Posts Tagged: iora health

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This is a question that we hear constantly at Iora Health from investors, Care Teams, and especially from electronic health record (EHR) vendors. Why not buy an EHR off the shelf? Why not work with another developer to build what we want? The short answer is, prior to Iora, Rushika Fernandopulle, MD, MPP, CEO and co-founder of Iora Health, tried all of the above; he and Neil Patel, MD, published a paper detailing their poor experience with eClinicalWorks in supporting the type of care we have at Iora today. So with this in mind, why build our own EHR (or as we call it, Collaborative Care Platform) to which we affectionately refer to as Chirp?

Simple. No one else has built what we need and here’s why:

  1. Other systems are too focused on billing, coding and encounters. Modern EHRs are abstractions of the paper record, with an innate focus on a given encounter and the notes/billable claims derived therefrom, rather than the clinical story of a patient.  Each time a patient and doctor meet, every piece of information must be documented in a way that a third party reading it could understand the patient in their entirety. The most crucial elements of care, anything that occurs outside of a visit, any synthesis done by providers, or any changes over time, are effectively lost in the modern EHR.
  2. We lose the story and the relevant data. Within EHRs, data is either too structured, with infinite checkboxes replacing sentences, or insufficiently structured. For example, errors such as a patient’s son who has been listed as seven years old for the last five years are easily overlooked amidst the clutter of the traditional EHR. This structure results in a jumbled patient story, no ability to analyze clinical data, errors propagated with each copy, and a worsened chance of making good clinical decisions.  

OK. How is Chirp different?:

  1. Chirp is designed to support a clinical team that cares for a population of patients. By first emphasizing communication about the administrative aspects of health care (faxes, follow ups, lab reviews, check ins, etc.), teams are able to accomplish everything necessary for their individual patients within one workflow. Chirp shifts us away from encounter-based care, hunting through multiple software systems, toward a work task structure, so that the care of a population can blend in seamlessly with an otherwise busy clinical day. Teams can spend their time in relationship-based primary care, rather than in an endless stream of seven minute visits. Other EHRs have the care of individuals and populations as two separate systems for two separate audiences and completely miss that a population is comprised of individuals who need care.
  2. We need the ability to innovate constantly. The Iora Clinical Model is always evolving. Decisions that made sense in 2012 make less sense in 2016 as we grow and learn. With a third party product, we have no hope of convincing someone else to build what we need. With our own software and amazing team, we have the ability to test things and move forward with changes in real time based on real world experience. This process replaces the slow, usually inaccurate, large changes done in one sitting to a software platform.

At Iora we are building an entirely new model of care delivery; we have been able to innovate payment, team composition, physical space, workflows and of course, our software.  It is the ability to grow all of these elements at once that has led us to create a model of care that lets us truly connect with our patients and help them solve their problems, each and every day. Chirp is a vital part of the puzzle that makes that possible.

Health Coaches, Cori & Audra

Medicine Coupled with Compassion

Modern medicine is incredible. We can give you a pill and lower your cholesterol, give you a pill and lower your blood pressure. We can set a broken bone. We can save lives; we can extend lives. We can fix so many problems. It’s totally amazing.

But then there are all these health problems that biomedicine doesn’t have a quick-fix pill for. There’s no pill for loneliness, and it’s a common problem that definitely affects your wellbeing. There’s no quick answer for losing weight, or getting fit. Balance is a really important issue at our clinic. So many of our patients are afraid of falling and feel unsteady. There’s often not a quick fix for improving balance. I think that most of the time, when it comes to health problems like these, patients are kind of left to go it alone. Part of the health coach role is to support patients with problems that take more time. No doubt they have to put in the legwork, but they don’t have to do it alone.

Sometimes the role of the health coach is just to hear the patient and understand what they’re going through. At the Shoreline clinic we have two patients named Dan and Mary Ann. They have been married for a long time. And it is really obvious when you meet them that there’s a lot of love. They just have a very kind way of interacting with one another.

Dan was diagnosed with Alzheimer’s disease at a fairly young age: in his mid-sixties, which was devastating for Mary Ann. And this last year was particularly hard because Dan’s condition worsened quite rapidly. And as it worsened Mary Ann had to take on more and more caregiving responsibilities.

Audra is a health coach who works in Shoreline with me: Mary Ann and Dan are on her patient panel. For any of you that have been caregivers, you know it can be really taxing work. At one point Mary Ann was sending emails to her health coach, Audra, nearly every day. Often Audra would have really solid advice for her, or something tangible to offer. With the support of Dr. Levine and Debbie Yoro, our clinical social worker, the team provided care that was so far above and beyond the status quo. But sometimes Mary Ann would come to Audra with problems that didn’t have a clear answer. When this happened Audra would just hear her out and be there with her. What resulted was really special. Mary Ann developed a very trusting relationship with Audra and the care team as a whole. It was clear that Mary Ann felt like we were on her side: that we were a team. She knew we had her best interests at heart.

There’s no cure for Alzheimer’s disease. But what is so great about the Iora model is that it recognizes that, yes there is value in fixing people’s problems, but there is also so much value in helping them cope when their problems can’t be fixed. Mary Ann sent us a note recently and it included a quote from the poem ‘Kindness’ by Naomi Shihab Nye. It read, “Then it is only kindness that makes any sense anymore; only kindness that ties your shoes and sends you out into the day.” What I love about Iora is that it’s not just medicine. It’s medicine coupled with compassion. It’s difficult to measure the value of human compassion in medicine. But when you hear stories of real human experiences, it just intuitively makes sense. The care that is provided at Iora is so exceptional partly because we recognize the value of the healing relationship and actively work to foster meaningful connections.

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A part of something bigger

What led me here to Iora? That’s an interesting question. Healthcare was never interesting to me. I went to school for filmmaking and the only real thoughts I had of the health system was that it was expensive. I avoided doctors and hospitals like the plague. Being healthy, I could get away with that.

Then, life changed. I met my husband, a type 1 diabetic, and about nine months later, my video editing job came to an end. After several months of hard thought I realized that while I was pretty good at filmmaking, it wasn’t the right place for me. Not knowing what was, I took a job doing accounts receivable at a Skilled Nursing Facility.

Work was disheartening. I watched families struggle to try and figure out how to pay for rehab and long term care. I called 85 year old widows on social security to tell them they owed money for their time with us while they were trying to figure out how they were going to pay to heat their house that winter. And the worst was the sad realization that the work wasn’t about what was right for the patients, but rather what was best for the facility.

And it was just as disheartening on the personal side. There was a lack of communication between my husband’s doctors. We had little to no support in general, especially when we had to figure out how to do what the doctors prescribed. While his primary care doctor was better than most, she didn’t have the time to spend with him or with his specialists that would have been truly beneficial. We felt like numbers, not names and certainly not people.

We are told from a young age that we can do anything we put our minds to; that we can change the world. But on so many levels, at work and at home, it felt like I was constantly swimming upstream, with someone telling me why we couldn’t do something, why some change or another wouldn’t work. Just three years out of school and I had stopped believing that change was possible.

The spring after we got married, I started looking for a new job. I stumbled across an administrative/finance position at Iora Health. While I had no interest in continuing in healthcare, I needed to pay my bills. Honestly, I didn’t expect much, but when I read the company description, I felt an immediate connection. You could feel the honesty in it. These people believed they could change things.

I applied for the job knowing that I could do about half of what they were looking for, and that I could learn the rest if someone was willing to teach me. I never expected that I would actually get a call, but the next day I received an email asking for a phone screen. After talking to Paul Dufault for a half hour, I was hooked. I dug up everything I could on Iora (which wasn’t much beyond the The New Yorker’s “The Hot Spotters” article), and the more I read, the more excited I got. As the interview process progressed, I realized that I wanted this job more than I’d ever wanted any job. What they were doing made so much sense to me. I never thought about the fact that it was a start up or that in six months I may not have a job, or that they could fail. It didn’t matter to me; I wanted to be a part of this.

When Iora’s Chief Operating Officer, Zander Packard, told me that they wanted to hire me but they weren’t sure when they could bring me on, I told him I would wait. We set up a time to check in in a few weeks. That was in March of 2012 and I started in May and haven’t looked back since.

The past three years have been an incredible journey. I’ve watched the company grow from 30 people with two practices in two states, to 150+ people with 12 practices in seven states. I’ve grow in leaps and bounds as my role evolves. I’ve done everything from ordering lunch and scheduling meetings, to writing company policies and creating processes. I found a company that believes that if you do the right thing, the rest of the pieces will fall into place. The bottom line is important, but it’s not the first thing.

Margaret Mead once said “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.” I never felt that this was a truer statement than I have working with this amazing group of people at Iora Health.

Scott Jacobson

One Coffee at a Time

The work we do is challenging and sometimes it is easy to succumb to feelings of doubt, thinking that all our hard work is in vain. However, there are examples that highlight the difference we make. One such example is one of our Health Coaches, Vero’s, most challenging patients.

She is a 23 year old patient. When she came to us it was clear that she was suffering. She has type 1 diabetes, difficult enough for a young adult to handle yet she also suffers from ulcerative colitis. After an extended hospital stay and major bowel surgery, she was left with an ostomy, a difficult situation for anyone and particularly debilitating for a 23 year old.

Her surgeon told her she would have to get her sugars under controlled before they would reverse the ostomy. Dealing with an ostomy bag was not only a hindrance on her social life, it limited her job opportunities.

Not surprisingly, she also suffered from major depression which became a compounding factor in managing her multiple medical problems. She tried talk therapy but never really felt comfortable opening up. Antidepressants didn’t make a dent. She was mired in despair and despite our efforts to engage her in managing her blood sugars, Vero’s texts often went unanswered. We knew she would spend days in her room, crying and isolating herself. She would frequently break down while at work. We begged her to come in to talk to us.

Finally, one day without prompting, she did. We could tell she was on the edge and didn’t know where to turn. She had decided to put her trust in us as a last resort. She opened up to us and all her emotional and physical traumas began to trickle out. It was a very emotional meeting and it was only the beginning. We offered more therapy from a professional, but she really just wanted to talk to her Health Coach. We decided that coffee with Vero every other week would be a start. She left that meeting only a step back from the edge but she was moving in the right direction.

And then, Vero received a gift of beautiful flowers.

One Coffee at a Time Vero

The note reads:

I HONESTLY WANT TO THANK YOU FOR EVERYTHING THAT YOU HAVE DONE FOR ME EVEN THOUGH I AM A PAIN IN THE BUTT I’M SO GRATEFUL THAT YOU HAVEN’T GIVEN UP ON ME YOU TRULY ARE A GODSEND

Over the past couple of months Vero’s coffee meetings have been a huge success. She has shared some of her deepest secrets that have clearly been weighing her down and blocking her from moving forward. She has felt comfortable enough to establish care with Nina, our social worker, so she can get the trained help she needs in dealing with her significant past traumas. From a medical standpoint we are still working on her sugars with the goal of reversing her ostomy. She is by no means a picture of health, but we are taking baby steps, in the right direction.

This patient has been a huge reminder to me that despite the monumental task we have in front of us, we do make a difference in people’s lives, everyday. Because of the unconventional resources we have to help us connect with our patients, we are able to continue to find creative ways to make breakthroughs and put our most challenging patients on the track to leading healthier and more fulfilling lives. I know that there are times we feel like no matter how much we try to help our most challenging patients, that they can’t or won’t change. It is so wonderful to be reminded that by showing our patients that we truly care about them and that we won’t give up on them, our positive attitude can have an impact. Great job Vero!

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Commonality: finding the common threads

Commonality is the state of sharing features or attributes. It’s an amazing thing when that is found when providing a patient care, care they deserve. In October 2013, I remember sitting around the table in room seven at the Culinary Extra Clinic, Iora Health’s first Las Vegas practice that sits in the Stratosphere’s shadow. Every stakeholder was represented at the table: a very sick patient with multiple acronyms using most letters in the alphabet, a sponsor, a primary care physician and a clinical health coach. Each was there realizing this was the most important thing they could be doing at that time.

Let’s go backwards to go forwards. This patient is under 40 years old and is trying to get their second kidney transplant. They quickly became very ill and it was determined the right course of action was to send them to the emergency department. However, an even better course of action involved a direct admission. Direct admissions need cooperation and communication with the admitting physician, all hospitalists and sometimes sponsors.

The roundtable discussion on that fall day allowed the patient to raise concerns with yet another hospitalization. It allowed the health coach, who had the closest relationship to the patient, to provide an additional voice for the patient and advocate for their needs. It allowed the physician to make a sound clinical decision. And, lastly, it allowed the sponsor to witness all of this and provide input.

Everyone at the table had a voice. While it is not uncommon for physicians and sponsors, especially if they are benefit administrators or the insurance company, to have a voice, let’s be honest, at times they may have too much of a voice, too much to say, chastising patients for poor choices and/or costing the system too much money. But what if we all started to sit around the table and voice our questions, comments and concerns. What if the common theme or commonality amongst us is cooperation and communication? How would that change things? How would that change health care and restore humanity to that end?

These are all things to think about, to contemplate. While we do that, please, let us find the common threads amongst us: the desire to be heard, to be cared for and to be respected.