Patient Gateway; East Boston, Part II

In the last post, I described my day at two different care organizations; Partners, and East Boston Neighborhood Health Center.

Continuing, a summary of….

The Practices:

Brigham and Women’s Hospital, Dr. David Bates: I shadowed David for several patients who are on his panel and well known to him. David uses the Longitudinal Medical Record produced by Partners Health Care, integrated with Patient Gateway. Jonathan Wald, MD, the Physician Lead, was next door working with a colleague to talk about Patient Gateway in practice. I think there were a ha’s for all of us about how to use a resource like this, including how to bridge the world of regular electronic mail and the PHR. David visibly practiced Information Therapy in front of me, when he printed out a document to describe a condition for a patient he was treating. The LMR as I understand it, does not automatically produce an after visit summary. I didn’t see David use Patient Gateway features during our visit, but we did have some time to talk about PHRs and the interest in supporting good research for the production of good outcomes knowledge about how to use them in practice. Jonathan is working on the issue of patient adoption, which he may comment about separately

East Boston Neighborhood Medical Center, Dr. Stephen Simon: EBNHC uses EpicCare, and has used it since 1998. Physicians have been documenting and ordering using the system for about 4 years. Their urgent care is also on the system. In shadowing, I was able to observe the first visit in this experience in Spanish, which was important for me to see. In the exam rooms at EBNHC, screens are pointed toward the exam table, where physicians can review data with their patients together, and I saw this happen in the visit(s). Stephen was very facile with EpicCare and has taken the time to customize it for best use. EBNHC does not yet have a PHR active for its patients.

One thing that was really important for me to see was a difference in focus. During my time at EBNHC, the staff was applied to recent health care reform policies that have gone into effect in Massachusetts, which affect everything from co-pays to drug formularies. It was impressive to note how much this was on the minds of the staff here, to support a transition that is successful for their patients. This issue did not come up in conversation at the other medical centers – different populations, different needs. I honestly know very little about this initiative as I don’t live in this community, but it’s clear that it should be understood as a modulator of capabilities. At the same time, EBNHC is also pioneering electronic prescription transmission from its EpicCare system.

The PHRs:

Partners, as I mentioned earlier is positioned for adoption, and are making plans to integrate the Patient Gateway into practices more. The system has good functionality and can provide staff experience in using technology to reach patients wherever and whenever they need to.

EBNHC, in contrast, does not yet have a PHR online. The considerations here are the impact of system upgrades, which must be done accurately, and continued optimization of portions of their system. Much like the Institute for Family Medicine in New York, they maintain a very robust EHR with a smaller staff pool. It’s actually very impressive. In fact, during my time there. Dr. Kuebler was updating parts of the system based on requests for her peers, like in near real time. That’s nimble! This can also make readiness for the jump to PHR more challenging at the same time. One key issue for this population is the need for a multi-lingual PHR. Coming to East Boston really brings home the fact that the time now upon us to address disparities in the way systems are designed so that they are accessible by the same population that accesses the health system. It felt very real when I was there.

Of course, Josh and I would like to follow both organizations as they continue on their journey to support their communities in the distinct ways that they do. I think both will contribute to the conversation significantly.

With thanks again to Drs. Wald, Bates, Kuebler, and Simon, and the staff and patients at Brigham and Women’s Hospital and East Boston Neighborhood Health Center for the gift of their time.

World Usability Day, Washington DC patients’ experiences

PCHIT links for November 2nd through November 4th: relaunched with My Heath Manager today

This is a link to Kaiser Permanente’s press release about the relaunch of the site with My Health Manager. As the release states, the personal health record is continuing to be a large focus of Kaiser Permanente’s work in health information technology. All of Kaiser Permanente’s regions are now operating a personal health record as of this year now that Ohio is online.

Of interest, they are also going through and replacing “your” references to “my” references around the site. For the PCHIT initiative, we are following the progress of Kaiser Permanente as a benchmark organization, and they are a sponsoring partner.

One of my to-do’s is to schedule an in depth tour of I am a user (and builder!) of Group Health’s PHR, which is based on similar technology. I know from my own physician and patient experience that more interaction like this is the right step forward for the people we serve.

Kaiser Permanente Puts Personal Health Record Front and Center

Building Adoption – PCHIT at Partners Health Care

Entrance to Beacon Hill Primary Care

Massachusetts General, Beacon Hill Primary Care

Today was spent at two practices at within Massachusetts General primary care, part of Partners Health Care. Another new addition to the process was the fact that Jonathan Wald, MD, the Physician Lead for Partners’ Patient Gateway, also shadowed with us. I thought shadowing with both Josh and Jonathan was great. Both should be posting their experience here, so I will let them do that.

We actually started the day at the Stoeckle Center for Primary Care Innovation, hosted by Susan Edgman-Levitan, PA, its Executive Director. Susan is a hero for patient-centered care in my (and many individuals’) eyes and kindly introduced us to some of the innovation in primary care that’s happening here. And it’s great to hear about innovation in primary care. I honestly had to do a soft reboot during our discussion because there’s more happening here than I could glean prior to our visit. So, we’re coming back for more, and this is why it’s good to come in the first place.

First, the pictures, and then a description of the practices. Click on any to see them full size:

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“When I walk in the room, it’s like going to medical school.” : PCHIT in Boston

Thad Schilling, MD, and Caroline

Thad Schilling, MD, and Caroline, Harvard Vanguard Medical Associates

These were the words of Caroline, who’s Thad Schilling, MD’s, Medical Assistant at Harvard Vanguard Medical Associates‘ Medford Medical Office. She was commenting on the fact that Thad uses a whiteboard when he teaches patients about their health. This has the impact of involving his team in understanding the patient’s condition as they support the care.

Yesterday, Joshua Seidman and myself shadowed practices at the Medford office (Dr. Schilling) and at the Kenmore office (Dr. Kate Koplan). We went to see what was happening at Harvard Vanguard because they have an established PHR, MyHealth Online, that’s produced by a very respected EHR manufacturer. I was interested in MyHealth Online because it’s a system very similar to the one that Group Health produced for its members in Seattle. However, patient adoption of this system has not been at the levels of Group Health. I wanted to get some insights on the issues at the exam room level.

This was also Josh’s first time shadowing in a medical center, as part of this project at least, so it will be good to read about his perspectives doing this along side me. Consent was obtained from each patient of course, and it actually worked out well to have us alternate shadowing experience. Thad had a relatively busy schedule and he has experience with people learning from his practice, so Caroline and his stewardship worked out really well.

First some pictures, and then the rest of the story:

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Blogs and/or Peer Review, how will they co-exist?

Of late there has been discussion in the role of blogs in communication, both for relaying information, and stimulating action. Much of the discussion in my environment about this is generated by the fact that I am blogging most of what I am doing, and intentionally so (such is the life of a change agent/leader type).

On the micro level, it has been interesting and great to explain to the organizations and people that I meet that I am blogging what I see/do (with the exception of any personally identifiable information of patients). The reactions are varied, as one might expect and there isn’t really a lot of time to explain everything there is to about Web 2.0 because people are busy just doing what they do.

On a macro level, I have a prepared talk that I have given about blogs and their role in change management / communication. I think they have a huge one now and into the future, especially in a learning organization.

At the same time, I think about the value of peer review in describing what I’m doing. What is it?

When I look at the communication revolution that is happening with Web 2.0, I’m unsure that MEDLINE citations are the most important standard for creating portable knowledge in health care, especially in the areas I am working with, Informatics and process management and improvement (LEAN and Toyota Management System).

As it was pointed out to me last week by our advisors, the Medical Home movement came from a PDF on a Web site, and I would call that piece pretty transformative. A lot of the data I have used in patient centered health information technology has been very robustly compiled by the Pew Internet & American Life Project, also very transformative.
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Patient-Centered Care: What Does it Take?

Speaking of “what am I observing for,” Holly Potter from Kaiser Permanente let me know about this excellent report from the Commonwealth Fund. It’s a nice review of the history and components of Patient-Centered Care, accompanied with data from interviews of key experts in the field.

For this project, it helps add a little structure to our observations, because there are discrete things we can look for. The report takes the reader through two example organizations that have these attributes. The checklist it cites is:

  1. Leadership
  2. A strategic vision, clearly communicated (“from the boardroom to the bedside”, or I might say, “from the boardroom to the exam room”)
  3. Involvement of patients and families at multiple levels
  4. Care for the caregivers through a supportive work environment
  5. Systematic measurement and feedback
  6. Quality of the physical environment
  7. Supportive technology

These concepts, especially #7, are right up PCHIT’s alley, as are others that were emphasized by our Advisory Group last week. We have to be careful that this initiative is mostly about #7, at the same time, #7 is a tool to serve the other 6 items.

In contrast to the way data was acquired about organizations, in interviews, I am going to the exam room myself (“Genchi Genbutsu“) to understand each organization’s experience. I think by definition, an organization that is interested in the answer to these questions probably has answered them well already.

The “Adjust” from the Advisory Group: Part I

Eytan-Pchit-Advisory Group

PCHIT Advisory Group – Slides

This post is first in a series will summarize our status and input from our Advisory Group (Blogs are about a little information at a time). Both the Group and this audience are welcome to comment. Our goal is to make any adjustments necessary, now, and continually improve our process as we do this.

The summary comes in the form of an “A3” document and a short set of slides. The slides are published here.

A reminder that an A3 document really just outlines a story. It’s probably best for this medium for me to discuss the work of each Advisory Group member (with the exception of Patricia Flatley Brennan, who could not be with us this first time) and the impact on adjusting our work.

To also keep this manageable, I’ll do it over the course of the week, one each day.

Michael Barr, MD, MBA, FACP: Michael, as Vice President of Practice Advisory and Improvement for the American College of Physicians, is leading the Medical Home work of the College. This includes establishing the “systemness” of the Medical Home, as well as understanding the economics of the Medical Home. He is working with payers to establish the benefit to patients and ability of Medical Home to address self-management goals. As currently devised, this model is most effective in practices where there are longitudinal relationships, such as primary care, but also in specialty care in certain circumstances. Several demonstration projects are set to begin in 2008. The College’s Center for Practice Innovation has been working with small practices to transform them, in line with Medical Home principles. The ACP is heavily involved in technology issues, at the level of some delivery systems. Finally, we are alerted to the publication of a white paper in the Annals of Internal Medicine on payment methodologies.

Adjustment: The impact of Medical Home discussions locally and nationally is very clear, and observations in PCHIT should be connected to Medical Home principles. Ted Eytan is presenting at the CPI conference in Washington, DC, on November 17 and will be spending time with CPI staff and practices as part of this involvement. The ACP white paper will be reviewed by us as well for implications for PCHIT.

“Your Primary [doctor] is like your mother. You don’t change your mother”

These were the words of our server this morning over a breakfast with Neil Calman, MD, who is in Washington, DC, to talk to our national legislators and researchers about health information technology.

How did this come up in conversation? Well, as our order was being taken, I noticed a brochure for her health insurance plan in her uniform. That visual alone said so much about how much health care means to us.

So I asked what she thought of her health care.

She told us that she was a breast cancer survivor for several years now, and that she had excellent cancer care. (She told us, “your patients have probably told you this – a part of you dies when you learn that you have cancer.”) After her treatment was completed, she was referred to her primary medical center to continue care. She said that whenever she goes to get care, though, her primary doctor is not available. She hasn’t seen her in awhile, and she told us it’s not the same. “Your mother knows everything about you.”

I asked if she had Internet access and if she used this to communicate with her care system. Yes, she said, but her primary doctor did not respond to her messages in a timely manner. “I know she’s very busy just like me.” She told us that she’s given this feedback directly to her plan. At the same time, she told us with some pride where she got her cancer care, and where she now gets her primary care. She also told us about several of her work colleagues who have been diagnosed with cancer. They are all aware of each others’ conditions.
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