Atlantic Monthly: Electro-Shock Therapy

This quote caught my eye about General Motor’s approach to planning their next generation electric car:

Perhaps most audacious of all was a decision to allow unusual public access to the Volt program. The industry’s standard procedure is to develop new products, especially risky ones, out of sight, unveiling them only when proven. GM decided to do exactly the opposite. The PR department flung open the doors. GM executives discuss the program’s progress as publicly as if it were a bill in Congress. They show off photos of batteries under development. They promise to let reporters ride in test cars. They lead them through the labs and design centers and even into the wind tunnel. They run ads, for instance in this magazine, touting the Volt in the present tense, as if it already existed. By earlier this year, expectations were so high that President Bush was commending the car, and it had developed a national grassroots following. This article is itself a product of the fishbowl strategy.

GM is using the publicity to excite the public, of course. It is also using the publicity to push itself. “We thought it would be a motivating thing to do,” Wagoner says. “Certainly it gets everybody aligned”—not always easy in a giant corporation. And GM wants credit for trying, which it never received for the EV1. “If it fails,” Harris says of the Volt, “we want people to know exactly why it failed. It wasn’t lack of commitment or passion on our part; we hit a hard point we couldn’t get around.”

On the other hand, I don’t see a newer update than March, 2008 on the official Volt Web site. There are blogs about it though, and it’s possible that those publishers have good access to how things are going.

Click on the image to see a much larger version…just 1 page.

Issue & Focus

1. The California Healthcare Foundation is dedicated to the improvement of the lives of Californians managing chronic illnesses.
2. There are many community stakeholders involved in supporting this goal; their work could be improved by making connections to each other that are meaningful for patients.
3. This is part of a broader strategic plan to support the objective of involving patients and families in all aspects of their care. This is the identified gap to be closed through this work.
4. California Healthcare Foundation is seen as catalyst and partner for patient engagement in California. It’s scope is 36,000,000 Californians

Current Condition

1. All chronic conditions can benefit from better patient engagement
2. Hypertension is a good example of one - recently published studies demonstrate both the gap and the opportunity with non-office-based approaches

Problem Analysis

1. Divided into three areas : Clinical Gap, Technology Gap, Partnership Gap, that California Healthcare Foundation can connect partners to assist with
2. Clinical Gap: Patient role in recognizing blood pressure out of control; currently this rests with the physician, in an office-based setting
3. Technological Gap: Chronic disease assessment is typically performed in the office or medical setting
4. Partnership Gap: Stakeholders (patients, payers, providers, connectivity providers) are not connected to patients and one another at the same time
5. The societal costs of inadequate management are spread diffusely; few organizations are able to to see the total harm from this perspective

Target Condition

This pilot seeks to create a functioning ecosystem that supports chronic disease management across the lifecycle, with the best candidate being hypertension

Action Plan

We began by interviewing example employers, health care providers, and technology providers to understand which approaches and components appeared most promising. At this time, it seems most reasonable to approach this first from the employer perspective.

Next step will be to convene a group of potential partners in July, 2008, at California Healthcare Foundation, to discuss how pieces would fit together.

A presentation would be made to the CHCF Board in the fall, with funding and activity to begin in 2009.

Cost / Cost-Benefit / Waste Recognition

There are recognized wastes, which include unnecessary visits for blood pressure monitoring, inadequate medication therapy, and inadequate use of the health system, for patients who have not been seen in the past 12 months.

There are costs including, technology costs (although the goal is not to build anything new), and realignment of incentives to support non-visit-based care.

Followup / Unresolved Issues

Points of concern and planned countermeasures

1. What is the metric for patient access? (Pacific Business Group on Health is working on an employee engagement survey; metrics for patient access to their health data may need to be developed)
2. How can this complement the launch of both a P4P measure for blood pressure management, and a HEDIS “Relative Resource Use for Uncomplicated Hypertension” measure for 2008?
3. Data for presenteeism and productivity loss does not seem intuitive (I have reviewed this in depth and we can bring in clinical champions to verify)
4. Partners and aligned interests (will do due diligence to support cooperative business models of partners)
5. How to engage patients in things like biometric monitoring and blood pressure control (there is data supporting patient interest in this monitoring, but most importantly will go to the factory floor, and will bring an employee/patient advisor on to the team)

That’s the latest script that goes with the story, more or less. Comment away, and keep in mind that each comment will change the A3 a little every time.

Health care found to be better with online help - Nice localization of the landmark Group Health study on managing hypertension using Web services, from the Seattle PI.

So…if the study and the community agree that this kind of care is better, and there is data to show that diagnosing “white coat” hypertension is cost-effective, and payers already have reimbursement policies for ambulatory blood pressure monitoring (and older type of technology to figure this out), why not create more modern policies for home blood pressure monitoring?

Medical Education Evolution - New Social Network on Ning devoted to improving medical education in the 21st Century, thanks to Jen McCabe Gorman for setting this up. Hosted on the Ning platform - if you are interested in reforming medical education please join.

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If we want to change the way blood pressure is managed away from the doctor’s office and toward the place where it is managed best, we have to envision how that would happen. Here are a few scenarios. What do you think? Are these realistic?

This week’s photograph is of myself, with Susan Edgman-Levitan, PA, Executive Director of the John D. Stoeckle Center for Primary Care Innovation. Susan invited me as a guest to the Center to learn about the primary care practice of the future being envisioned at Massachusetts General Hospital, as well as the work under way at the famous Lab of Computer Science.

I enjoy working with Susan because she knows how to laugh. And in advocating for patients in her friendly style, she’s kind of like this…

This is a bit overdue for me given that I learned what I learned about CCR at the ASTM Workshop in May, 2008, conducted by David Kibbe, MD, MBA, and Steven Waldren, MD. I think what I learned is important for supporting patient-centered HIT, so I’m putting my summary here. A reminder that the beauty of Web 2.0 is that nothing is ever finished - feel free to clarify or correct anything I’ve gotten wrong.

The seminar itself was very enjoyable, nicely paced, and I learned as much from the students (including fellow blogger Vince Kuraitis and Sam Faus from Sujansky and Associates) as from the teachers - that’s always the right combination.

Why was CCR created?

CCR stands for “Continuity of Care Record. (link to official site here) ” I think the “why?” of anything is the most important - knowing where things come from tells us where they’re going…

In 2003, there was a desire to figure out a way to take the “green form,” which health care providers used to transmit a patient’s medical record summary to the nursing home, digital.

(In the clinical arena, the transfer to a nursing home is one of the most delicate times for a patient and their family. Inaccurate or missing information can have an enormous impact when the receiving institution is not staffed to reconcile and adjust therapy the same way a hospital is.)

In their discussions, David told us, they began asking about making this XML-based standard “a record for the patient” that could be used for all kinds of care transitions, not just to the nursing home. And so, CCR was born.

(Comment from me - (a) yet another innovation from those in our profession who care for our geriatric peers (b) CCR is fairly new on the scene, 2003 is recent in Informatics history)

CCR was vetted through ASTM International, which from my understanding, is atypical for this organization, which now has a very small focus on Health Informatics. There are other standards bodies, most notably HL7, that have traditionally working in health information.

What exactly is CCR?

Note: The paragraph below is superceded by the comment attached to this post by David Kibbe, MD, which more accurately explains the content and licensing of CCR. Thanks, David!

CCR is two basic things - a “Schema Definition” that resides an a fairly easy to read spreadsheet. And an implementation guide, which provides the “how to” of every element. Both are licensed under the Apache GNU License. This is not 100% the same as open source - but I think it does mean anyone writing software can use this standard to move data around.

CCR uses eXtensible Markup Language, or XML. XML is very standard in modern Web applications. For example, the piece of software that I am writing this blog post on is going to send my words via XML to my blog, and my blog doesn’t really care what software I used to send it my words from, as long as it uses the right XML code to contain it in. This is important in a standard - it’s connected in a logical way to standards already used by other industries to move data (getting us away from the “health care is different” model).

Is CCR supposed to help with portability and interoperability?

As David explained to us. These are two different things. Portability means you can move the information to another place, via paper, fax, or digitally. Interoperability is the ability of “XHR” software (”X” can mean “P” or “E” for EHR or PHR - get it?) to communicate and exchange data so it can be used for its intended purpose, for example to trend with data like it, or to be used to support population health.

CCR is supposed to help with both, using an approach that is not based on a paper chart - it is concerned with vendor-neutral, human and machine-readable structured data.

Why isn’t CCR based on the concept of a medical chart?

I have worked in large systems that computerize medical charts using state of the art software. This part took me some time to understand. A medical chart is divided into various sections, organized a certain way (depending the doctor/hospital where it’s used unfortunately), and serves various clinical and legal functions. It’s a lot of things to a lot of people.

CCR on the other hand, is more like, “What do I need to know about you (and what do you, the patient need to know about you) for you and I to take care of you right now.” It’s a summary of the most important things, but not necessarily everything. At the same time, it can have multiple observations, like a list of past blood pressures for example. It can be a summary of just one outpatient visit, or of 10 years in a healthcare system. It’s flexible that way. We learned that MinuteClinic, Inc. uses it in the former way, to “summarize” one visit to a practitioner and transmit it as needed by the patient.

Part II coming soon: More of What I Learned about CCR

I am posting this presentation that I created, commissioned by the California Healthcare Foundation, and supported by the Center for Information Therapy and indirectly, Group Health Cooperative.

It is the presentation that created the need for me to define Health 2.0. It is also the last presentation I will give as as a Group Health employee, and the only time I will be able to give it, due to my my career change.

It’s in slide show format, so feel free to click on any of the images and page through. I had a lot of fun putting it together because it allowed me to reflect on what I learned and how much I have changed in my thinking in just the past year. May the same trend continue.

I would like to extend special thanks to Crosskeys Media, producers of the excellent show “Remaking of American Medicine,” for allowing me to use portions of the content in the interest of supporting patient centered care. I encourage anyone interested in this topic to view or purchase the show. There is an educational license available that allows for use in teaching (as a whole piece, not intended for editing by users). It’s worth it.

Feedback and comments welcomed.

• A patient’s advice to hospital communicators | Article | Homepage articles - When you read this, it seems like everyone is trapped in a system that they are powerless to change. Patients probably wouldn't have it work this way. A great way to have the doctor slow down is to have them prepare an after visit summary.

• The power of two: Random thoughts from a random guy - What do patients think about having high blood pressure? The blogosphere has answers.