Yesterday I had the privilege of speaking at the pre-course for Internal Medicine 2008, American College of Physicians annual conference, in Washington, DC. The topic of the pre-course was the focus on the individual practice, and was facilitated by the great team at the Center for Practice Innovation, including Michael Barr, MD, MBA, FACP, Paula Woodward, MPH, BSN, RN, and Maria Rudolph, MPH.

I really like working with this group first of all because Michael and Paula assemble entertaining and fun experts, like Gordon Moore, MD, Rodney Hornbake, MD, and Peter Basch, MD. All of these physicians, and fellow panelist, Maria Rudolph, are “current” in the field and honest and passionate about improving patient care, which includes being able to stage agreement and disagreement. It’s sort of East Coast, and I like it.

The second reason I like this group is because they represent the overwhelming majority of care environments for patients in the U.S. (over 90% get care from small practices). In terms of promoting patient-centered care for every patient in every system, these are the physicians who have both the ability to innovate and the fiduciary responsibility to make it work for their practice. Putting those two together makes for a perspective that is supportive of HIT and patient centered HIT (that’s what I observed) that succeeds for patients, and those who care for them. I think that’s what we want.

We were asked to provide some parting words for this group, and honestly, I feel a bit awkward being a teacher to this group of practitioners. In many ways they see a lot more of healthcare than I do. In any event, my parting words were that when it comes to HIT, they know more than they think they know, and are well suited to ask, “how will this work for my patient?” That and they should ask every patient if they access the Internet.

ACP enters the blogosphere this week with ACP Internist. A great move for this specialty society, in my opinion.

My visit was capped with a trip to see my colleague David Kauff, MD, from Group Health Cooperative. I have to say that I had to make my way through quite a bit of product placement (more than I would expect to see in 2008), and I wasn’t allowed to take pictures in the exhibit hall, but it was well worth the trip to meet up with one of my favorite internists.

While 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

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The 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.

As part of our visit last week, Josh and I made sure to stop in at New York City’s Primary Care Information Project. As today’s press release indicates, PCIP is demonstrating success in promoting electronic health record use among New York City physicians.

There is a component of this work that involves implementation of the personal health record, and we spent time with Melinda Jenkins, Ph.D., FNP, and Joslyn Levy, RN, to learn more about this part of the project. We were given a demonstration of the patient portal that comes bundled with the eClinicalWorks product. As I have seen at the installation in Washington, DC, eCW has relatively robust integration within the EHR for patient access. I have not yet seen this in action personally, but I did speak with Sal Volpe, MD, a user of both the eCW EHR and PHR (see this post for that conversation).

The success that PCIP has achieved has come from focusing on the build for the provider side of the system. We learned that the patient access component is coming with the “Cycle 2″ portion of the project, which was scheduled to be kicked off the day after we visited (good timing!). In the meantime, Melinda and the team have been working on improvements to the out-of-the-box portal to promote self-management and longitudinal care.

Since Melinda is a contributor to this blog (see her posts here), we’ll let her continue to fill in the readership on her work. So far, the news is good from New York that health information technology can be implemented in our care system, even for the most vulnerable populations.

We stopped in to say hi to Mat Kendall, MPH, PCIP’s Director of Operations, and second to none (even including myself, I think) in the optimism department. Mat is a pro at creating visual systems in his office, which he graciously allowed me to photograph and display here, as great examples. Students of the Toyota Management System will appreciate the impact of keeping this work visible. Keep up the great work, New York!

Click on any image to see it full size

A little bit behind on blogging this week, and a little out of order because we’re back in New York City, working with some of the stars we began our journey with.

The quote comes from a conversation I had with one of those individuals, Sal Volpe, MD, who now as part of his process of care, regularly prints his full progress notes and gives them to every single patient. Sal’s board certified in Internal Medicine, Pediatrics, and Geriatrics, and is running the eClinicalWorks EHR in tandem with its patient portal. And this is how we got connected.

When I knew we were coming up, I learned from fellow blogger (on here) Melinda Jenkins, that there was a physician who had the eCW portal up and running. I of course asked if I could visit, meet, or talk to them, and Sal is him. His practice is located in Staten Island, New York.

Sal has about 50 patients up on the patient portal, out of a panel of about 1,700, so he’s just starting out. But he’s not worried about it - he would be happy with 1,000 patients online. He’s currently running a half-time practice, and prior to his work on the eClinicalWorks project, he’s had experience across a breadth of health plan administration and other physician leadership roles. He’s got a blog (of course), which is at http://ehrphrpatientportal.blogspot.com/.

So I asked him about the case for an EHR, and the case for a patient portal. He talks to a lot of medical groups about this. Given his health plan experience, he has a good understanding of how the benefits accrue in terms of quality, billing, and service, and he’s got optimism for the future.

The quote above says something about small practices’ ability to innovate. Sal told me that he can use the tool of the transparent progress note to communicate about needed prevention or testing not just to the patient but to their families. He knows I’m going to blog about this because I think it is a big deal.

We continue to find a lot of good things happening in New York around health information technology and patient access. More posts on the way…..

Sites Visited

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

Innovative, and Pressured

Blackhawk Medical Center:
New displacing Old

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

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

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

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

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

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

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

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

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

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

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

Unresolved Issues

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

Countermeasures

Charts, scanned, secured, and ready for permanent storage

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

Ways to Engage

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

*A note about practice size

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

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