spirit of health professionals who are changing the way they practice because they want to perform better for their patients. Scenes like this are happening all over the United States. Thanks and congratulations to West County Health Centers and (again) to the Redwood Community Health Coalition for sharing their enthusiasm with patients everywhere.

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.

Read the rest of this entry »

The quote in the title is from Mark Snyder, MD, Associate Medical Director, Information Technology, Mid-Atlantic Permanente Medical Group, who once again, volunteered to demonstrate how Kaiser Permanente improves medical care for patients using the latest technology. This happened at Kaiser Permanente North Capitol Medical Center, which takes great care of a community that includes the United States Capitol.

Mark was demonstrating the After Visit Summary, in this case, to a group of leaders from the District of Columbia Primary Care Association, which is currently undertaking an impressive program to implement health information technology in safety net medical centers in Washington. Senior Project Specialist Lauren Mardirosian was in attendance, along with Tracy Knight, NW Social Services Director from Bread for the City, and Deborah Parris, Health Information Manager from Family and Medical Counseling Services.

I set up the visit, with Kaiser Permanente’s help, because I am excited by the fact that our members’ experience can help patients in every care system, locally and nationally. It’s a virtuous circle - sharing our experience brings other experience back that we can use to do even better, and the cycle continues. I have really learned the reinforcing power of sharing in this journey. It’s even more enjoyable when I get to work with colleagues like Mark and Medical Center Chief Doug VanZoeren, MD, who willingly give their time alongside me.

What about the After Visit Summary? Mark showed that by involving the patient in its development, he makes the creation as important as the delivery in achieving its goals - involving patients and families in their care. In an era where we talk about Web2.0, Health2.0, and focus on user generated content, I think this is a great example - we create the record of what happened today, together.

DCPCA is implementing a modern electronic health record system, manufactured by eClinicalWorks, that has this capability. A care system that I visited in Sonoma, California, is already generating these for patients. Sometimes a piece of paper (albeit one that is also available on the Web in real time, on Kaiser Permanente’s personal health record, kp.org) can be as revolutionary as the people who put it together.

Thanks again to DCPCA, Mark, Doug, and Kaiser Permanente North Capitol Medical Center members and staff for their interest in helping patients everywhere.

Pictures: Click on any to see larger. Note: The patient displayed is a test patient. No actual patient information was demonstrated during the visit.