State of the research on online patient portals

By Courtney Lyles, PhD

My main area of research over the past few years has focused on getting diverse patient groups to engage in accessing their medical record information online, through websites called online patient portals that are linked to electronic health record systems in hospitals/clinics. Portals typically involve allowing patients access to viewing their test results, visit summaries, and sometimes emailing with providers. Because most healthcare systems (with the exception of places like Kaiser) have only just recently created these portal websites as a part of the Meaningful Use certification process, there is a huge need for research studying their use and effectiveness. 

This post includes my thoughts about what we know and don’t know from the research to date, especially in light of two recent systematic reviews on 1) the effect of portals on outcomes  and 2) how patients with chronic disease and their providers view using an online portal.  (Apologies in advance that it is a very research-specific post!)

Achieving Health Equity is Risky Business: Secondhand Smoke and Vulnerable Populations

By Dean Schillinger, MD

The constructs of “vulnerable populations” and “vulnerability” have increasingly gained a foothold in the fields of Clinical Medicine, Genetics, Epidemiology and Public Health.  Vulnerability, outside of the health context, is broadly defined as susceptibility to attack or to physical or emotional damage. In Public Health, vulnerable populations are typically conceptualized as culturally, economically, geographically or socially defined groups who experience health disparities in relation to a pre-defined dominant (e.g. less vulnerable or invulnerable) group. In Epidemiology, however, vulnerable populations are characterized as groups who experience “greater risk of risks.”  This framing of vulnerability acknowledges that (a) health or illness is often a result of social risks that give rise to environmental exposures (or risks), and (b) these social and environmental risks compound one another to generate a higher and higher risk of being exposed to a causative agent, either at one point in time, or over the life course.

A Trip to Rikers Island: The Community Aging Health Project and Aging Criminal Justice Populations

Geriatrics may seem tame, but so far it has taken me to SF County Jail and, recently, to Rikers Island. 

I and several other geriatricians were hosted by the medical services and the Deputy Medical Director, Dr. Zachary Rosner, our guide through multiple checkpoint and buildings. With this crew of geriatricians, we spent a day and a half doing trainings for about 30 health services staff and 30 correctional officers as part of Dr. Brie Williams' Community Aging Health Project (CAHP).  We did hands-on exercises on geriatric syndromes such as hearing and vision loss, dementia, incontinence, medication issues, mobility impairment and assistive devices, and we even taught exercises for inmates to do in their cells to prevent falls. We helped them think about critical issues, such as when “behavior” could be a sign of dementia, or failure to follow an order may be a sign of hearing loss.

There is no corner of U.S. society that is not affected by growing numbers of older adults in our population.  This includes jail and prison populations. While the US population saw a doubling of adults over 55 years old from 1990 to 2009, in prisons the number more than tripled.  

This presents problems for many who serve criminal justice-involved populations.  Older criminal justice populations have more chronic health conditions and different social service needs. Functional impairments can impact their ability to care for themselves independently, inside and outside of correctional environments. On all fronts-- "inside" and "outside"-- the need is growing for geriatrics training and sensitivity.

Dr. Willams has made this need her mission. CAHP, supported by Tideswell at UCSF and the Langeloth Foundation, developed geriatrics training for a spectrum of professional networks that face the reality of an aging criminal justice population-- social workers, correctional offers, police, and jail and prison health service providers. They have already delivered many trainings across California to jail and prison health services staff, correctional officers, and SF police. 

Rikers Island was the first dissemination site.  “The Island” is New York City's main jail though it is actually a huge complex of buildings, accessed by only one bridge.  It has many buildings; one is a woman's facility ("Rosie's") and the rest of the 10 jails are for men.  Rikers also has an extra prison on a barge that is floating just off the Bronx.  All in all, they house over 11,000 people a day.

On top of our trainings, we were able to see the Geriatrics housing unit with a capacity for 30 men over 50 years old.  At the time we visited they were all lying in bed.  The communal room was not open and dinner was not yet served (at about 4:30pm to mirror the 4:30am breakfast).  One older gentleman who appeared about 80 listened quietly to something on his headphones and several others greeted us and briefly asked us for medical advice.  One of the biggest problems: the low toilet seats and wet floors in the communal, one-room bathroom.  It was hard to get on and off of them and even scarier to contemplate a serious fall.  They can have canes, but not walkers or wheelchairs in most units (one medical unit allows these if needed).  The policy varies across jails and units, but even a raised toilet seat, a common remedy in the community, could be a weapon here. For mobility and frailty issues, no solutions are simple or obvious in a correctional setting.

We also saw the women's jail and attached clinics (medicine, specialty, dentistry) and infirmary where sicker inmates are housed.  Among the women there was one, just over 50, who described myriad medical problems, including a wound that was so difficult to heal she had been in the infirmary for weeks.  Another approached us to ask about what could be done for her- she fell on a wet floor after a property search left debris and food on the ground on her unit, and she said she still did not know what was wrong with her back. 

After our visit, we all agreed that the staff and officers were one of the most engaged group of people we had ever trained.  While Rikers is a huge place, and the aging of the population will continue to put huge pressure on their system, I feel hopeful that this training made an impact and may help this particularly vulnerable and incarcerated population.

Photos: 
1) Tim Gruber (http://www.motherjones.com/politics/2012/09/massachusetts-elderly-prisoners-cost-compassionate-release)
2) Rikers Island, wikipedia: http://commons.wikimedia.org/wiki/File:USGS_Rikers_Island.png#mediaviewer/File:USGS_Rikers_Island.png

by Anna Chodos, MD

Nutrition and the Tax Code

By Hilary Seligman, MD & Marydale Debor, JD

On December 31, 2014, the Internal Revenue Service issued the long-awaited final ruling implementing Section 501 (r) of the Patient Protection and Affordable Care Act of 2010 (ACA). This section of the Internal Revenue Code deals with the conditions hospitals must meet in order to retain their nonprofit health status.  In an exciting development, this new code directs attention to the elimination of “root causes of disease,” especially among medically underserved, minority, and vulnerable populations.

Martin Luther King Day, 2015

By Margaret Wheeler, MD

For this Martin Luther King Jr. Day, in the fiftieth anniversary year of the Voting Rights Act and the Selma to Montgomery March, it is hard not to draw comparisons between those days and ours.  

Prostate Health Support Group for African American Men

By Nynikka R. A. Palmer, DrPH, MPH

Prostate cancer among African American men is one of the most intractable cancer disparities. African American men bear an excess burden of prostate cancer across all stages of management, including presentation, diagnosis, treatment, survival, and quality of life.

On point: Broadening pain management options with acupuncture

By Maria T. Chao, DrPH, MPA

As I think about the year ahead, one change that I’m really excited about is the prospect of acupuncture for patients at San Francisco General Hospital (SFGH). In the US, pain management is the leading reason that patients seek care from acupuncturists. Acupuncture utilization has increased by 50% over the past decade, but is not commonly used by non-Asian minority populations and those with limited income. Barriers to use include high out-of-pocket costs and limited access to services.