Patient Flow Enewsletter
Volume 1, Issue 4
Tuesday, March 2, 2004
Coordinating health care services through a network of 11 acute care hospitals, six diagnostic and treatment centers, four long-term care facilities and more than 100 community health clinics is a daunting task. The challenge is made all the more complex when the patient population speaks more than 100 different languages and dialects. That's the situation facing administrators at the New York Health and Hospitals Corporation (HHC). HHC provides medical services to New York City residents regardless of their ability to pay, treating more than one million patients a year just in its emergency rooms.
Dr. Benjamin Chu is the president of the Health and Hospitals Corporation. Born and raised in Manhattan, Dr. Chu has long been interested in analyzing how even minor system changes can have dramatic results on patient care. Having previously worked in emergency medicine, Dr. Chu says the willingness to experiment with health system change is a job requirement for both hospital administrators and effective ED staff.
In New York City, where 40 percent of the population is foreign-born, and nearly one in 10 kids has two foreign-born parents, tinkering with the health system requires careful consideration of how to make it most accessible to people with wide social, ethnic, linguistic and cultural differences. Dr. Chu has increasingly turned to technology to help improve speed and quality at New York's public hospitals, and is even exploring how technology can help HHC staff bridge the legendary communications gap between patients and care providers.
Interview: Benjamin Chu, M.D.
Q. You've spent a good part of your professional career in and around New York emergency departments. What in your opinion is the current state of overcrowding?
I think the flow of any emergency department is inherently touch and go, but in New York, I actually think overcrowding in the ED is improving. It's certainly nothing like the late 80's, when we found ourselves struggling with the crack epidemic, AIDS, tuberculosis and federal downsizing of mental health and social service programs all at the same time. Serious overcrowding is really only happening in two of our EDs right now, and it seems to be mostly caused by demographic shifts. Both hospitals are in communities that have experienced a huge influx of new immigrants. Before these immigrants get settled and find resources in their community to address their health care needs, they have nowhere to turn but the ED that is in their neighborhood.
Q. You've been very successful in enrolling many uninsured residents in public programs. How have you done this?
We knew that the best way for us to manage our uninsured patients was to try to figure out if there was any way for us to get them covered. I know it sounds simple, but it's actually not so easy, so we made it a primary goal. Our emphasis has been on using every public insurance program in New York state, plus our own municipal programs, to enroll as many people as possible. Our entire system is engaged in the effort to facilitate insurance enrollment, and we have partnered with many community organizations to work with us in this challenge. This massive effort has shown impressive results. Since 2000, the number of uninsured patients using our facilities has been reduced by almost 20 percent. Getting our patients insured has allowed us to better manage their care, including enhancing their access to preventive, primary and ambulatory care. In fact, we've been able to increase primary care visits by more than 70 percent in 10 years, and ambulatory surgery visits by 100 percent.
Q. Your colleagues often credit you with a genuine eagerness to embrace technology to maximize efficiency. What is HHC doing?
For a long time we've been very committed to investing in technology systems that help provide our clinicians with quick, comprehensive information about our patients. Investing early in an electronic medical record system has certainly made a big difference in our ability to be more efficient and increase quality. It's all based on tracking outcomes and the premise that providing clinicians with the sum total of information about patients who are alike will lead to healthier patient populations. We're currently working to aggregate the patient information we have in individual records on one data platform that allows us to retrieve on a population basis all lab, pharmacology, vital signs and other information on our patients in seconds.
As a result, health information on 1.2 million patients a year can be compiled, and we can begin to characterize those patients and look at specific interventions, trends and outcomes that might better meet their health needs. We're doing a lot of work with this right now to manage chronic disease, like diabetes, congestive heart failure, depression and so on. It makes sense - doctors' experiences are episodic and one-on-one; they can't possibly track and retain information on all of the patients and put the pieces together instantly. We're repeatedly seeing that reviewing how populations of patients are doing with respect to specific outcomes on an aggregate basis helps us to better target resources and improve those outcomes.
Q. Given that you run a public hospital system in a metropolis facing a severe cash shortage, how do you make the case for investing in technology?
With persistency, focus and a lot of luck. We've been at this for 15 or 20 years now, and all of the staff has completely bought into the concept. Once people understand how much more effective you can be, as well as understand the power of better documentation, it's a fairly easy sell. We also looked for opportunities for funding. For example, we took advantage of a state mandatory Medicaid waiver program, got significant money from that, and then applied a lot of that funding to pay for technology.
Q. You treat the most diverse patient base in the nation. What are you doing to bridge the inherent language barriers?
We're working with diverse populations and dynamic communities with more than 100 languages and dialects. This is a challenge that is nearly impossible to stay on top of, but we are doing a number of things. Most importantly, we locate our facilities in immigrant areas, so that they become part of the fabric of the local community and serve as an employment center for the community. That's very important because it allows us to attract an employee base that reflects the community and speaks the appropriate languages for the patient pool. This doesn't happen overnight, but it happens eventually, and our employee base has become much more diverse because of it. Even though we have translators on board at all of our hospitals, there are never as many as we need, so it's helpful that our employees can serve as informal translators for our patients and their families. In addition to our staff translators, we use a lot of volunteers and, increasingly, translation technology.
We're actually experimenting at two hospitals with simultaneous translation equipment that is similar to what the United Nations uses and provides real-time translation between clinicians and patients. (See description of Team/Technology Enhanced Medical Interpreting System). We also recently launched a website for people with limited English proficiency. All of our forms - including health care proxy and patient care information forms - are available and translated, along with hyperlinks to other limited-English-proficiency sites. We're working on a system where our computer-generated medication information will print out with labeling and pharmacy instructions already translated into the appropriate language. And we're piloting the use of multi-language translators who guide patients through the entire process to see how it affects efficiency and outcomes.
Q. How do you work with the community on your programs?
In a system like ours, you can never have enough people - it's hard to treat patients when you don't speak the same language - so we try to work closely with the community as a bridge whenever we can. We still need to find different ways to engage the community, but we're making progress. We have our own community advisory boards throughout New York with public health groups, members of the community and local politicians. They all have a vested interest in making sure the hospital is thriving and meeting patient needs, and they help us develop linkages with community-based organizations that can help us reach the patient population. We also work closely with community health centers to facilitate enrollment and get patients enrolled in appropriate health insurance programs, if at all possible. Faith-based groups and churches have been a big help with this, as well as with promoting screening and other disease prevention programs. I'm looking forward to working more with the business community, which can help us in many ways, including building a philanthropic base of support.
Q. What do you believe the lasting value of a program such as Urgent Matters can be?
I think the nice thing about the Urgent Matters program is that, because it's working with institutions located in different settings and facing different circumstances, it can actually help a very wide range of institutions that are suffering from ED inefficiencies and overcrowding. There are different strategies that can be effective at improving through-put and determining how to efficiently get patients from the emergency room to wherever they need to be, and this program is helping to identify and define evidence-based, reliable strategies. Such a program gives all of us new ideas about possible directions to pursue and helps us to learn from each other.
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Ben Chu, M.D.
President
Health and Hospitals Corporation
New York, NY
