Innovation in Collaboration: What 18F and Kaiser Permanente South Bay have in common



18F , where collaboration happens View on Flickr.com

I think I’ve mentioned a few times here that I’m guest lecturing in colleague Carol Cain’s (@ccain) summer course, Stanford BioInformatics (Stanford University Biomedical Informatics 207), aka “Digital Medicine: Designing IT Innovations that Improve Healthcare.”

Since I’m coming from Washington, DC, Carol asked me to include something about health policy, and what do I know about that, so I asked my very knowledgeable colleague Ann Kempski (our Director for Government Relations) for a few ideas. She gave me some, which I put into the double-rainbow machine for further processing, and the one of the examples that’s fresh in my mind are actually two examples, from two different places, in very large organizations, who are working to improve health for a lot of people.

18F.gsa.gov

That’s the actual URL -> 18f.gsa.gov and there’s a really simple twitter handle that goes with it (@18F). I heard about it from Adam Dole (@AdamDole) , most awesome (recently) Presidential Innovation Fellow, who went on a walk with me (which is where all discoveries happen) to a meeting hosted by the General Services Administration and asked me, “Is it affiliated with 18F?” To which I replied, “What’s 18F?”

Here’s 18F:

It’s in the middle of a very government-ish building on 18th and F streets (get it?) in an organization that’s not supposed to innovate. Except that they’ve discovered that you can innovate in a large organization (and I believe you can only innovate in one). It’s where the Presidential Innovation Fellows are housed, and where presentations are given including ones about hacking bureaucracy.

What’s special about 18F and health policy? Well… 18F is where a lot of fixing of HealthCare.gov happened, by a lot of talented people. I’m not going to tell that story here, instead I’d focus on the environment that allows innovation to flourish.

I was told that GSA is one of the few agencies that is using a web-based email and document collaboration platform (I’ll avoid using vendor names for the purpose of this post, since I don’t think it’s relevant). You know, the kind that allows you to not attach documents to messages and send them to people who don’t know what to do with them. This alone caught my extreme attention…more collaboration, less e-mail.

Notice the sign: “Get Excited and Make Things.” Innovation is ideas AND execution.

Kaiser Permanente, South Bay Medical Center

All the way across the country, in Harbor City, California (near Los Angeles), is a pretty large, technologically superb, clinically excellent medical center, Kaiser Permanente South Bay Medical Center  physician led and professionally managed, where I went with our Digital Workforce Team in late June, 2014, to learn about…collaboration.

They don’t have a “big room floor plan” like 18F (although they are constructing a brand new hospital which will open in 2015) because they’re actually preventing illness, saving lives, producing health. What they do have is a focus on connecting the people who are delivering high quality medical care.

They are also using one of those web-based social collaboration platforms with the specific intent of connecting people, supporting purpose….and reducing email. There are medical directors of physician wellness and the Area Medical Director, Barbara Carnes, MD, is supporting the use of this technology to connect all staff, including doctors, and nurses. This is a complement, of course, to the system that already connects members/patients to everyone, the world-class kp.org, now surpassing 4.5 million members online.

Orthopedic surgeon Abtin (“Abi”) Foroohar, MD, showed us how he’s using the platform to connect with his fellow physicians. As he pointed out to us, there’s an inherent increased collegiality and collaboration in a multispecialty group practice in an integrated system that is not matched in fee for service medicine. At the same time, working on staying connected brings huge gains in people’s perception of their purpose and mission.

Commonalities, Health, Policy

Why the focus? Isn’t it obvious that people should collaborate and therefore they will?

They should, but it turns out that in the era of Health Information Technology, and technology in general, sometimes they don’t. Physicians who used to have combined hospital/outpatient practices now have one or the other, which reduces their exposure to their colleagues. They chart on computers with fixed locations, they communicate via messages sent in text, test results, and digital progress notes.

Both of these teams are solving huge problems for people with great need. Electronic Health Record systems are not going to automate all communication and web sites aren’t going to build themselves, and not certainly using old methodologies, that’s definitely what I see in this post-EHR organization and at 18F. The policies that create the environment where more people can get health care that’s of a quality not previously imagined will also create the need to think differently to make this happen. With a combo of changing technology, changing behavior, changing minds. That’s what I saw at 18F and Kaiser Permanente South Bay Medical Center.

By the way, Kaiser Permanente also has an 18F-type floor in Oakland, called iThrive (don’t you love all the catchy names of these places). Come by and see it sometime :)

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Crowdsourcing Medicine in the Digital Age, with Bob Wachter, MD



Bob and Ted (click to enlarge) View on Flickr.com

I got to spend time yesterday with one of the “other” social media physicians, Bob Wachter, MD (@Bob_Wachter) as he crowdsources his upcoming book, tentatively titled: “Disrupted: Hope, Hype and Harm at the Dawn of Medicine’s Digital Age.” – see: Crowdsourcing My New Book on How Computerization is Changing the Practice of Medicine in Surprising Ways | Wachter’s World for more.

I think I’ve known Bob since circa 2008 when we discovered that each other knew what a blog was and how to use it :) . Bob is a bit unique in this sense in that there are not many physicians at his level of accomplishment using social media for this duration and this level of authenticity (see: Bob’s Biases | Wachter’s World). And it is true, he did coin the word “hospitalist.”

With all of this in mind, it was relatively easy to give the tour of the Center for Total Health (@KPTotalHealth) and then have a conversation about health information technology, what’s working, where things are going, what’s happening at Kaiser Permanente. I think I’m not supposed to quote everything we said here, to preserve journalistic integrity. Hat’s off / +1 / name your celebration for someone like Bob, who is crowdsourcing this work as it’s being produced. It’s definitely not the norm for authors like him. I do it for presentations whose topics are new to me (see: Crowdsource Request: Being a transgender ally and unconscious bias | Ted Eytan, MD), but really, every blog post is a crowdsource, of me, based on the feedback I get. I can tell Bob works the same way.

I will, though, pull one quote from my archives that might be useful here. It’s from this post in 2011: Now Reading: A Fortunate Man: The Story of a Country Doctor, by John Berger | Ted Eytan, MD – a book that was recommended to me… as a comment on this blog:

It may be that computers will soon diagnose better than doctors. But the facts fed to computers will still have to be the result of intimate, individual recognition of the patient.

That was written in 1966. Yes, 1966.

Two other pieces of work I recommended are:

On the above, no I am not living in the past, believe me. Jack’s leadership approach is very current and continues to guide me, and to live in the future as maybe some of us do requires that we understand where we came from. Sometimes there’s no other precedent around us.

Oh, and don’t forget, health information technology has a role to play in a healthy environment that has less carbon, but only if you do it right : #greenhealthcare part 4: Health Information Technology helps health care be green | Ted Eytan, MD

Bob is super thoughtful, curious, humble, waaaay smarter than he lets on, and open as a leader. That combined with the relationships he’s established in his work is going to make for an informative piece when it’s published. I asked him if he’s capturing his journalistic moments visually on his journey. He said he’s not. I suggest he start….

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Walking Gallery IV: #Artscape2014 Baltimore, MD, USA



I’ve never missed a yearly Walking Gallery of Healthcare event, now in its fourth year, phew!

This year’s was especially cool because it was sponsored by Kaiser Permanente Mid-Atlantic States (@KPMidAtlantic) at Baltimore, MD’s Artscape 2014 (see: Regina Holliday’s Medical Advocacy Blog: The Walking Gallery at #Artscape2014). This kind of support may seem like the obviously cool thing to do in 2014, however, I remember the days when people asked me, “how did you meet this Regina Holliday person again?” and the reaction being a mix of surprise and impressed-ness when the answer wasn’t “at a medical meeting somewhere.”

Now I am joined by doctors and nurses (and their children) in walking. Witness Michael Dias, MD, Permanente surgeon and Baltimore Physician in Chief for Kaiser Permanente Mid-Atlantic States (@KPMidAtlantic), whose daughter Olivia painted a beautiful jacket with her health story.

Since last year, the event itself is smaller, but the movement is not.

There is as much interest in my walking jacket(s) today when I wear them as there was when I first got them. People who see me remember my jacket from the last time they saw me, sometimes a year before. They are still among my most prized possessions – the other funny quote I remember from way back when was when someone said something to the effect of, “so you lost a jacket in this whole painting business,” and I was thinking, “I actually gained my best jacket in this painting business.” You can read about my jackets here.

I wore my jacket when I gave this talk just a few months ago: Presentation: Being a Transgender Ally and Unconscious Bias | Ted Eytan, MD. This demonstrates to me that the work to involve and respect the people we serve keeps changing and is at the same time ever-present. It will never go away, and that’s fine with me. What else are we here for in health care :) .

I get to partner with my colleague Carol Cain, PhD (@ccain) to give a guest lecture at the Stanford University Division of Bioinformatics next week (Stanford University Biomedical Informatics 207), and in putting that together, have been looking for examples where HIT improves health for people, communities, and society. I was reminded in Baltimore about the need for Health IT to improve health and health care not just by lowering blood pressure and cholesterol, but by lowering anxiety, fear, information divides between physician/health system and patient/society. What else are we here for in health information technology :) .


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Mentors around every corner: Holly Potter and Diane Gage-Lofgren



Authentically yours, Diane Gage-Lofgren (View on Flickr.com)

In this decade, someone once said to me, “health care executives are not supposed to be on social media. The risk is too great.” To which I said, “that’s funny, Diane Gage-Lofgren (@DianeLofgren) tweets me all the time.”

In the decade before this one, someone once said in a room of leaders, “How does a health system decide how and when to be visible in the social media space? To which Holly Potter (@htpotter) said, ‘we used to have time to think about that, now we don’t’”

And here I, and a whole generation of doctors, nurses, patients, and health care leaders are, a product of their transformation(s).

As the story is told (and documented on social media, of course, (see: Presentation: Driving Total Health with Health IT and Health 2.0 (HIMSS 2010 – Atlanta) | Ted Eytan, MD), Holly and I had parallel epiphanies based on very different experiences in different (but aligned) organizations.

We came to the same conclusion, which was that our success in changing health care was going to be predicated not on telling people how perfect we are, but on letting people know what we were doing and listening as part of a dialogue.

Diane came into my life as a co-executive sponsor of the effort that supported the renaissance of Kaiser Permanente’s image at the same time it was undergoing a technology and quality renaissance. The outcome of this work is clear, Kaiser Permanente now has 9.3 million members and has the most #1 quality ratings of any health plan in the United States, and the place where I work, the Kaiser Permanente Center for Total Health (@KPTotalHealth) in Washington, DC, regularly receives visitors from all of the world who ask, “how?”

Patients included, Holly Potter (View on Flickr.com)

During Diane and Holly’s tenure, our organization became very facile with telling stories, and not on behalf of our members, with our members. Two very tangible places are the Kaiser Permanente Newscenter, which has now been re-imagined as KPShare, as well as the Kaiser Permanente Care Stories blog.

Diane brought me in to host my very first panel of Kaiser Permanente members, to speak to her organization at their all hands meeting. I still remember that day and the things they told me, especially “Of course you can mention my name in your blog, we WANT people to know what good health care is.” (see: Bringing the Patient Experience to Life : Focus on Patient Stories (Presentation) | Ted Eytan, MD).

Official ‘Patients Included’ badge View on Flickr.com

This led to even more “patients included” experiences that were not just fun, they meant something to everyone involved (see: What member / patient engagement looks like #iRetreatKP | Ted Eytan, MD). Talk about paving the way / making an imprint. Now we’re doing a lot more than bringing members to meetings, we’re involving then the way we design health care, which is a dream come true.

Holly and her team set a new pace for communication with stakeholders. Although she or her team have never (ever) told me what to write on this blog, they have kept a watchful eye over me, in the way I want to be watched – to make sure our members are supported and protected. It’s just the kind of wisdom and judgement that a physician should have in the social media space. Most physicians in the US/world don’t have this. I and my colleagues are lucky.

Humble beginnings, Diane Gage-Lofgren View on Flickr.com

Holly Potter, Setting up a new place to talk about health, in Washington, DC, 2011

Both Diane and Holly have supported myself and other nurses and doctors in connecting with patients and members wherever they are, in whatever venue they are, to further the cause of human-centricity in health and health care.

The most famous of these is of course Regina Holliday (@ReginaHolliday), who, thanks to them has an interview, done by me, memorialized in the Library of Congress (see: It’s here! The Regina Holliday interviewed by Ted Eytan StoryCorps Interview (audio) | Ted Eytan, MD).

There are a lot of other connections I have made with patients, members, that are not famous, but that were made on social media, that allowed a type of listening (by me and the health system) that was previously impossible in health care. The details of those connections will never be published here, but wow, they have been meaningful. They’ve changed my life.

Have you met or known a senior executive, at the top level of an organization, who always takes the time to acknowledge your work, say thanks in messages and in person, over and above what you expect from a senior executive? That’s Diane, who by the way is an accomplished and pretty excellent writer. In my opinion, she’s quite natural in social media as well. If I am considered as good as her, I am in good shape :).

Many gifts from Holly, this is just icing (View on Flickr.com)

Holly has, in her executive role, also set a high bar for engagement, as I referred to at the beginning of this post, by opening up new worlds and people to the health care system, who our country is just learning is and should be in the business of “health.”  Her imprint continues to this day, when people say to me things like, “actually, there is no other health system in this (health) space. Just Kaiser Permanente.”

I just learned that Diane has accepted the role of Senior Vice President for Marketing and Communications for Sharp HealthCare. 

Remember the 20th Century, when career transitions were considered abnormal and health care was opaque on top of that? It resulted in a lot of lost wisdom and innovation for the improvement of health. That’s not the century we’re in now, career transitions do happen, we can learn that there are better ways to do things, and we can want to know about them because our leaders tell us this is the right thing to do. Diane and Holly certainly helped create this new reality.

Thank you!

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Photo Friday: Thank you Liz Taylor in Watercolor, Shaw Neighborhood, Washington, DC USA



This week’s photograph is of the (now) iconic 50-foot tall mural of Elizabeth Taylor in watercolor. From Dacha Beer Garden Glams up Shaw With Gigantic Elizabeth Taylor Mural | InTheCapital:

Although Taylor is no doubt a alluring figure to look at, there is a deeper meaning behind the mural. The mural is meant to pay respects to the late actress for her foundation’s generous support of the Whitman-Walker Health Center, which helped to prevent the spread of AIDS and provided treatment to those affected by HIV/AIDS.

The mural exists in a neighborhood experiencing a renaissance following its destruction after the assasination of Martin Luther King, Jr. (see: Photo Friday: Progression Place, Washington, DC | Ted Eytan, MD for photos of 7th Street in 1968)

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Latest adoption data for kp.org



Yesterday on a tour of the Kaiser Permanente Center for Total Health (@KPTotalHealth), one of my esteemed guests, Larry Wolf, Health IT Strategist at Kindred Healthcare and Co-Chair, Certification and Adoption Workgroup, Health IT Policy Committee asked about the adoption curves I showed for Kaiser Permanente’s personal health record, kp.org.

Because of that and since I’m giving a guest lecture as part of my colleague Carol Cain, PhD’s (@ccain) course: “Digital Medicine: Designing IT Innovations that Improve Healthcare Stanford University Biomedical Informatics 207” later this month, I needed to update them anyway, so here they are. 

The totals are out of a member population of 9.3 million members, with the average practice having 67% of the eligible members (Internet users over 18 years of age) registered to use the portal. Enjoy, and remember, it is possible to engage patients.

Kp org data update 44882

Kp org data update 44883

Kp org data update 44884

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Just Read: Medicare bids farewell to the 20th Century in covering transgender person care, and maybe pokes fun at itself, too…



even assuming the NCD’s exclusion of coverage at the time the NCD was adopted was reasonable, that coverage exclusion is no longer reasonable.

In english, this means that Medicare’s former determination in 1981, 33 years ago, that gender confirmation surgery should not be covered, is now history. Medicare entered the 21st century only 14 years too late. With glass-half-full, that’s 3 years faster than the length of time it takes for science to make it into practice :)

Definitively stated: Gender confirmation surgery is safe, effective, backed by science

There is an excellent review of the literature within which puts to rest any notion that gender confirmation surgery is experimental (it isn’t), that there isn’t evidence to support its use (there is, plenty), that it isn’t safe (it is).

The experts cited note that the surgical procedures used in gender confirmation have been validated (and are covered) in other medical conditions, such as Mayer-Rokitansky-Kuster-Hauser syndrome, or MRKH, in which women are born with a complete or partial absence of a vagina, cervix and uterus.

With regard to safety, 1985 appears to be the turning point year, where surgical technique improved to the point that compliation rates and hostpital stay requirements went down significantly.

The decision also points out something that wasn’t called out in 1981, which is the lack of safety in a situation where treatment is not offered:

…(Gender Dysphoria) ..if left untreated, can result in clinically significant psychological distress, dysfunction, debilitating depression and, for some people without access to appropriate medical care and treatment, suicidality and death”

By the way, all of these symptoms of no treatment, leading up to and including death, are covered in health insurance plans even if the medically necessary care is not. In other words, as stated by the American Medical Association, coverage for this care is probably preventive.

Laughter is good medicine – do I detect a little humor in here?

I assume there are many ways to wipe away a 33 year legacy. You can do it with solemnity but you don’t want to appear too solemn because then the legacy won’t be sufficiently wiped. I suppose you can inject some humor into it as well, and that’s what I spy in this paragraph on page 18:

the 1981 report (and the NCD) cited an alleged “lack of well controlled, long term studies of the safety and effectiveness of the surgical procedures and attendant therapies for transsexualism” as a ground for finding the procedures “experimental.”

…and then goes on to say that the same report cited studies that ran in length from 3 months to 13 years and

If these studies do not qualify as acceptable long-term studies, the basis for such a conclusion is not adequately explained in the NCD record.

This is unmistakeable medical speak for “you have got to be kidding.”

What else can I say except, I enjoyed it :). In reality though, a subtle poke at the past helps a new generation of medical professionals tease apart data and bias, which are clearly and transparently wrapped up together in the previous coverage decision. Which is now vaporized.

Health plans are changing their coverage decisions in response

A careful review performed by my digital librarian (Google) shows the impact. Check out the difference in this coverage decision from a large commercial health plan in California, from 2012 to 2014. You can see the edits that move this medically necessary care into the same domain as all other medically necessary care. Check it out.

“Use this page to view details for national coverage determination (ncd) for transsexual surgery (140.3)” – this is the “heritage” coverage determination, which was invalidated on May 25, 2014. (see original)

Fit for the museums of the future…

In addition to saving the coverage decisions above, I’ve also clipped the 1981 National Coverage Decision for posterity. One day it will hang on a museum wall (Perhaps this one? @LGBTMuseum ) where people will stare at it in disbelief.

This saga reminds me of a quote I will never forget by one of my medical school professors, Andrew Weil, MD (yes, that Andrew Weil), who once said, “We’ll look back at what we did to people with cancer in 20 years and be aghast.” Maybe that’s the quote that will be printed on the wall above these heritage pieces as well, and I am so happy to be in medicine on the other side of those 20 years. I only wish we didn’t have to wait so long.

seattle gay marriage 5

Congrats, sorry it took so long

Welcome to the present, Medicare, we’re glad to have you!

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