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For other articles and previous issues click here. February 9, 2004 Medical Records
on the Go Each January, thousands of itinerant workers begin a trek that takes them hundreds of miles north from Mexico to harvest the orchards and farms of Washington and Oregon. By August, they migrate to northern California to work “the crush” in the vineyards of Sonoma Valley, after which they move on to pick olives and other crops that grow in the fertile fields of central California. As the weather turns cold in the fall, they return home to Mexico for two or three months, perhaps to spend the holidays with their families. In January, they head north for Washington to begin the cycle once again. These workers and their families, who are said to number as many as 700,000 in California alone, are largely impoverished and poorly educated. At a higher rate than the general population, they suffer from injuries and chronic illnesses such as diabetes, hypertension, asthma, and allergies. Their nomadic lifestyle allows for little or no continuity of care. Furthermore, their circumstances and culture often pose great obstacles to seeking, let alone receiving, medical care. Lack of language skills, poor understanding of their medical conditions, and the need to see providers unfamiliar with their history results in substandard care, the unnecessary repetition of examinations and immunizations, inadequate follow-up, and increased potential for medical errors and adverse events. Compounding these problems has been the fact that while the workers travel, their medical records generally do not. Each doctor visit is like a new beginning, with the worker once more unable to adequately relay the history of the medical problem and the healthcare provider approaching the patient without sufficient or reliable information. It’s a system that has not only led to deteriorating health for this workforce, but placed a strain on state and federal funds that pay for unnecessary or repetitive testing and treatment for acute and chronic conditions that might have been staved off with appropriate care. According to Ricardo Uribe of Vineyard Workers Services (VWS), a nonprofit organization that for the past 12 years has been helping to meet the needs of agricultural workers in the Sonoma Valley, most of the migrant workers are agricultural people who come from Mexico with, at best, two to six years of education in English. They have difficulty, he says, with the most basic communications, such as signing their names, stating their addresses, or explaining their medications—a limitation that can be life-threatening when a medical emergency occurs. The workers are often unaware of the nature of the medications they take. “As far as they’re concerned, it could be candy,” he explains. “They usually carry little pieces of paper in their wallets with information scribbled here and there, and they hand those over to the triage personnel who typically can’t decipher what’s on the paper.” Thanks to one mother’s creative solution to a family healthcare crisis, a select group of workers that migrates from field to orchard to vineyard will not have to rely on scraps of paper or struggle to overcome language barriers to receive quality medical care. Instead, workers will have password-protected medical records that are as mobile as they are. Cynthia Solomon, founder and CEO of Access Strategies, Inc., a Sonoma, Calif.-based healthcare consulting and planning company that since 1990 has been working on projects that focus around special populations such as the uninsured, has enabled VWS to bring this health-enhancing technology to the farm workers. The workers are provided with easy-to-tote identification cards that can be presented to medical personnel, who, with the workers’ permission, can use the information to access the workers’ medical records via the Internet. This technology allows both the workers and their healthcare providers to gain rapid access to the workers’ medical records and know what medications they are taking, what they may be allergic to, what testing has been performed, what treatments have been given, and what continued treatment, testing, and follow-up are required. Grant money has allowed Solomon to transform one of her company’s software products, FollowMe, into a Spanish-language version called VIA—the foundation for what is essentially a portable electronic health record specially tailored to the needs of migrant workers. Now, says Uribe, when a worker becomes ill, “someone at triage or the hospital can use this card to look up the records so they can quickly help people and avoid communication problems.” Although the program is new, Uribe can already point to its lifesaving outcomes. He remembers when he was called in by Santa Rosa Memorial Hospital to help providers communicate with a migrant worker who was suffering from renal failure. The 32-year-old man had just come from Mexico and started working on a ranch. He suddenly became extremely ill and was rushed to the hospital, where it was discovered that one of his kidneys was failing. The worker did not understand the seriousness of his condition, and Uribe was obliged to explain that he would require dialysis every three days, his legs would be inflamed, and his condition was life-threatening. At the same time, Uribe enrolled the worker in VIA, which would allow the man to receive appropriate ongoing treatment despite language barriers and mobility. The worker lived approximately two miles from the nearest bus stop, from where he would travel six miles to the dialysis clinic. “When you are on dialysis, at the end of the day, you start to get really weak, and he was walking on a back road trying to get to the bus stop,” Uribe says about the migrant. “He was going all over the road, and a policeman came by and saw him and probably figured there was just another drunk on the road whom he had to pick up.” Realizing that the officer was probably taking him in because he thought he might be drunk, the migrant worker reached in his wallet and gave the officer his VIA card and pointed to where it indicated that he suffers from renal failure and requires dialysis. The policeman helped him into the back of the car and drove him six miles to the dialysis clinic. Because of the VIA card, he was able to demonstrate that he was not drunk, but was sick, and furthermore make clear the precise nature of his illness and his immediate need. “He probably would have died otherwise,” says Uribe. “He’ll have an ongoing need for treatment as he moves from place to place, and now he will be able to present the card, and they’ll always know what’s going on.” Besides working with chronic conditions, VIA most benefits those with allergies—bee stings are plentiful in the fields—and children who require documentation of immunizations. Several hundred migrant workers have been enrolled in the small pilot program that in its first two years has already captured the attention of hospitals, health agencies, social services offices, the Mexican government, and major U.S. government agencies, such as the Centers for Medicare & Medicaid Services. According to Uribe, the program, with support from the Rural Community Assistance Corporation, seeks to enroll 2,000 California farm workers in the coming months. Grant money is also allowing Solomon’s company to move the VIA technology into a second version, which will be “read only” so that when a physician or other medical provider enters information on a particular person, that information cannot be changed. “Right now,” says Solomon, “since VIA is owned by the consumer, anything that anyone puts in there can be changed or taken out. Many of the providers we talked to were initially concerned about that, so we’re addressing that by making the program ‘read only.’” VIA records can contain a great deal of information, including x-rays, allergy information, dental records, and patient histories. The new version, she says, will also allow the patient to determine what parties have access to which records. “A dentist, for example,” says Solomon, “could be given permission to only go to the dental records, or a viewer may be given access to only allergy records.” THE MOTHER OF INVENTION When this medical emergency occurred, Alex arrived at an emergency room unconscious, but no one had his medical records. “They had no health information on him, couldn’t reach me, and couldn’t reach his neurosurgeon,” recalls Solomon. “By the time we got on board, they had already done two CT [computed tomography] scans, and it was a mess. If they’d given him the wrong antibiotic, it could have killed him.” Solomon realized the importance of having Alex’s medical information all in one place and accessible. She took a second mortgage on her house and hired software programmers. With her familiarity with the healthcare field, medical practices, and physicians, she had the knowledge, along with the programmers’ expertise, to develop a prototype of a portable medical record specifically tailored for people with chronic or serious medical conditions. “Now when Alex travels, I don’t have to worry because he carries his little card and can give the log-in and URL to healthcare providers, who can download his information immediately,” she says. In an emergency, providers can view his last CT scan and use that as a comparison, so they might only have to do one CT scan rather than two or three. They’d also have access to his lab and other tests. Soon, Solomon realized how this technology could work for other populations. Her company works with many health agencies in Sonoma County, which has a high migrant population. “Many of these workers have a similar problem,” she says. “They don’t stay in one place too long and have serious chronic medical conditions such as asthma, diabetes, and hypertension.” Typically, she explains, workers go to a community agency that can offer services and then move on without the information. They usually don’t know who they saw or when and are hard-pressed to describe the care they received. “So, what we thought we could do is test the FollowMe technology, customize it to migrant farm workers, and provide a way for them and the providers caring for them to store some important information so that when they go from community to community, they don’t have to have tests and procedures duplicated,” Solomon says. WIRED FOR ACCESS In addition, most of the farm workers have children who know about the Internet and may use it at school. However, the workers’ Web savvy is still lacking. Solomon recalls one migrant who was enrolled in VIA through a VWS outreach worker. “He loved it and wanted to use the Internet, so he and his wife went out and bought a computer, brought it home, hooked it up, and couldn’t understand why they couldn’t get on the Internet because they didn’t know they needed an Internet connection.” Once again, Solomon saw a need and filled it. She got a grant to hold Internet classes for migrant workers and produce a simple, 15-page guide in Spanish and English that explains computers and the Internet. There are additional services for migrant workers who wish to be part of the information superhighway, says Solomon. The California Endowment and the California HealthCare Foundation, for example, have invested heavily in technology centers for farm workers. “In our little community alone, we have two centers that have multiple computers and T1 lines,” Solomon notes. The workers can also access the Internet at public libraries and often at public schools. “One of our next projects is to start doing an in-service with librarians,” Solomon says, “because they’re often left out of the loop on what technology is out there, and they’re a great source of outreach and information.” SECURITY AND ACCEPTANCE The only hurdle in getting the workers to participate in the program is the ever-present fear of the government, particularly the long arm of the Immigration and Naturalization Service (INS). “They’re afraid that we have a list here or some information is going to be given to the INS,” says Uribe. “There’s always fear that somebody is going to come and round them up, so we have to reassure them that they are the only ones who can give out their information. We try to explain what HIPAA is all about, and we try to explain the laws on privacy here in the United States.” Solomon agrees. “There’s a tremendous fear of anything to do with the government on the part of documented or undocumented workers, so we had to stress that: one, we weren’t part of the government, that the government doesn’t have access to it; and two, even if the government did have access, there’s nothing in the file that’s going to say if one’s legal or not legal. The information that’s in there is what they [the migrant workers] put in there. If they don’t want to put in their Social Security or driver’s license number, they don’t have to. There’s nothing required. It’s their space.” This education targeted another initial obstacle rooted in cultural attitudes. The Mexican workers, who are usually male, are most often reluctant to see doctors. “The men have that macho attitude that they’re not going to go see a doctor until they’re dead,” says Uribe, “so they’re a bit resistant. Nevertheless, once they’re made to understand it, they’re glad to have something that can make it easier if they do need to see a professional when they become ill or have a toothache.” In the case of migrant workers, this technology is a simple solution to a complex problem. Portable medical records based on FollowMe technology can be purchased by individual consumers who wish to keep track of their medical history, log children’s immunizations, or manage records pertaining to chronic conditions. It’s particularly valuable, however, for farm workers, who for so long have been largely ignored by the medical system. The program, says Uribe, provides a win-win situation for everyone. The workers are encouraged and empowered to seek and obtain better healthcare, healthcare providers are grateful to have adequate information from which to base decisions, and the cost of healthcare for migrant workers—the burden of which is on taxpayers—is reduced. — Kate Jackson is a staff writer at For the Record. For more information about FollowMe, call 800-300-4400 or visit www.followme.com. For information about VIA, visit www.vwsvia.org. |
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