March 28th through March 29th:

• WordPress ? Search and Replace « WordPress Plugins - Wordpress 2.5 is out. I have a feeling this plugin will be useful to have handy
• JAMA — Preserving Confidentiality in the Peer Review Process, March 24, 2008, DeAngelis and Thornton 0 (2008): 299.16.jed80000 - With tremendous respect for Catherine DeAngelis’ leadership during a tough situation. I am left wondering if the best place to hide is out in the open - if peer review became more Web2.0 like. What would happen in a situation like this?
• Findings From the 2007 EBRI/Commonwealth Fund Consumerism in Health Survey - EBRI - About 2 percent of the population is enrolled in a consumer directed health plans. Significant points for me: (1) almost half of the population with a chronic condition reports not filling medications or skipping doses or delaying care due to cost. Sobering reminder that patients can and do choose to do what we doctors prescribe. (2) “There have been no significant gains int he provision of information on provider cost and quality by any health plan type over the three years of the survey. There has been no increase in the share of CDHP or HDHP enrollees who say their health plans provide them with quality and cost information about their providers, and they remain no more likely to receive such information than enrollees in more comprehensive plans.” Okay, one more point - they did not ask about the impact of involvement in care in choosing a health plan - no mention of medical records access or involvement in information sharing at the level of the encounter.
• My Starbucks Idea - How about doing this for a health care org?
• Bronson Beta - Mail.appetizer - Nice Mail notification tool, Leopard

In the wake of the controversy surrounding the Troll Tracker blog, which was managed anonymously by a Cisco Systems patent attorney who recently was unmasked, I found the Sun Microsystems Corporate Blog Policy. What I like about it is that it provides information to help staff make decisions as professionals. It even encourages good technical blogging practices. At the same time, it does not suggest a blog free-for-all for employees, just that they understand what the impact of a blog can be for Sun’s customers, staff, and shareholders:

Advice: By speaking directly to the world, without benefit of management approval, we are accepting higher risks in the interest of higher rewards. We don’t want to micro-manage, but here is some advice. 

In my opinion the blog policy itself brands Sun as an employer of choice in promoting innovation of ideas in its industry. I think this is a policy that would promote safe and productive blogging in the health care industry as well.

This is a community where there are visible reminders everywhere to recommit yourself to what’s important.

The PCHIT blog is moving to its new home at the Center for Information Therapy next week.

We’ll post a link to the new blog here, and then automatically redirect all traffic to the new site.

This blog was started along with the initiative in October, 2007, and will, as planned, move to a site hosted by the Center for Information Therapy. Josh and the IxCenter will maintain things there, including the 141 posts and 155 comments that resulted from this effort.

The new blog will continue to discuss important developments at the intersection of HIT and patient-centered care and build on related work going on at the IxCenter.

Ted will continue to write about his own experiences in health information technology, patient empowerment, reducing disparities, and physician (and patient!) leadership at http://www.tedeytan.com/.

We learned so much from the committed organizations we visited, all of which involve practitioners dedicated to promoting patient-centered care. We also learned, as one medical director colleague once said, that we are living in a hailstorm of innovation. We thank all of the organizations and the people who support them, for their time and interest in their patients and communities.

We also thank the supporters of this work

Grumbach K, Mendoza R. Disparities In Human Resources: Addressing The Lack Of Diversity In The Health Professions. Health Aff. 2008;27(2):413-422. [Accessed March 27, 2008].

This is a nice analysis of solutions from the Family and Community Medicine Team at University of California, San Francisco, to support diversity in the health professions, which unfortunately have not yet reached levels comparable to the general population, especially in allopathic medicine.

There are two concepts that reinforce that this is not just an issue for health care, it is an issue for society, and the people and businesses that depend on a strong health care system:

The business case highlights the customer service and competitive advantages to the health industry of having a workforce that is culturally and linguistically attuned to the increasing diversity of the nation’s health care consumers.

and

A wide group of organizations—including the AAMC and other health professions educational organizations, higher education institutions, consumer groups, and Fortune 500 companies—contributed amicus briefs and other documents in support of the University of Michigan in Grutter v. Bolinger, signifying a more concerted effort to identify and organize stakeholders interested in supporting diversity efforts.

Many physicians, myself included, work in the most downstream parts of this ecosystem, and it’s therefore helpful to consider that there are places we can be to create a more effective care system for everyone. From my travels to date, it’s clear to me that these are worthy investments of my physician colleagues’ expertise. None of us enjoy waking up to a world where the quality of health care is dependent on things other than the fact that you are a human being.

A lot of stuff going on this week…

• Apple Digital Fitness Companion System? - Mac Rumors - It was/is only a matter of time. Hello Health2.0, courtesy of iPhone
• The computer will see you now | Economist.com - A nice biographical piece about Larry Weed, father of the problem oriented medical record.
• EMC, Partners collaborate on hypertension program - Daily Business Update - The Boston Globe - An employer that thinks about population health and sets up a PHR in concert with a health system. Interesting…..
• Subscribe to ringtones via iTunes - Easy way to get ringtones - a ringcast?
• Mashable?s Guide to Upcoming Web 2.0 Conferences - A plethora of get togethers to get up to speed on the latest in Web 2.0.
• leanblog.org | Lean Blog: The Waste of Handwritten Notes | Lean Manufacturing | Lean Healthcare | Toyota Production System - Yes, Leadership. From patients and their families too. The kind of leadership that brings the patient perspective into every conversation.
• Apple - Support - Downloads - MacBook, MacBook Pro Software Update 1.1 - Help with keyboard freezing issues caused by Leopard
• Healthcare 360 -
• GHI - GHI Medical Home Pilot - I think this is very promising for supporting EHR adoption and patient access to their own clinical information. Ties in very nicely with NYC’s PCIP project.
• Public health system struggles to reach gay ?hidden population? - Washington Blade - Another vulnerable population that could benefit from outreach - many are underserved even when well insured.
• Cocoa Programming for Mac OS X - The resource for programming on MacOSX, and iPhone as well

Bodenheimer T, Berenson RA, Rudolf P. The Primary Care-Specialty Income Gap: Why It Matters. Ann Intern Med. 2007;146(4):301-306.[Accessed March 27, 2008].

Sepulveda M, Bodenheimer T, Grundy P. Primary Care: Can It Solve Employers’ Health Care Dilemma? Health Aff. 2008;27(1):151-158. [Accessed March 27, 2008].

Where I am living and working, primary care is receiving a lot more attention - more than I have ever experienced it getting. That could be because I have been living and working in a place (Seattle) where primary care and family practice is well understood and now I am in a place where maybe it is not understood as well (Washington, DC), or there could be a change in conversation happening nationally. I think it’s a little of both.

I recently read the attached articles - there are many more from these distinguished authors, and for every article, many many blog posts covering the topic of primary care survival.

The articles, for me, highlight the idea that from a societal perspective, primary care helps people achieve their life goals through optimal health. The societal part means that this is good for people, their families, their employers and their communities. Paul Grundy, MD, in particular is raising awareness of the role of employers in supporting a balanced care system.

The articles also highlight that not everyone is taking a societal perspective in the discussion. From the Bodenheimer article:

It’s unclear whether the medical profession - with different specialties having distinct monetary interests and different estimations of the professional value of their work - can agree on substantial changes in payment policy on its own

This strikes me as a wise statement to make based on current conditions. At the same time, in the work I have done to help transform a health care system using LEAN (Toyota Management System), I have learned that this condition can change, and physicians can come together, if the view we take is one about the patient (which is really one about society).

When I walk into a room in my health informatics role, I feel that I am representing myself as a physician, rather than as a family physician. This helps me be aware of the contributions my specialty colleagues make to improving primary care and the skills of the people who deliver it. Their contributions are significant. Because of this experience and my experience practicing the Toyota Management System, I have an interest in the inclusion of all physicians (and all patients) in this discussion. I am wary of writing that implicitly or explictly states that the tension should be or is between primary care and specialty care. I think our patients and our society are wary of that idea, too.

I’ll end my comments there and welcome others’ ideas.

Imagine that you are going to launch a new program, like patient access to their medical record online, and a visitor from another institution asks for a tour of the work in progress. Then imagine that it isn’t a member of the staff that does the demo - it is one of your patients. I think this idea would sound foreign to most organizations. It’s pretty normal here, and Christine did a great job, on her own, without any oversight or hand holding. This is the level of trust that exists here.

Images, click any to see larger

I have actually never had a patient demonstrate their own access to the electronic health record to me. This was the first time in my career. I am so used to doing the demos and describing what patients want, and this was so different because it included the things that worked best, but also the hopes and dreams for using this tool to be involved in care. Christine not only did the demonstration for me, but also 3 Medical College of Georgia Students, and part of the research team on a funded project to introduce patient access into hypertension care.

In the hopes and dreams part, Christine talked about uses of the system that we might consider concerning as medical professionals, such as writing messages that conveyed a significant level of concern about her condition (she lives with MS), but when she explained it, it made sense, and it became not so concerning.

This was a theme throughout the visit - the normalcy of patient and family involvement in care. This was very evident in the 3W Neurosciences unit and Ambulatory clinic. Countertops are reduced or eliminated. The layout is open. There is no such thing as “visiting hours.” Signage is welcoming and participation is encouraged. There are alcoves for family conferences, and even computers set up for families to use. There is guest wireless throughout the hospital.

As you watch the Remaking of American Medicine show and look at the data associated with this tranformation, it’s very clear this is not only good for families and patients (and society), it’s good for business. Quality is up, mortality is down, patient satisfaction is up, profits are up - all the right trends for a hospital serving a vital population like this.

This organization of course is part of a health care system with many challenges - physicians and nurses have significant time challenges, and even the physicians in training here are at risk in terms of their future enjoyment of the profession. I casually ran my idea of a 4th year rotation on patient-centered care (which would include elements of LEAN such as process flow, physician leadership, and service and access methods) with our student hosts, and they provided a little balance to the concept and assistance with messaging. Matt, Kim, and Brandi reminded me about the immediate needs of physicians in training and the way that they learn about and commit to new training experiences. I’d therefore like to propose a rotation on success in practice beyond the diagnosis - enjoying work, life, and balancing both successfully. Being patient centered guarantees that this is the outcome for any physician, in my opinion.

The thing I am super interested whenever I meet people who have done exceptional things is, “Why?” I noticed that in the PBS show, Medical College of Georgia was an institution in which their transformation was not set off by a patient tragedy. So I asked Pat about this and here’s what she said:

What started this and kept it going and I may have told you this in a way is that we developed a value around the inclusion of the patients voice in our work from the beginning of the design process for the new childrens hospital. I personally was a senior executive back then and I was utterly transformed by the power of the patient’s (in this case, parents and children) perspective on what mattered most in care and I could see that this was a strength that we were denying ourselves as executive leadership. We also had very good mentors way back then in Bev Johnson and the Institute for Family Centered Care and I think we were just open to learning. Because I became so committed and over time could show the hard results in terms of outcomes so did the rest of our leadership. I think it is really that simple….just persistence over many years, Ted.

I think this is very remarkable - Pat and the Medical College of Georgia did not wait for a patient to be hurt to transform their system. I keep reading and hearing about organizations that transform only after a tragedy. We’re health care, we cannot wait for a tragedy, right?

When we were touring 3West, Pat, Roslyn, and Bernard showed me a plaque, signed by every staff member that represents their commitment to patient and family centered care. The first thing I did was look at the date that it was first signed, and of course wondered if it was up to date. As I did that Roslyn said, “Whenever we get new staff, they add their signatures, too. We haven’t had new staff in a long time, though, because people stay here.”

I can’t wait to see the innovation that will come from Medical College of Georgia in the launch of their patient access system. This will take Patient and Family Centered Care beyond their physical buildings and wherever patients and families live, work, and play.

With thanks again to the patients, families, staff, physician and leadership at MCG for being great teachers, so that every patient and family can be involved in their care, whether or not they are fortunate to be supported by the MCG Health System.

And, I am not going to consider patient access to their medical record successful until a patient does the demo.

The quote in the post comes from Roslyn Marshall, RN, Nurse Manager of the 3West Inpatient (Neurology and Neurosurgery) unit at Medical College of Georgia, in Augusta.

Images: Click on any to see larger

Just as with several other organizations I have visited, I did not imagine that I would be heading to Augusta, Georgia to learn about how to involve patients and families in their care, but I’m glad I did. This is a place where so many things that are seen as abnormal in the rest of health care, are normal (see this paper for a description of patient centered care, with a focus on MCG). In an environment like this, it’s okay to ask “why?” when it comes to issues of involving patients and families in their care.

The occasion of my visit is related to a grant that Medical College of Georgia has received to study the use of a personal health record to improve hypertension care. With respect to the idea that being as close to the patient as possible is important, Ms. Pat Sodomka, Senior Vice President of Patient and Family Centered Care, hosted my visit on behalf of the organization.

Part of my study included watching the excellent program, The Remaking of American Medicine, which featured Medical College of Georgia in its last hour, and it was amazing to see how much has been accomplished both in involving patients and their families, and in transforming the organization.

Today, I’ll post about what I saw clinically. Tomorrow, I will post about what I saw systematically in this leading edge care system.

I began in Family Medicine and Internal Medicine, where practitioners and patients are both busy, and integrating one or two electronic health records in the care that they use. This is what I observed when shadowing family medicine specialist Bill Phillips, MD.

Besides data from their own organization, they need to integrate the needs of patients working to stay healthy in a system with an affordability crisis. In my own practice, I had not had to think about which big box retailer offers which drugs for $4 , or even free, as a loss leader. However, this is a big issue for patients. I reviewed the formulary for Wal-Mart’s $4 program - it’s extensive.

I was able to shadow the Director of the Osteopathic Medicine Program, Julie Dahl-Smith, DO, who is also board certified in Family Medicine, as she performed a manipulation visit and acupuncture visit for a family. This made me think about the value of patient involvement through a personal health record. The treatments that Dr. Dahl-Smith provides are distinct from the allopathic treatments that I have been trained to do. There’s an opportunity for patients to become more knowledgeable about the treatments that work best for them through patient access.

I spent time with Shilpa Brown, MD, who manages her own faculty practice as well as a residency practice and extensive student teaching. Patients in each have distinct needs. I also observed some key differences in workflow between private practice and academic practice. Faculty are ultimately accountable for 1, 2, 3 or more residents’ care, whether that care is provided in person or virtually. There is much that MCG will contribute in this area as an innovative academic medical center.

In between, I visited with the Neurosciences Interdisciplinary Rounding Team, which includes nurses, pharmacists, students, residents and attendings, led by Dr. David Hess. This is a unit, 3W (which I will talk more about tomorrow) that serves patients and families not just locally but regionally. What would it be like if a family member who is based far away from Augusta could connect with their family’s care team electronically? The team was open to this idea.

This organization is unique in my travels because it is a full academic medical center with many top notch training programs, which include a family medicine residency and an osteopathic residency. It is also special in the way it involves patients and families in the care, through its advisor program. The program reaches all the way into undergraduate medical education, and every new program seeks involvement. Patient advisors are free to visit MCG facilities and talk to patients and families about their care.

As I was being guided to the Internal Medicine clinic by Bernard Roberson, Director of Family Services Development, we passed by one of the “commons” (a different way of thinking about a waiting room that’s more patient centered) and a patient waiting to be seen said to us, “Tell me more about patient and family centered care.” It turned out it was one of MCG’s Patient Advisors, and I think we both saw it as a welcome sight. That’s how things are different here.

Tomorrow, a post about the system-ness of Patient and Family Centered Care at Medical College of Georgia.