By: Viji Sundaram in Mountainview, California
A much heralded push toward digital patient portals, commonly integrated with electronic health records, may be exacerbating health disparities between rich and poor, instead of reducing them, as they were intended to.
In fact, for a variety of reasons, “you could argue they increase disparities,” said Suneel Ratan, chief strategy officer of Community Health Center Network and the Alameda Health Consortium, who has researched the use of patient portals in Bay Area community health centers.
Last year, MayView Community Health Center’s three clinics – here in Mountain View, Palo Alto and Sunnyvale -- launched their patient portal tool to meet “meaningful use” requirements in order to receive federal incentive checks, a part of the Electronic Health Records Incentive Program. The program was designed to help health care providers move away from a paper-based system. A few mouse clicks allows a doctor to navigate the entire medical history of a patient.
Patient portals, which have been in use for more than a decade in larger hospitals nationwide, are commonly integrated with electronic health records. They are secure online websites that give patients 24-hour access to their personal health information from anywhere with an Internet connection. It’s a way of patients being engaged with their care team and on their own time, with the hope that it will lead to better health outcomes.
Among other functionalities, patient portals typically include online appointment scheduling, bill pay, prescription renewals and the ability to accept patient-generated data on allergies and other health issues. Patients also have access to lab results.
MayView, a federally qualified health center (FQHC), spent about $30,000 in staff time to build its portal, the clinic’s Executive Director Kelvin Quan said, noting that the tool was not only to meet the federal “meaningful use” standard by tethering it to electronic health records, but also to “meet a standard in adopting the patient care model known as ‘Patient Centered Health Home,’” a kind of one-stop shop for patient care.
Soon after MayView launched the tool, many patients enrolled, but enthusiasm seemed to wane after a few weeks, when the program became something like “white noise,” [a collection of sounds that are a mere distraction] as MayView’s Medical Director Dr. Aarti Gupta described it.
Enrollment figures in MayView’s program show that of the clinic’s approximately 6,600 patients, only 600 are currently enrolled. Of them, only 200 are active users.
Quan believes the tool’s low patient penetration is because “technology doesn’t work for our population,” a good percentage of whom are Hispanic and Asian and Pacific Islanders. That could be the reason why East Palo Alto-based Ravenswood Family Health Center, also an FQHC and with a similar patient demographic, has low usage of its patient portal – 10 to 15 percent -- according to Chief Executive Director Luisa Buada.
"The majority of our patients are Spanish-speaking with lower literacy (including health literacy, reading literacy and computer literacy) rates," said Dr. Justin Wu, Ravenswood's Clinical Informatics Officer. "Add to that the current political climate with mistrust around immigration issues and a general hesitancy to give out information or have health information online, and I think it helps explain some of the problems we've been having with patients in using our patient portal." The two clinics reflect a national usage trend that showed that Asian Americans, Latino Americans and African Americans were 23 percent, 55 percent and 62 percent less likely to register for digital personal health record access, respectively, compared to non-Hispanic whites.
First off, “many of our patients can’t afford computers. If they can, their [technology literacy level] makes it difficult for them to navigate the information,” Quan said.
For those who have the app on their cell phone, the font is so small, they can’t read it, he said.
David Lindeman, director, Center for Innovation and Technology in Public Health and the CITRIS program at UC Berkeley, believes that if some of the text were taken out of patient portals and replaced with images and videos the tool could possibly be embraced by more patients.
A study done two years ago by five academics shows why the patient portal program has been relatively successful at Kaiser Permanente, a large grouping of hospital and practices, as well as the nation’s second-largest insurer. By 2015, Kaiser had registered 70 percent of their 5.2 million patients on their portal, well above the health care industry expectation of 50 percent, according to Quan.
The bulk of Kaiser’s patient portal education material – not entirely simply written -- is geared toward white, middle-class people, who are better educated. Patients with a post-graduate education are more likely to register than adults with a high school education or less on to My Health Manager.
“You have to meet the patients where they are coming from,” said Quan.
My Health Manager enrollees can email their care team members with health questions and expect a response within 48 hours.
Most of MayView’s patients are on Medi-Cal (the federal-state health insurance program for low-income people, known as Medicaid in the rest of the nation). Some are undocumented. Care providers at the clinic are already stretched thin, Gupta said, one of the reasons why MayView’s patient portal lacks the e-mail communication functionality.
“If they had to respond to queries from their patients on the computer, it would take time away from attending to patients” who prefer face time with their providers, Gupta said.
Besides, “Medi-Cal will not reimburse them” for computer time, Quan said.
Ratan said most FQHCs don’t have the resources to implement robust functionality in their patient portals. But at least one he has worked with has deployed a patient portal that includes medical records, in addition to appointment schedules and refills.
Republished in partnership with New America Media.
By Belen Febres-Cordero in Vancouver
Upon arrival, immigrant populations in Canada tend to present less allergies than their Canadian-born counterparts, but prevalence increases with time, a national study finds. However, exposing them to ethnic foods and cultural practices that they were accustomed to may help reduce allergies in this population, according to the researchers.
“There is no definitive answer as to the cause(s) of the definitely noted increase in allergies in immigrant populations when they move to Western countries such as Canada. However, the pattern is real and needs to be analyzed”, says Dr. David Fischer, President of the Canadian Society of Allergy and Clinical Immunology (CSACI).
As first-generation immigrants to Canada, Dr. Hind Sbihi (picture below), Research Associate at the University of British Columbia, and Jiayun Angela Yao, PhD candidate at the same institution, became intrigued by allergy rates among newcomers and conducted a study to understand the role that genetics and environmental factors play in the development of non-food allergies, such as hay fever.
The researchers explain that in the past decade, the media, public and researchers have mainly focused on food allergies “It’s critical to raise awareness for non-food allergies given their high prevalence in our population, and posing a big burden to our health care system,” they add.
Canada has some of the highest allergy rates
This is particularly true because Canada has some of the highest allergy rates in the world. According to the American Academy of Allergy Asthma & Immunology, approximately 10-30% of the global population has hay fever. While in the United States roughly 7.8% of people 18 and over has this allergy, almost 20% of the population in Canada is affected by it. Considering these statistics, Sbihi and Yao wanted to understand if immigrants in the country would also display an increase in allergies.
“Our study highlighted the unique opportunity to investigate allergies in migrant populations, who are going through a natural experiment, in which the environment around them changes dramatically in a relatively short period of time,” they explain.
To conduct the study, the scholars used the data collected in the Canadian Community Health Survey, which gathered information about the health status, lifestyle habits and basic demographics of a large and representative sample of Canadians. In the survey, respondents were asked whether they had non-food allergies – diagnosed by a physician-, and whether they were immigrants to Canada and if so, their time since arrival. “We took the responses to these questions, and assessed the statistical association between non-food allergies and immigration status”, they say.
Following this method, the study found that only 14.3% immigrants who had lived in Canada for less than 10 years had non-food allergies, while the rates for immigrants over 10 years and non-immigrants were 23.9% and 29.6%, respectively.
These results suggest that environmental factors, such as pollution, levels of sanitization and dietary choices, carry more weight in the development of allergic conditions in Canada, Dr. Fischer explains, while Dr. Sbihi and Yao add that more research is needed to pinpoint what those factors are, and to better understand how allergies arise by country of origin.
They also highlight the need for undertaking multicultural strategies to improve newcomers’ health.
Ethnic foods may help
Dr. Sbihi and Yao add that it is also important to understand that allergies are symptoms of a loss of internal balance that results from a dysfunction of the immune system. “Providing immigrants with means to access food or cultural practice that are ethnically-friendly may help them transition smoothly into the new environment without perturbing their natural balance,” they suggest.
“Our best hope to curb the increasing trend in allergic disorders is to prevent it. Prevention can only happen when there is a good understanding of risk factors that come to play in the development of these disorders.” For these reasons, they suggest that raising awareness among health practitioners about the link between immigration, environment and allergies might help in their patients’ management.
“The main role for medical practitioners is to work with patients to recognize if they have allergies, to manage them acutely with their patients and if necessary refer them allergist if there is some doubt about the diagnosis or for more definitive management,” says Dr. Fischer.
Commentary By Dr. Nanah Sheriff Fofanah-Sesay
Female genital mutilation (FGM) comprises of all procedures involving partial or total removal of the female external genitalia such as the labia majora, labia minora, clitoris and other injuries to the female genitalia for non-medical reasons as defined by the World Health Organization (WHO).
Proponents of this act often engage in these behaviors to adhere to and preserve an ongoing cultural tradition that failed to take into consideration the dignity, physical trauma, emotional trauma, and human rights of young girls and women.
In a recent article titled SALWACE’s “imitated not mutilated” Campaign, the author/s referred to Bondo (a society for the performance of FGM) as “the recognition of adult women to choose what they want to do with their own bodies.” The author/s further describes the act of FGM as “labiaplasty” and “clitoroplexy” and other forms of “so-called female genital cosmetic surgeries.”
The Patriotic Vangaurd
ONE of the biggest sources of conflict between South Asian couples is the perceived over-involvement of in-laws. This belief that in-laws are “meddling” in the relationship is a perception that both men and women alike seem to feel.
In the book “Multicultural Couple Therapy,” Mudita Rastogi notes that in her counselling work with South Asian couples in the United States, it was rare for the couples to not mention in-law problems, and that it was common for them to cite the in-laws as the main source of the relationship problem. Women typically mentioned feeling judged or persecuted by in-laws, while men felt in-laws meddled in their relationship with their spouse.
NEW UBC research finds that many online resources for preventing Alzheimer’s disease are problematic and could be steering people in the wrong direction.
In a survey of online articles about preventing Alzheimer’s disease, UBC researchers found many websites offered poor advice and one in five promoted products for sale—a clear conflict of interest. “The quality of […]
As diet and exercise become increasingly prominent in Canadians’ lives, many Vancouverites have turned to yoga to supplement their fitness regimen. It is now the second most popular leisure activity in the country.
More than just a physical activity, yoga is also one of the most diverse spiritual traditions in the world, influencing numerous faiths…
By Dr. George I. Traitses If you are looking to lower your blood pressure, yoga might be the answer. A new study has found that yoga has countless benefits for people who have high blood pressure. The study was presented at the annual meeting of the American Society of Hypertension recently. By simply practicing yoga,
The Philippine Reporter
A program aimed at improving healthy living in the South Asian community – and being promoted in local temples – is catching on, thanks to the efforts of “wellness ambassadors” like Simon Fraser University co-op student Roman Bhangoo.
Developed by Fraser Health’s South Asian Health Institute, the Sehat program (Sehat [...]
WE all have bad days, even bad weeks. Life takes its toll on all of us causing occasional sleepless nights, changes in appetite and mood. But what if they persist and those symptoms are in fact the early signs of something more serious?
Often we dismiss the early symptoms of depression and anxiety disorders as […]
by Gayathri Naganathan in Scarborough
I was born at the Vavuniya General Hospital in the winter of 1988, in a town that is often referred to as the gateway to the northern Vanni region. As so many other families before us, we fled Sri Lanka during the civil war, amid death, destruction and uncertainty.
We arrived in Scarborough, Canada, in the early 90’s, in what would become the single largest Sri Lankan Tamil diaspora community outside of South Asia. I grew up speaking Tanglish (a blend of Tamil and English), eating string hoppers and spaghetti, and listening to A.R. Rahman and the Backstreet Boys.
In short, I am a ‘third culture’ kid, a blend of the home we left behind in Jaffna and the home we worked hard to create in Canada. So as a Canadian medical student when I was presented with the opportunity to spend several weeks training in any field and in any country around the world, the natural choice for me was to go “back home”.
Having spent over two decades away, I didn’t quite know what “back home” would mean on this first visit back. After months of phone calls, emails and planning, at the end of June, I arrived at the Jaffna Teaching Hospital, ready to start my five weeks of electives in internal medicine and general surgery. Unsurprisingly, I spent the first few days overwhelmed by the experience.
I have been volunteering, working, and learning in hospitals for most of my life. For most, hospitals are places that cause anxiety and stress, but for me, they are often a place of familiarity and comfort, somewhere where I feel engaged and useful. Despite years in this environment, the Jaffna Teaching Hospital felt foreign to me. The wards, the equipment, the staff uniforms, the very rhythm of the place was completely alien.
The most obvious difference was that everything was done by hand. There was not a single computer in sight. Having worked in a health system that is increasingly digital, this was a big change for me. I also soon discovered that patient records are not kept locked away in a filing cabinet at the clinic or hospital.
Rather, the patients themselves carry their clinic books, lab reports and even MRI scans to each appointment with them. While cumbersome and running the risk of losing documents, this system gives full autonomy to patients over their personal health records and also allows for the mobility of those records from one site to the next.
Despite (or perhaps because of) this system, the consultants (in Canada, we call them “attendings”) are able to see a massive case load in a very short period of time. This was most obvious on clinic days where upwards of 40 patients were assessed, treated, and dismissed and/or given a date for follow up, all within the span of two to three hours. It’s a whirlwind of papers shuffling, names being called, patients shifting in and out of the examination rooms, and notes hurriedly scrawled into clinic books.
I was equally stunned the first time I stepped into the casualty theatre – a carryover, it seemed, from Sri Lanka’s civil war, when trauma patients would flood into the hospital every day. Two tables, with one anesthetist each, for procedures that require general anesthesia.
All other procedures were conducted under local anesthesia on stretchers flying in and out of the large operating theatre. And, at the centre of it all, a group of dedicated and talented registrars and surgeons operate on everything from in-grown toenails causing infection to inguinal hernias, all using proper aseptic and clean protocols.
As a student, it was incredible to move from one table to the next and see so many different techniques and procedures happening simultaneously.
To me, this was controlled chaos. And this phrase echoed through my mind again and again as I proceeded through my weeks of training in Jaffna.
But beyond the differences, the language of medicine remained a constant thread to which I could hold. Human anatomy is the same the world over. And I marvelled as I watched my general surgery preceptor carefully reveal the facial nerves of a patient with a suspected tumour over his jaw bone. Like the branches of a tree, the branches of cranial nerve seven spread out across one half of the patient’s face, beginning to divide and separate just in front of the ear. It was like I was looking at a diagram in a textbook, the dissection down to the tumour was so precise and clean.
Acetaminophen too is the same all over the world. Whether we call it Panadol, Paracetamol or Tylenol, all three can be used to bring down a fever, all three can be used to relieve pain.
Though the medicine was fascinating, the most enriching aspects of this journey to Jaffna were the people that I had the privilege of meeting. From the patients, nursing staff, and fellow medical students to the registrars and consultants who served as my teachers and mentors, the people I met throughout my five weeks at the Jaffna Teaching Hospital made the experience unforgettable. They worked to bridge the cultural and linguistic gaps between us, provided thoughtful and insightful answers to my questions, and facilitated opportunities to practice clinical skills and learn new techniques.
What do you do, for example, with a patient with diabetic foot ulcers who can’t afford to buy shoes? Or having to label an otherwise medically fit patient as a “poor candidate” for kidney transplant because all such surgeries are done in the private sector and require hundreds of thousands of rupees to carry out?
I feel honoured to have had the opportunity to be a learner in Jaffna, and to speak to patients and practise medicine in my mother tongue, Tamil. I feel especially privileged to have met the dedicated, passionate, and talented physicians and medical students who propel medicine forward in Jaffna. Despite systemic barriers, low resources and a significantly complex patient population, they persevere, they innovate and they thrive.
As a teacher and friend from my general surgery elective in Jaffna so poignantly stated, “We have the resilience gene”. And I could not agree with him more.
Gayathri Naganathan is a second year medical student at McMaster University in Ontario, Canada. She is a daughter of the Tamil diaspora and a proud “third culture” kid.
-- Canada's economic development minister Navdeep Bains at a Public Policy Forum economic summit