It’s time again for an internet holiday, so there will be no publishing on this blog for a bit. You can read about the philosophy behind the internet holiday here.
I also like to call up this story as a good reminder to keep things in perspective.
See everyone in a week or so.
This week’s photograph, and a few additional ones below, are at dusk, where the inauguration stands are being taken down in front of the White House. You can see the smile on a fellow photographer in the image. There was a small crowd of visitors wishing our new president well.
About a month ago, I posted a review of Safeway Foodflex , which intrigued me as a novel health management tool that uses data that is far more significant than that generated in medical care – what we eat. You can read the review here.
I noted in the review that the site was down when I wrote my post – it was confirmed for me that this is because the site was in the midst of a major overhaul to improve its usability and focus. With that in mind I wanted to revisit to see what was different. I did get a little help understanding some of the features, but I have not spoken with the team at Safeway yet. They are of course welcome to comment/add information to what I write here!
The impact of transparent sharing
As the title of the post says, there is a really nice evolution happening here. First, its important to point out that the revolutionary concept that started with the last version is carried forward here – that your grocery will provide you (me) with the data we generate with our purchases and help us (me) leverage it for our health. Think about this for a minute – how much purchasing data do we generate in our daily lives, and how transparently is that shared with us?
A note about sharing personal data
In this blog review I struggled a bit regarding whether to share screenshots from my own account. Even though it’s perfectly legal, I have a rule in my professional life that I never demo my own medical record. My rationale behind this is that it’s poor form to use my account as a demo because it may unintentionally create an expectation for other employees/leaders that their personal medical information is sharable in public forums, even though there is no such expectation – my employer vigorously protects the privacy of its members/patients information. The better course is for organizations to create demonstration systems.
In this case, I decided that since I am a customer of Safeway and not an employee, that it’s okay since I’m not creating expectations for other customers or employees of Safeway. The application of the above is that I would not expect to see a Safeway employee demo this system using their own personal data.
I have blurred out my purchase details in any event.
Goal oriented: The case of sodium
I decided to focus on my intake of sodium, because I happen to dislike a lot of it in my diet, and as you can see from the screenshots below, I was able to go to household trend for sodium, zero in on a hidden source of it (fat free salad dressing, I really had no idea), find an alternative, and then see the impact on my trend. Slick.
What an improvement over conventional medical care today – in the doctor’s office we just don’t have time to review a person’s diet history, and usually just a few screening questions are possible, like “do you salt your food?” or “do you drink whole or nonfat milk?” I could imagine a nutritionist or a physician prescribing the use of this site with a goal to get sodium below a certain amount.
I think the site does a good job of not being prescriptive since it is not run by a health system – the focus is on USDA requirements without any valuation about whether there is “too much” of any nutrient. A health system involvement could make this a bit more relevant, by tying the results to clinical goals, however.
Future expansion
The site is not currently linked to Safeway.com for ordering of food. In addition, there still isn’t linkage to product images or food labels. I understand that this is a bit similar to the challenge in health care of putting drug labels and medication images together. It’s not an easy task.
Even more possibilities through integration of community and the health system
The site is a great example of Health 1.0 (and that’s a compliment, the competition is Health 0.0), through its liberation and simple management of the data. The power of this information included in a patient’s health record could be significant.
For example, in the future people could compare food choices with other patients who identify themselves with certain chronic conditions and maybe the quality of the management. You could ask, “Show me the shopping list of people with hemoglobin A1c’s under 7.0″
Or as Susannah Fox noted in a comment on the last post, “show me the shopping list of other families managing severe food allergies,” and “allow me to send a list of products (or evan a full shopping order) to family who we are visiting in preparation for a visit.”
In interactions with the health system, in a future world, maybe there could be a print format co-designed with a health system for reporting nutrient intake, and setting goals. In a world of HIT interoperability, I’d also be interested in standards for electronically conveying nutritional information into a personal health record, and ultimately into an electronic health record for use in medical care.
And of course let’s not forget even farther ranging applications, like Twitter integration (“Mother, I noticed on your Twitterfeed that your caloric intake is down over the past 2 weeks, are you feeling okay?”) and mobility.
A PHR for Food
I think Safeway’s work in this area should be watched and supported – I can imagine so many exam room conversations that could be impacted by a good discussion of what we eat. The foundation for those discussions is information – perhaps a discussion of Food 2.0 might be worthwhile at the upcoming Health 2.0 conference…..
Images: Click on any to see larger
The question asked in the title of this post is one I have as well, so I’ve decided to ask it in this post.
It was posed by e-Patient Dave in a comment on this post illustrating the challenge of test result sharing with patients today.
He’s referring to California Health and Safety Code Section 123148 , which makes it illegal to share certain kinds of test results with patients online. It also says:
In the event that a health care professional arranges for the provision of test results by Internet posting or other electronic manner, the results shall be delivered to a patient in a reasonable time period, but only after the results have been reviewed by the health care professional.
Knowing what we know about health care, reasonable time period and “only after the results have been reviewed” may be in conflict.
I understand this law was passed in 2002, so in 2009, I’d like to ask patients and those who care for them what they know of the rationale here? If you do not live in California, is there any such legislation in your state? If this law no longer existed, can people envision what the harms (and benefits) would be?
This week’s photograph is of the Albert Einstein Memorial, in front of the National Academy of Sciences Building, in Washington, DC.
I had not known about this work before I was invited to go on a walking meeting with Claudia Williams, Director of Health Policy, for the Markle Foundation. The memorial is impressive both in its larger than life-ness, and its accessibility – you can literally sit next to Albert. Claudia pointed out that this memorial is an interesting juxtaposition to the Lincoln Memorial, just across the street, which I really wouldn’t have considered before she mentioned it.
Given my interest diversity in the workplace, in health care, and equal access for patients, I was especially uplifted by one of the three quotations engraved on the bench:
As long as I have any choice in the matter, I shall live only in a country where civil liberty, tolerance, and equality of all citizens before the law prevail.
Part of the fun (and magic) of walking meetings is learning more about one’s community through the perspective of another person. When a person schedules a walking meeting with me (using the excellent TimeDriver tool), I ask them in the scheduler to tell me where to meet them, so I can enjoy experiences like the one I had with Claudia and Albert.
This article caught my eye because it’s the first look (that I’ve seen anyway, let me know if there are others) of what I have been calling the “California effect.” No, not the California effect of passing laws that limit patients access to their own medical data online (which has been ineffective). This is the California effect that was effective, around banning smoking indoors. What happened after that was that a whole generation of children grew up and moved to other places in the U.S. and asked their communities, “why is this place that allows smoking indoors so abnormal?” I saw a hint of it at Group Health Cooperative as well, where patients leaving the health system would ask their next doctor, “Where’s your EHR/PHR?”
This study doesn’t study patients, though; it studies doctors. Ones that have been trained in a technology-rich environment at Vanderbilt University, and who then begin working in a diversity of environments that use and don’t use Health Information Technology tools. The authors chose to study the electronic health record component, and not the personal health record component. More on that later.
328 physicians out of a total of 679 graduates were surveyed. The authors excluded people who had undeliverable addresses in the denominator, but I would prefer to look at “intention to survey,” so depending on your approach, at least more than a 50% response rate was obtained. It’s important to note that 54 percent of the respondents reported working at an academic medical center, so there’s a heavy sampling of AMC work environments here.
Absence of HIT was associated with lower perceived quality of care in many domains surveyed, including safety, efficiency, and system learning. Of considerable note, this group reported having less confidence in their knowledge about drug interactions and drug management than they did during their training, even months after changing institutions. Additionally, many respondents felt weakened in their ability to prescribe medications safely.
That’s the headline. However, looking deeper. There are a few curiosities:
And this interesting summary statement:
One implication of this study is that if HIT reduces error rates but is not yet ubiquitous, administrators at technologically sophisticated environments might need to expose their junior physicians to unsupported and less safe care environments as learning experiences.
The implication of the above is that resources should be spent on introducing physicians-in-training to paper based practice to support safety in a potentially unsafe environment.
The authors asked about the impact of HIT on communicating with patients and families, and the study shows that there wasn’t a significant one attributed to HIT in the Vanderbilt institution, a place that is advanced in the area of personal health records (from my limited knowledge, someone please add information about that if you have it).
Even if we assume that a HIT-enabled environment is always “more safe” than one that isn’t (and you could read the Health Care Renewal Blog to challenge that assumption – safety is not inherent in HIT, it’s in the system that it’s a part of), I think the resource should go to training skills that work in any environment, HIT or not. I am speaking of process improvement, collaborative/enterprise thinking, and patient centered care. This includes things like analysis of clinical workflows to look for and eliminate waste, learning how to write to patients and involve them and families in their care and understanding of their medical information, and leadership/support of entire care teams. On the process improvement work, there is much that can be done in a paper environment even before HIT is implemented. It’s likely that doing work that reduces waste and increases standardization makes HIT easier to implement. At the very least, creating a culture of looking for problems and focusing on the impact to the patient is as important within a HIT-enabled environment as one not-so-enabled.
Speaking from a LEAN (Toyota Management System), problems are gold, and this study is very helpful. I think it points to an early “California effect” with regard to HIT. It’s possible that clinicians trained in these environments will be more observant of not just HIT, but well-implemented HIT. The study also points out that we may still be thinking of Health Information Technology as a physician endeavor. I think it would be interesting for a large health system that has a fully deployed personal health record to survey patients who have left and ask about their confidence in managing their health and staying healthy.
See how many different aspects of this experience could be improved (security, privacy, confidence, accuracy) if the patient had online access to their results, linked to explanatory health information and interaction with their care team at their convenience.
While the situation is obviously a parody, it seems to have enough elements of truth in it that I wonder if the writer experienced receiving test results recently. Without overanalyzing, I would say that the piece does a great job of showing the impact of disempowerment. Thanks to the 30 Rock team for the great example.
In California, a patient wouldn’t have a choice except to receive the results via telephone or in person, because it’s been illegal since 2002 to share pathology results with patients over the Internet, even if the patient and/or the doctor wish them to be communicated that way.
This week’s photograph was taken at Washington, DC’s Loeb’s New York Deli , and has Anita Samarth and Trenor Williams, MD, assisting fellow customers with their breakfast meals. This kind of thing just happens in a city/state that’s the #3 most extroverted in the United States.
The occasion of our breakfast was a monthly dialogue of a group of mid-Atlantic health information technology professionals that get together regularly to learn from each other and and to believe that everything is possible, because it is. Here’s a photograph of the full smiling group (except for me, the photographer…).
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