Can a more advanced patient portal improve face-to-face visits? Appointments are often so jampacked with questions, screenings, and taking notes that it’s increasingly difficult to analyze patient data and provide insightful, in-the-moment guidance. Shasta Community Health Center bet that a revamp of its patient portal could enable patients to take a more active role in their care while also improving provider workflows. In this episode, we discuss how staff, patients, and other key stakeholders all collaborated on retooling and expanding this platform.
Listen and subscribe to our podcast on Apple Podcasts, Spotify, and elsewhere. Below is a transcript of the episode, edited for readability.
EPISODE TEASER / Charles Kitzman (guest)
“From an administrative perspective, I wanted to use portal very specifically to remove what I consider… I call it “noise” and I’m using air quotes, but “noise” from the face-to-face encounter. And that includes the front office process, as well as the back office. … I fundamentally felt that if we could build a lot of these screening tools, and then deploy them to the patients well in advance of their appointment, that the data can be in the chart at point-of-care with no effort on behalf of the clinical team. Further, if it’s already there, we can integrate it into the pre-visit planning. And so they really know ahead of time what they’re getting into, what they can address. They can triage what’s important for the patient and then address it accordingly. And that’s the goal.”
Jessica Ortiz (host):
I’m Jessica Ortiz with the Center for Care Innovations. Today, we’re talking about one of the exciting projects that Shasta Community Health Center has been working on for the past eight months. Our hope is that by sharing the highs and lows of this digital health solution, safety net organizations can apply the lessons learned to their own challenges.
Jessica Ortiz:
I’m here with Charles Kitzman, a member of our Tech Hub learning network, which is comprised of 14 tech-forward California based community health centers, clinic coalitions, and primary care departments in county health systems that are working to accelerate the adoption of innovative technology. We partner with our Tech Hub members to vet, pilot, evaluate, and spread innovative digital health solutions, targeting Medicaid markets and historically underinvested communities. We are excited to bring you this story today.
Jessica Ortiz:
Charles, can you tell our listeners a bit about who you are in your organization?
Charles Kitzman:
Sure. First, thank you, Jessica, for letting me talk with you today. My name’s Charles Kitzman. I am the Chief Information Officer at Shasta Community Health Center in Redding, California. I’ve been at this post for just over 15 years, which is really strange to me, but time flies when you’re having fun. I was originally hired to take the organization live on electronic health records. I was hired in September of 2006, and we went live in May. And they decided to keep me around, and then in 2010, the board decided that with this increased reliance on technology and digital health data, that they really needed a chief information officer. And so I applied for it and I’ve been here ever since.
Charles Kitzman:
And it’s been a huge honor. I love working here. We’re a larger primary care delivery system – arguably the largest in 50 miles in any direction. So we also serve as a specialty hub for many of the rural and frontier clinics that are out in some of the less populated counties like Lassen and Modoc. My background is really in education, in the humanities. That’s what I studied as an undergrad. I do have a couple of master’s degrees, one in clinical informatics from Northwestern. I have an executive MBA from UCLA, and then I’m very, very close to finishing my third, and hopefully final, master’s in health administration from A.T. Still University.
Jessica Ortiz:
Thanks Charles. We’re really happy to have you. We’d love to hear more about your project. Where did you get started?
Charles Kitzman:
I think it’s important to kind of set the table just in terms of timing and context. We’ve had a portal for about a decade, and the platform that we were on was being sun-setted, and our vendor made that widely known and allowed us enough time to prepare for it. During that time, the vendor had purchased a platform and they were in the process of retrofitting it to be interoperable with their platform. We have a solid relationship with our vendors, so we signed up. And in the second phase of implementation, it became very clear to me that they still had considerable work to do. Some of it in my judgment needed to be reverse-engineered, and it created too much of a burden and I didn’t want to have a moving target for a project like this.
Charles Kitzman:
So we decided to back out that arrangement to allow the vendor more time to optimize that platform. That was completely my call and my team’s call. And then we surveyed the landscape – the Center for Care Innovations is great for being able to look at what other people are doing and what tools they’re using and what their experiences are. And so that was one resource we went to. The California Primary Care Association – it has a HIT Care network comprised of mostly CIO types within California –that, too, is a nice forum for sharing ideas and information. So we decided [to back out of the arrangement] because we were unsure of how long we were going to need this stop-gap platform, we’d just signed a one year contract at the time.
Charles Kitzman:
We wanted to be fair to the vendor, give them the opportunity to be successful with their work, and then we also wanted to see what these other vendors had. And so we chose InteliChart’ they have quite a few FQHC clients. They also are vendor-agnostic, which we liked, because when a company is that flexible, you know that they’re developing good tools that don’t take you down rabbit holes that are proprietary or something like that. So that’s why we made the change. We partially were forced to do it, and then it was a judgment call just on the quality of the platform.
Charles Kitzman:
InteliChart excited us for a number of reasons. We had been vetting another intake program called OTech for the patient intake process, very expensive product, that I know some of my colleagues use. But once the pandemic hit, which is around the time that we wanted to get started on this, having kiosks and having people touch the same screen over and over again during the pandemic is probably not the best idea. So we didn’t do that, but we did look at InteliChart that does have a patient intake component to it, as well as the portal component. So we thought we could probably work with this and have really two solutions in one if we did it correctly.
I will say that our original experience with portal was not a bad one. We did have a lot of folks sign up. A lot of our clinical teams had gotten used to it. Our experience has been chronicled through the California Health Care Foundation. There are some publications that are directed at our experience with portal back in the beginning. We developed a lot of tools. We developed interactive forms, for example, for anticoagulant patients to use that had home INR machines. And so we did as much as we could with it, but because it was sun-setting and because it was a little bit limited, it was time to move on. And we always felt that our portal should be able to do more for us. And so it was just the right time to take the next step.
Charles Kitzman:
From an administrative perspective, I wanted to use portal very specifically to remove what I consider… I call it “noise” and I’m using air quotes, but “noise” from the face-to-face encounter. And that includes the front office process, as well as the back office. Over the past several years, FQHCs have just had so many additional responsibilities thrust upon the clinical teams and nothing ever gets removed. So year to year to year it just seems things are stockpiling on that face-to-face visit, so much so that these processes choke out the opportunity for the teams to do anything meaningful with the tools that they’re asked to use. So if you’re spending all your time asking questions and chronicling the answers, in the hustle and bustle of a busy clinic, you hardly ever get the chance to take a really decent look at the results and provide guidance to the patient based on what those answers might be.
Charles Kitzman:
I fundamentally felt that if we could build a lot of these screening tools, and then deploy them to the patients well in advance of their appointment, that the data can be in the chart at point-of-care with no effort on behalf of the clinical team. Further, if it’s already there, we can integrate it into the pre-visit planning. And so, they really know ahead of time what they’re getting into, what they can address. They can triage what’s important for the patient and then address it accordingly. And that’s the goal.
Jessica Ortiz:
Thanks, Charles, for all that context. I have a more specific question: During the InteliChart configuration planning process, how much time did you spend with the different stakeholders such as clinicians, operations, patients?
Charles Kitzman:
We did do a patient advisory group. We’ve done about four of those over the years. It’s always good to check in with your patients and see what they want. They help set your priorities. And so we did do a patient advisory group for this. We did cross-pollinate our stakeholder group. I cannot overstate that a portal implementation or a patient intake process – just because it’s technology related, it’s not an IT project. It’s not. It’s an operational project. And you have to treat it like that, and if you don’t, that’s your first mistake, you’ll probably fail. So bringing people to the table that are going to be touching the tool, are going to be answering questions about the tool, are going to be promoting it among our patients, they need to have a voice.
Charles Kitzman:
And they have desires, too. I think early on, I remember one of our first stakeholder groups, we had clinicians and nurses, MAs, scribes involved. And I said, “My goal, when we’re done with this, is I want you to feel the difference between a portal patient and somebody who does not use a portal. I want those encounters to be so smooth and so easy for you and so meaningful for you, that you will know instinctively that this person is using this tool, versus somebody who clearly is not.” And they thought I was crazy, but I think we’re getting closer and closer. The stakeholder groups, I would say, we spent a good four sessions every other week for about an hour and a half, 90-minute sessions. And we had a lot of help from InteliChart. They have robust project plans, a lot of really good questions to ask, things to consider, approaches to take. They participated but did not guide our strategy at all; they were very respectful in that regard.
Charles Kitzman:
But they were there to let us know where the guardrails were. So if we started to get super excited and like, “Wow, we could do this.” And they were, “Wait, wait, wait, slow down, Charles. Not quite yet.” So that’s a good element to have with those stakeholder groups. But to answer your question specifically, I would say couple of months, about four visits, 90 minutes total. And the engagement level was good, it was high, and I think we got a lot out of it.
Jessica Ortiz:
How much resistance did you see with any of the workflow changes associated with the project?
Charles Kitzman:
A little bit, not so much from the clinical teams. In as much as risk plays a role, that’s always going to be there. So for example, I’ll give you an example – when we deployed the PHQ-2 and the PHQ-9 through portal. And those are mapped, there’s discreet data capture, accounts for our quality metrics, everything. But there’s always the question, okay, we’re deploying these, they could be read off ours, a high PHQ-2 can trigger a nine. We deploy a nine. What if that’s a very high score for depression screening, maybe it’s off the charts or it’s very, very high. It could be an indication that that patient is in crisis, and it’s off-hours and nobody’s here, what do we do? So we did have our behavioral health folks involved, and when we did a trial of that process, they audited all of the results to make sure that we were designing things safely and doing things appropriately. And ultimately, they signed off on it with some recommendations.
Charles Kitzman:
Certain staffers are going to be resistant to change no matter what. We have a high Change Culture here. We’re always doing process improvements. I think it’s really just part of our culture. And we try to be open and honest about that when we hire people. With that said, I think we did get some resistance with the front office workers because they were so used to giving a certain stack of papers to people, and we were starting to eliminate them. There’s some anxiety that’s baked into that if that’s your job and you have a very tactile experience of delivering things to the patient, talking them through things, and that starts to disappear.
Charles Kitzman:
It can make you anxious a little bit, frankly, and so we needed to assure them that their job, instead of the paper shuffle, is more quality control now. Instead of doing data entry, you’re going to audit the data that’s entered, and you’re going to verify it with the patient. But it’s a different dynamic, it’s still an important job, it still needs to be done, and a human needs to be involved. And so those types of assurances, I think, are helpful and they have been. But those are the only two. You have to remember, [we’ve had] a lot of experience with portal. So, it wasn’t foreign to anybody. It was just, we were doing things on portal that we had never done before. And that expansion came with a couple of… Yeah, we ruffled some feathers a little bit. We smoothed them over though.
Jessica Ortiz:
Yeah. Changes are just inherent to the healthcare industry, and I think during this period of time very few folks are shielded from the change and the disruption that we’ve experienced all collectively over the last two years. So it’s kind of “go with the tide,” right? I want to know more about the… You could maybe think of us as a vetting process or part of the planning process and thinking about how, for example, at CCI, we have this framework for making sure there’s a mission fit, operational fit, and sustainability of whatever digital health solution or innovative solution that you’re using. How were you thinking about this, and did this type of framework play into your decision making?
Charles Kitzman:
It did. We are familiar with the CCI approach, and we did employ it. The mission fit for us was built on and based on our previous experience. Enrollment for a while was really difficult on the previous platform because it was non-automated, it took an act of volition for a worker to create a token and give it to the patient. You had to manage variability in tech literacy patient to patient. It was really, I mean, a crapshoot, whether they were going to be successful or not enrolling themselves. We set up a helpline and all of that, but in hindsight I think just the enrollment process was, frankly, a barrier. So when we were vetting, it’s one of the first things we asked, “How easy is it to get on this platform?”
Charles Kitzman:
And the InteliChart platform has multiple options for this, including creating tokens if that’s what you want to do. We did not, so we said, “What else you got?” They have a self-registration process where patients can enter demographic data about themselves and submit it. And then they have the ability to just communicate with the health center that way. And some feel like that’s a bad thing. I think it’s a great thing. For example, our managed care plan gives us a list of thousands of patients that are assigned to us, but the data that they give us is expired. It’s no good. They give us a physical address and a phone number, neither of which are any good. But when you think about it, a lot of the free email services that are out there, that’s arguably the least likely thing to change for many of our patients.
Charles Kitzman:
And so if they give up their demographic data and their email, and we can validate that either through email or finding a new phone number for them and connecting with them, we’re bringing otherwise elusive patients into the fold. They can’t see any patient information until they’re validated, but they can communicate with the health center via the web. That’s really great. They also have a feature where for every kept appointment, if a patient is not currently enrolled in portal, they get an invitation automatically, and it’s great. It’s been working great. They charge an extra premium for that feature, and we decided to turn it on when we went live and we have not turned it off yet and we’re eight months into it. We’re still getting more enrollment. We just passed 7,200 patients in eight months. That’s remarkable. That comprises about 25% of our total patient population by comparison.
Charles Kitzman:
I’ll tell you that Kaiser took about 12 years to get to 30%. Of course, they started much, much, much earlier, but it’s a growth curve that I think we can be proud of. And eventually, I think we’ll get to the point where word will spread and it will just be common knowledge among our population that this is a tool that they can use. And we’ll turn that feature off and rely on self-reg[istration] almost exclusively, I think. So that fits our mission for the operational piece. It was a bit of a fit. I mean, it wasn’t perfect. I think in the past, a lot of the portal management fell to the informatics team in terms of managing routing groups and where these messages go and who’s going to be managing them, and so on and so forth.
Charles Kitzman:
This new platform allowed for some shared responsibility, which was attractive to me personally. I like to see our middle management and our leadership take responsibility for their departments. And so now currently, the routing groups are exclusively managed by the center managers and the leadership within the departments. And that’s appropriate. I’m often the last one to know who left and who’s coming into a department and things like that. They are the first to know, and so if they just take a little bit of time, they can update things accordingly and people can manage the volume appropriately, so that’s good.
Charles Kitzman:
To the question of sustainability, that was the big question mark. You’ll remember that we wanted to give our vendor an opportunity to fix their platform. We saw this as a stop-gap. We did not want to let this grant opportunity pass us by. We thought that we had an opportunity to do some really creative work, and so we did — we jumped in. The vendor has done a remarkable job on their platform. It looks good. It’s very functional. Dare I say it looks a lot and acts a lot like InteliChart. So all things being equal, given the amount of work that we’ve done so far and the time and effort that we’ve put into this platform, the vendor solution would really have to be so significantly better and with way more functionality for us to change horses in midstream.
Charles Kitzman:
That turned out not to be the case. I think they’ve done a fine job, like I said. It does basically everything InteliChart does, but we’re kind of already in, and we like what we’ve done. As a vendor they’ve been supportive. Whenever we have issues, they get resolved. They’ve done right by us, and so – InteliChart has. So we’ve already extended our contract with them for another couple of years at least. And heaven knows about the road ahead, but for now this is the tool. This is what we’re going to use. And I think we’re almost halfway through a two-year project cycle. There’s so much more we want to do with this platform, and we will.
Jessica Ortiz:
That was really impressive, the enrollment that you were seeing through this project. Do you have something else that comes to mind that’s a highlight that came out of this project so far?
Charles Kitzman:
Yeah, I think the enrollment piece is great. We’ve had consecutive all-time high message counts for the last three months in a row, and so it’s really great. And I share that information with my staff and with the center managers and the people that are in the trenches, and they love to see it and we’ve set up friendly competitions and all the rest, it’s great. I would say the forms creation has been really great. Being able to capture discrete data from our patients via portal is awesome. It’s just so cool. So that has been a real success. We’ve gotten hundreds and hundreds of completed forms through the portal. And keep in mind for everything that comes in via portal, that’s one less thing that our staff have to do when the patient walks through the door. So my overarching goal of being able to have of a palpable differentiation between somebody who’s choosing to use portal – a patient, and a patient that’s not, that’s really starting, the staff are starting to feel it, and they’re going to feel it more. So I’m excited about that piece.
Charles Kitzman:
The other thing that we’re allowed to do that I think is underused, or I think other community health centers are not aware of or not leveraging, is we have the ability to target certain populations. So once you have over 7,000 patients, that’s a lot of patients. And if you have something that’s regulatory like a sliding fee application, those are things that most people don’t think about, but it’s a cumbersome process and it takes a lot of time, and we have to do it, and we have to do it annually. So you can write a query and figure out all of your portal patients that are overdue for their sliding fee application, and you can just pump it out to them.
Charles Kitzman:
You could target 500 at a time and have that stuff come in and it’s tucked away and it’s in the chart and no alert is going to go off for your front office staff. When they come in, it’s already there. And it’s being captured discretely. So when we have to answer questions and whatnot on our UDS report, the work is already done and it’s reviewed by humans, but not entered by humans, which is a little different. Those two things, the enrollment you’re right, Jessica, the enrollment thing is exciting, but those two pieces, the forms creation and the way that our patients are using them, and then the bulk messaging to targeted populations is also… You get a chance to be kind of surgical with it, and that’s a lot of fun, too.
Jessica Ortiz:
And on the other side of that, I have a two-part question for you. Could you share with the listeners the biggest challenge from your project and just anything you would’ve done differently based on what you know now?
Charles Kitzman:
That’s always the million dollar question, right? I think the biggest challenge was probably educating newer staff on the merits and possibilities of portal. And that maps over a lot of different positions within the organization. So if you gather up all your MAs, LVNs and RNs and say, “Why did you get into healthcare?” They’re not going to say, “So I can email patients.” That’s not going to be their answer. That answer is going to be far down the list. And so what I’m really trying to say is that a lot of people that get into healthcare have a super strong emphasis on interpersonal relationships. That’s who they are; they want to help people. And they purchase major stock in that interpersonal connection. And they’re right, it matters. It’s part of the art of medicine in my opinion. Strangely, we had the mandate for vaccinations among healthcare workers in California, as you well know. We had a lot of folks that took a stand on philosophical grounds and frankly left the practice, and many of them will be leaving healthcare as a result.
Charles Kitzman:
It’s a sad thing, but it left us in a lurch. We had people that were left over having to do double and triple work while we scramble to recruit and fill some of these gaps. That was a few months ago. And then I just mentioned that we have all time high portal messaging for three months in a row. Those two things are connected, because a lot of our leadership discovered the reality that through portal, they are able to help more people efficiently. And that’s just the truth, anybody that says otherwise, they just have a hard argument to make because I look at telephone statistics for our triage and the average call is 18 minutes. I can help five people via portal in 18 minutes. So you do the math and you have an exponential gratifier as far as access goes.
Charles Kitzman:
And so the providers certainly believe it. They are among our highest users. The support staff are dynamite and they help as well. But I think they had to learn it for themselves. There’s a difference between the egghead saying, “This is great. You should use it. What’s the matter with you?” I’m the egghead, by the way. And then them learning for themselves, that a couple of RNs talking, “Oh, I’m so overwhelmed. I wish we had more help.” I’ve been steering people to portal and they’re having these conversations on the floor, and peer endorsement as much as anything in this industry is the straw that stirs the drink. And so when they hear it from others that are doing the same job, it means more than coming from the Ivory Tower up here making decisions without consideration.
Jessica Ortiz:
I was wondering just overall, how is it to innovate in the middle of a pandemic? And we have all these changes, we have shortages and healthcare workers are burned out, rightly so. There’s a lot going on. How did that impact this project?
Charles Kitzman:
Well, most of the stuff that we did on portal, we sort of compartmentalized our efforts, and frankly the grant process allowed for that easily. So we had dedicated resources that we could use for development, testing, deployment. Most of the innovation that we had to do specific to the pandemic really was in two different areas. One was the quick switch to video visits and telephonic visits. And we handled that in a couple of days. So that was not difficult for us. I had it done in my IT team and they were just like, “Boom, done.” The other piece was trying… So that’s one area, we just had to figure out the logistics of making that switch. The other piece of it was how to make the documentation and coding requirements, which seemed to change every day, elegant for our staff.
Charles Kitzman:
That took more effort, and we had a task force that was dedicated to that. So it wasn’t as if we had to crowdsource everything, we could really take small pieces of my team and say, “Okay, you guys are going to handle this, and then you guys are going to stay on portal and keep that all rolling.” My big fear, honestly, was that all of these external tensions would kill the project and we’d have to put it on the shelf and I didn’t want to do that. So I think in some ways we got lucky, but we worked hard and we tried to put our best foot forward for our clinical teams but another day at the office for us, I think. Like I said before, it changes the norm here so we’re kind of used to it.
Jessica Ortiz:
And Charles, you’re a part of our learning network, and here we’re big believers in collaboration and not reinventing the wheel. How did your peers in the learning community support and help you push this project forward?
Charles Kitzman:
My peers have always helped. They’re always a big help. The CCI learning community is great. I got to talk about this project every step of the way with all of them on a regular basis. We got to publish milestones that we had achieved. We were able to get feedback from them. There’s a cohort of about seven CIOs in California that we all kind of tax each other quite a bit, but the members of that cohort were really instrumental in giving me clear eyes going into using in InteliChart as a vendor, what to look out for, that type of stuff. That was huge, very helpful. I think also learning how different populations in different parts of the state embrace portal. We’re largely rural. I mean, by federal standards, Redding is considered urban, but my colleagues in LA that have paid me a visit tell me this is not urban. So there is a stark difference I think still between rural and urban patient populations.
Charles Kitzman:
A lot of it maps over tech savvy, even health literacy. They’re different, and so it isn’t always that what I hear from my colleagues in San Francisco, I can’t always treat it as sacrosanct. But it does make for good dialogue, because I can say, “Yeah. Well, everybody’s got this. Of course broadband is awesome. These people live out in the hills and they can’t connect. What do we do? Blah blah blah.” So understanding that there are differences and things like that, having professional colleagues, I mean, that’s my lifeblood. People give me some credit for being an innovator. I’m a collaborator, I think, more than that.
Jessica Ortiz:
I’ll second that, Charles. The short time that I’ve known you, I have witnessed you be a collaborator in this community and being willing to not only share what you’re working on, but to provide feedback to others who are facing similar and different challenges that they bring to the table. So really value your expertise, Charles. And I’m wondering what’s next for you? What’s the next step here?
Charles Kitzman:
Well, we’re working on continued forms creation. We’re rolling those out, maybe one every couple of weeks – two, three weeks. The big project right now is the staying healthy assessment that is sort of a state-mandated annual assessment. It’s a big project. By the way, we already digitized it. Now we have to re-digitize it for the portal, and we will. We’re doing that in a couple of languages. I always tease my colleagues, like we speak “country” and “Western” and in Shasta County, but we do have a small Spanish speaking cohort that we’re going to develop these assessment tools for. And we want to automate them as well. So when they’re done creating the assessment and submitting, we want to give them back guidance immediately in their portal, and hopefully they’ll read it and then if they have questions when they come in, our providers can play offense instead of defense in that. What a treat that will be.
Charles Kitzman:
Other things not related to this project, I’m spending some energy on acuity adjusted empanelment and scheduling. I think I did a broadcast for you guys in August on that topic. That is something that I’m spending a lot of energy on. That’s an exciting project for me, I like it a lot. And then I’m getting into a lot of clinical decision support space right now to try to figure out how do I leverage the terabytes of data that we have at our disposal to help our clinical teams and our population health managers. And then the last thing is that we are prepared to build a 36,000 square foot “mommies, babies and children’s center” across the street from our main facility. We’re going to destroy the buildings probably in February and begin work on building that out. It should take about a year, maybe 14 months to complete. But I suspect that I’m going to be having a project related to maternity or pediatrics pretty soon. So there’s no finish line in this business, Jessica, there’s just opportunity. It’s all good though.
Jessica Ortiz:
Yeah. That’s right, Charles. And we are excited to continue to follow up with what you’re up to, continue to engage in this learning community.
Jessica Ortiz:
And also for our listeners, Charles is our resident musician who likes to play a musical number for us every once in a while and we always really appreciate it. So we’re going to close this session by thanking Charles for joining us, sharing your expertise with the broader community, and finish us up here with a nice little jam.
* Charles plays a guitar jam / ditty *
Charles Kitzman:
See you next time.
Jessica Ortiz:
Beautiful. Love it, Charles. Thanks for doing that.
