- D.C. Homeless People Use Cellphones, Blogs and E-Mail to Stay on Top of Things – washingtonpost.com – Pointing to the ubiquity of connectivity. Think Twitter for condition management.
Posts Tagged ‘safety net’
D.C. Homeless People Use Cellphones, Blogs and E-Mail to Stay on Top of Things – washingtonpost.com
March 26th, 2009Building a Consumer Focused PHR Conference, Sonoma California October 14-15
October 9th, 2008- Building a Consumer Focused PHR Conference, Sonoma California October 14-15 – Information about the conference, designed for MiVia partners and network providers, and organizations serving vulnerable populations.
Now Reading: Patients’ attitudes to the summary care record and HealthSpace: qualitative study
October 2nd, 2008
This is another article passed to me by Sophia Chang, MD, as it relates to another area of our work together, promoting patient online access in safety net health care organizations.
The work is a qualitative study of attitudes of a group of patients representative of low health literacy, “potentially stigmatising conditions,” or difficulties in accessing health care regarding the National Health Service’ Shared Care Record (SCR), which appears similar to our Continuity of Care Record. It currently has medications, allergies, and adverse reactions, and is scheduled to include a minimum data set. Also discussed with the participants was the HealthSpace, which is a “personal health organizer available via the Internet,” so my guess is, similar to what we call a personal health record.
Despite the fact that 95% of the population in the sample area received a letter informing them about the SCR and HealthSpace, there is very little recall of SCR, HealthSpace, or even the letter itself (14 %). Some of the useful points for us to think about for a safety-net population:
- People without “potentially stigmatising conditions” including their official advocates (required to be included in the study) were unfavorably disposed to the SCR. However, people who actually had these conditions felt the benefit outweighed the risk. The authors highlighted this discrepancy even more by citing advocates as “people who claimed to speak for vulnerable groups.” It is in interesting what we find when we talk to the patients themselves.
- Speaking of patient involvement, it is not clear from the article how and if patients were involved in developing the materials mailed to community residents. Clearly this is a very complex program and from the comments it appears that explaining the SCR and HealthSpace is akin to explaining how the health care system works in general. It’s a great magnifier of problems elsewhere perhaps.
- “Empowerment” versus “Engagement” – comments suggest that those who are actually less engaged have more favorable opinions of SCR and unfavorable opinions of HealthSpace, indicating that they see the SCR as an advantage in reducing personal responsibility. The authors say this should be discussed further, and cite the work of Judith Hibbard and findings that “empowerment” may require cognitive skills that “not all citizens possess.”I suppose what I make of this is the idea that by itself, these technologies don’t create engaged behavior in patients that we expect. At the same time, I’ve discussed the idea that they do create different behavior in the clinicians who are accountable them.
So how would I apply the information here in the promotion of patient online access in the safety net? I might think about involving patients in the design of systems up front, to make sure that the features are compelling to them. I would convene focus groups (maybe with the support of an interested funder) to look at everything including marketing materials and approach to make sure that efforts aren’t wasted.
This article is a helpful reminder that even with the best intentions, those who design programs don’t live the lives of those who should benefit from them, and as I tweeted recently, people with chronic illnesses think about them for longer than the time they visit a medical center or log into a web site.
e-patients: Safety Net Populations
September 19th, 2008e-patients: Safety Net Populations
The nice thing about the blogosphere is that when you get behind in your blogging, someone else will help you out. Thanks to Susannah Fox for writing about her experience with us in Oakland, California, around the sharing of Pew Research Data with safety net health care organizations.
The comments on the post are especially heartening, in that they support that involving the audience in the presentation of information is meaningful. In this case, they presented just as much information back, which is as it should be.
If I can have one claim to fame in the convening world, besides audience involvement, it is that internet access, checking e-mail, using the Web is allowed at the discretion of attendees. At the last two meetings where I suggested this, people seemed a little caught off guard that this is okay. I want to change that. Just as in the Results-Only Work Environment, in the Results-Only Meeting Environment, respect for people deciding what is most important to them creates the pressure I like, that I/we need to be more interesting than an e-mail inbox.
PHRs for the Disadvantaged « Chilmark Research
September 6th, 2008- PHRs for the Disadvantaged « Chilmark Research – Discussion of patient online access in the safety net is starting to go (more) mainstream.
Patient Online Access in the Safety Net: Adam Szerencsy, MD and Neil Calman, MD’s slides
August 30th, 2008These 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.
Patient Online Access in the Safety Net: James Kahn, MD’s slides
August 28th, 2008Continuing 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.
Patient Online Access in the Safety Net: Hilary Worthen, MD’s Slides
August 24th, 2008“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.
Patient Online Access in the Safety Net: Ted’s Slides
August 21st, 2008I 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)
Patient Online Access in the Safety Net
August 19th, 2008I 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.
Now Reading: Pew Hispanic Center’s Hispanics and Health Care in the United States
August 17th, 2008
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
August 7th, 2008- 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.
Video: “Goin’ Live” – West County Health Centers, Sonoma, California
July 25th, 2008Jonah 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.
The Patient is Still the Focus: 21st Century Family Medicine in Sebastopol, California
May 3rd, 2008Earlier 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 more: The Patient is Still the Focus: 21st Century Family Medicine in Sebastopol, California
“A Process, Not a Souvenier” – Sharing After Visit Summaries with DC Primary Care Association
March 23rd, 2008The 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.
A mini-tour of MiVia
March 13th, 2008Yesterday, I wrote a post about my visit to Sonoma, California, and the health care that MiVia is enabling. Heidi Stovall then gave me a tour of the application, and allowed me to take screen shots of it to post here. All of the information in the screen shots are not from real patients, so there is no personal health information being displayed.
Let’s take these one by one. And here are the images that go with the tour. Click on any to see full size.
- This is the patient login, and includes their identification screen. Notice the LAC. That’s a “Limited Access Code” and allows a selected person access to the information, for example a care provider in an emergency.
- A chart note. This allows a provider to document right into the patient’s personal health record. An interesting paradigm – the customer of this system is the patient, not the provider (sort of how I think these systems should be designed). Important to remember that these patients typically do not have medical records in other EHRs.
- The printable ID card. I mentioned yesterday that this is not an actual ID, but to the users, it signifies “belonging” to something. At the same time, it can be given to a provider to signify that “there is a place you can go to learn about my medical and dental history.” It’s worth noting that my health plan offers this, but via a telephone service, not through the Web (I can access my own information, but I do not have an access code I can give to someone to do it for me).
- A medical summary report. A easy place to find out about a person’s medical and dental conditions.
- Sharing preferences. The patient can automatically add their record to the roster of a participating provider. If they do not add this, the provider can also add the patient by getting access code information. Again, the heritage of a patient-centered application is apparent. I think this looks very simple and understandable.
- Pain and symptom diary. What’s significant here is that the patient-centered nature of this record means that patients can document in it as much as providers can. It’s a basic interface to be sure, but physicians know that a cornerstone of pain management is for patients to document what they are feeling.
- Dental Records. Again, a basic interface, but it’s a bit of a breakthrough in my experience to combine oral health and general health in one place. From the patient perspective this makes total sense. From the physician perspective, we are used to segregating “medical” and “dental.” Why? Tradition? Because we went to different professional schools? I think the patient’s way is the best way.
- CCR Export. I think this is one of the most promising features. It’s clear that this is a group of patients that are unlikely to be served by a health system with a tethered PHR, and one of our findings is that a tethered PHR is not the only way to serve patients. What if this subset of the community could upload their record to a tethered system, for example, if they receive care in a tertiary care hospital, or if they obtain a specialty consult in a system that has an EHR? In this case, they will still use MiVia as their portal. The idea is that the specialty care provider could either document here (copy their note), or send a CCR export to MiVia.
Here are some thoughts:
» Read more: A mini-tour of MiVia
“Because Everyone Wants to Belong” – MiVia, a community’s personal health record system
March 12th, 2008Imagine that you were working internationally and had a serious stomach ache and needed to see a doctor. When you went into the medical clinic, the doctor asked you what medicines you were taking and what the status of your medical conditions were. What if you didn’t know or couldn’t tell them because you were in so much pain or you had seen a doctor but they didn’t give you a copy of your medical record. What if you lived in that same community for 5 years, but weren’t sure if you needed any medicine or treatment to prevent illness, and no one was keeping track. What if it felt like you didn’t belong….
While in California, I was honored to be invited to visit with the principals of MiVia, based in Sonoma, California. Here’s a short history of the system
MiVIA™ (My Way) was designed as a collaborative effort of Vineyard Worker Services, St. Joseph Health System- Sonoma County and Community Health Resource & Development Center in 2002. Since then, these community based organizations have worked closely to help improve the quality of life and health conditions of farm workers living and working in the Sonoma Valley and beyond.
Today I will post about my experience with the health care associated with MiVia. Tomorrow, I’ll post a virtual tour of the system.
I arrived at the MiVia headquarters in Sonoma, a humbly-appointed, former OB-Gyn practice, where I was greeted by Cynthia Solomon and Heidi Stovall. Heidi offered me the choice of an overview of the work before heading over to the mobile health units. Of course I chose to go to where the work happens, and Heidi told me the story along the way. During our ride, I learned that MiVia was born out of a personal family need for members with significant health conditions to have their medical information available at all times. Then, in looking at the community, for them to have this access as well. What Cynthia and Heidi did was take their experience managing private medical practices, and apply it to community clinic settings, and ultimately in the care of this population (farm workers without ready access to care), and I am so glad I got to see it from this perspective.
We arrived at La Luz Community Center, where the St. Joseph’s Mobile Medical Clinic was parked, and I was introduced to Jessica Alcantar, one of the “Promotores de Salud,” and Jackie Williams, the Supervisor of the Clinic. Jessica showed me how she brought families into the care system by signing them up for MiVia first. The Promotores program is an innovation of this health system, and is essential to the use of the personal health record system. It allows anyone to have access to MiVia, and the team also does educational sessions about the use of the Internet for this population. Jessica told me that as an exercise, she taught the use of Google Earth to show people how they could find their nearest library. I asked about the value of the Internet in this population, and Jessica said, “They know the advantage of being able to connect with people back home.” A great demonstration of the shattering of conventional wisdom that the Internet is only useful for some and not all.
MiVia was developed in collaboration with the people it serves, and one of the unanticipated “wins” of the system was the MiVia ID card (see pictures). These can be printed on demand off of the Web, and are also issued to members as laminated card. For the people being served, this is often the only identification they have, their only tangible “belonging” to this community. The card is not just identification…more on that tomorrow.
In La Luz, a healthy cooking class was taking place as patients were being seen in the mobile clinic.
Here are my pictures from the visit, click on any to see full size, and then the “continue” link below to read on….
» Read more: “Because Everyone Wants to Belong” – MiVia, a community’s personal health record system
A Medical Home enabled by technology in Sonoma, California
March 11th, 2008While in the Bay Area, I had the opportunity to visit with Jason Cunningham, DO, at the Sebastopol Community Health Center in Sonoma, California. The Sebastopol Community Health Center is part of the Redwood Community Health Coalition, which is embarking on an ambitious electronic health record project, using the eClinicalWorks application.
Jason is a Board Certified Family Medicine specialist practicing a full spectrum of the specialty, including OB, pediatrics, and inpatient care. Unfortunately, I came to see the Center after he had finished seeing patients for the day, so I was unable to shadow. However, Jason embraced the idea of a walking meeting, so I could say I shadowed in the community as opposed to the medical office as we put steps on the pedometer.
Jason’s health center is designed to pilot an advanced medical home model, facilitated with a complete electronic health record. There are less patients receiving care at this brand new center while different approaches to care are tested in the practice. Specifically, there is more involvement of support staff in panel management, and a focus on excellent primary care provision, with a goal of creating a sustainable approach across the community. What I was really impressed by is the fact that this work is being done with the current reimbursement system as it is; in other words, the team is working to demonstrate better outcomes and affordable care through a focus on comprehensive primary care, within a safety-net, federally qualified health center system that emphasizes in-person visits. They are not waiting for a change in reimbursement approach to do this work.
In terms of the layout of the medical center itself, you can see from the images below that there is a focus on bringing the patient into the care experience. The patient sits across from the physician, and the computer, a tablet PC, is arranged so that both physician and patient have access to the information being used. Jason is also using after visit summaries with his patients, as shown in the image (test data shown), so that they leave with a written description of the visit and next steps. I of course think this is a key part of patient centered health information technology.
The surrounding community is both beautiful and also working diligently to provide access to regular, quality, primary care across the population.
Images, click on any to see full size
» Read more: A Medical Home enabled by technology in Sonoma, California
“Our patients, not my patients” – UNITE HERE Health Center, New York City
February 29th, 2008The 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.
PCHIT Personas: Vulnerable Population
February 27th, 2008In 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.
“A resilient population” – Baltimore Medical System
December 20th, 2007We are three months into the PCHIT initiative, and we would like to add additional sites that are local to the Center for Information Therapy, to establish a longitudinal relationship of proximity to care systems.
One such care system is the Baltimore Medical System, which I toured with Chief Medical Officer Kyu Rhee, MD yesterday. We went to the Belair-Edison site and the Middlesex site.
I have to say here that the day was a very interesting one for me, as I spent the morning at a Kaiser Permanente medical center in a nearby community, and the contrasts were very striking. Both organizations are working hard to improve their service in admirable ways, even if their service challenges are vastly different.
BMS is undergoing a significant transition, into the electronic age. It is also undergoing a leadership transition, with Kyu accepting a new position at the National Institutes of Health, where he will further pursue his interest in reducing disparities in health. Our tour was a little bittersweet because of this, as Kyu bonded with colleagues at the two medical centers we visited.
Kyu has been Chief Medical Officer of BMS for 2 years, with previous experience as a medical center Medical Director and internal medicine/pediatrics physician in a safety-net medical system in Washington, DC. BMS serves about 55,000 patients at 11 sites (as of 2006), and it funded acquisition of its EHR, manufactured by Misys, on its own, which is remarkable for an organization like this. As the data that Kyu pointed out, 8% of community health centers have EHRs. This puts BMS in the 92nd percentile. It also frames my work a bit, as I have been tending to visit the early adopters – having an EHR is far from being the norm.
» Read more: “A resilient population” – Baltimore Medical System
La Clinica de La Raza, EHRs and PHRs
December 11th, 2007This post is a continuation of my experience at La Clinica de La Raza in Oakland, California. As I mentioned previously, it was a great experience and I was welcomed by the staff and providers who serve this community.
I mentioned that most of the clinical work performed here uses a paper medical record. There is laboratory testing and medication look-up, as well as scheduling features. I asked both Steve Schiff, FNP, and Bina Patel, MD, their thoughts about going electronic, and even communicating with patients online. Because providers share a communal work space, I received additional perspectives. Patri Zayas, MD, the Medical Director, also stopped in to say hello and answer questions about the Medical Center.
Bina told me that when she looked to move to California, she interviewed at 7 safety-net medical organizations, and none of them had or were planning to get electronic health records. She hoped to use an EHR in her new clinical environment. I asked her about e-mailing with her patients. She said that she does some of this now, and would look forward to doing it more comprehensively. She trained in a location with an electronic health record and is very comfortable with the electronic tools she has access to here.
I also talked to Steve and his colleagues, and learned that many patients in this community don’t have good reading skills, and often, the individuals in the home that can read are children, and not at a level that is sufficient for translating health information. A real dilemma. It is not one PHR fits all. Many providers here do not have experience with electronic health records, except perhaps at patients at other systems, such as Kaiser Permanente. As I spoke with Patri, I understood that the clinicians here have a good sense of what the right clinical goals are for their patients, but it may be hard to conceptualize how to get there with an electronic health record right now. I felt the same way when we started our journey 5 years ago.
I was very kindly invited to the all staff meeting held on that day by Suzy Mejivar, the Manager of the Clinic, which was a celebration of a lot of hard work by the staff. La Clinica had passed a level of volume of encounters that had never been achieved before (and I recalled a comment made at another safety-net medcial centers that encounter numbers are essential in this environment to survival). Suzy individually thanked each staff group for all of their teamwork. She said, “Love each other, respect each other, and work together.” She even complimented one of her case managers when she said that she knew they were doing a good job because she was at her aunt’s house when her aunt received a call from La Clinica. This is a measure of the integration in the community that this organization has. Suzy did ask me to introduce myself to the group, which I did, and when I said, “Our practice has been fully electronic since 2004,” I got a sense of excitement from the staff present.
What next?
» Read more: La Clinica de La Raza, EHRs and PHRs
“Isn’t she the cutest? She’s my patient, too”: La Clinica de La Raza, Oakland, California
December 10th, 2007These were the words of Bina Patel, MD, who introduced the new baby of one of her female patients to me in an exam room. To another family physician, these words are magical, and the way that Bina smiled when she said them was an instant reminder to me of why family medicine is so special. We live to take care of whole families and their communities, and a lot of pride comes from being able to be there for all of them.
This is part 1. Part 2 will be posted tomorrow, in the interest of readability.
From La Clínica’s Web site:
La Clínica has played an important role in the East Bay by offering low-cost quality health care services for multilingual and multicultural populations at 23 locations in three counties: Alameda, Contra Costa, and Solano counties, with many of our patients served in the City of Oakland. La Clínica’s comprehensive services include: pediatrics, family medicine, women’s health care, mental health services, dental and vision care, and health education. We offer these services regardless of people’s ability to pay or insurance coverage.
To most effectively serve the diverse community of the East Bay, La Clínica hires health practitioners who fluently speak Spanish, English, Chinese, as well as Hindi, Arabic, and Amharic. We also make a concerted effort to recruit doctors, nurses, health educators and other providers who come from the same cultures as our patients.
The commitment to supporting the community with providers that reflect its own culture was very evident when I was invited for a visit. What was also evident when I entered the facility was the amount of care that was being provided – a lot. There was what I would say was a level of activity I had not encountered at Kaiser Permanente or John Muir Health – a “buzz.” It was reflected all the way into provider workspaces, which are shared.
On the day I attended, there was a bit of what I called a “cake explosion,” with the staff celebrating a colleague’s birthday. I had to include pictures here, and especially one of the slice plated on a fraction of a plate – this organization is concerned with affordability all the way down to their celebrations! Kidding aside, the way the staff celebrated each other on the day I visited was impressive.
Pictures: Click on any to see full size
The practices
“I want my doctors to meet me half way” : Lifelong Medical Care, Part I
December 2nd, 2007
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.
» Read more: “I want my doctors to meet me half way” : Lifelong Medical Care, Part I
Health Plan Perspective; Cambridge Health Alliance, Boston
November 12th, 2007My journey in Boston was completed with a visit to one of the large health insurers in the region, and to Cambridge Health Alliance, which serves Cambridge, Somerville, and Boston’s metro-north communities.
While in the area, I did manage to make a visit to the LEAN Enterprise Institute, where I was thrilled to meet James Womack, the author of several works that have shaped much of the work underway at Group Health and other health institutions. While at LEI, we talked about the penetration of LEAN into the health care space. Organizations in Boston are lucky to have access to this teaching and research resource so close by.
Health Plan Perspective: I visited with a physician in one of the region’s largest health insurers to learn more about the financing environment and its relationship to patient centered HIT work. As people in the field are aware, Massachusetts is home to the nationally recognized eHealth Collaborative, which is bringing 34 member organizations and pilot communities to support adoption of EHRs statewide. As the MAeHC web site, states, this is a $500 million proposition. In the discussion I participated in, two key questions arose from the plan perspective: 1. Who owns the personal health record? and 2. How and if will it be adopted? These are very helpful questions to keep in mind as we talk about innovations that require participation from a whole system (providers, patients, financing) to be successful. As I come from an environment where all are aligned within the same organization, it’s good to know what the key issues are. There will tension between interventions where ownership has been reasonably well established, such as disease management, and for which outcomes can be measured. Everyone wants to make investments that directly support beneficiaries. A recent article I read pointed out that there is much experimentation going in in the health plan sphere. The challenge, therefore, may be around focusing strategy toward PCHIT. The key questions mentioned may need to be answered to get us there, which is helpful to know.
Cambridge Health Alliance: The practice: My guide on my visit was Hilary Worthen, MD, Director of Medical Information Systems for CHA, and primary care practitioner for 25 years. Hilary and I did the thing I enjoy so much – walking through the community to understand it better, which brought us to Union Square Family Health and its Medical Director, Rachel Wheeler, MD. Cambridge Health Alliance, like East Boston Neighborhood Health Center, is fully electronic, using the EpicCare electronic health record.
The pictures (click on any to see full size):
» Read more: Health Plan Perspective; Cambridge Health Alliance, Boston
