Greenhalgh T, Wood GW, Bratan T, Stramer K, Hinder S. Patients’ attitudes to the summary care record and HealthSpace: qualitative study [Internet]. BMJ. 2008 Jun 7;336(7656):1290-1295.[cited 2008 Oct 2 ]

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.

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.

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.

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.

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)

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.

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.

This is where leaders Nancy Oswald, the Executive Director of Redwood Community Health Coalition, and Mary Szecsey, the Executive Director of this and 2 other medical centers provide their support, and they came to meet us and talk more about this. Mary asked me if I had ever been given a “FQHC Financing 101,” and I hadn’t, so she provided me with an overview which was immensely helpful.

We talked some with the group, which included Jason and Harriett, about the opportunities to launch the patient portal that accompanies the eCW product that they are using. The team here is receptive to any idea that prioritizes the patient experience.

The challenge the group identified is communication. As them improve things a little every day, they will need to support a growing user community to adopt and improve the best experience. I think my writing about Sebastopol Community Health Center may be both a blessing and a bit of added work in the attention that it brings to this team.

I hope in writing about our time that the outcome is that more of the primary care world will know about practices like this and in turn these efforts will be supported. I think this is a story that reminds patients, nurses, and doctors that primary care is a wonderful and vial part of our health care system, and it can still be done well, as seen from the patient’s perspective.

To answer my concern expressed earlier, cool stuff is happening in California, in primary care, in the safety net, in health information technology, in patient centered care, all together.

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.

Let’s take these one by one. And here are the images that go with the tour. Click on any to see full size.

1. 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.
2. 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.
3. 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).
4. A medical summary report. A easy place to find out about a person’s medical and dental conditions.
5. 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.
6. 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.
7. 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.
8. 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:

Every community has patients that depend on community supported care, in systems that may or may not have robust HIT infrastructures.

In many communities, EHRs are being implemented, in some cases with patient access over the Web. I am not sure that MiVia would necessarily replace a proprietary EHR patient access system; however, it could very much complement it.

What I have learned from my experience is that health care, and the health information associated with it, should be wherever the patient is. It sounds obvious, but what can happen is that a patient can be admitted to a hospital, where a medical record is created in one electronic system. The patient can then be discharged and then another medical record is created in the outpatient setting, which is counter to the idea of medical information following the patient. What if the person and family are not regular users of these settings? Who will put their medical story together?

Putting those ideas together, imagine an employer of farm workers or underinsured or uninsured individuals wanted to do what they could to keep employees well, even if they did not sponsor health insurance. Imagine a community that had a solid strategy for implementing an EHR and even a personal health record in the safety net, but there are still individuals who do not get care in even that safety net. Could a product like this be the “glue” that allows every patient to have access to their own information? Could the idea of a “Promotores de Salud” program be part of every community health system’s benefit program such that all patients have electronic access to their own clinical information? I am used to the idea of charity care being “all of the emergency room visits for which we were unreimbursed.” What if we turn that around and say, it’s “care that we provide in the community to prevent emergency room visits?”

Going back to the story at the beginning of yesterday’s post – what if you did see that doctor who may not speak your language, or you wondered if anyone knew if you needed preventive care. If you could give them a card that said, “It’s all here,” maybe providing for yourself and your family might be a little less scary both for you, and for the health care professionals that want to keep you well.

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….

The mobile clinic itself is very modern, with an Internet connection via satellite, and with exam rooms and a small laboratory. The clinic is supported by the St. Joseph Health System of Sonoma County as part of their Community Benefit program. MiVia is used as the electronic health record as well as the personal health record for these patients. Providers do their documentation right into MiVia. I did not shadow a patient visit, unfortunately, due to a desire to maximize the privacy of patients in this particular environment.

Jessica next gave us a tour of the mobile dental unit, at a different location. Jose Fernandez was the Promotore supporting dental care at this facility. MiVia is a personal health record for comprehensive health – oral health included. This is the first PHR system I have seen that does this. In some ways, this system is more comprehensive than what are offered to patients in the most advanced health systems. I spoke with Chris Tomaszewski, DDS, the dentist, and Susanne Hansen about their provision of dental care. Chris said that she’s very comfortable with mobile dentistry, as she formerly practiced for the Navy, and both Chris and Susanne seemed to echo the feeling I got from all of the providers that they really enjoy what they are doing. As with the mobile medical unit, this appeared state of the art to me. Chris does the data entry into MiVia so that patients’ oral health issues are present in their record wherever they go. In addition, the comprehensiveness of the record allows the dental team access to the medical history of the patient.

Both the Promotores and the mobile health units are funded out of the Community Benefit office of St. Josephs. What impressed me about this was that the Community Benefit was applied proactively in this community to reach a group where they are, as opposed to reactively, by providing care in the emergency room / tertiary care setting.

Right now, there are about 5,000 patients’ records in the secure MiVia system. Tomorrow, I will post on the features of the system, which include patient control and access, and even temporary access on demand.

I think this work is very important in the transformation of a health system to become accountable and accessible to patients. The MiVia team are serving a group of patients that would otherwise not be served by health information technology efforts in the community, and in many ways, their service is better than their insured counterparts. Heidi and Christine estimate that there are 15,000 farm workers eligible to be a part of this system, and are working to fund the system to provide that care. If I think about the fact that every community has a population like the one that MiVia serves, and will not be served by other systems implementing HIT, this could be a key piece of ensuring that every patient in every care system has access to, and is empowered by, their own clinical information. MiVia is being designed for interoperability (more on that tomorrow, as well).

My question to the people I met was, “why did you decide to do this?” and the answers remind me why people that go into healthcare are exceptional. I think what is special about this provider group is that they get to see the impact of what they do for the community, and of the many things about this work that can be applied to all of health care, it is helping every piece of work be tied to the impact that it makes for a patient and their family.

With thanks to Heidi, Christine, Jessica, Chris, Susanne, Jackie, Jose, and the MiVia and SJHS Community Health Clinics Teams for their time and inspiration.

Tomorrow I will post a virtual tour of MiVia, including the features that make the scenario described at the top of this post not so scary for this population, because they deserve not to be scared.

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

Jason is interested in changing that, and bringing more providers into the world of the EHR. He showed me the work he is doing to support management of his panel’s quality goals, with an interest to do this community wide. There is a plan to bring patient access to this system later this year, once the first three medical centers go live. We spoke a little bit about this – the medical home model, as described in presentations like this speaks about the MA-physician teamlet. In the care system I come from, the patient is part of the team, via access to their own health information online and print (e.g. the after visit summary). We have found that this is a critical part of the medical home – because a patient’s medical home is really where they live and work. This can be done with RCHC’s system, and I think RCHC’s efforts plus the efforts of MiVia (see tomorrow’s post), plus other local providers’ work could result in an entire community with access to their own clinical information.

I think it’s an important distinction that Jason is moving ahead to make an ideal care system work first compared to other places that look at structural issues first in deciding to innovate. I think think this is a great place for physicians to be leaders, as Jason is – to show how things should be for patients so that a system can then support it.

I remember a comment I heard at a meeting about primary care last year that, “medical students deciding to go into primary care are good at reading balance sheets.” I remember feeling uncomfortable with that idea in my own experience. I knew how to read a balance sheet in medical school, but I also knew how to read the face of a person (a patient) who is helped to achieve their life goals through good health. I think both of us shared this same experience in choosing family medicine. Jason and I both agree that in the work we do, every patient deserves to have the best of every system out there, not just the best of whatever system they receive care. My time in Sebastopol reminded me of something I have mentioned several times on this and other blogs: people who choose to go into health care are exceptional people, because they have to be. While we respond to incentives like most humans do, we also respond to the calling that got us here. Great things can happen even when they aren’t supposed to. After they happen, a system should be supportive of them still happening.

My only regret about coming to Sebastopol was that I did not observe the process of care with real patients, as I have done with other sites I have visited. My sense is that a lot of innovation is happening here and the work of Redwood Community Health Coalition has the potential to be the model for other safety net systems, or systems in general, to excel in primary care. Thanks again, Jason, and the entire team a Sebastopol Community Health Center for being gracious hosts!

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.