As Jay says, we’re speaking tomorrow, at SXSW – The panel is called Sick Clicks, the Evolution of Health Online. See you there.

I like this. It demonstrates that our police department acknowledges that this a problem that is affecting a lot of people, and uses a creative way to get the information out.

And PS, if you are coming to visit Washington, DC, take this seriously. Do not use your smart device near a metro doorway or even in a public space, such as seated in a restaurant. You may find its presence in your life a distant memory….

Several people asked for the slides after the event, so here they are in graphical form.

Lots of people prefer the slideshare.net experience when viewing slides, so if that’s what works for you, Holly has uploaded the slides here, with embedded YouTube videos.

If you’re interested in the sources/links from the presentation, they are beneath the slides, for your researching pleasure.

Comments/questions welcome, as always!

Atul Gawande, MD and Jack Cochran, MD, NGA meeting, Washington, DC

A few weeks ago, Jack Cochran, CEO of The Permanente Federation (the company I work for) mentioned that he would be speaking alongside Atul Gawande, MD, in DC, and that I should try to come. I didn’t realize fully that he was speaking in front of the Governors of the United States of America, and definitely not that he was going right after The First Lady of the United States, Michelle Obama.

In any event, I got to go, so I’m going to share that experience here.

The First Lady

The First Lady was great. She talked about her family’s values with regard to exercise and eating. She’s leading an important conversation about why we need to treat childhood obesity as a societal issue, with multiple causes and solutions. (Disclosure: Kaiser Permanente is a founding partner in The First Lady’s Partnership for a Healthier America)

She spoke of food deserts, which are communities where families do not have convenient access to grocery stores and purchase processed and other less-healthy foods at convenience stores and corner markets.

I do not live in a food desert currently, but I did last week (this photograph explains it all), and I can definitely relate to the feeling of needing to pack high calorie, high sodium, non-perishable foods into the grocery bag, and how unsettling it feels. Great for The First Lady to work on making healthier food choices available to families in communities across the United States.

View from the TelePrompTer

Atul and Jack

Of all the things on our country’s governors agendas, it’s impressive to think that they made health care the lead issue of their winter meeting. And equally impressive that they asked to hear from physician leaders first.

The title of this post is from a comment made by Jack that started with, “Don’t say you can’t do this (high quality, patient-centered care) because you’re not KP. We didn’t know we could do it until we did it.“

As Dr. Gawande is very well known (understatement), so here’s a little bit about Jack: He’s a plastic surgeon who delivered care in the fee for service world and became curious about the Kaiser Permanente system in his community in Colorado (“If care was needed, physicians wrote me – ‘please deliver this care’), and became a plastic surgeon in that system. He eventually became the Executive Medical Director of the Colorado Permanente Medical Group where he fostered an environment of physician leadership (of the servant kind), innovation, and personal accountability and responsibility. And, Kaiser Permanente Colorado’s results speak for themselves.

In 2005, I had the good fortune/serendipity to be a student in the national Permanente Medicine and Management course led by Jack, where I and physician peers learned about what we could do to make health care (not just Kaiser Permanente) a better place, starting with us. A lot of the advice I give to others (and to myself) originates from the approach I learned here.

With my excessive interest in patient and family involvement – I picked up on a few significant things said by both leaders:

1. By Atul, who spoke about “how much faster things went” when the patients were in the room. (This is not a fluke, go with it)
2. By Jack, who started his remarks with “This is for the patients.” and later “This is about what this does for patients” (We enjoy leaders who never forget this)
3. By Jack, who, when talking about the deluge of medical information that physicians need to keep abreast of included, “and what our patients find online.” It’s not that he said this, it’s the way he said it – as important as anything else a physician needs to know. (A personal health record leaves an indelible and positive impact on a medical group)

Blast from the Past – “You have the power”

At the event, I happened to sit behind Mary Selecky, The Secretary of Health for the State of Washington, and amazingly, we both remembered a moment, exactly 10 years ago, in a class at the University of Washington School of Public Health where we learned about making change.

My colleague, Abigail Halperin, MD, and I were students in the School of Public Health, working on ending the sale of tobacco products for profit by the University of Washington, and during the class, Abigail asked Secretary Selecky what she could do about ending this practice. Her answer, to us and the class was, “I don’t have the power as the Secretary, you have it as the student.”

It turned out she was right; the decision to end the practice was ultimately made by the Associated Students of the University of Washington, and we got there by working with the student body, not the Administration, who resisted the change.

The value of physician leadership (in addition to the leadership of every other stakeholder)

The not-so-subtle nudge from Secretary Selecky in 2000 made a difference, just like Atul and Jack will, by using their talents to help others lead.

I know that both physicians vastly understate what they know about how to create change in medicine and health care in a venue like this.

That’s okay, one of my tenets is “frequency is better than duration” – I think this experience will come out over time, and it’s going to be helpful to people who wonder if the impossible is possible, a great role for physicians.

I sent Beverley a link cloud with resources available from Kaiser Permanente which are available online.

If you have useful information for Beverley, feel free to post links in the comments, or send directly to her at bkane1[atSign]stanford.edu.

Dear Medical and Medical Informatics Colleagues,

Our Stanford Practice of Medicine (Intro to Clinical Practice) course is introducing a segment this spring to teach med students how to maintain rapport with patients while using the electronic health record.

Do any of you, your institutions, or EHR vendors have guidelines, white papers, or teaching materials for EHR etiquette?

Thanks in advance for anything you can send us. I will be happy to share our course materials when finalized.

Beverley

_____________________________________________

Beverley Kane, MD Program Director, Medicine and Horsemanship

Stanford University School of Medicine Center for Education in Family and Community Medicine

http://familymed.stanford.edu/

See Emmy Award-winning Stanford “Medicine & Horses” video on NBC-TV

http://www.horsensei.com/nbcnews.html The Manual of Medicine and Horsemanship: Transforming the Doctor-Patient Relationship with Equine-Assisted Learning http://www.authorhouse.com:80/BookStore/ItemDetail.aspx?bookid=49669

_________________________________________________________   

Conditions like this don’t stifle innovation, they ignite it, and it’s one of the several reasons I think mHealth (“the use of wireless communication devices to support public health and clinical practice”) is different than eHealth (which I’m referring to as desktop Web/computer interaction in health/health care).

I credit Susannah Fox, the Internet’s Informant General, for stimulating the thinking. In 2008 at Health 2.0 in San Diego, she said, “Recruit doctors, let e-patients lead, go mobile” and the data she has been generating since has ceaselessly has been pointing to that reality.

More recently, Washington, DC, hosted the mHealth Initiative Networking Conference last week, and this week, Health Affairs hosted a briefing on their latest issue on E-Health in the Developing World (side note, I know I’m behind in noticing this, but I love HealthAffairs new print form factor – less tome-y and more open).

The mHealth Networking Conference was remarkable for me in terms of the spark I noticed on the part of the attendees and the slightly different focus – a little more public health-y, a little more do-great-things-for-society-y. And, I’m going to say it, a little more exciting for someone like me because of the possibilities that go beyond the desktop web. To learn about them in the City where people believe everything is possible, because it is, is just icing on the cake.

So here’s my list:

#1: When we talk about the web, we still worry about the people who are just not online. According to Susannah’s team, its hovering at 26 %. mHealth is different, everyone has a cell phone or is going to get one, relatively speaking. If you compare use visually, the cell phone thermometer shows much greater penetration – all groups are “pushed up” to higher degrees of access.

Wireless internet users’ demographics; this is kind of huge

Speaking of Mexico and the developing world, the parallels are relevant in the United States to vulnerable populaition, and this is another key difference. Desktop web access favors more educated, more affluent people. There’s an inverse relationship when it comes to wireless. Look at this data from December: If you look carefully, you’ll see something amazing. Access statistics for Black and Hispanic respondents are higher for wireless access to the Internet than for Whites. It’s almost as if the “haves/have nots” are reversed. For people interested in reducing disparities, this is…kind of huge. That’s difference #2.

Difference #3 has to do with ease of set-up. When I speak with iPhone developers or people involved in mobile, I hear the words “difficult, challenging,” which is different than what we heard in 1995 when anyone (me included) could code an HTML page and put it up.

Difference #4, when we talk about the web, there’s not a discussion of telecommunications companies and their innovation. When we talk about mHealth, we have to include telecommunications companies. This year at HIMSS10 , in Atlanta, it’s not Sanjay Gupta, MD (whose work I have great respect for) that I want to see speak the most. it’s Dan Hesse, CEO of Sprint/Nextel. People with telecommunications experience, in my opinion will be very important moving forward. In a analogous way, I am as drawn to the CTIA as I am to AMIA .

Susan calls it

Difference #5, Reverse Innovation – Unlike the web, a lot of the “cool” stuff has already been pioneered, outside of the United States. Susan Dentzer said it best at the Health Affairs briefing: ” Clearly the US is the developing country when it comes to mHealth“. The term reverse innovation comes from General Electric (this article from Harvard Business Review explains it) , and it means that a lot of the inventing to be done is happening in India, China, South America, and as the article linked to above points out, in Mexico. What may work best is something that comes from a place with far less resources than we have. Kind of what health care, a resource-poor industry when it comes to innovation at the level of public health and primary care, needs.

ZipHealth: Where would you rather track your health; here, or on a desktop website?

Difference #6, it’s more personal. Some of the apps we saw last week, and others I am hearing about, are things that might not work on the desktop web so well, because a desktop or laptop is not as “personal” a device. The idea of storing information on a web site and forwarding to your doctor seems to make more sense on a mobile phone, because it’s something you hold that’s yours, that you can “share” with someone. Not the same for a web site on a computer.

I want to clarify that this is not 6 reasons why mHealth is better or has more scientific evidence behind it. This is just differences. I’ll report on two great papers in the Health Affairs issue on this shortly.

Comments/additions/subtractions welcome.

As I received this message from the PR agency promoting this work on behalf of the Robert Wood Johnson Foundation, asking me to post the information (which I get regularly from various organizations, I pick and choose what are relevant, organizations are discovering the value of social media):

This week, the Pioneer Portfolio will be at TED2010. While they are there, they will be engaging in discussions about what they see as a truly revolutionary movement in health care toward an approach that is more data-driven and patient-centered. We’ll be sharing that conversation on Twitter by using the hash tag #pioneerdata.

I also was reading this post:

Live-Tweeting Events is Dying. What Can Be Done? – Mark’s Cheeky Posterous

About why or why not Live-Tweeting events is useful or if it should change/morph, and it made me pause and do a little thinking.

I am a “serendipity’s coincidence” user of Twitter, so I see what I see whenever I see it, so it feels to me like livetweeting is waning, but I don’t know if it is or not.

Then, I watched the YouTube video posted in the above RWJ blog (which stars some of my favorite people) and thought about some of the comments which were that “data is only useful if it’s actionable/contextual.”

Live-tweeting being potentially useless, data only being useful if contextual and actionable….

I didn’t come away with any disagreement of the above ideas at all. Just a twist – the LEAN/Toyota (yes, Toyota) expression, which is, “Seeing the impact of what you do.”

And so, here’s my tie-in of all of this – I think data by itself IS useful, and Live-tweeting by itself IS useful.

Why? Because if the impact that comes from making it available in the first place.

On the issue of livetweeting, it may not matter to me whether an event is livetweeted or not, or whether those tweets cause me to take action. It does, however, matter, if an event is not allowed to be livetweeted or such transparency is encouraged. About a year ago, I was invited to an event hosted by an organization that I am not affiliated with and summarily told that no tweeting would be allowed. No discussion about whether this could be done responsibly, or whether there could be benefit from the work and ideas of such happening. Just, “No.”

The impact? If I were to be invited by that same organization to another event, I would prioritize an event that’s more open, or I’d decline altogether, mostly because I’m concerned that the interest in learning and growing just isn’t there.

On the issue of data being actionable, I encourage people to think about just the impact of the data being available, and honestly, I worry that the expression, “it has to be actionable” will be used by some with less noble intentions to decide, “therefore we shouldn’t make it available.”

So in conclusion

• Let Live-tweeting continue to serve as a marker of openness rather than of an organized approach to sharing information. If both happen, terrific.
• I respect the RWJ Pioneer Portfolio as a “portfolio” of great ideas, and therefore my favorite project has to be the My Open Notes project (official site here), because it’s about making information available first.

With thanks and respect for the great ideas in the above blog posts, and I hope that My Open Notes demonstrates what others have written about for over 40 years, that this topic didn’t need to be researched in the first place….

• It is DC-relevant, and really to residents of any other major urban centers, who are environmentally and socially supportive of their communities, and
• I want to enter it into the “record of the Internet,” making this information searchable for any other customers of these companies who experience this situation – spirit of social media, etc.

And the information is this – Visa Enhancement Services, which exists to help card holders “Take advantage of the security, flexibility, and convenience that come with a Visa card,” including an auto-collision damage waiver, does not offer this security, flexibility or convenience for Zipcar drivers.

I have gone ahead and pasted in their letter of determination to me, again, in the interest of helping other customers understand what might happen in a situation where they attempt to use this benefit, now that my situation is concluded (click to see full size).

To quote (again, to help the search engines out there):

Zipcar Members entered into a “Vehicle sharing service subscription contract” with Zipcar and not a rental agreement. Zipcar Member’s relationship as a member of Zipcar, entitled you the use of an automobile but did not constitute a “rental transaction” as required under the terms and conditions of the Visa Auto Rental CDW Program.

Now, I did discuss this carefully with Visa Enhancement Services, including the explanation that DC charges Zipcar rentals with a Rental car tax. The individual I spoke with there said that it doesn’t matter if my locality considers this a rental car. Regarding the issue of Collision Damage Waiver, ZipCar does offer a buy down to zero deductible, and I did decline that.

The final person I spoke with at Visa Enhancement Services was professional and cordial, but ultimately unhelpful in creating understanding around Visa’s stance on this issue. He suggested that the Zipcar company initiate a written dialogue with the head of their Division, on behalf of Zipcar members. He stated that Visa doesn’t get that many claims from Zipcar members; I honestly find that hard to believe.

So, despite what the letter says (“we reserve the right to accept this claim later” – really, why put that language in there if there’s no intention of doing such a thing…), I don’t think Visa’s going to change their mind on this one.

Most importantly for me, I should state, the damage I experienced was not personal injury inducing to anyone or anything, which is infinitely more important than the financial impact, and there are options to mitigate that going forward (see below)

Compared to Visa, a different (and great) experience with Zipcar

I have to say, they’ve been terrific. I contacted them right away using their procedures and they were understanding that I am not the only one who has experienced this with Visa, and they managed the repair and restoration of my membership quickly and efficiently. After all was said and done, they even offered an unsolicited token of gratitude for my loyalty as a customer.

And that’s on top of the fact that every interaction that I have had with them has had an excellent level of customer service, from start to finish.

Zipcar does offer the option to buy down the deductible of their rentals down to zero, so there are clearly stated options to prevent this in the future.

Which one do you like / trust more when this happens?

There’s a social media aspect to all of this…

For people in this situation, and from what I’ve seen online, there’s going to be a tendency in this situation to decide whether you “liked” dealing with Zipcar or Visa, and ultimately whether you “trust” Zipcar or Visa, or really any company who you approach about their assurances and ability to deliver on them.

I have read some commentary online about whether Zipcar’s policies are unclear or if their approach to a situation like this is confusing. At the same time, I’ve stopped owning a car since 2008, and I don’t miss it one bit, mostly because of Zipcar’s flawless customer service and approach to making cars available only when they are needed. That means a lot. And it’s worth putting it out there for others to appreciate.

From the perspective of my experience then, of the two, Zipcar is the organization that is doing more to support people like me in making the decision to keep 2-6,000 unnecessary pounds of aluminum, glass, and steel out of my community.

So there you have it, entered into the record of the Internet.

if anyone coming across this finds themselves in the middle of a seeming tug of war over this issue feel free to use my experience to innovate around a creative solution that supports yourself, your community, and a healthy environment.

People like me wish Apple would sell a version of its headphones that are not white. These appear to be setting us up as targets.

I was a recent victim of an iPhone snatcher in downtown Washington, DC, and in comparison to some of the crimes detailed in the blog post above, I consider myself very lucky.

It was going to happen eventually that wearing a $600 device would increase personal crime. I can’t help thinking that there’s a way to harness the wisdom of crowds and the very technology being sought after – maybe a "findmyiphone" aggregator that could help communiites and the police zero in on where these devices are ending up.

It’s worth noting that my stolen phone localized itself to the same location on multiple days, near a large Washington, DC, shopping mall, in Pentagon City, before I remotely secured it and wiped it clean (what a great feature – thank you Apple!).

To attest to the seriousness of this issue, even our local gym is passing on the warning:

Attention Members:There has been a report of an increase in robberies over the past week in the Golden Triangle/U Street area. Although not directly related to the club we thought it would be helpful to pass along the following alert from Metro P.D.

Golden Triangle Crime Alert

The Metropolitan Police Department has asked us to pass along the following information. As of late there has been an increase in street robberies around the DC Metro area. The Second District is not immune from these incidents. There is not a specific suspect lookout but there is a very specific target – the iPhone. To help combat this problem, MPD is asking the users of all phones and PDAs to use good street sense when carrying and using your mobile device.

Always be aware of your surroundings. It is a good idea to use your phone while stationary in a spot that will enable you to talk and observe your surroundings at the same time. Keep your mobile device close to your body and make sure it is out of sight when not in use. Please pass this along to reach as many people as possible.

Thank you,
MaryKay Moe

Operations Coordinator
Golden Triangle Business Improvement District

As Washington, DC is the #epicenter of many innovations (and health care transformation), it is also a leader in many social issues, some not so enjoyable. Let our experience prevent others from having the same in this case.

Thank you for being a loyal user of the Revolution Health Personal Health Record. Unfortunately we will be discontinuing this service as of the end of February 2010 and removing all records, information, and data from the Revolution Health Web site.

So that you don’t lose the information you’ve entered into the system, we strongly suggest that you download your personal records as a PDF to print and save for future reference. To do this, simply follow these instructions:

1. Log in to your Personal Health Record.
2. From any page of your record, click on the “printable version” link on the top right corner of any page. When you see a pop-up box asking you to “Select the following sections to include in your print out,” simply make sure that the sections you want to print and save are checked and then click the “Submit” button.
3. Once the PDF is created (this only takes a moment), you can print directly from it and/or save it to your computer. To print the PDF, click on the printer icon at the top left of the page. To save it, click on the disk icon to the right of the printer icon.

If you encounter a problem printing or saving your records, please e-mail our customer service department at CustomerCare@revolutionhealth.com for assistance. Even after the Personal Health Record is no longer available, Revolution Health and our partner sites will continue to offer you the same great health information and community pages as always. We hope you continue to visit Revolution Health often to take advantage of our offerings.

Thank you,
The Revolution Health Team

The irony is that this message comes on day #2 of the national meeting of physician and other Kaiser Permanente leaders involved in supporting My health manager at kp.org, Kaiser Permanente’s personal health record.

As I asked people here what they learned in day 1, it’s basically the opposite of what is expressed in the message above. This is a personal health record that is thriving, with demand from members/patients continually increasing, and an internet services group working as hard as ever to deliver next-generation services. If anything, they have not appreciated how successful this personal record has become, and this discussion allowed them to stop for a brief moment and appreciate.

Here’s a slide from a recent presentation showing the growth in use:

I hope that people receiving the quoted message do not see this as a sign that personal health records are not desired or wanted by patients. The opposite is very much true. The difference is that a personal health record that provides what people want is something that is wanted (I know, obvious). Such a thing exists. Ask for it where you deliver or receive care.

I specifically remember what Regina and the group said (in paraphrase) – “Show me the DNA of a high quality doctor.” and “Demonstrate that this/you are a doctor that I’m going to love.”

This is a very different need than “Tell me what I need to know about when to get a flu shot.” Not that patients don’t want this information also, of course.

In doing some more reading and experiencing, I thought about the outcome of social media in health care in creating engagement with the profession and health system compared to the outcome of providing information. Beth’s blog has a nice discussion about this (Engage, then Educate) in regard to the San Francisco Symphony. My hypothesis is that the principles are the same.

With that in mind, my colleague Rahul Parikh, MD, a practicing pediatrician and accomplished writer across many venues, worked on an experiment together and we’d like your feedback.

Click on any image to make it larger

This is his physician twitterfeed for patients:

This is him tweeting one way, let’s call it “standard” (more “education”):

This is him tweeting a different way, let’s call it “DNA – Enhanced” (more “engagement”):

Here’s the input we would like:

1. Do you notice the difference in the content/approach?
2. Which way would you want your own doctor. to tweet? (or a different way not shown here)
3. If you were looking to choose a doctor, does either approach draw you more to a potential physician?

Thanks for your comments in the comments, and thanks again to the patients, who continue to demonstrate that they are more than willing to help us perform well for them – all we have to do is ask.

You can also follow and tweet either Rahul (on his professional feed, different than the one above) or myself. Don’t worry, we’ll compare notes.

Kaiser Permanente // brand tags – Catching up on Jay Parksinson’s blog reminded me about this great little site. Although Jay uses the lookup of Mayo to illustrate a point about the health care industry focused on sickness, the lookup of Kaiser Permanente doesn’t follow on that theme….

…and the methodology anyway is more “fun” than accurate. However, the result for Kaiser Permanente does reflect the theme of a talk that Holly Potter and I are giving at HIMSS 2010 this year.

We’re calling it Driving Total Health with Health IT and Health 2.0, and we’re finishing it up now.

The title out of context is probably a little confusing. We were asked to talk about the impact of social media in what we do (surprise).

We are trying to make the point that getting engaged with patients/members where they live work and play using an electronic health record / personal health record, is naturally going to lead into engaging with them outside of the health care transaction. And this (HIT and Health 2.0) is a means, not the end, to helping people achieve their life goals through optimal health.

Holly and I gave a similar talk at Mayo Clinic Scottsdale, and we are retooling it a bit for this (HIMSS) audience, with some new patient stories and experience that we’ve had since then.

If you are going to HIMSS (or if you aren’t) and you have ideas for us about what would be useful to hear about, please feel free to post in the comments. This is my first HIMSS ever….

(PS, on a similar note about patient involvement, colleague Kate Christensen, MD, and e-Patient Dave, will also be speaking)

Kaiser Permanente is in the Top 50 U.S. places to work. It’s at #38, Apple Computer is #22. Not bad. Both Kaiser Permanente and Apple Computer also are on the list of employers that score a perfect 100% on the corporate equality index.

Washington, DC is joining the ranks of communities that provides equality to its residents, in the DC Council action yesterday to provide equality in marriage, expected to be signed by law by the Mayor, and not expected to be blocked by Congress.

In encouraging a colleague to blog the other day, I was asked, “How much of your personal life do you include in your blog?”

My answer to this is that I post things that are relevant to the three major things that are part of my professional existence:

• Health (as a means, not an end; of people, family, community)
• Diversity
• Washington, DC

So this information counts as bloggable. A great employer and a diverse community are good for health and happiness. Enjoy, and congratulations to Kaiser Permanente and the District of Columbia. I’m glad I know you.

Kudos and sincere thanks to the National Partnership for Women and Families and its hosted Consumer Partnership for eHealth for hosting the discussion entitled ““How Access to Information Can Empower Patients and their Caregivers” yesterday. It was the right place, right time, right group of people. I think we nearly split the atom.

e-Patient Dave in his post on e-patients.net did a nice job of summarizing the feeling on the part of the patients in the room, so I’ll just post what was going through my mind here.

After showing the images that I previously posted on this blog (you can see them here), a question was asked about sharing of lab results, imaging results, physician notes, and the like.

As you can see from Dave’s review of things, there appeared to be a difference of opinion about “when.”

The problem I see with the response of “yes, they should have their results; however…” or “yes they should see their data, but…” is that it reminds me of so many conversations I have had that go something like this:

“Ted, minorities (such as yourself) should have equal rights, no question about that. Just not now.”

That’s the reality I have lived, and I think for someone who is struggling to be respected in our health care system, this is how responses like the above can come across, as Dave’s blog post shows. This is why I turned to Dave and Regina and asked them to provide their personal experience, which they did, and very passionately so.

Instead of wondering,”Should the doctor see the results first?” let’s ask a deeper question: “When can patients have their data?” And…in more and more health systems, the answer is “whenever they want it,” with off-the-charts satisfaction on the part of patients and clinicians.

Yesterday really helped me understand that this is not going to be an easy conversation, however, I’m happy to participate in it, and invite the patient to be in the room while it is happening.

Why? Because I may have gone to medical school, but I have not yet had stage 4 metastatic renal carcinoma or cared for someone who has.