We were guided by Urban Health Plan‘s inspiring CEO and Chief Medical Officer Paloma Hernandez and Samuel De Leon, MD, who allowed us to observe the process of care at their Bronx, NY-based care system. Invited guests included Susan Beane, MD, the Chief Medical Officer, and Linda Erlanger, the Director of E-Commerce, from Affinity Health Plan, which, “..for 18 years, has been operating managed care programs designed to address the needs of low-income populations. We are a mission-driven organization, striving to achieve positive change in the lives of the families and communities they serve.”

The goal was to do something we had not done before, bring stakeholders together to see the the actual place where the facts of health care impact the patient (for a nice description of the philosophy behind this, based on work done at Toyota Motor, see this post).

First, some photographs. Click on any to see full size.

Asthma, an Epidemic in this Community

I shadowed Mayra Nadal, MD, who is a pediatrician, and like all of the other physicians at Urban Health Plan, are using a fully functional electronic health record, manufactured by eClinicalWorks.

After a few visits, I noticed that several of her patients had severe asthma, and were being treated very intensively. One patient, a young boy, was on multiple ambulatory medications yet he was still not able to breathe normally.

I learned from Mayra that this is a sad reality for this community – this population is at exceptionally high risk for being affected by asthma. This is well known in the community. What I saw in the exam room were the best attempts of this care system to blunt the impact of this disease (and Urban Health Plan has distinguished itself nationally as a leader in managing chronic illness). Mayra showed me that they had taken extra care in the build of the EHR to include standard asthma histories and tracking of asthma plans because of the prevalence. The tools looked very complete; at the same time, they are the tools an informaticist wish they didn’t have to build. It doesn’t seem right that children in the Bronx community should grow up without an expectation to breathe normally.

Mayra was very facile with the EHR, and like me, prefers the use of an EHR because she can type faster than she writes. When I asked about online access to health information to patients, she was receptive to the idea that patients’ families would have access to ordered tests, if they had Internet access. This might be useful for things like newborn screens and other screening exams.

Overall, the impression I got from observing physicians here was one of competence using a state of the art EHR in practice. It is also worth noting that Samuel De Leon, MD also provided a very visible optimistic brand of leadership throughout this part of our experience.

On creating a prepared, proactive care system

After Josh and I individually shadowed, I presented information about the “proactive, prepared care system,” that uses technology to provide patients access to their own health information, and obtains information from patients to provide care whenever and wherever it is needed.

All of the invited guests then shadowed physicians in adult medicine and pediatrics, and we debriefed, which demonstrated the idea of “noticing 10 things every 10 minutes.” Each visitor had several insights that they brought from their experience, which added to the discussion. This included Rachel’s observation that every parent had a yellow, paper child health record that they guarded very closely in every visit. It came from the hospital, and was used as a baseline for monitoring immunization use. Parents want to stay up to date. Susan observed the process of “maxpacking” a visit, where a provider brings additional effort to bring a patient up to date on preventive interventions all at once, in the interest of preventing future complications.

What are our interests?

The value of the day came when all of the participants discussed their interests in supporting the community’s health. Urban Health Plan, as a high-functioning delivery system, are experts at health care process and work to ensure the best access and highest quality care experiences. Affinity Health Plan, as a payer, are experts at supporting the overall well being of their community and work to keep community members “found” (and not lost) within the health care system, so that they can provide for themselves and their families. The goals, of course, fit perfectly together (at least they do from my perspective). Of course, patient centered care, and patient centered health information technology can only help in these areas.

This is where the creativity of these leaders will come together to do something great for their patients, their community, and society. Specifically, we learned that maybe adults are not the target population for patient access; it may be children and adolescents, given the asthma epidemic and patterns of computer use. This was an unexpected finding of our time together – another benefit of going to the factory floor to get the facts.

The day was not about changing the course of either institution, it was about understanding facts. As I posted on another blog that I run on LEAN in health care, a visit to the Gemba should result in the kind of inspiration that makes people want to come back to learn more, to improve a little each time, so that they keep coming back. I’d call us successful, then.

Thanks again to everyone at Urban Health Plan and Affinity Health Plan, as well as the United Hospital Fund of New York City. Let’s do it again here, and somewhere else, too!

In the meantime, we’ll look forward to the innovation that will happen around patient centered health information technology at Urban Health Plan. I think both organizations will impress New York and set a high bar for delivery systems and health plans across the nation.

The facility is about 10 years old, and to my eyes, it seems very well designed, as well designed as any outpatient medical center I have seen. This is a medical center that has transitioned to the EHR that the rest of the Institute uses, so they have experienced the return of space back to the practice now that paper charts are gone. You can see a scanning station in one of the images – this is where the medical records room used to be.

This medical center is interesting in that it also houses a dental practice, which coexists well according to the Medical Director. It was pointed out to me that the dental exam rooms have no doors, to promote team efficiency. The dental practice also uses a dental-specific EHR, that in this case does not communicate with the medical EHR. I have long been fascinated with dental practices, because I believe that they have done a lot of work to maximize workflow in the era of electronic records that allopathic medicine could learn from. I have seen that dentists do a great job of involving care team members in the use of the EHR and in producing documentation, and this was the case here, when I asked how documentation was supported.

You’ll note the picture of the flourescent viewbox – physicians are forgetting how to use this in the area of digital radiology, and that’s the case here. There are challenges in this medical center in not having on site radiology, though. Radiology services can be challenging to arrange, and retrieval of exam data that goes with it can be equally challenging. This has implications for a personal health record and patients’ desire to have complete results available to them.

I was also able to talk with Paloma Hernandez, CEO of Urban Health Plan of Bronx, NY, and her Medical Director, Samuel De Leon, MD, about visiting this organization as one of our future sites. I got the sense of their innovation by the fact that they are now piloting iris scanners for patient identification, linked to their EHR system. It looks like they are doing outstanding work, as is the Institute.