Neil Calman, MD
President and Chief Executive Officer, Institute for Family Health; Chair, Department of Family Medicine and Community Health, Icahn School of Medicine at Mount Sinai
Perspectives from the Field Interview Series
Interview with Neil Calman, MD
President and Chief Executive Officer, Institute for Family Health; Chair, Department of Family Medicine and Community Health, Icahn School of Medicine at Mount Sinai
(http://www.institute2000.org/about-us/leadership/executive-staff/neil-calman-md-abfp-faafp/)
June 30, 2014
Interviewer: Jane Hyatt Thorpe
Questions:
1) Please introduce yourself and tell us about your current position.
2) How does what you do intersect with health information exchange? [Alternative: how do community health centers use health information, beyond treating patients?]
3) What potential benefits are there in health information exchange for community health centers and the overall health care system?
4) What are some barriers or challenges to fully realizing that potential? [Here, perhaps raise issue of not being able to share with other professionals and support services outside of immediate treatment team.]
5) What do you see as the most promising long-term solutions to these challenges?
6) In the meantime, do you recommend any short-term strategies that community health centers can use to maximize the use and exchange of health information for patient care and overall system improvement?
Transcript:
Question 1
JHT: Welcome to Perspectives from the Field, a series of interviews with experts in the field, brought to you by Health Information and the Law, a project of the George Washington University’s Hirsh Health Law and Policy Project and the Robert Wood Johnson Foundation. Today we are speaking with Dr. Neil Calman, President and Chief Executive Officer of the Institute for Family Health.
Hello, Dr. Calman, how are you?
NC: I’m great, how are you?
JHT: Good, good. Thank you so much for joining us today. We’ll get started. Would you please introduce yourself and tell us a little bit about how the work you’re doing with community health centers in particular intersects with health information exchange?
NC: Sure. I run the Institute for Family Health, which is a network of 29 locations, which are all federally-qualified health centers. Some of them are homeless health care programs, some of them are school health programs; the majority are what you would know as full community health facilities with primary care, mental health, and dental. So, we are spread over 150 miles and therefore have relationships with many different groups of specialists and many different groups of providers in the community who help us with what are now called social determinants of health, help us with our patients in terms of dealing with housing problems and social issues, and we also have many affiliations with different hospitals. So, you can imagine that in this era of electronic health information, that the sharing of information between these different providers is critically important. And so we’re deep in the throes of, in some cases, just figuring out how doctors can transmit information from primary care doctors to specialists and back; in some cases, trying to work on electronic connectivity with our emergency departments and our inpatient units; and in some cases (and I think, most challenging) trying to figure out how to link in providers who aren’t really traditionally health care providers but who are helping our patients with their social, economic, housing, and other needs.
Question 2
JHT: Wonderful. I want to come back and make sure we focus on some of the challenges you spoke to, particularly sharing information outside the immediate treatment team, but before we talk specifically about challenges, could you review with us what you perceive to be the key benefits of greater exchange of health information between providers and patients and others who are working with community health centers as part of your system?
NC: Well, I don’t think that there’s any question that we’re talking about benefit here. You know, the traditional modes of communication were grossly inefficient, people trying to pick up the telephone and calling folks and leaving messages and trying to get calls back when we were in session with other patients – it created an almost impossible barrier to efficient transfer of information. So I think the electronic transfer of information has really enabled people to communicate asynchronously but at the same time much more efficiently across these boundaries. And, in fact, we’ve noticed a lot better communication between hospitals, emergency rooms, and doctor’s offices as we’ve been able to do more and more electronically.
JHT: And is your experience that the exchange of information between community health centers, hospitals, and other providers is happening through the use of electronic health records or are there other modes of exchange that community health centers are using?
NC: Well, I think we’re still, depending on who’s on the other end, we’re still using the telephone, still handing people things that are written on paper to bring to other providers, you know, we’re using fax whenever electronic communication isn’t available. So, we’re kind of doing this however we can, but I think the move is generally towards more electronic communication.
Question 3
JHT: Great. A little bit earlier, you referenced some of the challenges to fully moving towards the use of electronic health records or communicating electronically, and it sounds like, obviously, there continues to be movement towards that, still using phone and paper where necessary but really trying to move towards exchanging information electronically. What are some of the greatest challenges that you find that community health centers, in particular, are facing in terms of greater use of electronic exchange of health information?
NC: Well, I think the greatest challenge for us is that the people on the other side of this exchange have very varied capabilities. So, you know, we have hospitals where we have no electronic connectivity to be able to exchange, for example, a discharge summary from the hospital to the Institute. However, we’ve been kind of piecing together things that we’ve been able to do, which is create kind of a discharge document on the hospital’s side and even something that we can securely transmit over to our health centers that may not be part of a formal exchange mechanism. We’re working with “Healthix,” which is a local, regional health information exchange. They connect some of our hospitals and we can get some real time notifications of people who are admitted to the emergency room or to the hospital, but still are unable to get discharge information back at the time of discharge. We have a linkage with Ellenville Regional Hospital, which is a small, critical-access rural hospital, where they actually have a module of our electronic health record system that we’ve installed in their emergency room so that when they see a patient in their emergency room that doesn’t have a source of primary care, they can actually go and book an appointment right into our system for the follow-up and attach information that they think we would need to be able to follow up with the patient. So, it’s like every one of our hospitals has different kinds of capabilities, and so we’re kind of piecing this stuff together until the grand day when all of this electronic exchange will take place, in what I think will be a fairly seamless kind of format.
JHT: So, from what you’re saying, it sounds like now it’s primarily based on the partnerships and the relationships you have with other health care providers in the area, where you may have patients in common as they’re traveling perhaps between your centers, the emergency room, and other specialists, and it’s really based on those connections you have with those other providers.
NC: Yes, that’s true, and when the other providers are using the same software that we use, which is Epic, there’s actually a module that enables us to almost be able to access their entire medical record that’s on the other side, whether it’s from the hospital to the center, or from the center to the hospital, with the patient’s consent. So that’s like the highest level of integration but clearly, there are many systems out there, and so when people are on different systems, you know, the integration at that level goes away and you depend upon regional exchanges, or we’re just beginning to be able to go live in a very limited way with Direct protocols, Direct exchange. So we’re using the tools available to us as they evolve, and very dependent on our partners, as you said.
JHT: For those in our audience who may be unfamiliar with Direct, can you spend a couple of minutes just explaining how that Direct, query-based interaction works?
NC: Well, I think the Direct interaction is really – the best way to understand it is to think about it as kind of the “electronification” of the facts, but with the ability to send a document, which some people call a CCD, and to be able to transmit a document that has various components of information that would be relevant to that particular transaction, and it gets securely transmitted using a standardized protocol. It’s similar to the way one would imagine a fax going back and forth, a standard document that might get printed by a computer. That’s the most simplistic way of thinking about it and in a sense, it really creates an almost magical way for people to be able to transfer information from one place to another because, as we think about the incredible variety of information transfers that need to take place, you know, being able to standardize some sort of document is a good starting point. It’s only a starting point because if you think of the information that needs to be transferred for different purposes, in some sense, we’re going to need to create a model upfront that enables us to make a smart transfer of information, so that the cardiologists get the cardiac information that they need in much more detail, whereas the podiatrists or foot specialists aren’t going to need all that but are going to need any information that’s relevant to the treatment they’re doing. Otherwise, I think we’re just going to be flooding people with information and it won’t really be all that useful. So, you know, it’s a start, to be able to create a standardized document for transfer, and I think it’s a great start. Once that protocol is widely implemented, it will enable us to transfer very specific pieces of information to the specialists that we use and the hospitals when we’re referring patients, and to get information back in a usable format that can then be incorporated directly into our electronic health record, so it doesn’t necessarily have to come back as a document file, but it’s actually information that can be incorporated into a patient’s record.
JHT: So, so far we’ve talked primarily about sharing information with other physicians or with a hospital, but earlier in our interview, you referenced sharing information with other support services, housing and things of that nature. What challenges have you encountered in trying to share patient health information with the broader community beyond immediate care providers?
NC: Well, I think that’s a mountain that’s yet to be climbed. You know, to try to figure out the consent process so that patients really are consenting to this wide-open availability of their information to people who aren’t really health care providers, and I think that has a lot of concerns both on the provider’s side and on the patient’s side, in terms of what information is relevant to somebody. If you’re sending somebody for assistance with housing, information about any possible disabilities, cardiac conditions, pulmonary conditions, things that might affect the type of housing that would be suitable for them would be relevant information, but other information of a more personal nature, maybe information about prior bouts of depression, abortions, or other kinds of things that people might not think is really relevant, and isn’t really relevant, to those kinds of transfers shouldn’t be transferred. So the ability to segment the information and figure out what’s important to be transferred is a whole issue there as well. And I think, most importantly, technically, the kinds of systems people are using in these agencies aren’t really health care, electronic health record systems, so they’ve been left out of the loop of this whole development of standardized protocols for the transfer of information, and that needs to be re-looked at as well. So I think we’re still quite a ways away from that possibility, but a lot of people are far along in the development of care management, care coordination software that sort of works as a stand-alone to link health providers with others, and how those things eventually integrate into electronic health records, I think, remains to be seen.
Question 4
JHT: So you referenced some care transitioning, care coordination tools and software – do you think that’s probably the most promising long-term solution to some of these challenges, perhaps aligned with greater patient engagement and thinking about patient consent forms and how patient consent would relate to sharing this information beyond immediate care providers?
NC: Yes, I think that is the most likely the way that it’ll develop. The only thing is that we don’t want to add back the inefficiencies that paper brought us. And so, the idea of being able to create that document that would then get sent to a care coordination or care management kind of software and be able to capture information back into the electronic health record is a piece that still needs to be developed. So that providers who are seeing a patient aren’t going to have to write down their whole social history and then have to write it again into another software program that would be used for care coordination.
Question 5
JHT: So, given some of these challenges but also some of these promising potential longer-term solutions, what in the short term - obviously, given the work that you’re doing, overcoming some of these challenges, enabling broader flow of information between providers as well as with other types of support services that may be beyond the immediate care team - are there any short-term strategies that you would recommend overall to help maximize the exchange of health information within the patient care system as well as outside the patient care system?
NC: Well, I’ve always believed that patients should be at the center of the decision and so, for me, if I were the software developer, I would be producing this information in a format so patients could literally check boxes as to what parts of their record they would want to be revealed, and in so doing, would also be consenting for that information to be sent, and then to also indicate who they would want it to be sent to. So I would put the patient back in the center or hub of this information transfer piece, because I think providers are going to do this badly and they’re not going to be able to check in with patients all the time to know what kind of information is relevant, what kind of information people are going to want to be transferred, and it’s only going to take a few missteps for somebody to just say, “you know what, I’d really rather have my information locked down because I really don’t want everybody knowing everything about me.” So I think if we don’t get the patient back in the middle of this decision somehow and enable them to indicate which pieces of their information they want shared with whom, I think it’s going to be a very difficult process to make this work.
JHT: And in your work, what have you found to be the most effective tools or resources to really put the patient back in the middle and have that level of engagement where they’re able to make more informed decisions about consent and with whom their information is shared, etc.?
NC: Well, we haven’t really been able to deal with the “with whom their information is shared” piece in any kind of significant way because the software just doesn’t support that, but I think we have been able to engage a large number of our patients, now I think numbering almost 25,000, by using the patient portal into our electronic health record system, which not only gives them access to their electronic health record but, through a system that we worked on with the National Library of Medicine called MedlinePlus Connect, the patients can actually hyperlink from the terminology that they see in their medical record to MedlinePlus to be able to understand what those terms mean, what the lab results mean, and even to look up their medications. So, I think that there is an ability to use some publicly-available tools like that – MedlinePlus Connect is available for connectivity to any electronic health record system that uses standard nomenclature and I think that using tools like that and using electronic health record patient portals, people will choose to become much more involved in their own care. So our patients are communicating with our providers and - you know, it’s not a rapid uptake. I mean, we’ve been up to this probably for close to 5 years now and we only have about 25,000 of our 100,000 patients signed up, which is not a great number but considering that we work with a really underserved population, many of whom don’t have access to computers at this point, I think that that’s not bad. We’re now moving towards trying to engage people a lot more through their smartphones and other electronic devices that we think are even more prevalent. To me, that’s the major tool that we have available to us right now.
JHT: Wonderful. Well, this has been incredibly helpful and we really appreciate your time today, Dr. Calman. We’ll be posting materials relevant to this interview shortly. Thank you again!
Further Resources:
• Institute for Family Health:
– http://www.institute2000.org/priority-areas/
• Information about Direct:
– http://www.healthit.gov/policy-researchers-implementers/direct-project
• Information about MedlinePlus Connect
– http://www.nlm.nih.gov/medlineplus/connect/overview.html
• Summary of HIPAA:
– http://www.healthinfolaw.org/federal-law/HIPAA
• HealthInfoLaw.org materials on HIT:
– http://www.healthinfolaw.org/topics/58
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