Integrating Behavioral Health Care, Social Work and Primary Care

There is no question that there is an enormous push now for what is being called Value Based Purchasing of health care services.  In a sentence, payers would like to pay providers for achieving certain outcomes related to reducing the overall cost of care, while keeping people healthy by improving their care.  It is a worthy goal.

As primary care physicians have struggled to move in this direction they have encountered two major obstacles.  The first is that many patients with the poorest health and the highest health care costs have behavioral health and/or substance abuse problems.  The second is that social factors, long considered out of the purview of medical or mental health care, have emerged as major risk factors for ill health and extraordinarily high health care costs.  

So to prepare for the future, where payment will be based on cost and quality (together referred to as “value”), health systems must figure out a way to integrate care for behavioral health, social and substance use issues into their delivery models – either through providing those services on site, or through referral arrangements.

Many people now talk about integrating care and there are many organizations and providers trying to achieve this.  We often see this as the introduction of psychiatrists or other behavioral health providers into a primary care practice or the development of a referral relationship with good reporting back and forth between primary care and mental health. 

I have wondered what truly integrated care would look like.  You know, the kind where each specialist focuses on their own area of expertise but every person seeing the patient in the office is responsible for every aspect of their care and well being.  I believe an essential tool here is a fully integrated electronic health record – one which organizes progress notes chronologically irrespective of who the provider of care is that wrote the note or whether they are a primary care provider, behavioral health provider or a social worker trying to get housing for the patient.   Just as importantly however, is the requirement that every person touching the patient is working to help the whole patient and shares a common interest in all parts of the patient’s well being.

Let me cite an example of how I will know when we have achieved this level of integration. 

A 53-year-old patient with hypertension, diabetes and depression is seen bimonthly by her primary care physician and is being seen in every month by the Institute’s psychiatrist.  The psychiatrist reads his own prior note to recall the patient’s last visit to him and then proceeds to read the most recent primary care note as well.  He notes that the patient was started on a new hypertensive medication on the last visit.  He asks “I see Dr. Jones started you on a new medication for your blood pressure last visit.  How is it going?  Any problems with it?”

The patient answers, “As a matter of fact, I had to stop it after a few days because of a rash.  I guess I was allergic to it.”

“If you don’t mind, I’d like to check your blood pressure while you are here since it was a bit high on the last visit to Dr. Jones,” says the psychiatrist.

“Sure.  That would be great.”

As it turns out, the patient’s blood pressure is very high.

The psychiatrist then asks when the next appointment is scheduled with Dr. Jones.

“Not for another 6 weeks,” the patient replies.

“After our counseling session, I’d like you to see someone for your blood pressure before you leave.  Would that be OK?”

“I’d greatly appreciate that.”

At the end of her visit with Dr. Jones, he calls the nurse on the primary care team, explains the situation and the patient is put in with a physician on the team to adjust her medications.

Get it?

It’s not about people with different interests in the patient each sticking to their own domain.  It is about each member of the patient’s care system being concerned about the whole patient.   That’s the Holy Grail.  Now we just need to figure out how to get there.

Provider Accountability Meets Patient Choice

The health care system overall - and community health centers and family practices are no exception – have been constructed on a very paternalistic model.  We pretend we know what is best for our patients and make a system of comprehensive care that requires continuity, appointments to be kept, and patients to obey our orders for preventive care.  And we are increasing being evaluated and paid on our ability get our patients to comply with all of the preventive and chronic care imperatives that are determined to be today's best practices.

While we are evolving this system, patients are choosing to go to other models of care for urgent issues, camp physicals, immunizations, as well as for simple problems.  They seek problem focused, convenient, rapid throughput visits without being engaged in discussions driven by our advice about other issues and our response to EHR-driven reminders.  

We have to pay attention to what is happening now that new immediate care options are available more and more to our patients and we have to figure out where our comprehensive care model fits in.  I don’t have the answer to this yet but we have been talking about it a lot in our management team meetings.

Imagine that your life is in disorder and its three days before school starts, you forgot to get your child’s immunization updated and need a school physical form filled out.  Our health centers see this as a disruption in our appointment system and have difficulty  accommodating this type of visit in an efficient manner.  

Our patients, however,  can now go to any of a dozen local sources of immediate care and get this done.  I think we need to be able to figure out a way to keep our patients with us, while still allowing them to have a short visit if they need it, to accommodate their last-minute issues (haven’t we all had them at one time or another?) and still maintain them in our practice.   If we stick with our old model of requiring people to get care the way we think it should be done and remain oblivious to their chosen care model and the proliferation of places where they can get it respected, then we are truly in trouble.

The real issue now is that accountability for quality will still lie with their primary care provider team, yet our patients will have more and more choices for more convenient care in between their main chronic illness visits.  How we will adjust our practices to deal with that?

HIT Megatrend: Patients will have Instant, Complete, Unfettered Access to their Medical Records

Healthcare Needs Help On Transparency

(from Information Week - Posted by Chris Murphy on Thursday Jul 14th at 6:11pm)
Dr. Neil Calman wrapped up Tuesday's InformationWeek Healthcare IT Leadership Forum in New York City with a few predictions, including one portending radical change in people’s access to their health records.
He started with the big picture. "If there's one thing that's going to revolutionize healthcare--whether it's IT, ACOs, any aspect of health reform--what you're going to see is patients taking back healthcare from their providers," said Dr. Calman, a physician who is CEO and cofounder of the Institute for Family Health, which runs 17 health centers in the Bronx, Manhattan, and the mid-Hudson Valley in New York State.

Then Dr. Calman got more specific, including one prediction destined to raise some blood pressure:

"You're going to see patients want complete and unfettered access to their medical records. Forget all this about where we're going to keep the data to ourselves for seven days before it's released to patients, or we're going to create models of abstracted data to give to people. They will have total and complete, instant access to their medical information, whenever, in multiple formats, however they want it."

Each of those modifiers -- complete, unfettered, instant -- would rip away a security blanket that healthcare providers and health IT leaders cling to when they start talking about giving patients access to their medical records.

Instant: Some providers give patients access to lab results, but they wait several days so that doctors have time to talk with their patients about the results.

Complete: Should patients be allowed to read their doctors’ notes? To access every lab result? To see images they aren't qualified to assess?

Unfettered: This will mean letting patients have their full health records -- and not just through a hospital's sanitized portal, but as a raw download they can take with them, Dr. Calman predicted. And they'll have to offer a means for the patient to make comments, or corrections in places where they think the information is wrong, he said. Dr. Calman's fellow panelist, Karen Marhefka, associate CIO for UMass Memorial Healthcare, said giving patients the ability to comment on records was a concern when UMass Memorial assessed vendors for its planned patient portal. Its lawyers advised against allowing other sources into the providers' clinical data, even if comments could be identified as coming from the patient.

Dr. Calman predicted that every major electronic health record system or portal will soon allow patient input, and that it shouldn't be controversial. "Every single thing we do in medicine depends on what the patient told us," he said. "… The subjective part of every progress note is us writing down what the patient told us. We don't have any way of independently verifying it. But all of a sudden, when the patient can write it themselves, it becomes something the lawyers are all freaked out about. Anyway, these are the transformations that are going to take place. They just change the way we think about everything in healthcare."Some 15,000 people now use the Institute of Family Health's portal to view records, Dr. Calman said. But he predicted it won't be long until patients expect to get their records in a downloadable form of their choosing--and that HIPAA and other regulations will be amended to give patients that kind of portable access to their records.

Concerns that patients will misinterpret lab results are legitimate. And letting patients add their own comments or data to their health records does raise some new legal liability questions. But health IT leaders and their clinical peers shouldn't waste their time trying to stop this transparency movement and instead must pour their energy and intellects into coming up with workable solutions. (And there was plenty of that in evidence at the forum.)

Concerned that a patient will misunderstand a test result? Health providers will need to arm that patient beforehand with information about what the test's looking for, and where to get more information about it. They'll need to push EHR vendors to build more such links into their products -- links to reliable data sources, right from an EHR portal.

Giving people access to their medical records is closely related to another phenomenon: people turning to Google or Facebook as soon as they get a diagnosis. Anyone who has done that knows you're likely to read a lot of worst-case scenarios and quackery, and can understand why Debra Wolf, a professor of nursing at Slippery Rock University, says that social media "frightens me to death."

People are "going out to find patients like themselves," said Wolfe, in an earlier discussion at the InformationWeek Healthcare Forum. "What frightens me is they don't know how to safely evaluate a website."

Noteworthy is the fact that Wolfe is looking for ways providers are helping patients get better information, not hoping to cut off access. At some hospitals, when nurses are discharging patients, they’ve been trained to ask, "Are you using a website for health information?" and offer tools to assess a site's quality and reliable sites that people might consider using. People will inevitably look to the Web and social sources for healthcare insights, so "we need to meet them out there," Wolfe said.

Same goes for people's digital health records. As patients demand access, health IT leaders will need to focus on making that experience valuable, not getting in the way.

The Teaching Health Center: A Great Program Threatened by Republican Shortsightedness

After decades of concern for the deep and worsening crisis in our country due to a shortage of primary care physicians, the Obama administration proposed - and passed as part of the health reform bill, a program to directly fund health centers for the training of primary care physicians. Combining the longstanding committment to excellence in primary care with the social committment of the primary care providers that practice in community health centers, the idea of using this successful model to train a new generation of primary care providers was brilliant. Directly funding these programs was essential in that programs funded through hospitals often direct large portions of the training to the inpatient setting to extract more inpatient service from the residents in training. But the model, like other important parts of the health reform legislation is under attack.

H.R. 1216, authored by Congressman Brett Guthrie (R-KY), rescinds the unobligated portion of the $230 million in total mandatory funding available to support Teaching Health Centers (THCs) for FY2011-FY2015. This bill would make the program subject to the annual appropriations process rather than committing the $46 million per year for FY2012-FY2015 in the health reform legislation to fund Teaching Health Center activities.

This year HRSA announced 11 THC grantees, of which 9 are community health centers with our own Institute for Family Health's Kingston Family Practice among them. Funding this year through this program will support the expansion of our Kingston rural residency by 12 residents. The residents will train along side our dedicated primary care physicians - all practicing in medically underserved communities. 6 of these residents will be training in our remote rural center in Ellenville, New York, (pictured below) where they will learn what rural medicine is really like, and, upon graduation, will become part of a cadre of physicians trained to practice in parts of the country where there are few if any primary care services.

If enacted into law, H.R. 1216 will make it challenging for us and the other 10 programs that have already made the decision to participate in this program based on a promise of continuous funding. The new legislatiion being proposed means that the programs would have to fight for limited discretionary funding each year. The National Association of Community Health Centers has said "In this difficult budget climate and with House Republicans reluctant to support the implementation of health reform, despite clear statements by Energy and Commerce Members on both sides of the aisle that this legislation advances a worthy goal of training more primary care physicians, if H.R. 1216 were to become law it puts the new THC grantees future funding in jeopardy."


We need to do everything we can to support the continued funding of Teaching Health Centers. The primary care shortage is real and even in its first year, substantial increases in primary care training will be achieved through this program. Let's keep a good thing going!

ACOs and Federally Qualified Health Centers: A Lost Opportunity to Transform the Health Care of America’s Most Needy?

As our Nation struggles with the troublesome duet of embarrassingly poor health outcomes and seemingly unstoppable escalations in health care costs, a model has emerged with promise to blaze our way out of this quagmire. And unlike many other advancements in medicine, the first beneficiaries of this model are America’s most needy residents. The model, the Federally Qualified Community Health Center, incorporates almost every aspect of what health care experts believe are the fundamental characteristics of an advanced model of health care organization. Strangely, unless action is taken immediately, that model will be overrun by the implementation of Accountable Care Organizations – or ACOs – when ACOs have been developed to accomplish many of the same goals. Here’s what is happening…..

The Medicare regulations for ACOs were released on March 31, 2011 in draft for public comment. In brief, ACOs are meant to establish a financing system where payment enhancements are made to the ACO, and then to the providers, based on achieving specific health care outcomes and reducing (or in some cases stopping the escalation of) health care costs. This is achieved by assigning patients to ACOs based on their historical place of care and assigning cost predictions based on their historical utilization of health services and other health-related characteristics. So everyone – or almost everyone – wants to be an ACO so they can get the financial rewards from their efforts to improve care for their patients and reduce overall health care costs. In New York City, hospitals, medical groups and FQHCs have been planning their ACO strategy since the legislation outlining the goal of ACOs was passed last year in the health reform bill. Yet to the shock of the FQHC community, they were determined, along with Rural Health Centers (RHCs) and some others, to be ineligible to sponsor an ACO.

The implications of this will have enormous, negative impact on the future of FQHCs. To understand this, one needs to envision the advanced model that FQHCs have been developing over the past decade. To start with, they are governed – not just advised – by a board of directors that is made up of a majority of the health centers users. They are built in the community, governed by the community and therefore, serve as a model of how health care providers must be responsive to the needs of those they care for. They have been early adopters of electronic medical records, have been achieving certification as Medical Homes at a blinding rate (the highest recognition a primary care provider can achieve today). They have expanded hours to expand access, provide multilingual care where appropriate, and often integrate chronic disease management, mental health and dental services in one location. They engage networks of specialists to care for their patients – even though 1/3 of the patients they serve nationally lack health insurance. In short, they are the model for what everyone in the U.S. needs. So what is the issue?

ACOs will control the flow of funds for improved care and reduced costs and to insure that the benefits of these added payments accrue to those who have invested in the formation of advanced delivery systems, they must be in a position to control the distribution of these funds. We have always said that a rational system of care is built around a strong foundation of primary care – the FQHC. With hospitals and multispecialty groups in control, the same power relationships that exist now will exist in the future and what is worse – the same model of care and the same catastrophic economic results. We cannot afford to let this happen. The main question at stake here is whether we want hospital controlled ACOs sitting at the center of these new models, struggling to make up for the falling volumes of high-cost services they provide by fighting over market share with other hospitals, whether we want multispecialty group practices at the center of the ACO model with their frequent overrepresentation of specialists and underrepresentation of primary care or whether we want primary care as the ACO’s core – providing a rationally constructed system where the training of primary care practitioners in preventive care, care coordination and chronic disease management provides the foundation for improving quality and reducing cost. We all know what we need to do!

The elimination of FQHCs from the list of eligible ACO sponsors seems to result from a technical issue but it is hard to imagine that a technical work-around could not have been developed by CMS before the release of the draft regulations. The technical problem is that FQHCs are required by CMS to bill Medicare differently than practitioners in private practices bill. FQHCs do not use HCPCS codes to indicate the type and level of procedure done and they do not indicate the specific doctor who saw the patient as the claim form has only a place to indicate the clinic provider number. Because of this historical method, CMS claims the inability to collect baseline data back 3 years as they propose to do and the inability to attribute care to an individual provider. But for those FQHCs that choose to sponsor an ACO, this data is retrievable through a review of the medical records that contain this information. For those on electronic health records, this data could be extracted electronically. For those whose records are still on paper, a sampling methodology could be developed. Claims could be reprocessed for qualifying Medicare patients – those that CMS tells the center might be a candidate for an ACO by virtue of the FQHC providing a plurality of visits to the individual patient. The reprocessing would not effect payment but merely provide the needed baseline data for these patients. I am sure there are other solutions as well – and they need to be developed now.

The country needs FQHC’s as the sponsor and integrator of ACOs – especially as more uninsured patients achieve coverage through health reform in the ensuing years. ACOs sponsored by FQHCs would be based in a system with the most sophisticated primary care delivered in a fashion that by its very nature treats patients in order to improve their health outcomes and reduce their costs of care. We need to advocate quickly and powerfully that FQHCs be included as potential leaders of ACOs, in a position to insure that the distribution of funds through the proposed shared savings models is done in a manner that preferentially supports primary care.

ACOs and Population Health - It's the Denominator, Stupid !

ACOs or Accountable Care Organizations were created by the health reform legislation proposed by President Obama and passed by the legislature one year ago. They are the Nation's new hope in reorganizing the financing (and, it is hoped, the delivery) of health care to support improved outcomes. Patients are not required to belong to an ACO and the ACO does not restrict the patient's access to any caregiver they choose. The ACO is, however, incentivized financially to help the patient organize their health care to achieve a better outcome and thus, save the health care system money. The money saved, in one model being proposed, is then shared between the payer (the insurance company or government in the majority of cases) and the provider (the ACO).

Now that the Medicare regulations have been proposed (by CMS on 3-31-11) it is clear that the attribution method used to assign patients to an ACO does nothing to encourage a health care provider to reach out to their community to engage new patients. To be in a particular ACO, the patient has to get the plurality of their care with a provider in that ACO. To be paid a premium for that patient's care, the provider must focus on optimizing the care of that patient - definitely a good thing to do.

But if I want to improve the outcomes for people with diabetes in the community, I have to outreach to the community, focusing not just on the patients who are already getting a plurality of care from me, their doctor, but rather on the at-risk patients, patients lost to follow-up, and patients who have scattered and disorganized care - using emergency rooms as their family doctor. Only by reaching those patients who are not regularly in the care of a given provider can we achieve better outcomes at a community level.

The problem is not unique to ACOs. All quality improvement programs, rewards for doctors to improve the care of their patients and all quality recognition programs for providers focus on improving the care of patients we already see. This is surely important as doctors everywhere give suboptimal care - usually missing needed preventive health care interventions and focusing on acute care needs. But to improve population health we must reach out to those who do not have a regular source of primary health care.

To accomplish this we need to change the entire process of quality reporting and add some community based outcome measures into the expanding list of measures that are used to evaluate the work of physicians. As we move our patients into ACOs, we must be sure to simultaneously increase our focus outside of our practices and make sure that we engage people not currently in organized primary care systems.

As we develop quality reports we should run them all in two ways. First, we should run them to assess the quality of care we are giving to the patients who have committed their care to us - those who, for example, have been to see us at least twice in the past year. Second, we should run our quality reports using, as a denominator, any patient who has ever been into our health center with the condition being evaluated. This will measure how well we do with patient engagement, how well we are doing with outreach to those lost to follow-up and will encourage patients who have dropped out of care, to re-engage. Even if we do not have the resources to do frank community outreach, efforts to reach this group of patients will help to address those who are not in care and will help build our patient base as well. ACOs need to develop a mechanism to support this type of work in our practices, lest they just become another reward for caring for those who are already committed to a source of care.

Let the Work Begin !

It is hard not to be amazed by the accomplishment of our President, Barack Obama, in getting a complex, far-reaching, health reform bill through the legislature. It took his focused vision and a determination to use the mandate of his election to make it happen – the most important health care legislation in the nearly 50 years since Medicare and Medicaid were enacted.

Lest anyone think that politicians truly represent their constituents one needs only to look at the unified position the Republicans took against the health reform bill. It was summed up best at the beginning of the debate on health reform when the Republicans declared that they needed to beat Obama on health care to bring down his administration. They tried. They lost. The American people won.

Now comes the time to make health reform work. To do that we will need to focus on a few important issues. First, we must insist on forward motion, paying no attention to the remaining opposition. Passage of the bill is only the first step. Implementation of the many opportunities we now have will require all of our attention and our creativity as health professionals. Second, we will quickly need to focus on the question of primary care supply. In the two free clinics that are run by our Institute for Family Health, more than half of the people who come for care come for preventive health services and for the management of common chronic illnesses such as hypertension and diabetes –the effective treatment of which is closely linked to improved health outcomes and reduced health care costs. But primary and preventive health care providers are in short supply and we will need to address the workforce issues now, or find ourselves with a newly insured population with nowhere to use their new insurance card. During the Clinton health reform attempt I appeared on McNeil-Lehrer on PBS and said “Even if every American were to get an insurance card today – most would have nowhere to take it – especially if they live in the inner-city or in a remote rural area.” Unfortunately, years later the story is still the same.

Even with these issues ahead of us, one thing is undeniable. Lack of health insurance disproportionately effects people of color in New York City and New York State and across other areas of this country. To the extent that lack of insurance is also closely tied to delays in care and worse outcomes for almost every condition studied, providing insurance for tens of millions more Americans will help to decrease (but not eliminate) health disparities between people of color and whites. And for that reason alone, we should celebrate!

Let the work begin!

How to Guarantee Disparities in Health Outcomes: A Primer

Bradford Gray, PhD, a distinguished health services researcher has published a very important study which demonstrates yet another reason why our health care system is designed perfectly to get the disparities in health outcomes that result.(1) Dr. Gray and his colleagues concluded that “minority patients in the New York City area are significantly less likely than whites to be treated at high-volume hospitals for cancer surgeries, cardiovascular procedures, and other services for which high volume and positive outcomes are related”. In other words, racial and ethnic minority patients are much more likely to get essential procedures done at hospitals that do fewer of them per year – a factor well known to contribute to poor health outcomes.

For those of us who provide health services in New York City none of this is a terrible surprise. We all know that those specialty hospitals that advertise on radio and television that they provide the best care in their field – Memorial Sloan Kettering for cancer, Joint Disease and the Hospital for Special Surgery for orthopedics, NYU’s Rusk Rehabilitation Institute and Calvary Hospital for end of life care – all have among the lowest rates of admissions for the uninsured and those on Medicaid.(2)

There are many reasons for this, as we have come to learn. For one, most Medicaid patients are in managed care now and hospitals and managed care companies must negotiate rates in order for the hospital to be considered "in-network" and thus accessible by people who have chosen to enroll in that managed care company. But as we have learned from folks at Sloan-Kettering, no Medicaid managed care company want to contract with them for their Medicaid enrollees. With a reputation as the only specialized cancer center in New York City, a single managed care company that puts Sloan-Kettering in its network will find itself the plan of choice for people with cancer, thus driving up its costs and reducing its profits. The same dynamic will take place for the other specialty hospitals as well. Do patients know, when the sign up for a particular managed care plan that it will likely restrict them from recieving services at the highest volume specialty hospitals if and when they come to need them? I think not. Young people don't sign up for a managed care plan thinking that they might develop cancer - yet when they do - and find themselves unable to go to a specialty hospital for treatment - they unknowingly become a potential victim of health disparities - treatment at a lower volume hospital with a potentially poorer outcome. Sad, when we are talking about the basic human right - the right to live.

There are no villians here. The facts are that we continue to create - through policies in the State, through limitations in funding, through a competitive rather than a cooperative marketplace of health plans, hospitals and doctors - a system that perfectly produces the disparities in outcomes that we achieve.

Bronx Health REACH is a consortium of over 40 community and faith based organizations that has been working in the Bronx for over a decade to reduce – no, eliminate – disparities in health care treatment and health outcomes. We have been working to change the policies which create racial disparities in out-patient care in the voluntary hospital sector in New York City. In facilities that operate “clinics”, the clinics are the places where the poor are treated in a system that provides care that is inferior in many aspects to the “private” care given in other parts of the system. Students, interns and residents - often supervised by a rotating group of attending physicians – are the main health providers that patients see. Troublingly, these doctors rotate monthly through the clinics making continuity of care almost impossible. The clinics have very limited ability to coordinate care with referring community physicians, another cause of discontinuity. Obviously, these doctors are also the least experienced, and these factors together explain, with an unproven yet logical extension of Dr. Gray’s research, another reason why outcomes can be expected to be worse. Everything that contributes to inferior care contributes to the premature death and disability people of color in New York experience.

Like I said before, the system of care in New York is designed to get just the disparate outcomes it achieves. Let’s redesign it.

References:
1. B. H. Gray, M. Schlesinger, S. M. Siegfried et al., Racial and Ethnic Disparities in the Use of High-Volume Hospitals, Inquiry, Fall 2009 46(3):322–38
2. New York State SPARCS Hospital Discharge Database,Table IX

For Medical Students: Primary Care, the Uninsured and Painful Lessons that Lie Ahead

On a rainy and blustery evening last week, I had the pleasure of speaking to an amazing group of first and second year medical students at Downstate Medical School in Brooklyn – part of the State University of New York. I am not sure whether they came for the Thai food or to hear me speak but I had the opportunity to tell stories of my medical school, residency and practice experiences – each highlighting some of the fundamental values underlying primary care. My message was that patients are increasingly demanding primary care as a trusted way of negotiating an otherwise incredibly confusing and fragmented health care system. I stressed that primary care physicians must stay focused on the needs of their patients above all else and that our loyalty and responsibility towards our patients must always remain first and foremost in our minds and actions – unfettered to the maximum extent possible – by advertising and loyalties to our hospitals or peers.

As I wrapped up my comments two questions came from the audience. The first, quite predictably, concerned my feelings about the “government controlling health care” and how I felt about that. I asked if the young woman asking the question from the very back of the room was asking about the much debated “public option” in the current health care plan passed by the House last week and she nodded affirmatively. I explained that the plan does not call for the government to control health care, rather that we would be adding another type of government subsidized and managed health care plan to the already existing government plans – namely Medicaid and Medicare.

A tougher question came from a young man in the front of the room who asked how our community health care system could survive financially taking care of the number of uninsured that we currently cared for. And that question truly cuts to the heart of the health reform debate, though I wasn’t fast enough on my feet to realize it at the time. Our 24 site community health care center network in Manhattan, Bronx and the Mid-Hudson Valley cares for over 10,000 uninsured individuals and provides them with over 35,000 visits a year. I explained that to pay for this we literally cobble together funding from dozens of sources. Our Federal 330 grant pays for some, New York State indigent care funding picks up another piece, and grants that support the care of the Homeless, the care of some uninsured patients affected by HIV and dozens of other grants for sub-groups of our uninsured patients – all go to support this work and keep us afloat. I stood there proud that our organization – the Institute for Family Health – had been able to accomplish this.

Yet I missed a real opportunity to underscore the fundamental reason we need health reform in this country. People need health insurance. Our country cannot depend solely upon health centers like ours as the safety net for everything patients who are uninsured need for their care. They must have coverage to pay for all the essential health care services they need. Primary care is the front end of an entire health care system which must provide access to people for diagnostic services, treatments, hospitalizations and medicines. With people of color 2 to 3 times more likely to be uninsured in New York City providing insurance for everyone is an absolutely essential step towards eliminating racial and ethnic disparities in health outcomes. And with primary care providers already struggling to create viable practice models in underserved areas, only full insurance coverage of the people who need these providers can sustain these practices and attract new doctors to these areas.

I am sorry I missed the opportunity to explain more to the students in Brooklyn last week about the failings of our current health care system. But I am not worried that their education will be lacking for very long. Soon the students will begin their clinical rotations in the hospital and there they will no doubt experience, first-hand, the failings of our current system to provide health care for all our people. They will see people suffering the effects of poorly treated chronic diseases – losing their legs and their kidneys to long-standing diabetes. They will see people with cancers that would have been curable if only they had been detected earlier. They will see people with advanced infections that have gone untreated for days or months and now require prolonged hospitalizations. These lessons will hit hard and perhaps some of them will understand and will choose to become the next generation of primary care physicians and the new champions for needed change in our health care system.

Sexism Effects Clinical Decision-Making as Well

In repsonse to my last two blog posts, a number of readers responded that women, not just people of color, experience bias and disrespect in the health care system. This brought to mind a study done over 20 years ago by a brilliant colleague of mine, Dr. Jonathan N. Tobin. His 1987 Study published in the July 1 issue of the Annals of Internal Medicine (Volume 107, pp 19-25) revealed that there was substantial "Sex Bias in Considering Coronary Bypass Surgery".

The abstract of that study reads in part:
" In a study of 390 patients consecutively referred for nuclear exercise testing, abnormal results found in 31% of the women and in 64% of the men affected physicians' decisions to recommend catheterization in men only; 4% of the women with abnormal radionuclide scans were referred for catheterization compared with 40% of the men (p < 0.001). This 10:1 ratio was independent of age."

Gender bias, racial bias, bias against obese individuals, bias against those who speak a language other than English - all affect the care that patients recieve in the health care system. And they have secondary effects as well - as some of the commentors on my previous blogs pointed out - they make one loathe to go to the doctor at all. And with no medical visit, the odds are that people neglect needed preventive care and comprehensive care for chronic conditions. Can this problem be helped through training? Perhaps. But we have a very long way to go. And tragically - for decades since the Tobin article was published, there is little evidence that we have made any substantial progress.

CNN Report on Aparthied in Medical Care in New York City - a follow-up note

(The message below was posted on Anderson Cooper's blog in response to many comments recieved about the show that aired on July 20 on AC360. It is scheduled to air again on Saturday July 25 on Dr. Sanjay Gupta's House Calls)

My name is Dr Neil Calman and I was the physician interviewed by Dr. Gupta for the segment on racism in medical care. For those of you who may have missed it you can see it by clicking on the link below:

http://www.youtube.com/watch?v=8j51CYlSFRQ

First, I would like to express my appreciation to CNN, Anderson Cooper, Dr. Sanjay Gupta and his senior producer Caleb Hellerman for a thoughtful and accurate portrayal of the difficulties people of color in New York (and certainly in other parts of the country) have in obtaining good medical care. This report was the result of an investigation of the named hospitals in New York City done more than a year ago and which formed the basis of a complaint to the New York State Attorney General.

I also sincerely appreciate the many comments on CNN’s blog from patients – many of whom were not Black - who were also misdiagnosed, mistreated or otherwise received inadequate care and concern for their medical problems. These stories require our attention as American’s receive grossly inadequate care while our country spends 2 to 3 times more per person than some other countries that achieve far better outcomes and whose residents live longer and healthier lives. That is why we need health reform and need it now. It also speaks to the need for more primary care physicians – so every person in America that wants one, can have an ongoing, supportive relationship with one main provider who cares for almost all their medical needs and advocates for them when they need to see a specialist or when they need specialized care or a special procedure.

I want to address the issue that being Black is not what the CNN story was about but rather was the same story that could be told by poor or uninsured white people as well. Telling the story of only a few Black ministers in the Bronx was not meant to suggest that the problem was exclusively one faced by people of color. The people interviewed were just examples of over 100 phone calls made and recorded by our researchers who looked at how people were sorted into different models of care in New York City based upon the type of insurance they have. In New York City, because of the predominance of Blacks and Latinos among the uninsured and those on Medicaid, sorting people of color into systems with less well trained providers, no continuity of care, no emergency call systems and no communication back to the patients primary care provider – all contribute to the inadequate medical care that many receive and contribute to the poorer health outcomes Blacks experience.

Some people say that its all about education – or poverty – or lack of insurance. In fact, imagine that each of these things – education, financial well-being and good insurance coverage – are all things people need to get the best medical care. And also imagine – what hundreds of published studies have shown – that race, independent of all these other factors, is a predictor of poorer health care processes and poorer outcomes. If you imagine this, then you can understand that the question is not which of these factors is more important – but how many strikes do you have against you when you seek medical care. Race is one factor and being Black or Latino is one strike. Being poorly educated is another strike – especially when that means a poor understanding of the diseases that are important in your own preventive care plan, your family’s health or the diseases most prevalent in your community. Lack of financial means may create a situation where you put off, sometimes indefinitely, needed preventive care measures or put off buying the prescription drug not covered by your health plan. And being uninsured is a fourth strike as it is the greatest predictor of bad health outcomes.

Racism in health care is a common experience of people of color so let’s stop saying that race does not matter. We know it does. It is one very important factor in why people get bad medical care. . So is poor education, poverty and lack of insurance.

Our health care system needs to do better. We need to fight racism in medicine wherever it occurs and that is what the CNN story is about. We also need to get health reform passed now! That will largely fix the insurance issue. We need many more primary care physicians so everyone can have a trusted physician they know over time and who will care for all their basic medical needs. And we need a better campaign to educate all America about the importance of preventive care, good care for their chronic illnesses and about the health behaviors that can help them lead healthier and longer lives.

As President Obama points out – this is not a debate over politics. Everyone knows we need to fix our very broken health care system. Everyone has a horror story to tell somewhere in their personal experience or the experience of their friends or family. We have to do better than this and we can.

CNN AC360 Dr. Sanjay Gupta Covers our Attorney General Complaint Re: Dsicrimination in NYC Hospitals

Bronx Health REACH Attorney General Complaint to be featured on CNN's AC 360
Segments Produced by Dr. Sanjay Gupta – Monday July 20
10pm-12midnight [1]

Monday night, July 20, 2009, on CNN’s Anderson Cooper 360, Dr. Sanjay Gupta will be airing a two-part segment on racial discrimination that results from separate and unequal care provided by private teaching hospitals in New York City. Since 2005, Bronx Health REACH has shown, through its research efforts, that in many institutions in NYC, people covered by Medicaid and those who are uninsured are routinely treated in separate hospital-based facilities and by different providers than those who have private insurance. Furthermore, inadequate after-hours coverage, absent communication back to referring providers, and limited appointment availability all create disparities in care and lead to worse health outcomes. Because 16 times as many African-Americans and Latinos in the Bronx are covered by Medicaid or are uninsured compared to Whites, this creates de facto discrimination based upon race, a practice that is both immoral and illegal.

As you may remember, in June 2008, Bronx Health REACH, a coalition of community-based, faith-based and other organizations led by the Institute for Family Health, filed a civil rights complaint with the Office of the Attorney General of New York State. This complaint and the allegations contained in it were prepared and filed on behalf of Bronx Health REACH by New York Lawyers for the Public Interest (NYLPI).

Through multiple visits to New York accompanied by his producer and film crews, Dr. Gupta has interviewed faith leaders, patients, and REACH staff to bring this issue to light. The REACH Coalition has been working in the Bronx for nearly a decade to reduce racial and ethnic disparities in health outcomes for patients with diabetes and heart disease. Our hope is that national exposure of this issue will help end these practices in New York City and will make sure that equality in health services becomes part of our Nation’s health reform agenda.

REACH began its investigation of the out-patient referral practices of three hospitals named in the complaint - Montefiore, NY Presbyterian, and Mt. Sinai – after hearing multiple stories shared by patients in the coalition’s member organizations, as well as learning the experiences of primary care providers seeking to obtain out-patient specialty care for their patients. In consultation with researchers from New York University, hundreds of scripted phone calls were made and recorded over a period of months to the physician referral lines of the named institutions. In addition, REACH obtained the recorded testimony of a number of patients who experienced this discriminatory care and suffered because of it.

Our research findings show systematic channeling of patients into different care systems based upon their type of insurance – or lack thereof. As documented in our complaint and other findings over the years, it is commonplace for New York’s voluntary teaching hospitals to separate patients at the point of entry to their outpatient practices into two systems of care: their clinics and their faculty practices. Worse yet, while the faculty practices function the way we would all want to get care—with good continuity, reports sent back to the primary care providers, after-hours call by the group’s doctors, and access to the best that New York medical care has to offer—the clinics offer patients a rotating group of residents and fellows with little or no continuity of care; provide no communication with the primary care providers who referred their patients there for care; and often refer patients to the Emergency Room if they have questions or problems after-hours. Given this difference in care systems, differences in outcome should come as no surprise.

I know you all believe we can do better than this. We must do better, particularly as we promote the concept of medical homes for patients throughout New York State, and health reform at the national level. The vast sums of money that the State and Federal government put into health care for those who receive Medicaid and the uninsured obligate us to do better. In fact, recent increases in Medicaid out-patient rates mean that hospitals are now, in many instances, getting paid more by the State than private insurance is paying for their covered patients – and getting inferior care.

For far too long the health care system has blamed patients for their own poor outcomes, pointing to their delays in seeking care, their inadequate follow-up with appointments and their lack of compliance with treatment. The experience of the more than 100 primary care providers at the Institute for Family Health, and the experience of the members of the organizations of the Bronx Health REACH coalition tell a different story. New York’s voluntary teaching hospitals have created clinic systems that are difficult to negotiate, that provide care that patients quickly realize is not the best the institution has to offer, and that severely jeopardize their health and their lives. While these factors alone do not explain the 7 to 8 year decrease in life expectancy that Blacks and Latinos experience in the U.S., nor the increase in hospitalizations for conditions that are treatable in office settings and the excess morbidity and mortality suffered by people of color for almost every disease studied, we must change those aspects of our health care system that contribute to these tragic and disparate outcomes.

Filing a complaint with the Attorney General was a last resort to fix a problem I have been addressing on behalf of Bronx REACH and the Institute for nearly a decade. I have met personally with leadership from a number of voluntary teaching institutions in New York City, have presented findings of our studies at dozens of professional meetings, have had multiple discussions with the Greater New York Hospital Association leadership, and have discussed this issue with the former Commissioner and senior staff of the NYS Department of Health on multiple occasions over the years. In 2005, we published a report Separate and Unequal: Medical Apartheid in New York City, which received substantial press coverage and resulted in a number of public responses from voluntary hospitals. In private discussions, many agree that systems should be changed, but there has been no motivating force to stimulate this change.

I expect that the institutions named will once again be highly critical of the complaint and the CNN report, and will defend their practices in the same ways they have previously. First they will claim that faculty practices are not part of the institution but are merely affiliated private practices. This argument is both spurious and irrelevant. Personnel who are paid by the hospital and staff their physician referral lines, facilities that are licensed to the hospital, and systems that the hospital has established are sending people down different paths of care based upon their insurance status.

Next they will claim that billing requirements make it essential that clinics are run separately. This is also not true. Nothing prohibits privately insured patients from being seen in a hospital licensed out-patient facility, and doing so would not jeopardize private insurance payments in any way.

Finally, some will claim that they will be unable to attract patients from the suburbs and from outside the country if the services they offer must be integrated with the care of clinic patients. This is perhaps the most disturbing rationale of all. I invite leadership of these institutions to come to our Institute practices where corporate executives, patients referred from our homeless centers for follow-up, and a broad cross-section of New York comes for care, sit in the same waiting room and all have access to the best care we have to offer. As health care providers we, of all people, need to demonstrate a commitment to ending discrimination based on insurance status with the disparate impact it has on racial and ethnic minorities.

Traditions and long-standing systems do not die easily, but this one can and must. We have encountered a number of departments at each of the institutions where department leadership—either for moral or practical reasons—have decided to integrate the care of all patients into the same system. Hospital leadership should take note of these successful models in their own institutions and adopt their practices broadly and completely. Nothing less than that will provide our patients with the care they deserve and nothing less than that will help to eliminate the disparities in care that continue to exist in our institutions.

Please make time to watch Anderson Cooper 360 on Monday night, and share your thoughts with us by commenting on this blog. Please join me in encouraging our colleagues in voluntary teaching hospitals across New York City to address this longstanding injustice and inequity in care.
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[1] As with all news broadcasts, changing current events may necessitate changing the broadcast date or time of these segments

Who will Represent America’s Poor as We Move Toward Health Reform?

Both the Administration and the Congress have been gearing up for health reform for many months. There are some good signs that both branches of government are taking health reform seriously. The President has spoken out on many occasions on the need for health care reform which includes a transition toward electronic health records on an accelerated timeline. Congressional committees have held a number of hearings and discussions. But the voices of our most underserved populations and those who serve them directly have largely been absent. This must change because poor people in our country, the uninsured, and people of color are sicker and die disproportionately because of lack of access to care and differences in the quality of care when it is given. Many in our most vulnerable communities use the emergency room as their only source of primary care because they have no health insurance, speak languages other than English or lack access to adequate preventive and primary care services.

As a result, those most at risk experience poorer health outcomes for almost every chronic condition studied and for most surgical procedures. This is the definition of health disparities and why our nation experiences the high cost of treating them. As our nation becomes even more of an ethnic melting pot, these disparities will only get worse if we don’t get health reform right this time around. By 2050 nearly one in two Americans will be persons of color – folks who experience higher levels of chronic disease, shorter life spans, less health insurance and generally poorer health due to lower participation in health insurance plans and less access to care.

But where are these voices in the current health care debate? Both the Administration and the Congress hear regularly from a chorus of organized representatives from the health care industry as they should. But the voices of those most affected by health disparities and the voices of those providers, hospitals and insurers who are most knowledgeable and most involved in their care are largely missing from the current national debate. A recent Senate panel on health care reform included some of the most distinguished names in the health care community. Unfortunately these panels did not include a single representative from underserved communities or those who serve them. If we are to truly reform health care in this nation, this must change.

This Administration and our Congress must enact measures that implement coverage and access for those who cannot now afford health coverage while paying attention to the worsening shortage of primary care providers in our nation’s poorest urban and rural communities. The use of electronic health records and health information technology must also focus on the maximizing the affects of these changes in underserved communities.

As the Administration and the Congress move toward health reform, they must widen the net of the communities and their representatives to whom they are talking. In the establishment of the Health Information Technology Committee of the Department of Health and Human Services, a designated seat was established for "An expert in the health of vulnerable populations". I am pleased to have been appointed by the Administration to that position and look forward to input from my colleagues from a broad spectrum of safety net provider organizations and from community and faith-based organizations to help bring the voice of America's most medically underserved folks into the critical discussions concerning the widespread deployment of HIT. What an exciting time this is and what a great responsibility we have to get it right!

In Memory of Steven B. Tamarin MD - a Great Physician and a Great Friend

I am deeply saddened to relay to you news of the death of Steven B Tamarin MD, a personal friend, a great physician and one of the founders of Family Medicine in New York City. Steve died unexpectedly in his sleep while visiting his cousin in Massachusetts. His loss is a tragedy for all who knew him and loved him as I did. While others sought his advice as their physician, I was the beneficiary of decades of close friendship with this incredible person. Steve could sit quietly and with uncanny attentiveness when you broached him with a personal problem as a friend. His listening skills were impeccable. Yet he spoke out vociferously about issues that moved him.

Steve was an outspoken advocate for women’s rights, an ardent supporter of the Tipitapa project in Nicaragua where he visited and worked many times over the years – as well as being one of the smartest and most dedicated physicians I have ever met. He read medical journals like they were novels that he couldn’t put down – enthralled at every new study that provided insight into the workings of the human body in health and disease. One could not spend even a single dinner with Steve without him being called on his cell phone by his patients – many of whom he had cared for over decades. His patients adored him and many travelled great distances to see him after moving away from the Upper West Side where he practiced. Steve always ran late and appointments meant little to him. He was dedicated to enjoying every patient encounter himself and gave his patients whatever time they needed to share their concerns with him.


Over a decade ago Steve became a member of the Institute for Family Health's Board of Directors and as the only physician on our Board, was depended upon to challenge our clinical protocols when needed and provide advice on issues of medical controversy. He was also a past president of the New York State Academy of Family Physicians – a position he held with distinction and one of which he was most proud. He continued to be involved in the Academy on a local level, bringing politically important issues to the forefront at all times.


Steve's own spirit was sustained by music. I was often the beneficiary of his incredible music collection as he burned compilations of his favorite blues songs for me on CDs and would share his eclectic musical selections proudly. While we were both on the Board of the New York State Academy of Family Physicians we took dozens of trips by car to Binghampton NY where their headquarters was located and braved many a snowstorm together across Route 17. We both loved those trips, brought CDs from our collections and sang out loud half way across NY State. I am sure that all who were close to him have their own stories of settings where Steve was so outwardly exuberant that an unknowing observer would think him insane.


One special evening he invited me to hear a particular Cuban pianist about whom Steve had encyclopedic knowledge and about whom I knew nothing. We went to a very classy jazz club somewhere in Manhattan where people were dressed to kill and where the staff were dressed in tuxedos. We were seated a few rows from the piano which was lit romantically and the crowd applauded enthusiastically after a long wait when the performer entered the spotlight. Steve could hardly contain his enthusiasm. As the first number began the crowd fell silent. Not 30 seconds into the first piece Steve could no longer contain himself. He was so excited he jumped out of his seat, threw his arms in the air and yelled "you go man! - play that thing!" While the crowd was appalled, the pianist nodded his head and smiled at Steve - obviously flattered and embarrassed. I recovered a few minutes later and crawled out from under the table.


I can't get the picture of Steve skiing out of my mind. We spent many a winter weekend at his parent's home in the Berkshires where we would sneak away to Brody Mountain during the day to ski. Steve had the best snowplow I had ever seen. Not to be mistaken for a real skier he always wore a long winter coat that went down to his knees and would snowplow down the steepest slopes at breathtaking speed his arm waving his ski poles wildly in the air and often yelling enthusiastically about what a fantastic day it was. In the evenings we would sit by his parent's twenty foot high fireplace in their Berkshire get-away and play guitar together - or debate the implications of the latest medical findings. It is time that I will always cherish.

Steve was one of the first of the new generation of Family Physicians in Manhattan. Along with the late John Falencki, they forged the path that many of us followed. We are forever indebted to them for their foresight and courage.

Steve will be sorely missed by his family, his patients, his friends and his colleagues. Whenever we parted - whether I was driving him home from a Board meeting or after spending the New Years weekend we would hug. Either he or I would say "I love you, man." and the other would reply, "I love you too." Life doesn't bring us many friends like that.

I am heartbroken to lose him.

Medical Apartheid In NYC Voluntary Hospitals

On June 9, 2008 a complaint was filed with the Attorney General of New York State, Andrew Cuomo, by Bronx Health Reach, a coalition of faith based and community based organizations with health and human services providers. The complaint describes descrimation against people who are convered by Medicaid and the uninsured when they seek out-patient medical care in New York City's Voluntary Hospitals.

See July 18, 2009 Blog post for more detailed information.

Teaching Our Doctors and Our EHR to Speak English (and other languages)

Mary Sampson waited in Exam Room D for her bimonthly blood pressure and blood sugar check. She was a relatively new patient in my practice who I had only been seeing for a few months. Upbeat and proud of the great control she maintains of her hypertension and diabetes she always greets me with a hug and a smile and asks about my family before I even get a chance to ask about her. Her eyes were red today and she had been crying. “I am so worried”, she said. I cancelled my last two appointments because I couldn’t face the bad news. She held out an envelope for me to take it. It was a letter from me, and I was mystified by her reaction. Had I sent her a letter with bad news and forgotten it? I took the envelope from her hand and pulled the letter out to read it aloud. Mary sat with her eyes closed and her hands clenched together.

“What is wrong?” I asked her.

“Just tell me what I need to do, OK?” She replied.

I looked at the page I remembered spitting out of our electronic health record one evening at home. It was the letter I send all my patients after I receive lab results, diagnostic test results or consult reports. This one was formatted to report on normal mammography results.

I read it our loud.

“Dear Ms Sampson,

I am writing to report that your recent MAMMOGRAPHY WAS NEGATIVE. You should schedule your next exam in approximately 1 year. If you have any questions or concerns please feel free to call me at the office or on my cell phone.

Sincerely,

Neil Calman MD.”

“What do I do now?” she asked again.

“You wait and get another exam in about one year”.

“But what about the Negative test now?”

“Negative is normal!” I exclaimed. “Did you think it meant you had a problem?

Mary was speechless. Tears flooded down her cheeks. I stood up to hug her and repeated “I am so sorry”, over and over again. She slowly regained her composure after leaving a pile of damp tissues on my desk.

“I never got a letter from a doctor before, she said. I looked at it quickly and saw the word ‘Negative’ and I thought I had cancer. I have been so worried the past two months I didn’t even want to show the letter to my husband. He doesn’t know anything about this. He has a bad heart and I thought this would kill him.”

“Mary,” I said reassuringly. “Everything is perfect.”

Unintended consequences of progress, you might call it. But as with many seemingly trivial mishaps in the course of primary care practice, there are important messages contained within.

In 2002, as President of the Institute For Family Health, I led the implementation of EPIC (Verona, WI) one of the Nation’s most sophisticated and highly rated (KLAS Market Intelligence) health information technology programs in our network of thirteen community health centers in the Bronx and Manhattan, New York. Contrary to many horror stories in the health information technology literature, the 90 physicians, social workers, nurse practitioners and family medicine residents who work at the Institute welcomed this development heartily and immediately put some of its most powerful tools to work. Through training classes, on line instructional sessions and individual mentoring, in a few months we were almost completely paperless.

One of the most exciting parts of implementing electronic health records is how they help our communication with patients - at least most of time.

Restructuring Workflows to Incorporate the EHR

Prior to the implementation of the EHR we had done everything we were all taught to do to keep patients separated from their medical record and the information it contains. We kept charts outside the exam room door so patients could not look at them while they waited. We wrote in a complicated professional style with abbreviations that often were ambiguous and were sometimes not even understood by our colleagues when they covered for our patients and tried to use our notes. Many of us had handwriting that resembled hieroglyphics except that no historian had been successful in providing a book to assist in their translation.

Whose record is it anyway? Few patients go through the formal processes we put in place for them to examine their own records. Times have changed. Patients want to know so much more about their health and the Internet has provided limitless opportunities to access information on any health care issue of interest. Physicians have come to realize how extensively our patients’ lifestyle choices determine our ability to influence their health outcomes. Our relationship with our patients must become one in which we, as their doctors, serve them. They must have ownership of their health information, understand their health care needs in health and disease and understand how to obtain optimal care for themselves and their families.

We viewed the EHR as a tool to bridge the information gap with our patients and made many decisions in the setup process to enhance this.

We specifically rejected the option of portable wireless touchpad computers as they have screens which are visible only to the provider, and are often held cradled in the provider’s arm, preserving the secrecy of the paper charts they replaced. Even though not all patients choose to look at the monitors, the availability they offer creates a bridge of trust and improves the provider-patient relationship.

We chose to redesign the encounter to put the review of prior information in the context of the current day’s encounter, and use this as an opportunity to involve the patient in his or her own care.

Providers enter the exam room unprepared by prior review of the patient’s record. Their review of the record and any activity since the previous encounter is done in collaboration with the patient. Looking at the computer screen together, the provider might say, “Let’s look over the note I wrote on the last visit to make sure we have followed up on all your issues.” Then, “Now let’s go over all the reports that have come in since your last visit ... two consult reports and your blood test results.” Rather than being insulted by this, patients are immediately drawn into reviewing their own records with their provider at their side, where a discussion of the results and necessary follow-up are facilitated. Copies are printed for the patient to keep at home with their medical records.

But there is a flaw in our system, a serious one which must be addressed and that flaw is that health care professionals do no speak English the way other people do. We write funny and speak about patients in an unnatural way.

“The patient did not comply with my diet instructions.”

“The patient appears in no acute distress.”

“ This is a 34 year old Hispanic woman who appears to be her stated age.”

When I started going over my previous notes with my patients I realized how ridiculous these notes were. People were genuinely confused. Most were too polite to comment but some turned away from the computer and simply blanked over as I read the medical history, exam findings and plans from the past visit. I started imagining what my patients were thinking as they translated my writings into common English.

“head – normocephalic” (Is that better than just plain ‘normal’)

“lungs clear to auscultation” (I don’t remember anyone named ‘auscultation’ listening to my lungs)

“reflexes 2+ bilaterally” (Is that 2 a good score – shouldn’t they be a 10?)

“thyroid not palpable” (Nobody ever told me I didn’t have a thyroid gland. I wonder if I need one?)

“Babinskis down” (I never even knew I had a Babinski. Shouldn’t they it be up?)

I was also amazed at how many times we qualify what the patient tells us like we are always suspicious that they are lying to us.

“The patient denies having sexual intercourse for the past 6 months”

Even referring to our patients as “the patient” itself is a ridiculous was of depersonalizing the medical encounter.

Printers in Every Exam Room Promote Patient Education and Involvement

Another example of the critical decisions that need to be made in the set-up of hardware is the location of printers. We decided to install printers in every examination room so that information could be produced for patients as part of the entire encounter process. This not only improved the patient flow in the center, but made the vast resources of the EHR instantly available to both the patient and the provider. It also insured the confidentiality of patient information, eliminating the possibility of a document being picked up off a central printer and inadvertently handed to the wrong patient.

At the start of the encounter, while reviewing lab results and returned consult reports, the provider can print copies for their patients on the spot. The workflow used by most providers next involves a review of the nurse’s notes and the vital signs taken when preparing the patient to see the provider. Vital signs, as well as all lab values, can be trended, graphed and printed for patients. The most common use of this function is the printing of progress charts of weight or blood pressure, graphing patients’ improvements (or lack thereof!)

It is well known that patients frequently do not take all the medications they were prescribed.[i] The EHR permits providers to review the list of current medications the patient should be taking, and print a summary for them as well. Prescriptions are printed in the exam room, as are requests for labs and specialty consultations. All of these documents become part of a package of health information that the patient can take with them and keep as part of their personal health records.

Patients Leave the Center with a Full Report of Their Encounter and Follow-up Recommendations

Studies of patients leaving their doctor’s office indicate that they rarely have a complete understanding of what was done and what they are supposed to do next.[ii] To combat this, the Institute designed an “After-visit Summary” that contains patient-friendly headings and a printout of all issues discussed in the day’s encounter. The summary includes patient identifying information, a list of their measured vital signs, the chief issues as told to the nurse, the provider note, a complete problem list, a summary of active medications, any new orders written for the patient, including consultations, imaging studies, lab tests, and immunizations or medications administered in the center. Providers who use this feature regularly in our practice report that their patients remind them to print the After-Visit Summary if they forget to do so at the end of an encounter.

Reading the Afer-visit summaries is another issue altogether. Aside from the obvious problems of providers using medical terms that patients do not, for the most part, understand there is the additional issue of abbreviations that are totally meaningless to those who have not studied medicine. Some would say we made great strides in developing list of “approved abbreviations” to avoid clinical error s and improve doctor to doctor and doctor to nurse communication but we have not even begun the journey of translating these abbreviations into English – another frontier altogether.

When I type PND into our computer I get “PND” on the screen. When I type “.PND” the computer spells out Paroxysmal Nocturnal Dyspnea. But that is programmable. What I want to do is tell the computer that “.PND” should be written as shortness of breath at night when lying down”. Better yet, if the patient’s primary language is Spanish and is so designated in the EHR, “.PND” should be translated to “falta los respiraciones por la noche cuando esta acuestado.” In that manner we will truly be improving communication with our patients – both in the exam room and when we share our written summaries with them to take home.

Lab Results

The mysteries of laboratory reporting have also puzzled my patients since giving them copies of their labs to take home or sending them in follow-up letters. Scientists have standardized many lab results in International units or mg/dl (milligrams per deciliter) measures. Imagine telling a patient though that a change from a creatinine (a kidney function test) from 1.5 to 1.8 is highly critical but a change in BUN (blood urea nitrogen – another kidney function test) from 20 to 28 is nothing to worry about. None of this makes any sense to people not educated in medicine or laboratory science. And all of this is fine until we start to try to draw patients into their own care and setting their own goals. Rather than telling folks that keeping all their values at 50 is the goal and that the safe range is from 40 to 60 for all values – we tell them to keep their HgbA1c (glycosylated hemoglobin – a test of diabetes control) below 7.0, their LDL (low density lipoprotein or “bad cholesterol”) below 130 (or 100 if they are diabetic), their HDL (high density lipoprotein or “good cholesterol” ) above 45, their hematocrit (red blood count) above 35, and so on. Not only don’t the values make sense but their normal ranges are not standardized between tests nor between different labs running the same test using different methods.

What does all this mean.

We need to transfer health information back to patients – a job that will require a major transformation of the way we use medical language and even the units of measurement we use.

It is essential that we do this. A patient making six ½ hour visits each year to my office spends 3 hours out of 8760 or .03% of their life that year in my office. The rest of the time they need access to their health information to keep them informed of what they need to do and to keep them motivated to stay focused on the health care issues that are important to their continued well-being.

Health care providers have to relearn English and learn to translate their words and their measurements into terms that people can understand. Mary Sampson’s negative mammogram result was a positive finding for her but it could have been a lot more positive if she had known that negative was a good thing.

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[i] Safran DG, Neuman, P, Schoen C, Prescription Drug Coverage and Seniors: Findings from a 2003 National Survey, Health Affairs Web Exclusive, 19 April 2005; W152-W166. Available at Health Affairs.org (accessed 6/8/05).

[ii] Lukoschek P, Fazzari M, Marantz P, “Patient and physician factors predict patients’ comprehension of health information, Patient Education Counseling, 50(2):201-210.