Seeing the future 45 years later at the Brookings Institution: CHF and Payment Reform

When I was at the Brookings Institution ( @BrookingsInst @BrookingsMed )with fellow Permanente physician, cardiologist Priti Sood, MD, for MEDTalk: Treating Congestive Heart Failure and the Role of Payment Reform | Brookings Institution, this quote immediately came to mind:

We believe any group of physicians, or a foundation working with physicians, can easily duplicate the Kaiser Permanente success….freedom of choice is important; we believe that the choice of alternate systems, including solo practice, is preferable for both the public and physicians. - Sidney Garfield, MD, Scientific American, 1970

It’s this one because I noticed how changes in our health system are inspiring physicians today to learn and grow as leaders.

I also thought of this image comparison, from yesterday (shown by Darshak Sanghavi, MD @DarshakSanghavi)

And one of Sidney Garfield’s diagrams, drawn more than 45 years ago:

“Rationally organized medicine” – Sidney Garfield, MD (click to enlarge)

In the diagram, the physician is sleeping, there’s a metaphysical spider web in their office because patients are now being cared for within a system of care, that includes prevention and sick care in the right amounts, on a foundation of pre-payment and integration. Hospitals and a sick care system still exist in this world, they are used and available when needed, and they are top notch, fit for purpose. Today, the spider webs are still metaphysical (no doctor is sleeping in their office today, far from it), and the system of care is today’s Kaiser Permanente.

The innovation at Duke University and University of Colorado can be found on the Health Affairs Blog here (see: Payment and Delivery Reform Case Study: Congestive Heart Failure – Health Affairs Blog) , the blog about Sidney Garfield’s innovation 45 years ago can be found here (Where we came from – Sidney Garfield, MD, 1970 | Ted Eytan, MD). Compare and contrast, the future is coming true :).

Dont’ forget about leadership

Larry Allen, MD, MHS, Cardiologist from University of Colorado, touched on this in his talk when he mentioned that the better way of providing care that was developed wasn’t instantly adopted by his physician colleagues – it required leadership and cultural humility on his part to protect change in the interest of patients. This is true regardless of the payment model. Aligned incentives are important (and great), they do not magically change behavior though, they facilitate good leadership. That’s the part of Sidney Garfield, MD’s diagram above that isn’t obvious to many who see it for the first time.

Patients included

As it says on their web site, the format yesterday was very “un-Brookings,” more modern, intimate and maybe exposed/vulnerable of all of the discussion leaders, including the patient, Lee Satterfield, who is really Lee Satterfield, the chief judge of D.C. Superior Court, also Lee Satterfield, cancer survivor and heart failure patient secondary to the use of chemotheraphy, stroke survivor.

If you click on the first link about Lee, you can see the last four years of his service, in photographs, to the people of our (awesome) District. It’s a very important reminder about our role to focus on people’s life goals and how health makes that possible. Sometimes that’s forgotten. In the ideal health system diagrammed by Garfield above, the physician earns their salary, the hospitals start to empty (or in reality get used when needed) when the patient is achieving their life goals.

I was so glad that in the final panel discussion – a short sojurn to the pre-modern Brookings Institution – that Mark McClellan, MD made a point to ask Judge Satterfield for his thoughts, because the patient voice often gets lost when they are the one “non-expert” on a panel:

I have to say what I say on here all the time for cermonial purposes, I see many analogies to health and health care in this statement :)

You can watch the entire session here, and it’s embedded below. Thanks again for your time, Darshak, Brookings Institution, Judge Satterfield and our future health care leaders, including patients and their families.

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It’s Just Chemistry: Healthier buildings can have less harmful chemicals, with Arlene Blum, PhD

We had the privilege of hosting a healthy buildings event (see: Healthy Buildings: Reducing Use of Harmful Chemicals | Kaiser Permanente Center for Total Health) with our friends at US Green Building Council (@USGBC) featuring Arlene Blum, PhD  author, mountaineer, and founder of the Green Science Policy Institute, on reducing the use of flame retardants and the “Six Classes” of harmful chemicals.

As Arlene told us, “It’s just chemistry,” and detailed the properties of synthetic chemicals that have half-lives of two-thousand years, I harkened back to my organic chemistry experience in college which was less than successful for me (I’m not a very good cook, either). This time it was fine, she made it easy to understand.

The good news, as she explained, is that it’s easy to understand the health challenges of certain chemicals in terms of classes of chemicals, rather than specific ones, and there’s a web site, aptly named to walk you through them, in short order (15 minutes).

A healthier health system uses less harmful chemicals

As I went through the six classes curriculum, I was glad to see that Kaiser Permanente has led the industry in banning the use of the antimicrobial triclosan, which is an endorcine disruptor, estrogen enhancer, and testosterone blocker, for people who would rather not have their testosterone blocked or estrogen enhanced.

Same goes for halogenated flame retardants, which it turns out don’t retard fires (well, they allow the filling of furniture to withstand an open flame 12 seconds, unfortunately fires start in fabric not in fillings) and also damage endocrine, reproductive, and thyroid systems in the body (I see a recurring theme). Kaiser Permanente is going to work with suppliers to phase out halogenated flame retardants in medical furniture. And it’s not about phasing out compounds in just 38 hospitals, it’s about changing the market for these compounds at the level of procurement across the industry.

Green Chemistry

I first learned about the topic of Green Chemistry when I was at CleanMed Europe last year (see: CleanMed Europe LastDay: “Sustainable health system” definition : different here | Ted Eytan, MD), and I learned that there is such a thing (see:, there are scientists in the field, and it makes a difference. Some of the most common drugs used in medicine today are made using very toxic processes, and they shouldn’t have to be.

Finding and using safer chemicals is the responsibility of a health system, and it can be done: Kaiser Permanente Share | Environmental Stewardship | Safer Chemicals.

Interesting and great that scientists and mountaineers, architects, doctors, and building engineers in 2014 have a lot in common when it comes to spreading health, isn’t it :)

Rest of my photos are below, creative commons licensed, enjoy

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Just Read: Need for a Non-Discrimination Statement to Protect the Health of the Transgender Population

A week ago, I received this communication from Keshav Tyagi, who’s an MPH Candidate at the University of Southern California Keck School of Medicine:

Hi. I am an MPH student at the University of Southern California, and I am writing a paper about transgender health in the aftermath of the ACA. I was wondering if you knew of any good surveys or statistics I could use to assess the effects of non-discrimination clauses, such as the one made in CA by the DMHC in 2013?

This information was for a paper he was writing, which is now completed and I’m attaching here. The paper provides a nice overview of the public health implications of fair and unfair treatment of people based on their gender identity or expression. The history of our changing health system is just being written now.

Speaking of history, I noted this quote, from Ingrid G. Hoven, World Bank Executive Director representing Germany, published in a post written by Hasan Abdessamad, MD (@AbdessamadCan we bank on the World Bank on gender & SOGIE (“sexual orientation, gender identity and expression”) issues!? | Dr. Hasan Abdessamad:

I am comparing the current situation to that we faced 15 years ago when we addressed HIV. If we look back at how we initially handled the issue, we would be embarrassed. We need to hear their voices to gain better insight about their needs.

Thanks for sharing your work with me/us and for being part of a generation of health professionals who are engaged in helping the world learn to love better :) .

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Rand Paul speech alludes to unconscious bias

I was impressed at this part of the transcript, widely broadcast today (i.e. I did not watch the speech, I don’t post things on this blog that are political in nature, and this should not be considered an endorsement for any candidate) which alludes to the challenge of unconscious bias in our society today, without actually calling it out.

11:07 if you look at the war on drugs 3 out of four people in prison are black or brown
11:12 but your kids and grandkids aren’t perfect either
11:15 they police don’t come to your neighborhood, you get a better lawyer
11:19 these are some injustices. we have been people been concerned about injustice
11:23 we’ve got to be concerned about people who may not be part of our group here, who may
11:28 not be here today

The research data shows that it’s not just about where police go, it’s about what their brain maps when they see the image of a person who is White versus one who is Black, unbeknownst to them. Note that he speaks about ingroup and outgroup dynamics, whether or not he realizes he is. In addition, the words of the speech may or may not lessen the impact of unconscious bias because they don’t raise awareness of bias and its sources.

Depending on your browser, you may be able to access just these few seconds by clicking on this link: Rand Paul speech at the Freedom Summit C-Span 4/12/14, Start: 11:07,end 11:28

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Thanks for Publishing my photo and a comment: Assaulted with Google Glass

Reporter: “I was assaulted for wearing Google Glass” in San Francisco | Ars Technica

I’m always happy to have publications use my photographs, and this is no exception (they are all creative commons licensed).

I just noticed the irony of the two uses this week, once about the impending public sale of the devices (Thanks for publishing my photo: Google Glass Available to Anyone in the U.S. — for One Day Only | Ted Eytan, MD), and this story.

The discussion around the assault on the link above is fascinating. The motive of the assaulter in San Francisco can only be speculated. These are my reflections:

Safe use of technology in public? View ‘Glass Photoshoot DC 27401′ on

Safe use of expensive technology in public, well discussed in the comments in the link above. I recall that my “Sky Blue” team encouraged me to wear Glass out with me into the Chelsea neighborhood and I decided not to. Not because of New York, just because of having one more thing to distract me in an unfamiliar part of the world. I probably wouldn’t wear Glass in many parts of Washington, DC, either. Truth be told, the photograph that I took in June, 2013 captures a gentleperson who was walking toward me, and in my opinion was viewing the technology with more than casual interest. I’ll never know what their motive was, as I quickly left the area. This happened, though, when I was completely focused on the technology, I can’t imagine what would have happened if I was focused on something else.

The makeup of the Glass community itself. I discussed this previously in: Photo Friday: Google Glass V2 – My 6 months with Google Glass | Ted Eytan, MD

Back to the story in Whole Foods above, when we look to see how useful Glass is, it’s a study in selection bias. The kind of person who’s wearing Glass right now is the kind of person who’s enthusiastic about exploring using Google Glass. Part misfit, part innovator, part zealot, part luminary, part rebel, part “cognitive dissident”.

Due to the way the device has been distributed, I think there’s a reasonable conclusion to be made that the behavior of the group everywhere impacts at some level the way the technology is received anywhere. As I said in the blog post above, there’s a responsibility to support responsible behavior, so that an innocent user of the technology isn’t the recipient of misplaced anxiety.

Most importantly, I’m glad he’s okay. This is a good conversation to have.

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Thanks for publishing my photo: Google Glass Available to Anyone in the U.S. — for One Day Only

In Google Glass Available to Anyone in the U.S. — for One Day Only via @karissabe and @mashable

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Photo Friday: Faces of Innovation

Left to right: Lesley Levine, MD, John Mattison, MD, Ted Eytan, MD, Tad Funahashi, MD, Kaiser PermanenteView Faces of Innovation 39947 on

I took these photographs, except for the one above (I know a better camera when I see it) at Kaiser Permanente’s annual Innovation Retreat hosted by our Executive Vice President and Chief Information Officer Phil Fasano (@FasanoPhil).

In a recent Photo Friday (Photo Friday: Why aren’t more people asked about their goals? #TeamJess | Ted Eytan, MD) I said that I know some of the best doctors in the world. That’s still true, and it includes doctorates of Philosophy, Nursing, as well as other healers who innovate in an integrated care system less by building new things (they do that too), more by solving problems across the spectrum of health, as part of something bigger than our individual aspirations. Always a great reunion with the future. Rest of my photos below, enjoy.

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