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.
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I have had the opportunity to visit many countries and regions of the world. I lived in America for more than forty years. America is like a miniature version of the world. There are communities from every country and region living in America. Therefore, I had opportunities to interact with almost all different communities. Every year, we hosted Diversity Day. Hundreds of people belonging to different communities came to our farmhouse. From this extensive interaction with diverse communities, I got the impression that Punjabis are one of the unhealthiest people in the world.-- Delivered by Feed43 service
In my experience, the body is like an onion, with layer upon layer of past history beneath the visible surface. What does this mean?
Let’s start at the beginning, with a pregnant mom. Like many pregnant women, this mom has lower back pain. Unbeknownst to her, the baby’s head got stuck in an odd position in the pelvis. Labour is long and painful, and the doctor eventually resorts to using forceps to pull the baby out. The baby seems okay and everyone breathes a sigh of relief.
Commentary by Rohit Phillips in Aurora, Ontario
The fast-growing multicultural consumer segment of Canada represents a potential opportunity for pharmaceutical companies, especially if they can improve patient outcomes on a national scale.
For a small or mid-tier drug company battling to make headway in the general market, capturing a large portion of the multicultural market may be the path to improved profitability and growth.
Ethnic (or “Diversity”) Healthcare is all about the ‘culturally sensitive connection’ to effectively address ‘health and healthcare disparities’ that result from cultural differences. These differences influence the health and well-being of Canada’s growing visible ethnic minority population, which made up to 20 per cent of the total population in 2013 and is projected to grow to 32 per cent by 2031.
Fifteen years from now, it’s projected that visible minorities will make up 63 per cent of Toronto, 59 per cent of Vancouver, 31 per cent of Montreal. Together, these three areas will account for 70 per cent of Canadian GDP.
Genetic, Environmental and Cultural Factors
The factors contributing to varied drug responses are complex and inter-related. Differences in drug response among racial and ethnic groups are determined by genetic, environmental, and cultural factors. These factors may operate independently of one another, or they may work together to influence outcomes.
Biological Factors: The genetic makeup of an individual may change the action of a drug in a number of ways as it moves through the body. Clinically, there may be an increase or decrease in the intensity and duration of the expected typical effect of the drug.
Environmental Factors: Diet, climate, smoking, alcohol, drugs, pollutants —may cause wide variations in drug response within an individual and even wider variations between groups of individuals.
Cultural Factors: Cultural or psycho-social factors, such as the attitudes and beliefs of an ethnic group, may affect the effectiveness of, or adherence to, a particular drug therapy.
Being Culturally Sensitive
Multicultural marketing isn’t just attaching a face to your campaign.
It has more to do with presenting information in a culturally relevant way and context. Isn’t all communication and marketing about better connecting with the audience?
So, what aspects of any ethnicity do marketers and advertisers need to understand to connect their brand messages well?
Here are a few important ones:
1. Language: It’s not just about translation from English. The message must be written for and from the perspective of the minority language audience. Health promotion communication should also take into account the visual and oral cultural cues, like pictures and music.
2. Beliefs: Beliefs can be powerful forces that affect our health and capacity to heal. Whether personal or cultural, they influence us in one of two ways – they modify our behaviour or they stimulate physiological changes in our endocrine or immune systems. Many cultural beliefs have implications for healthcare, which may be direct or indirect.
As an example, many Asians believe that the number four is unlucky because when pronounced in Japanese or Chinese it sounds very similar to the word for “death”. Thus, items arranged in groups of four, such as pills or syringes, can symbolize bad luck for those people who believe in numerology.
3. Behaviours: Culture has a bearing on the way a person acts in response to a particular situation. Buddhist teachings emphasize ‘’face’’ or dignity. An individual’s wrongdoing causes the immediate family to lose face. Such behaviours have a direct bearing on disease screening and diagnoses as patients may not admit or realize they have health problems, especially mental health problems, as this may bring shame upon their family.
4. Communication style: Refers to ways of expressing oneself to others and can be very different for a Chinese-Canadian compared to an Indo-Canadian. Older Chinese patients tend to be polite and may smile and nod. Nodding does not necessarily indicate agreement or even understanding of medical facts. Understanding of verbal and non-verbal communication styles of these cultures is critically important during screening, diagnoses and outreach programs.
5. Notions of modesty: Modesty is highly valued in South Asian culture. An example is an elderly woman who may be soft-spoken and not advocate for herself. Important decisions are made in this culture only after consulting with family members or close family friends. Involving the family and friends in intervention/prevention programs and long-term care for specific ailments like diabetes, cardiovascular disease and cancers can go a long way in increasing compliance, raising awareness and generating brand loyalty.
Despite the many differences among the cultures that make up our nation, we all have the same basic needs: to be able to convey the symptoms and concerns of an illness, to receive competent care, to be acknowledged and valued.
A few fundamentals
When conducting situation analysis and a SWOT analysis of your business plan, the following are important for success:
· Explore implications of demographic changes (regional and national)
· Segment patient population by ethnicity
· Identify differences in disease incidence (determine if your product treats a condition in which a health disparity exists between the ethnic and general populations. For example, is mortality different among ethnic groups in your disease category?)
· Examine the growth patterns of your customer base
· Find out from physicians and managed care organizations what issues they encounter in an increasingly diverse population. Then identify challenges and opportunities your company can pursue
· Find out what your competition is doing to serve the needs of the “emerging majority”
Rohit is a seasoned healthcare marketing and advertising professional with an entrepreneurial instinct and a degree in pharmacy. Rohit is currently employed with The Gibson Group, a healthcare communication agency in Canada.
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-- Canada's economic development minister Navdeep Bains at a Public Policy Forum economic summit