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For other articles and previous issues click here. June 28, 2004 Electronic
Medical Records for the Poor The Children’s Health Fund puts records on wheels to serve the homeless. On April 29, The Children’s Health Fund (CHF) delivered a two-part message to Congress. President and founder Irwin Redlener, MD, FAAP, a pediatrician, first urged Congress to pass legislation to increase funding for the adoption of electronic medical record (EMR) systems in public and private health centers where medically underserved children receive treatment. Next, he advised lawmakers to hold hearings to demonstrate the importance of such systems. The announcement came in the wake of—and in support of—President Bush’s promise to earmark $100 million of his proposed 2005 budget toward support of EMRs. CHF is well-positioned to champion paperless records, having adopted it in almost all the health projects in its network long before many major hospital systems even began to explore the technology. CHF, supported by corporate donors, federal grants, Medicaid revenue, and private contributions, is an organization that was established to support the development of healthcare programs for underserved populations. The fund is involved in advocacy for child health access, health insurance for all children, policies, and issues that impact access to care for children—especially underserved populations. It also raises money to support the programs and policy and advocacy work. A program of the CHF, The New York Children’s Health Project provides direct services to homeless children and families. Affiliated with the Montefiore Medical Center as the clinical partner in healthcare delivery, it uses a mobile medical unit and mobile health team model to visit shelters and provide primary care on-site. “Medically underserved children are particularly vulnerable to the pitfalls of a paper-based health records system, and there are unique benefits to electronic health records that can enhance care to vulnerable populations,” Redlener said at the April meeting of the fund’s medical directors at the Russell Senate Office Building in Washington, D.C. According to Executive Director Karen Redlener, “We have a national network of 17 programs, all of which use mobile medical units and most of which have electronic patient records as part of their medical model.” It all began with the New York program. “It had one mobile medical unit and its target population was here in New York City, providing direct services at large homeless family shelters,” Karen recalls. The program was the brainchild of her husband, Irwin Redlener, and songwriter Paul Simon, who cofounded the program in 1987 and became partners in a venture that grew far beyond their expectations. The teaming of a doctor dedicated to public service and advocacy with a high-profile celebrity equally committed to bringing about social change garnered media attention at the outset. “A number of articles about the mobile medical programs and our project in particular were published—one in The New York Times and another in Newsweek,” says Karen. “A lot of people in communities across the country read about the programs and reached out to us. We had developed a model to care for underserved children that was applicable in many environments.” This interest helped CHF blossom to the point where it could begin to help other communities and advocate for larger issues. The Redleners brought a personal history of social activism to the project. They met in the early ’70s in Arkansas when both were involved with a VISTA (Volunteers In Service To America) healthcare program. They gained experience working at a rural community health center providing comprehensive services to underserved and poor populations. Over the years, they had both been working in different ways with high-risk populations, primarily focusing on children. “When Irwin’s career led him to become medical director of USA for Africa, he met Paul Simon, who sang on the highly successful ‘We Are the World’ effort,” Karen says. She notes that Simon came to Irwin because he was deeply concerned about the homeless population in New York and was interested in exploring what could be done. “In 1986, Irwin organized a tour of the homeless housing for himself and Paul, which gave them an incredible exposure to the devastating conditions of children and families in New York City,” Karen says. Both were moved to do something to make a difference, and soon emerged the concept of a mobile medical unit that could come on-site to where the children and families actually lived. “Since Irwin and I had been working together for many years, I got involved at the beginning,” remembers Karen. “We developed the program and started serving kids in 1987.” Throughout the years, she says, Simon has remained actively involved and supportive. Serving the Underserved People who become homeless, Karen says, have often had a period of time even prior to their homelessness during which they did not have access to a regular primary care provider. The project helps them address the many complicated medical issues that arise in homeless families. “We provide care directly, very comprehensively, and refer patients for all specialty needs and then facilitate that specialty care,” she says. Patients in residential facilities know to expect the mobile units on a regular basis and how to contact the mobile teams via a toll-free phone number 24 hours a day. An important function of the project is to help homeless families get regular care for the chronic conditions, such as asthma, that affect them disproportionately to the rest of the population. For example, CHF has a special childhood asthma initiative that’s been developed in response to the high rate of asthma among homeless children. “Between 35% and 40% of the children within the shelter system have been found to have symptoms consistent with asthma, so it’s a big concern of our medical teams,” says Karen. The shelters were constantly calling 911 for children having asthma attacks. The kids had to go the emergency department or be hospitalized frequently because their asthma was so out of control. “We focused on that and developed an asthma initiative to enhance education,” Karen says. “We developed asthma guidelines so that the clinicians are able to evaluate the stages of asthma, determine how serious attacks are, and prescribe the appropriate medication. Patients then can come back on a regular basis to reinforce the education and training in the use of the medications.” The project tracks its population and supports its patients in transition. “We keep in close contact with our patient population, and then when they are ready to be relocated to permanent housing, we have a health center as part of our network that we can refer them to, so we can provide continuity of care as they move into their housing,” says Karen. An equally important component of the project is education. “We help families understand the importance of accessing healthcare and ensure that they know what to look for when they become permanently housed,” Karen says. “It’s a window of opportunity to help families get medically stable and contribute to preventing the likelihood that they will become homeless again.” It’s crucial, she says, that families are educated to help them understand the system and then become capable of managing some of their chronic illnesses. Bringing Electronic Records to
a Neglected Population CHF looked for off-the-shelf EMR programs that might fit its needs. However, at that early date, there wasn’t anything available except electronic billing systems. The project worked with consultant JSI of Boston to develop a system that met its unique needs. It used that system until 2000, when it made the transition into a new generation of EMRs adapted from a commercial system—Amicore—which it still uses today. The Amicore product wasn’t designed to be used in a mobile environment and wasn’t necessarily meant to be used with an underserved population, says Karen. “So we took the basic product, adapted the aggregation process so that information from mobile teams that is collected each day is combined on a biweekly basis,” she says. CHF also adapted and developed guidelines or templates around the issues relevant to its patient population. This way, it could write specific history questions that address more social issues—such as domestic violence and homelessness—and could also target specific diseases prevalent in the population. CHF develops and customizes guidelines for clinical problems such as asthma and obesity—concerns that over the years have become more and more prevalent in the project’s target population. To be as comprehensive as possible in the collection of information in the medical record, the system also includes mental health and nutrition guidelines. “We have very complete medical records for a very complex patient population,” explains Karen. For example, in the case of the many asthma patients, all their information is kept in the EMR so the clinician can see what was previously prescribed, whether or not it was effective, previous symptoms, current symptoms, and whether or not allergy testing was performed. “All this complex information [is] right at the fingertips of the clinician providing the care, so it could be reinforced, managed, and modified for the patients,” Karen notes. The unique setting brings unique challenges. One involves ergonomics. “The healthcare providers are in a tight space using wireless handheld tablets connected to a server for live entry of clinical data,” says Karen. This system allows information about clinical encounters, immunizations, allergies, drug interactions, preventive medicine, and patients’ special needs to be stored and readily accessed. Another initial challenge was staff training. In the first generation system, data—such as problem lists, history of visits, and history of immunizations—was entered at the main office and printed on the mobile units. The second generation involved live entry, which required the medical team to learn a new system. “Some people weren’t so adept initially,” Karen recalls. “They had to learn a new system and a new way of keeping medical information.” Today, most healthcare professionals have grown up with advanced technology, so it’s not the problem it once was. Advocacy In May, CHF met with national medical directors on Capitol Hill to demonstrate the use of the EMR system. “It’s quite unusual to have such state-of-the-art technology in a program that’s not a traditional model and that is serving a very underserved population,” says Karen. “As people are beginning to think more about the importance of electronic patient records, we wanted to send a message that we don’t want underserved populations being left out of these new technologies. There’s certainly interest in moving big hospital systems to electronic records, but we need to remember the community-based, underserved populations as well.” Karen believes this message is compelling and will be heard in Washington. “There’s a real receptivity and bipartisan support for identifying resources with which to move in this direction,” she says. “We want to be sure that new technologies are applied across the board. If not, we’ll end up with a real digital divide between advantaged and disadvantaged populations.” For more information, visit www.childrenshealthfund.org. — Kate Jackson is a staff writer at For the Record. |
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