February 10th through February 14th:

• Wal-Mart To Open 400 Retail Health Clinics With EHRs - iHealthBeat - WalMart to become an EHR vendor to itself?
• Life as a Healthcare CIO: Always Look on the Bright Side - Terrific guide to being glass 3/4 full. Save as Draft - priceless
• Medicine meets a culture gap - USATODAY.com - American Academy of Orthopedic Surgeons is taking a leadership role in cultural competency. The medical profession still struggles with this concept, unfortunately.
• Super Friends - Wikipedia, the free encyclopedia - Who wants to be who in the patient-centered physician world? I’d like to be one of the wonder twins.
• Life as a Healthcare CIO: Web Content Management Systems - Right on to a CIO of an IT Department with this approach: “2008 will be the year of Web 2.0 for all my organizations”

Sites Visited

• Kaiser Permanente (Oakland Medical Center, Oakland, CA, West End Medical Center, Washington, DC)

Benchmarks in incentive alignment and scale

Kaiser Permanente, and organizations like it, are in many ways a benchmark for patient centered health information technology. They have the highest EHR and PHR penetration in health care. Kaiser Permanente currently has 1.7 million of its members using its PHR, and relaunched in November, 2007 as “My Health Manager.” Group Health Cooperative of Washington State is currently at 46 % of enrolled adults with verified access to the MyGroupHealth web site.

MyGroupHealth (ghc.org) adoption curve, 2002-present

The alignment of incentives is reflected in the slope of adoption by patients. The adoption curve for Group Health patients is significantly steeper than comparable organizations (see: Halamka JD, Mandl KD, Tang PC. Early Experiences with Personal Health Records. J Am Med Inform Assoc 2008;15:1-7.)

The work of these organizations is critical in demonstrating that patient centered health information technology can be a reality for all of health care. As we observed, they are post-implementation and involved in relaunch and refinements of their PHRs to support both patient workflow, and the workflow of staff who serve patients in medical centers.

If there are challenges in these organizations, it is that their work requires scalability beyond the typical physician practice, so there is always a risk that innovative ideas may be harder to implement. They are able to work around some of these limitations by supporting regions with higher levels of innovation (for example, the Colorado Region of Kaiser Permanente is a pioneer in teen-physician electronic messaging, see iHealthBeat: Kaiser Colorado Lets Teenagers E-Mail Doctors, Check EHRs).

In my visits to these organizations as a Permanente physician myself, followed by visits to other organizations described here, I noted an gap in knowledge about the potential of PHRs - an understanding of the benefits of PHRs of involving patients and their families in their care has been built up through experience among Permanente physicians that does not yet exist in other parts of health care. In addition, there is no official policy for knowledge transfer that I noticed. Group Health Cooperative generally shares knowledge in the interest of promoting patient empowerment. Kaiser Permanente is embarking on a significant initiative to share its experiences as well. In a session hosted at the California Healthcare Foundation, Holly Potter, Director of National Communications for Kaiser Permanente HealthConnect indicated to the group that, “We don’t have that option anymore” (see: Presentation: Blogs in Health Care) when it comes to delaying or restricting communication about its efforts to the community.

Unresolved issues

• Person to person knowledge transfer (attitudes, technical, workflow) to non-integrated care systems
• Risk of reduced innovation due to high expectations for consistent service across large populations

Countermeasures

Doug VanZoeren, MD, Mark Snyder, MD, and Ted Eytan, MD, bring leaders from the Office of the National Coordinator to Kaiser Permanente West End Medical Center, Washington, DC

This initiative represents a portion of the effort that Kaiser Permanente and Group Health Cooperative are making to provide knowledge to the entire industry. Other efforts include participation in national standards bodies, commissioning high quality research studies, and providing access to its operations (see: Office of the National Coordinator Visits Kaiser Permanente West End Medical Center). One of the most important efforts I have been engaging in throughout is to bring technical and execution expertise to organizations who are implementing PHRs. This will continue throughout the initiative.

It might be useful in the future for these organizations to put together a publicly available “toolkit” for PHR implementation, which would include everything from tested organizational policies, communication collateral, and staff and patient adoption techniques. Currently, this information is being transferred one to one by individuals within the organization. Perhaps a repository of experiential knowledge of basic items such authentication procedures could be made available for other organizations.

Group Health Cooperative has previously released its “Clinical Information System Rollout Toolkit” to the health care community for unrestricted use. We did not create a companion “PHR Toolkit,” however as a part of this work, I recently put together a basic PHR Toolkit that was forwarded to the Institute for Family Health, to assist in their implementation efforts.

Ways to Engage

Victor Silvestre, MD, Kaiser Permanente Oakland Medical Center

Kaiser Permanente is engaged at many levels to promote PHRs, including in the establishment of standards and sharing information, including on this blog.

Several staff members in these organizations are active in public conversations, such as on standards bodies, and are an excellent way to support involvement and knowledge transfer. In addition, given current initiatives to demonstrate the value of their care models, both organizations’ Communications departments will be useful in arranging for access to practices and Permanente physicians who can demonstrate the value of PHR-enabled practices.

I was recently riding home with a professional colleague who was (very creatively in my opinion) writing New Years cards for loved ones based on the Chinese calendar. We happened to be talking a little bit about LEAN at the time, and I remarked that she was using a mass production process to put the cards together. I mentioned the example given in LEAN Thinking, that it would take less time to prepare the cards using one piece flow. I couldn’t exactly quantify the difference, though, and she raised some excellent points about her need to have a mobile factory as we hopped up and down the east coast.

Thanks for Ron Pereira from LSS Academy for putting together a video that shows this. Even if you don’t have a postal carrier standing by to deliver each envelope, it takes less time to do your part as one piece flow.

This is a very accessible example that can be used to talk about Toyota Production methods in health care. How many other processes do you engage in that involve batching work?