The Patient is Still the Focus: 21st Century Family Medicine in Sebastopol, California

Earlier in my journey, when I visited technologically enabled practices in New York and Washington, DC, I wondered aloud to my project officer, Veenu Aulakh, MPH, from the California Healthcare Foundation, if California would also show itself to be a leader in 21st century medicine enabled by technology. There’s no question that systems like Sutter Health, Kaiser Permanente, and Sharp are national leaders – we were looking for leaders in smaller practices, where 90 % of Americans receive their health care.

Then we discovered Sebastopol Community Health Center, part of the Redwood Community Health Coalition.

I got to visit with Jason Cunningham, DO, the Medical Director and full spectrum family medicine specialist, in March, 2008, but I did not get to shadow him providing care. I wanted to come back, and so I did, this time with Veenu. Coming with Veenu also satisfied my desire to do some shadowing with our funders, because they can see things from a unique perspective. I was able to do the same with our New York funders, when Rachel Block shadowed with us in March. Veenu has an industrial engineering background, so she is not a stranger to shadowing or process improvement.

Jason and the staff gave us a warm welcome, and again it was like walking into the 21st Century (instead of the 19th). Not a single paper chart in sight. There was now an automated vitals machine. Care team coordinators (the role assigned to medical assistants in this model) were now using tablet computers to room patients. Jason and the team were further developing their electronic health record, manufactured by eClinicalWorks, to support a medical home practice.

First photographs – click on any to see larger size

To show the possibilities of collaboration in this new world, Jason informed us that he’s going to install the special build of the product known as “Take Care New York,” or TCNY, tuned for population management and with the experience of the entire Primary Care Information Project in New York city. In other words, California patients are going to benefit from an EHR that includes the experience of New York patients, seamlessly.

Proving the viability of a medical home, even in (especially in) the safety net

As space age as this practice looks, it is not funded predominantly through commercial insurance. Sebastopol Community Health Center is a Federally Qualified Health Center, with a funding stream tied strongly to in person visits. Despite this potential limitation, this health center is working to support visit-based AND non-visit based population care in a financially viable way. They are doing this by maintaining visit density, keeping overhead low, and providing team care coordinators with non-direct-patient care time to co-manage panels, assisted by an introspective EHR. Jason showed us how he can query his panel quickly to build exception reports and understand their health, right within the electronic health record. No separate registry is being used here, which means no interfacing and no double-entry of data.

The shadowing experience

We started the day with the team huddle, which was as futuristic as one would hope – each practitioner with a portable version of the electronic health record, reviewing the patients of the day and preparing for each individualized care experience. By now, Jason has discovered the best approach to using an electronic device in the exam room. Even though this site is described as an “alpha alpha” site, the technology seemed to melt into the background of the green rolling hills during the visit. This could be because the team are using low footprint tablet PCs in exam rooms. It’s also because the devices are used strategically for new vs. follow-up visits. The device is always positioned in patient view, with provider facing the patient.

I could also tell that in true continuous improvement fashion, little things have been changed and improved in the system over time. A new field here, a new way of communicating between the team about something here, an idea to use an exam room one way or another with the computers.

In between patients, I had a great conversation with Jenny, the Center’s Family Nurse Practitioner. She asked for my advice on how to document parts of the patient experience in the health record, and my best answer was to think about where the patient would expect it to be, every time, and put it there. We both agreed, I think, that one of the best things we can do as care providers is to treat a patients’ story with respect by recording it accurately, and making sure it is safely kept where it can be used to support ongoing care by anyone on the team, with all of the appropriate security controls, of course.

Teaching, for a lifetime

Because this medical center is prototyping the future workflow of the rest of the Coalition medical centers, there is always teaching going on of other providers. On this particular day, Harriett, the Care Team Coordinator (a Medical Assistant) was training a fellow Care Team Coordinator on the use of the system.

At one point during the day, Harriett came in for a short break during a very busy morning. I mentioned to her that I noticed that she has a very supportive teaching style. When there was a question, she would make sure that her student learned by doing – she was very good at not taking over the use of the computer, essentially empowering others to learn. A commitment to being an experimental medical center means a commitment to always teaching. I asked about this – how would it feel to be teaching every day for the next few years as the system rolled out, I asked? Her answer was, “This is for a lifetime.”

Fortunately for the Medical Center and her patients, Harriet has been accepted into the Physician Assistant program at University of California, Davis, and Jason has agreed to be her preceptor during her practical work.

I’m Still a Fan

Jason and his colleagues are pouring themselves into to this work, for the benefit of their patients and their community. As I said in March, I am hugely impressed with the initiative to provide the right care first and foremost, with an eye to finances, not the other way around.

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.

Ted Eytan, MD