I think this study:

JAMA — Abstract: Cardiorespiratory Fitness and Adiposity as Mortality Predictors in Older Adults, December 5, 2007, Sui et al. 298 (21): 2507

deserves its own post, and is significant when thinking of patient-centered health information technology. Why? Because in demonstrating an association with fitness and mortality (death) that is independent of adiposity (fatness - I love medical terminology, don’t you?), a change in focus of our health system is suggested, in my opinion.

Instead of tracking a measure that’s potentially hard to move, and with slow fluctuations, it’s possible that we should be tracking a different measure that’s easy to move, and with significant fluctuations - physical activity. It may be more important that patient-centered health information technology allow patients to track steps per day or some other proxy for active movement, on a regular basis, rather than a periodic weight check. And it may be more important to have a PHR implemented in the first place, because coming to see the doctor for a periodic weight check may not be good enough anymore.

One thing that this study supports in my own practice of medicine is my response to the patient who states that they have stopped exercising due to a symptom or medical condition (physical or emotional). I consider a history of “I’ve stopped exercising because of X” as dangerous as “I have chest pain” and treat it as serious as that.

I think that in the long run, stopping exercise is probably as dangerous as chest pain, if not more dangerous. I think this study backs up that idea.

I am adding images from Josh’s and my visit to Kaiser Permanente Oakland Medical Center in this post, plus a few quotes from Victor and his Medical Assistant, Monica.

I’ve just got these two things and it (the system) prioritizes them nicely - Victor Silvestre, MD

Victor said this as he pointed to the home screen of the electronic health record, HealthConnect. On the left were his day’s visits, on the right was his electronic In Basket, which included patient secure e-mail, right within his workflow.

I loved this quote because it echoes perfectly what my medical partner David McCulloch, MD, Medical Director of Clinical Improvement and Education, says about the patient view of health care:

Instead of many many things we need to give to patients, it’s just two things, illustrated above and in Victor’s quote.

I used to check for patient e-mail’s exactly 4 times per week. Now I do it millions of times a day - Victor Silvestre, MD

In this quote, he was referring to the impact of integrating secure e-mail into his workflow, as part of the EHR he uses to care for patients every day. The “millions of times” was in jest of course, but the idea is that as he touches the system many times a day to support patients who come to visit him in person, he can also simultaneously touch patients who are not in front of him, and blend that into his support of a whole population seamlessly.

It’s better than all…..this (waving a paper chart) - Monica, Medical Assistant

This was the answer when I asked what Monica thought of the EHR she’s using in practice with her care team. What I was that the staff was eager to use the new technology to do more for patients, and in several instances, to support physicians in using it better. That’s the nice thing about patient-centered health information technology - everyone gets to help everyone use it better for people.

Images: click on any to see larger. I’m including a bonus of myself and Ed Cohen, MD, who’s the Physician Lead for kp.org for The Permanente Medical Group and who helped arrange today’s visit in the interest of sharing knowledge.

Josh and I spent our day yesterday at two leading edge health organizations in the Bay Area, Kaiser Permanente, and John Muir Health. This post is about our time at John Muir Health. Like Kaiser Permanente, John Muir Health is a big place - out attention was focused on the John Muir Physician Network, which provides multispecialty care within owned and operated practices as well as within an Individual Practice Association.

And…it was very valuable. My background is as a family physician within an owned and operated multispecialty group, so even though I understand the implementation of both an EHR and PHR at an enterprise level, I am not acquainted with the environment of physician-owned practices. To this end, Michael Schierman, MD, hosted Josh and I at his practice at Blackhawk Medical Center, in Danville, California.

Michael is a family physician, originally from Calgary, Alberta, who shares his full time practice with two physicians who are general internists. His practice is leading the way for a transformation to electronic health records using the NextGen platform. In my work, I have also never seen the NextGen product, which is a fully CCHIT certified electronic health record, in action. Michael’s practice has only recently gone live, and he’s pretty facile with the system in practice, from my view. They are now doing the hard work of converting paper charts to the electronic work, and a great metaphor for this was Michael’s office. Before we visited, he apologized for any messiness in his office, which comes as a result of the paper charts he is diligently reviewing as part of the transition. Again, the value of being there is made apparent, because I could see that the transition to an electronic health record means everything from changing your workflow to uprooting your physical practice environment.

In the patient rooms themselves, the story was a very pleasing one. Michael was able to tell his patients that laboratory studies could be obtained without needing a paper lab slip, and prescriptions would be sent electronically from his laptop during the visit. His patient population, which is a busy and professional one, seemed impressed. In reference to my presence, he asked several of his patients what they would think about e-mailing their doctor. The comments that came back were very interesting, and tracked what we’ve heard at Group Health. There was a measured concern and respect for their doctor’s time that came with each response - “I would want to keep things to the point.” At the same time, Michael showed me his work list that was nicely displayed on his laptop. The question would be how this other avenue of communication would fit into this portion of his practice life.

Pictures: Click on any to see full size

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