C A L I FOR N I A H EALTH C ARE F OU NDATION Helping Patients Plug In: Lessons in the Adoption of Online Consumer Tools June 2008 Helping Patients Plug In: Lessons in the Adoption of Online Consumer Tools Prepared for California HealthCare Foundation Prepared by Joshua Seidman, Ph.D. Ted Eytan, M.D., M.P.H. June 2008 Acknowledgment In addition to funding from the California HealthCare Foundation, support for the PCHIT Initiative was provided by the United Hospital Fund, Kaiser Permanente, and the Group Health Community Foundation. About the Authors Joshua Seidman, Ph.D., is a health services researcher and president of the independent, nonprofit IxCenter in Bethesda, Maryland. He has worked with a variety of organizations to structure e-health inventions targeted to consumers, with the goal of improving health behaviors and informed decision-making. Ted Eytan, M.D., M.P.H., a family physician, is the medical director of health informatics and Web services at Group Health Cooperative, a consumer-driven, nonprofit health care system based in Seattle. He contributed to this report as a senior visiting fellow at the IxCenter. About the Foundation The California HealthCare Foundation, based in Oakland, is an independent philanthropy committed to improving California’s health care delivery and financing systems. Formed in 1996, our goal is to ensure that all Californians have access to affordable, quality health care. For more information about CHCF, visit us online at www.chcf.org. ©2008 California HealthCare Foundation Contents 4 I. Executive Summary 5 II. Overview The Patient-Centered HIT Initiative 8 III. PCHIT in Five Practice Settings Safety-Net Providers Health Plans Integrated Delivery Systems/Group Model Plans Multispecialty Group Practices Small Physician Practices 14 IV. Market Variations in PCHIT California Massachusetts New York Conclusion 17 Endnotes I. Executive Summary Health information technology (HIT) has the potential to improve clinical excellence, the care experience, and the continuity and affordability of care. Information technologies focused specifically on patients offer an opportunity to engage patients by giving them more control over their care and making them key partners in health-related decisions. An increasing number of innovative providers are using electronic tools such as electronic health records (EHRs) and personal health records (PHRs) to achieve this goal. To better understand the evolving role of patient-centered health information technology (PCHIT) in clinical care, the authors examined five different types of medical practice settings in California, Massachusetts, New York, Maryland, and the District of Columbia; interviewed physicians, patients, and others; and reviewed the relevant literature. They also looked at PCHIT from a regional perspective to learn about recent developments. The authors found that PCHIT is gaining a greater foothold in health care settings and that most clinicians are enthusiastic about delivering patient-centered care. The research also found that: n Some clinicians practice in an environment where the commitment to PCHIT is ambiguous. n As more providers successfully implement EHRs, some may become concerned about access to the records by both clinicians and patients. n Health plans are still uncertain about how best to harness data for PHRs and persuade enrollees to use them. n Some providers roll out PHRs without linking patients’ personal data to health information targeted to their particular needs. n Consumers are clamoring for PHRs that will give them access to clinical data linked to health information targeted to their needs. The PHR adoption curve in organizations that have taken this approach is steep. n Despite notions to the contrary, safety-net populations are enthusiastic about electronic access to their health care providers and have enough computer savvy to take advantage of patient- centric technologies. However, few community health centers can afford to offer such tools.   |  C alifornia H ealth C are F oundation II. Overview Patient-centered health information technology (PCHIT) engages patients in their care by giving them access to electronic tools, including health records at physician offices, personal health records on the Web, online appointment scheduling, and doctor-patient email. However, there is a significant disparity between what patients want to do online and what they are able or allowed to do. As Table 1 illustrates, about three-quarters of consumers are interested in electronically viewing their medical records and lab results, scheduling appointments, and exchanging email with their physicians. Yet few have such access, even though a sizable number would be willing to pay extra for it. Table 1: Consumer Access to Electronic Tools Would Pay Would Like to Already Tool Extra to Access Access Access Online medical records 78% 6% 26% and test results Online appointment 72% 10% 18% scheduling Email to doctor 76% 9% 23% Source: Deloitte. 2008 Survey of Health Care Consumers.1 Some large integrated delivery systems, multispecialty group practices, and community health centers have adopted PCHIT, many electronic health records (EHRs) now include patient portals, and commercial personal health records (PHRs) are proliferating. But PCHIT is far from widespread.2 Any technology that facilitates communications and helps consumers organize health information, act upon it, and weigh the implications of their decisions qualifies as PCHIT. Along with EHRs, PHRs, online appointment scheduling, and secure doctor- patient email, the term encompasses electronic access to lab results, decision-support tools, prescription refills, and other applications. Helping Patients Plug In: Lessons in the Adoption of Online Consumer Tools   |  To be truly patient-centered, an application must n Access to PCHIT tools by safety-net populations link a person’s health data to content that puts the and opportunities for providers to use such tools data in context for that individual and answers the to coordinate care for these populations. question, “What does it mean in my case?” The project team focused on clinical settings where HIT is replacing paper-based systems, rather than on PCHIT helps consumers take control of their health those with mature HIT or none at all, and on health and to be key partners in health-related decisions. care providers with a diverse clientele. This approach It also improves the quality and cost-effectiveness revealed hurdles faced by those that are considering, of health care. For example, research suggests that or in the process of implementing, information patients immediately forget 40 percent to 80 percent technologies. The team observed providers in of everything a doctor tells them in the exam areas of California, Massachusetts, New York, and room.3 EHRs can generate an electronic summary Maryland—locations served by most of the project’s of a doctor visit to be printed and taken home—a sponsors—and in Washington, D.C. powerful tool because it wraps the clinician’s notes around health content targeted to the individual. Clinicians and administrators often raised the issue of disparate access to the Internet among safety-net The Patient-Centered HIT Initiative populations and how that might affect PCHIT use. The findings in this report are based on the PCHIT Although income and other demographic factors do Initiative, which explored the challenges and have an impact, data suggest that many people— opportunities related to greater PCHIT adoption. A even those with lower incomes—now have access to team from the Center for Information Therapy in the Internet (Table 2). Bethesda, Maryland, studied the delivery of health care—particularly patient engagement with HIT— Table 2. Internet Access among Demographic by observing dozens of exam room encounters in Groups models of care that included community health Percent Who Demographic centers, health plans, integrated delivery systems, Have Access multispecialty group practices, and solo and small Household earns less than $40,000 61% physician practices.4 To promote transparency, the Household earns more than $40,000 91% project maintained an open-access blog regarding its No high school degree 41% observations. High school graduates 69% The initiative sought to assess: College graduates 93% n The technological innovations in place to Caucasians 78% facilitate more patient-centered care; African Americans 68% n How patients and clinicians used HIT at different stages of implementation; English-speaking Latinos 75% Source: Pew Internet & American Life Project.5 n How they communicated about improving n patients’ health; Opportunities for improving clinician-patient communication and the engagement of patients and families in all aspects of care; and   |  C alifornia H ealth C are F oundation It is important to think about PCHIT in the larger context, beyond Internet use, because there are new technologies that do not involve a computer on the patient’s end. For example, a mobile phone may be the most effective vehicle for certain populations to receive health information, be it in the form of an automated, multilingual phone call, a text message such as a medication reminder, or a more sophisticated combination of audio, graphics, and video.6 Language, health literacy, access to computers and the Internet, geographic location, and little if any continuity of care do pose significant barriers to widespread use of PHRs among vulnerable populations. However, it is possible to overcome such obstacles. MiVIA, a PHR designed specifically for seasonal and migrant workers in California’s Sonoma Valley, shows how electronic tools can be effective if they are adapted to meet particular needs.7 Helping Patients Plug In: Lessons in the Adoption of Online Consumer Tools   |  III. PCHIT in Five Practice Settings To get a better sense of the extent to which PCHIT has penetrated health care, the project team examined five types of clinical settings: safety-net providers, health plans, integrated delivery systems/group model plans, multispecialty group practices, and small physician practices. It observed daily activities; interviewed patients, physicians, and others inside and outside these settings; and consulted print and Web sources regarding PCHIT specifically and HIT generally. Safety-Net Providers Community health centers were an important focus of the PCHIT Participating Organizations Initiative because of concerns about the barriers that safety-net California populations face regarding access to health information technology. n La Clínica de la Raza The safety-net providers cited in this report were primarily federally n Lifelong Medical Care qualified community health centers, which serve an estimated one in eight uninsured patients. Seventy-five percent of patients at such n Redwood Community Health Coalition centers are uninsured or on Medicaid.8 n St. Joseph Health System National surveys suggest that the number of community health New York centers and physician practices with fully or partially implemented n Institute for Family Health EHRs is about equal, although these providers are among the n Queens Health Network minority of clinics and practices with EHRs.9 (There are no n Unite HERE! comparable data regarding PHRs.) While one might expect that n Urban Health Plan extremely limited resources would restrict the ability of community Massachusetts health centers to innovate in terms of HIT, observations of the n East Boston Neighborhood safety-net providers in this report revealed that many are as Health Center technologically savvy as their non-safety-net counterparts. Some n Cambridge Health Alliance even have state-of-the-art EHRs. One way they can finance HIT improvements is through a limited number of grants, depending Maryland on the region.10 n Baltimore Medical System District of Columbia Broad Interest in HIT n District of Columbia Primary Care Providers and some patients at these locations—including those Association that offer multilingual care—generally welcomed the idea of patient access to EHRs. Data from a recent survey demonstrate that interest in email access, online appointment scheduling, and electronic access to medical records and test results is equally high among insured and uninsured people.11 Few of the community   |  C alifornia H ealth C are F oundation health centers in this report have PHRs, although A Missed Opportunity Cambridge Health Alliance and the Institute for Several of the community health centers in this Family Health recently launched them. survey presumed that patients would not have access to EHRs or other electronic tools. A number of At community health centers, patients get them said this was not feasible because computers information about their care via electronic and or the Internet were not accessible to patients. But other means. They are receptive to the idea of the data in Table 2 indicate otherwise. An impact of connecting with their physicians online. However, this presumption, according to one EHR vendor, is communication among physicians is often that patient access to EHRs has not been included in disjointed, and patients themselves may end up implementation plans, even though other health care as the information go-between for doctors. The organizations offered patient access when they rolled fact that such patients already are at a striking out identical EHR systems. The consequence is a disadvantage when it comes to health information missed opportunity that could exacerbate disparities exacerbates the challenges caused by fragmented care. in HIT adoption and health care. Information Gaps Observations and discussions with support staff One patient reported that he had left an appoint- revealed that the potential for HIT at community ment with a specialist not knowing if he had a health centers is untapped. At a gathering hosted by medical problem or needed more care. Because his the District of Columbia Primary Care Association, primary care doctor did not have electronic access to one clinic administrator, referring to an effort to the specialist’s progress notes, he was unclear about make computers available in local clinics, said: what to do next. This patient commented: “I want “Whenever I walk into the waiting room, there is my doctors to meet me half way.” always someone using the computer” and “We’ll never know if people will use this if we don’t set it Patients grappling with gaps in information about up.” A primary care physician at Urban Health Plan, their care may consult others in the community or a community health center in The Bronx, New York, simply drop the matter. The project team observed that serves a largely Latino population, said: “Almost that neither physicians nor patients liked these of all of my patients use email. It would be great if alternatives and that during doctor visits, patients my patients would email me. It would be so much typically did not discuss such predicaments unless more convenient because it is so hard to connect by the physician asked. phone.” A recent study of oncologists suggests that physicians At community health centers where there were often do not ask patients about their feelings when no plans to deploy EHRs, some staff physicians opportunities arise: Only 22 percent of participants who had previously used the technology expressed said they followed up with prompts such as “Tell discomfort about this state of affairs and seemed me more about that” after terminally ill patients more eager than others to adopt EHRs. A primary expressed a concern.12 This finding may be relevant care physician working at La Clínica de La Raza in in the safety-net setting as well, especially among Oakland lamented that all seven health centers in patients who would like doctors to “meet me half California where she initially interviewed for jobs way” through better interaction and by providing were strictly paper-based. Her experience suggests more information between visits. that lack of HIT in these settings could have a negative effect on health centers’ efforts to recruit young physicians. Helping Patients Plug In: Lessons in the Adoption of Online Consumer Tools   |  Economical Tools Available the HIT space is leveraging [the HIT] infrastructure Expensive technologies such as EHRs are not a to be the conduit between clinical and administrative prerequisite for other, more economical patient- data; we can facilitate important data connections.” centered tools, as some community health centers can attest. At the Whitman-Walker Clinic in But conversations revealed many uncertainties about Washington, D.C., which has implemented an health plans’ role in advancing this tool. What is EHR system, pharmacists use Web tools such as the most productive way to harness data and engage MedactionPlan.com to prepare medication regimens consumers? Who should pay for and own PHRs? Is for print-out or electronic transmission to patients. widespread adoption by patients even possible? In addition, MedactionPlan.com enables consumers to create medication lists for themselves and family Who Should Pay for PHRs? members, and to receive medication reminders. Some experts believe that payers and purchasers should bear the cost because they would be the Patients who receive care at Queens Health Network primary beneficiaries. But they also caution that “the in New York City can deliver personal health rationale for payers to provide PHRs is not mature” information to other providers by swiping their and that “they may be reluctant to do so.”13 Other smart card through an inexpensive card reader. The researchers found that one large health plan’s PHR readers, which plug into any personal computer, are reduced the number of patient visits and phone calls located in emergency rooms in the city. Plans call for to doctor offices, producing savings that might make readers to be located in libraries as well. this tool more affordable.14 One hurdle that may inhibit PCHIT adoption Consumers also may be reluctant to pay for PHRs. at community health centers is reimbursement. One study found that diabetics were lukewarm to They receive payments on a per-visit basis, and no the idea of paying a user fee for a diabetics-specific reimbursement if a patient accesses services online. portal that would generate health care cost savings.15 Given that clinics are already squeezed financially, it may not be feasible for them to incorporate patient- Health plans realize that PHRs can greatly improve centered technologies. the management and cost-effectiveness of care for their chronically ill members. At one large plan, 30 Health Plans∗ percent to 40 percent of members who were actively No health plans agreed to let the project team visit managing their chronic conditions used the plan’s and assess their PCHIT. (Kaiser Permanente and PHR, compared to 10 percent to 15 percent of other integrated delivery systems/group model members generally. health plans are discussed in the following section.) However, a few plan representatives and others Data Challenges did speak with the team about their PHR-related After a health plan creates a PHR infrastructure, experiences as long as their comments remained there is still the challenge of converting disparate anonymous. administrative data into meaningful information for patients. The information must be presented in Theoretically, health plans would benefit a relevant context, tailored to patients’ individual substantially from more efficient use of resources needs, and delivered in a timely fashion. Another for delivering services and from greater participation big challenge is the lag time in administrative data of patients in their care. Moreover, they sit at a processing, which can make it difficult to send crossroads of data that could populate PHRs. As an targeted messages to patients at specific moments. executive at one large health plan put it: “Our role in 10  |  C alifornia H ealth C are F oundation Some clinicians reported that health plans are unsure Within the last six years, the number of adult about the relative value of investing in PHRs in enrollees at Seattle-based Group Health Cooperative comparison to other quality and cost-management who have taken advantage of access to a PHR programs, such as disease management. Clinicians’ through the MyGroupHealth Web site has grown to understanding of the benefits of PHRs may be 36 percent.19 quite different from plans’ strategic vision, which in turn may not be in tune with patients’ perspective. My HealtheVet Indeed, as Forrester Research concluded, health plan The U.S. Department of Veterans Affairs actively members “have not raced to adopt” PHRs.16 promotes My HealtheVet, a portal for benefits, services, and access to some health records. In Physicians who contract with health plans are not the future, veterans will be able to view their reimbursed for tasks they perform outside of patient appointment schedule, copayment balances, portions visits, such as email or phone communications. of their EHR, and more. Although patient adoption Reimbursing clinicians for such tasks could foster has not reached the levels seen at Kaiser and Group PCHIT in this setting. In New York, Group Health Cooperative, the VA system is innovative Health Inc. and HIP Health Plan of New York are because of its potentially high transparency. Pilot experimenting with the “medical home” model in sites allow patients full access to their entire medical which primary care physicians not only care for record through My HealtheVet, including physicians’ patients, but also coordinate services with other progress notes. health care professionals on patients’ behalf and are reimbursed accordingly. This reimbursement model The VA has not integrated patient-centered tools could support patient access to a variety of electronic into its health care system as thoroughly as Kaiser technologies, including email, appointment and Group Health Cooperative have. Physicians do scheduling, and clinical decision-support tools.17 not interact with My HealtheVet in their clinical work, and, outside the pilot sites, My HealtheVet Integrated Delivery Systems/Group still offers much less access to EHRs and fewer Model Plans direct links to health content explaining a patient’s Kaiser Permanente, which serves about one-fifth personal data. But efforts are under way to enhance of all Californians, and other integrated delivery connectivity. For example, surveys of My HealtheVet systems like it are in many ways a PCHIT users who participated in pilot testing and of benchmark. They have the highest EHR and PHR clinicians who provided services to them will yield, penetration in health care. About 20 percent of along with focus groups and interviews, insight on enrollees at Kaiser, or more than 2 million members, ways to make the portal more responsive to veterans’ use its PHR, relaunched in November 2007 as My needs. Health Manager.18 Leadership Role for Big Providers The HIT innovations and refinements at Kaiser, Participating Organizations Group Health Cooperative, and the VA are crucial California because, as large integrated delivery systems, their n Kaiser Permanente/Oakland Medical Center progress may inspire others to follow. A big challenge these three systems face is scaling their technologies Washington, D.C. down to the level of small medical practices, where n Kaiser Permanente/West End Medical Center the vast majority of health care is delivered. On the n U.S. Department of Veterans Affairs Medical Center Helping Patients Plug In: Lessons in the Adoption of Online Consumer Tools   |  11 other hand, they may be able to draw upon regional Mixed Results innovations. Kaiser Permanente Colorado Region, At the multispecialty group practices where patients for example, has pioneered electronic messaging can access their personal clinical information, between physicians and teens, an advance that other results have been mixed. Many clinicians expressed Kaiser regions could find useful.20 enthusiasm for such access, and some practices actively encourage patients to take advantage of Additional challenges will be transferring­—both it—for example, by distributing brochures at nursing internally and externally—the knowledge these stations. At Partners HealthCare, clinic managers providers have gained about technology, workflow, work with medical staff to encourage the use of and attitudes regarding PCHIT, and the risk that Patient Gateway—a secure electronic link that pressures for consistent service to large enrollee patients can use to communicate with their doctor populations will inhibit innovation. Other health about appointments, medications, and more—by care providers might benefit if large integrated posting announcements in prominent places about delivery systems were to assemble and publicly new services and by promoting access opportunities. release a PHR implementation “toolkit”—a repository of knowledge about everything from However, some Partners physicians communicate identity authentication procedures to strategies for with patients by email outside of Patient Gateway, promoting adoption of PCHIT by patients and staff. and clinicians there and at Harvard Vanguard did not consistently explain to patients the benefits of Multispecialty Group Practices using MyHealth Online and Patient Gateway. In Although the multispecialty groups cited in this addition, accountability for patient engagement report are structurally different, the key PCHIT issue varies: Partners assigns responsibility for the success for all of them is PHRs. of its PHR to a “physician leader,” while there is no such accountability at Harvard Vanguard. The PHR portal at Harvard Vanguard Medical Associates, a private group based in Boston, is At other health care providers in the Boston area, MyHealth Online, a feature of the commercial EHR most notably Beth Israel Deaconess Medical Center, system that Harvard Vanguard implemented several the PHR adoption curve among patients has been years ago. Partners HealthCare—a large, academic, relatively flat, data suggest, even though patients do integrated delivery system with many outpatient not have to pay any additional fees for PHR-related practices in the Boston area—developed its own services.21 portal, Patient Gateway. Interviews revealed that at both Harvard Vanguard Practices affiliated with John Muir Health, an and Partners HealthCare, HIT competes with integrated delivery Organizations Francisco, Participating system east of San multiple clinical initiatives for priority status. This chose a stand-alone commercial platform, California may hinder a coordinated approach to fostering RelayHealth, which includes a PHR; RelayHealth n John Muir Health PHR adoption. Moreover, their payers apparently do hasnnot yet HealthCare not make a significant effort to promote the tools, Sharp been implemented at all physician practices in the network. Sharp HealthCare, an and the two practices expressed uncertainty about Boston, MA the best way to do that in the absence of a “toolkit.” integrated delivery system based in San Diego, only n Harvard Vanguard Medical Associates/Atrius recently decided to invest in a PHR system. Clinicians and administrators said their organizations Health might benefit from strategies such as contests, n Partners HealthCare advertising, and integrating PHRs into clinical operations. 12  |  C alifornia H ealth C are F oundation Small Physician Practices A third pressure is the competition from local group- Ninety-three percent of physician practices have model practices, where HIT adoption tends to be fewer than six doctors, and 96 percent have fewer higher and there is more financial, technical, and than ten. Less than 10 percent of practices in this legal support. A recently published survey found that population have fully implemented EHRs, although the biggest barrier to EHR use among California up to 25 percent have partially implemented them.22 physicians is the cost of purchase, followed by the In California, 14 percent of physician practices have difficulty and expense of implementation.24 fully implemented EHRs, according to a recent survey.23 The Center for Practice Innovation (CPI), an amalgam of more than 100 small practices under the aegis of the American College of Physicians, is Participating Organizations fostering PCHIT adoption. CPI’s work demonstrates California that small practices have the ability to experiment n Blackhawk Medical Center with HIT because, unlike other practices that are part of health care systems, they retain control of Washington, D.C. workflow and other factors, which makes them more n Center for Practice Innovation/American nimble. For example, several use subscription-based College of Physicians messaging—a relatively low-cost option—and enable patients to enter personal data into the practice’s Blackhawk Medical Center, a three-physician information system.25 practice in Danville, California, illustrates the challenges small practices face. As part of the John Ideal Medical Home (www.idealmedicalhome. Muir Physician Network, an independent practice org), a confederation of health care organizations association that promotes HIT adoption among and individuals, promotes patient-centered, its affiliates, Blackhawk is in the process of fully financially viable information technologies in converting to an EHR system, which the practice physician practices. At IdealMedicalPractices. will tie into the network’s patient portal. Despite org, members share new technologies—including Blackhawk’s highly committed physicians and patient-assessment and feedback tools—and best office staff, the conversion has proved to be time- practices. The goal is to improve clinical operations consuming. at minimal cost. EHR Pressures The absence of active support for PCHIT Small practices cope with several pressures when applications in small practices may conflict with they implement EHRs. One is showing a return on patients’ enthusiasm for them. An informal poll of investment over the long term. A second is justifying patients by a physician at Blackhawk Medical Center the upheaval caused by transitioning from paper to showed that many were interested in doctor-patient electronic records. Indeed, on the project team’s first messaging. This mirrors the findings of physicians visit to Blackhawk, its lead physician apologized for at a small practice in Tennessee who discovered that the medical charts on his desk that he was reviewing among their patients who had Internet access, 78 in preparation for scanning. The transition was still percent were interested in electronically contacting, under way when the team visited again three months or receiving health information from, their doctor’s later. Converting to digital format involves an office.26 intensity of effort that can delay HIT initiatives to give patients access to health information. Helping Patients Plug In: Lessons in the Adoption of Online Consumer Tools   |  13 IV. Market Variations in PCHIT Regional quality-improvement and HIT initiatives, interventions by local or state government, and the competitive dynamics of, and history of health care delivery in, a particular market affect efforts to advance PCHIT. This chapter presents a summary of key factors—many of them related to the broader HIT landscape—that have shaped patient-centered technologies in California, Massachusetts, and New York. California Multispecialty group practices and integrated delivery systems are among the leading EHR and PHR innovators in California. The Palo Alto Medical Foundation, for example, was one of the first medical groups nationwide to give patients access to a PHR offering a wide range of personal clinical information and links to targeted health content on the Web. Other large medical groups also have implemented PHRs or other PCHIT tools, but they remain a minority.27 Some health plans have actively advanced PCHIT, among them Kaiser Permanente. Its members can access their clinical health records and all lab results, securely communicate with clinicians, review and renew prescriptions, request appointments, and link to educational content and self-management tools from their personal health information. However, there are still big HIT gaps in California. Among federally qualified community health centers and other safety- net providers, fewer than 5 percent of more than 500 clinics use electronic systems to manage clinical information.28 Efforts by state and local government to drive HIT adoption among safety-net providers have been limited. Grant Funding for HIT To fill this gap, The California Endowment launched the Community Clinics Initiative (CCI) in 1999. CCI has provided $41 million to boost the information management capacity at 163 clinics and 15 regional associations.29 14  |  C alifornia H ealth C are F oundation Several CCI grants in the last several years have According to one estimate, 29 percent of physician targeted HIT investment, although little of that practices in Massachusetts have adopted EHRs. effort has focused on patient-centered applications. Among these practices, 84 percent can document The CCI (now in partnership with the Tides patient visits via their EHR system, but only 47 Center, a nonprofit fiscal sponsor), the California percent can order laboratory tests by computer HealthCare Foundation, and the Blue Shield of and only 45 percent can prescribe medications California Foundation are sponsoring a project electronically.33 called California Network Electronic Health Record Adoption to foster EHRs at safety-net providers Patient Usage Falls Short in the state. This venture will build EHR support Based on the PCHIT Initiative’s observations hubs offering technology, technical support, vendor and anecdotal information, many consumers in management, and other services that community Massachusetts have electronic access to their personal clinics often cannot afford. health data, but few appear to be taking advantage of it. Many of Boston’s large providers have launched As of 2003, there were EHRs at 5 percent of PHRs tied to their EHRs, yet at practices the project medical clinics and 3 percent of dental clinics. team visited, less than 10 percent of the eligible About 23 percent and 9 percent of these providers, patient population uses them. respectively, had established committees to plan EHR implementation.30 The first and most active PHR—PatientSite, at CareGroup Healthcare System in Boston—has Massachusetts about 35,000 active consumer users, a recent study Surveys suggest that the largest health plans in the reported.34 Penetration is difficult to gauge in this Boston area—Harvard Pilgrim Health Care, Tufts case because the study did not cite how many Health Plan, and Blue Cross and Blue Shield of consumers were eligible to use PatientSite. Massachusetts—are the highest-quality plans in the country. New England’s decade-long focus on In December 2007, Gov. Deval Patrick announced a comparative performance measurement through new “compact” on health, with the goal of devising a variety of regional quality initiatives has created a comprehensive approach to tackling the state’s a competitive market for quality rankings. Of the entrenched health care problems.35 It is still unclear top 20 health plans nationwide, 15 are in New if patient-centered technologies will be a significant England.31 part of this initiative. This quality focus and the major impact of Boston’s New York large teaching institutions have spurred considerable The state and city of New York have assumed HIT adoption in large physician practices. Small leadership roles in HIT adoption—perhaps a bigger practices are increasingly getting wired due to role than in any other state. But few policymakers pressure from larger providers. For example, the have specifically called for patient access to and physician network Partners Community Health Care engagement in health information technologies. Inc. in the Boston area recently mandated that all of its small and medium-size practices connect to the In 2004, state legislators approved the Health Care network’s EHR by January 1, 2009, or they will be Efficiency and Affordability Law for New Yorkers dropped from the network.32 Capital Grant Program—often referred to as HEAL Helping Patients Plug In: Lessons in the Adoption of Online Consumer Tools   |  15 NY—that involves investing up to $1 billion over To spur HIT adoption by private medical groups, four years. Among the program’s primary objectives the state has deployed a private, non-profit is investing in HIT and health information corporation called IPRO to provide free assistance exchange. through the national Doctor Office Quality Information Technology Project. IPRO, which A main component in phase five of the program, assesses and tries to improve health care services regarding a future HIT infrastructure, is designing through innovative technologies and methods, helps a system in which medical information “follows the 350 adult primary care practices select, implement, consumer” so consumers “are at the center of their and optimize HIT systems. Although consumer care.”36 This effort is aligned with the consumer- access to personal health information is not an centric approach promoted by the American Health explicit objective of the project, its efforts may Information Community, a federal advisory body ultimately improve such access. that makes HIT recommendations to the U.S. Department of Health & Human Services. The various HIT endeavors in New York state prompted public and private partners to form the The Rise of RHIOs New York eHealth Collaborative, which builds With state and federal funding as a stimulus, many consensus on the state’s HIT-related policy priorities regional health information organizations (RHIOs) and collaborates on implementing technologies. The have formed in the New York City area and in collaborative aims to identify and overcome barriers communities statewide. RHIOs typically provide one to widespread adoption of HIT and thereby enhance or both of two core services: the governance body consumer engagement in maintaining and managing and policies for facilitating information exchange their health. among participating entities, and the technical infrastructure for automated exchange. Conclusion An increasing number of health care providers are The New York City Department of Health has adopting health information technologies that place launched the Primary Care Information Project, a patients at the center of care. However, a number particular emphasis of which is to help wire the city’s of technical, strategic, and financial hurdles are federally qualified health centers and other safety-net stifling further progress. Until these hurdles can be providers. A main goal of the project is to improve overcome, the full potential of these technologies to chronic care self-management, so it tries to advance engage patients in their care will remain elusive. the patient-centered applications in HIT. HIT at Community Health Centers Some federally qualified community health centers—such as those that are part of the Institute for Family Health, whose mission is to improve access to primary care, especially for the medically underserved—already have fully functional EHRs. But most are still in the preliminary stages of EHR and PHR development. In early 2008, the institute was to begin planning for integrating PHRs into fully functional EHR systems at community health centers. 16  |  C alifornia H ealth C are F oundation Endnotes 1. “Many consumers want major changes in health care design, 14.Zhou, Y.Y., Garrido, T., Chin, H.L., and others. “Patient delivery.” Deloitte: 2008 (www.deloitte.com/dtt/article/ access to an electronic health record with secure messaging: 0,1002,cid%253D192717,00.html). Impact on primary care utilization.” American Journal of 2. According to the National Alliance for Health Information Managed Care 2007;13(7): 418–424 (www.ajmc.com/files/ Technology, PHRs are “an electronic record of health-related articlefiles/AJMC_07julyZhou_418to424.pdf). information on an individual that conforms to nationally 15.Hess, R., Bryce, C.L., McTigue, K., and others. “The recognized interoperability standards and that can be drawn diabetes patient portal: Patient perspectives on structure and from multiple sources while being managed, shared, and delivery.” Diabetes Spectrum 2006;19: 106–110 (spectrum. controlled by the individual.” diabetesjournals.org/cgi/content/full/19/2/106). 3. Kessels, R.P.C. “Patients’ memory for medical information.” 16.Boehm, E. “PHRs: From evolution to revolution.” Forrester: Journal of the Royal Society of Medicine 2003;96(5): 219–222. November 14, 2007 (www.forrester.com/Research/ 4. The nonprofit Center for Information Therapy (www. Document/Excerpt/0,7211,43653,00.html). ixcenter.org) advances the science and practice of 17.“GHI and HIP launch pilot medical home network project “information therapy”—that is, making evidence-based with support from Commonwealth Fund.” GHI: January 8, health information available in a timely fashion to help 2008 (www.ghi.com/default.aspx?Page=555). meet the specific needs of individuals and to support sound 18.“Two million people using Kaiser Permanente’s personal decision-making. health record.” Kaiser Permanente: April 8, 2008 (xnet. 5. Estabrook, L., Witt, E., and Rainie, L. Information Searches kp.org/newscenter/pressreleases/nat/nat_080408_ That Solve Problems. Pew Internet & American Life Project: myhealthmgr.html). December 30, 2007 (www.pewinternet.org/pdfs/Pew_UI_ 19.Halamka, J.D., Mandl, K.D., and Tang, P.C. “Early LibrariesReport.pdf). experiences with personal health records.” Journal of the 6. A variety of information delivery strategies are profiled in American Medical Informatics Association 2008;15(1): 1–7 . Seidman, J., and Barish, D. Health Information Technology: 20.“Kaiser Colorado lets teenagers e-mail doctors, check Innovative Applications for Medicaid. Center on Children and EHRs.” iHealthBeat: June 27, 2007 (www.ihealthbeat.org/ Families, Georgetown University Health Policy Institute: articles/2007/6/27/Kaiser-Colorado-Lets-Teenagers-EMail- December 2007. Doctors-Check-EHRs.aspx?topicID=55). 7. For more information about MiVIA, see (www.mivia.org). 21.“Two million people using Kaiser Permanente’s personal 8. Ruskamp-Hatz, J. “Safety net providers.” National health record.” Kaiser Permanente: April 8, 2008 (xnet. Conference of State Legislatures: Legisbrief kp.org/newscenter/pressreleases/nat/nat_080408_ August-September 2005 (www.ncsl.org/programs/pubs/ myhealthmgr.html). lbriefs/2005/05LBAugSep_Safetynetproviders.pdf). 22.Health Information Technology in the United States: The 9. According to the 2005 National Ambulatory Care Survey, Information Base for Progress. Massachusetts General Hospital 11.2 percent of physician practices had a fully implemented and Robert Wood Johnson Foundation: October 2006 EHR system. The 2006 Survey of Health Center Use of (www.rwjf.org/files/publications/other/EHRReport0609. Electronic Health Information found that 8.6 percent of pdf). community health centers did. 23.Snapshot. The State of Health Information Technology in 10. Duke, E.M. “Remarks to the National Association of California. Use Among Physicians and Community Clinics. Community Health Centers.” Health Resources and California HealthCare Foundation: 2008 (www.chcf.org/ Services Administration, U.S. Department of Health & documents/healthit/HITAdoptionPhysicians.pdf). Human Services: August 27, 2007 (newsroom.hrsa.gov/ 24.Snapshot. The State of Health Information Technology in speeches/2007/NACHCaugust.htm). California. California HealthCare Foundation: 2008 (www. 11. “Many consumers want major changes in health care design, chcf.org/documents/chronicdisease/HITSnapshot08.pdf). delivery.” Deloitte: 2008 (www.deloitte.com/dtt/article/ 25. Focus on the Practice: Challenges, Choices, and Change. 0,1002,cid%253D192717,00.html). Meeting of the American College of Physicians, Center 12.Pollak, K.I., Arnold, R.M., Jeffreys, A.S., and others. for Practice Innovation, Washington, D.C.: November “Oncologist communication about emotion during visits 16–17, 2008 (www.acponline.org/running_practice/quality_ with patients with advanced cancer.” Journal of Clinical improvement/projects/cfpi/focus_ag.htm). Oncology 2007;25(36): 5748–5752 . 26.Walker, R.R., Sutton, G.R., and Pelletier, A.L. “Are your 13.Tang, P.C., Ash, J.S., Bates, D.W., and others. “Personal patients ready for electronic communication?” Family health records: Definitions, benefits, and strategies for Practice Management 2007;14(9): 25–27. overcoming barriers to adoption.” Journal of the American Medical Informatics Association 2006;13(2): 121–126. Helping Patients Plug In: Lessons in the Adoption of Online Consumer Tools   |  17 27. “Many consumers want major changes in health care design, delivery.” Deloitte: 2008 (www.deloitte.com/dtt/article/ 0,1002,cid%253D192717,00.html). 28.“Health care foundations announce $4.5 million program to speed adoption of electronic records in community clinics.” California HealthCare Foundation: May 4, 2006 (www.chcf. org/press/view.cfm?itemid=121207). 29.Health Information Technology in the United States: The Information Base for Progress. Massachusetts General Hospital and Robert Wood Johnson Foundation: October 2006 (www.rwjf.org/files/publications/other/EHRReport0609. pdf). 30.Ibid. 31.Best Health Plans 2007 Search: Commercial. U.S. News & World Report (www.usnews.com/directories/ health-plans/index_html/plan_cat+commercial/ state_id+MA/plan_name+/+Search/sort+rank/detail+more/ page_number+1/page_size+10). 32.“Boston health network requires all physicians to adopt EHRs by 2009 .” iHealthBeat: October 17, 2007 (www. ihealthbeat.org/articles/2007/10/17/Boston-Health- Network-Requires-All-Physicians-To-Adopt-EHRs-by-2009. aspx?topicID=54). 33.Feinman Houghton, S.F., and Doonan, M.T. Health Information Technology in Massachusetts: A Private/Public Partnership? Massachusetts Health Policy Forum: December 2007 (masshealthpolicyforum.brandeis.edu/publications/ pdfs/34-Dec07/Health%20IT%20Issue%20Brief%2012-05- 07.pdf ). 34.“Two million people using Kaiser Permanente’s personal health record.” Kaiser Permanente: April 8, 2008 (xnet. kp.org/newscenter/pressreleases/nat/nat_080408_ myhealthmgr.html). 35.Dembner, A. “Patrick to launch healthcare effort.” Boston. com: December 17, 2007 (www.boston.com/news/health/ blog/2007/12/patrick_to_laun.html). 36.HEAL NY—Phase 5 Health Information Technology Grants: Interoperability and Community-wide EHR Adoption. New York State Department of Health: October 2007 (www.health.state.ny.us/funding/rfa/0708160258). 18  |  C alifornia H ealth C are F oundation