This is a great book to read on sabbatical, as you can probably imagine. It had the overall impact on me of adding to my focus, rather than distracting from it, in a nice journey through several essays on subjects ranging from the potential of a second career to managing your boss.

I was reminded again that as fascinating as human beings are, they (we/I) can also be predictable. This is what I was thinking during the review of adult stages of development, which go from age 21 to 35 (”intimacy”) to ages 35-55 (”generativity”):

The transition between intimacy and generativity is, according to Daniel Levinson, the time during which the adult makes his last assertion for independence….His studies of executives indicate that at about age 37, the adult throws off the guidance or protection of older mentors or managers and takes full charge of himself.

So what to do with all that energy (which I tend to have a lot of at baseline anyway…)? There’s a nice essay from Peter Drucker on “Managing Oneself,” where he talks about the shift in the workplace from an organization guiding a person’s career to a person doing the guiding by asking “what should my contribution be?” In working with bosses, he suggests that people should observe them, find out how they work, and adapt themselves to make their bosses most effective. I agree - I have always operationalized this as “make your boss look good.” There’s also a nice discussion of values and ethics - it’s possible to have value conflicts within an organization, while respecting that everyone is acting ethically.

The concluding essay, “A Survival Guide for Leaders” is a good one for people in the field of Informatics, where the potential for upheaval of an entire profession manifests every day. There are practical strategies for handing both external and internal forces at play when leading a transition. These definitely happen in health care to be sure. At the same time I continue to experience the reality that the most incredible people go into health care, because an industry this challenging demands it. There’s a nice nod to a concept I was taught a few years ago - “watch yourself.” This is advice well taken - with as much as we all have to do to help others achieve their life goals through optimal health, awareness of our contributions and those of others makes a huge difference.

PCHIT links for December 26th through December 27th:

• Early Experiences with Personal Health Records — Halamka et al. 15 (1): 1 — Journal of the American Medical Informatics Association - As reviewed here: http://www.tedeytan.com/2007/12/27/242/
• Patient-centered Applications: Use of Information Technology to Promote Disease Management and Wellness. A White Paper by the AMIA Knowledge in Motion Working Group — Demiris et al. 15 (1): 8 — Journal of the American Medical Informatics Association - Nice description of what we know/don’t know about PCHIT. However, given that the rest of the world uses IT in a more customer centric way, are we going to wait for research?
• PHRs: From Evolution To Revolution by Liz Boehm - Forrester Research - Interesting commentary on health plans, PHRs, and adoption. Are health plans ready?

I really enjoy learning about the history of the communities I am a part of, and the U Street Corridor, adjoining Logan Circle, Dupont Circle, and Adams Morgan has an impressive one:

Here people of color responded with strength to the injustices of segregation, engaging in some of the nation’s first civil rights protests while simultaneously building a vibrant urban center of their own – “a city within a city.”

Located near the famed Howard University, the neighborhood was home to Edward Kennedy “Duke” Ellington. Its theaters and clubs hosted the brightest lights in American jazz — Cab Calloway, Pearl Bailey, Sarah Vaughn, and Jelly Roll Morton, to name a few.

In 1968, this neighborhood was a very different place, as it was devastated by riots following the assassination of Martin Luther King., Jr.. It is now being reborn, with a cultural diversity that it began with.

And…it’s sunny here during the winter. I had forgotten what that’s like :).

There’s an excellent viewpoint paper published in this month’s issue of the Journal of the American Medical Informatics Association:

Halamka JD, Mandl KD, Tang PC. Early Experiences with Personal Health Records. J Am Med Inform Assoc 2008;15:1-7.

It is a nice supplment to the paper previously published by colleagues at Group Health Cooperative about their 7 year experience implementing and operating a PHR:

Ralston JD, Carrell D, Reid R, Anderson M, Moran M, Hereford J. Patient Web Services Integrated with a Shared Medical Record: Patient Use and Satisfaction. J Am Med Inform Assoc 2007:M2302.

There’s a link to this paper as well as a presentation I made about the Group Health Cooperative story here.

The paper adds very helpfully to the body of knowledge about how to operate a PHR specifically. Unfortunately, there is no guidebook on how to make medical record information transparent. Some points of interest and comparisons to what I know about Group Health and Kaiser Permanente’s PHR systems:

• There’s a nice overview of lab, problem list, and clinical data sharing policies. There’s a spectrum here. Kaiser Permanente so far is the most advanced in my opinion, with real-time sharing of lab results in several of its regions, including Northern California, which results 21,000,000 labs per year. BIDMC is sharing imaging and pathology results after a delay, which is the most advanced I have seen. These pieces of data are the next frontier in many organizations, including Group Health. I liked that at BIDMC, they have set up sharing to be reconciled as most the most transparent setting when there is a conflict between members of a patient’s care team. I might suggest that we apply the same rule nationally - let’s have the medical profession adopt the most transparent policy in use at any given institution. We (at Group Health) have found this to be the most empowering of our members.
• On the point above, there’s really no place to go to compare sharing policies and devise a new standard for our profession. At the current time, each medical group is deciding based on its own judgement. Some involve patients and consumers in this decision. Some do not. There’s no “toolkit.” The last time standards for electronic messaging were published by AMIA was in 1998, if I am not mistaken.
• Adoption by patients seems to be less robust in Massachussetts relative to other places. The adoption curve for PatientSite looks relatively flat. Curves for Group Health and Kaiser Permanente are more like hockey sticks. This is something Josh and I are trying to understand as we work with folks in Boston (Harvard Vanguard Medical Associates and Partners Health Care have similarly appearing trends). The conclusion I come to is that we should not believe that low adoption equals low interest by patients.
• It was interesting for me to note that in Massachussetts, medication data may not be shared from health plan databases, but it may be shared from provider or retail pharmacy databases. Does this hinder support for PHRs from the health plan sector?
• Children’s Hospital in Boston operates a more patient-centric system out of the box. I could not discern what the uptake has been of this system from the article. Does this point to a tension between system flexibility and scale as we move ahead? Does the tethered nature of the largest PHR systems (Kaiser Permanente, Group Health Cooperative, BIDMC, Partners, Geisinger) probably make them easier to promote and manage as part of the patient-physician relationship?

This paper is very timely and another demonstration that patient centered health information technology has a growing leadership base within the medical profession. Perhaps a great next step might be for the medical profession to take these experiences and innovate in care standards about what we share with patients (as much as possible) and what we deliver with each clinical interaction (information relevant to the moment of care during and after the visit).

Today’s links are representative of the fact that we aren’t doing observations right now. Instead, we are preparing our first 90 day interim report for our partners. This means looking back on the last 90 days, and putting together our impressions at the interface between patient and health system, along with relevant background and policy information. We’ll post that here, of course.

PCHIT links for December 24th through December 26th:

• U.S. healthcare payers to limit IT investments in 2008 -
• ACGroup, Inc. Whitepapers - Nice overviews of the EHR market and physician practices
• PHRs: From Evolution To Revolution by Liz Boehm - Forrester Research - Interesting commentary on health plans, PHRs, and adoption. Are health plans ready?

December 24th through December 26th:

• iMedix - Find Health Information, Share Symptoms & Discuss Treatments - Israeli startup that connects patients to each other with the same condition(s). Imagine if their doctors could be part of the conversation.
• Metropolitan Police Department Crime Search, Washington DC - A handy tool for looking at crime statistics in your area. All the information is there.
• Customer Experience Index Snapshot: Health Plans by Bruce D. Temkin - Forrester Research - There’s an enormous opportunity for health plans to radically improve their customer experience ? and go after the majority of consumers that are interested in switching plans.
• gladwell dot com - personality plus - Malcolm Gladwell writes about corporate use of personality tests. I have not really been a fan of Myers-Briggs myself.
• Unicru Test Items - A potential employee posts the Unicru personality test used by many retailers.
• Rock Creek Park - Monuments, Statues and Memorials (U.S. National Park Service) - Descriptions of memorials in the Mount Pleasant / Columbia Heights area
• macosxhints.com - 10.5: Move apps between spaces with the app switcher - For Mac users out there, this is a tip that makes the new Spaces feature very usable. I’ve had it turned on for a few months now and getting the hang of it (I always try new things for a bit, but know when to stop trying them, this is why I am early major

This book was tailor made for the experience I am having now. It’s the travelogue of a man who goes undercover as an employee in some of our most iconic organizations: UPS, The Container Store (not quite, he didn’t pass the interview), Enterprise Rent a Car, Gap, Starbucks, and The Apple Store. This is a true trip to the Gemba, in that Mr. Frankel actually goes to work for the companies discussed as an employee. I am doing a similar thing, but I am not undercover, and I am not actually practicing medicine in the organizations I am spending time with (I suppose I could do something similar as a health professional, but at a huge cost to the organizations and patients they serve). I am, however, putting myself at the interface between the customer and the organization, and I, too, am thinking a lot about culture and about how people and organizations work. It’s an awesome experience, as I’m sure Alex’s was.

Throughout my journey, I have resisted using the term “front line” because the war analogy doesn’t make sense to me in health care. However, I liked the way that Alex described the “front line”:

In the military, the front line is the border between two opposing armies; in retail and service companies it is the invisible divide between customers and employees

This definition frames the experience well in terms of how organizations fixated on “brand” see themselves, and the author stimulates thinking on this, in my opinion.

No one is selling what we think they are selling

The thing we think these companies are here to do doesn’t seem to be the thing they are actually doing. An Enterprise employee is really selling insurance in the form of collision damage waivers. A Gap employee is selling lines of credit. An Apple Store employee is selling add ons (warrantees, etc) onto the main products. Starbucks is selling the “third space” that is not our homes or our work.

Read the rest of this entry »

PCHIT links for December 24th:

• Life as a Healthcare CIO: Standards for Personal Health Records - To prove a point about portability, John Halamka, MD, posts his medical record on his blog, in unstructured and structured formats.
• Health Privacy - Health Privacy 101 - HPP Releases Best Practices for Employers Offering PHRs. A good primer on PHR practices for employers.

December 24th:

• The etiquette of telecommunications | Getting the message, at last | Economist.com - The economist describes the first incident of spam, via telegraph.
• Are Suggestion ?Boxes? the Best Way to Go? | Lean Six Sigma Academy - Also interested in employee empowerment as much as patient empowerment. I should have installed one of these in my office before I went on sabbatical.
• Training Within Industry: Lean Jargon - Part III, Gemba (Genba), Genbutsu, Genjitsu - Catching up on my LEAN studies. Helpful guide to common LEAN terms. These are my favorites.
• Out of the shadow — Calman 19 (1): 170 — Health Affairs - Bearing witness to inequities for those we are trying to serve. I am having similar experiences in my work, and it has impact. Great article by Neil Calman, MD.
• Rising Popularity of Medical Blogs Raises Questions About Anonymity, Reliability - iHealthBeat - This is an important topic to me as a physician blogger. I do not blog about patient experiences except in the most general terms. At the same time, I think patients want to improve the system they get care in and we should (or I am) develop best practice
• Cultural Tourism DC - U Street Heritage Trail - Great map and walking tour of African American History. Perfect for the nation’s most walkable city