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

This is for you, Susannah Fox – This week’s photograph is of Regina Holliday and Cindy Throop who helped organize a flash mob in Dupont Circle. Regina’s shown myself and others of the power of the artists’s brush in creating change. I wouldn’t have envisioned this a year ago for health care.

The scene on Tuesday reminded me of another photograph I took a few weeks ago, while at BWI airport. It is of a letter written to Thurgood Marshall in 1954 about his efforts – “It is really wonderful what can be done with these television cameras.” Less than a mile from the spot Regina is standing is where Justice Marshall planned the strategy to overturn school segregation. The building is now called the Thurgood Marshall Center, pictured below.

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….

Health Care Law Blog: AHLA Connections: Legal Implications of Health Care Social Media – A (dare I say) beautiful article / reference written by Bob Coffield about health care and social media.

A few things relevant to my situation that are worth repeating/thinking about in other organizations:

• The presence of an internal social network (at Kaiser Permanente, it’s called Ideabook – referenced in this presentation), helps to manage the stated concern about superiors and subordinates friending each other on public social networks. The internal social network creates a professional environment for colleagues to connect and share interests, and in the one that we use, there is no accepting or ignoring of requests – a colleague relationship is established on request automatically.
• The presence of a useful social media policy. Here’s a link to Kaiser Permanente’s social media policy. Several people have contacted me and asked if it may be copied / used by their organization. The answer is yes.

Thanks again to Bob and team for being interested in this topic and in keeping patients engaged and protected, two of the most important types of care we provide for patients.

The State of Virginia’s decision to reinstate discrimination was immediately overshadowed by the District of Columbia’s decision to end it last week, creating lots of excitement in this territory-not-state part of the United States.

I really like the way the author of the article stated it:

When I picked up my paper (this morning), the images were joyful, depicting happy same-sex couples who were finally able to apply for marriage licenses in our nation’s capital. I went to the WaPo’s web site and discovered that it has a whole slide show of photos of happy couples.

I often tell my students that, in my humble opinion, one purpose of government is to help people be happy. The DC government did a good job on Wednesday.

Here are a few photographs of the happy couples, and a few humorous signs of celebrations (photo credits: (1) and (2) by Erin_M/Flickr.com, (3) Library of Congress (4) M.V. Jantzen (5) M.V. Jantzen ). Cupcakes were provided free of charge by Washington’s Hello Cupcake.

…and a few reminder photos of where we came from.

Okay, one more thing. The public statement made by Mildred Loving in 2007, on the 40th Anniversary of Loving vs. Virginia:

Loving for All
By Mildred Loving
Prepared for Delivery on June 12, 2007, The 40th Anniversary of the Loving vs. Virginia Announcement

When my late husband, Richard, and I got married in Washington, DC in 1958, it wasn’t to make a political statement or start a fight. We were in love, and we wanted to be married.


We didn’t get married in Washington because we wanted to marry there. We did it there because the government wouldn’t allow us to marry back home in Virginia where we grew up, where we met, where we fell in love, and where we wanted to be together and build our family. You see, I am a woman of color and Richard was white, and at that time people believed it was okay to keep us from marrying because of their ideas of who should marry whom.

When Richard and I came back to our home in Virginia, happily married, we had no intention of battling over the law. We made a commitment to each other in our love and lives, and now had the legal commitment, called marriage, to match. Isn’t that what marriage is?

Not long after our wedding, we were awakened in the middle of the night in our own bedroom by deputy sheriffs and actually arrested for the “crime” of marrying the wrong kind of person. Our marriage certificate was hanging on the wall above the bed.

The state prosecuted Richard and me, and after we were found guilty, the judge declared: “”Almighty God created the races white, black, yellow, malay and red, and he placed them on separate continents. And but for the interference with his arrangement there would be no cause for such marriages. The fact that he separated the races shows that he did not intend for the races to mix.” He sentenced us to a year in prison, but offered to suspend the sentence if we left our home in Virginia for 25 years exile.

We left, and got a lawyer. Richard and I had to fight, but still were not fighting for a cause. We were fighting for our love.

Though it turned out we had to fight, happily Richard and I didn’t have to fight alone. Thanks to groups like the ACLU and the NAACP Legal Defense & Education Fund, and so many good people around the country willing to speak up, we took our case for the freedom to marry all the way to the U.S. Supreme Court. And on June 12, 1967, the Supreme Court ruled unanimously that, “The freedom to marry has long been recognized as one of the vital personal rights essential to the orderly pursuit of happiness by free men,” a “basic civil right.”

My generation was bitterly divided over something that should have been so clear and right. The majority believed that what the judge said, that it was God’s plan to keep people apart, and that government should discriminate against people in love. But I have lived long enough now to see big changes. The older generation’s fears and prejudices have given way, and today’s young people realize that if someone loves someone they have a right to marry.

Surrounded as I am now by wonderful children and grandchildren, not a day goes by that I don’t think of Richard and our love, our right to marry, and how much it meant to me to have that freedom to marry the person precious to me, even if others thought he was the “wrong kind of person” for me to marry. I believe all Americans, no matter their race, no matter their sex, no matter their sexual orientation, should have that same freedom to marry. Government has no business imposing some people’s religious beliefs over others. Especially if it denies people’s civil rights.
I am still not a political person, but I am proud that Richard’s and my name is on a court case that can help reinforce the love, the commitment, the fairness, and the family that so many people, black or white, young or old, gay or straight seek in life. I support the freedom to marry for all. That’s what Loving, and loving, are all about.

* Together with her husband, Richard Loving, Mildred Loving was a plaintiff in the historic Supreme Court Loving v. Virginia, striking down race restrictions on the freedom to marry and advancing racial justice and marriage equality in America. (Mildred passed away ih 2008 at the age of 68. R.I.P.)

Love definitely won.

This week’s photograph is of the “famous infamous @epatientdave” and Kate Christensen, MD, who’s the medical director of kp.org, Kaiser Permanente’s web site for members. They are giving a presentation at HIMSS10 about involving patients and families, not just in their health care, but in the design of the healthcare system itself.

I used this photograph to illustrate the part of the presentation that Holly Potter and I gave at HIMSS10 that touched on Health 2.0.

I wanted to find something in my collection that describes what Health 2.0 means, along the lines of the famous/infamous definition commissioned right here from this blog, and I needed to look no farther than the SD card in my digital camera from the day before.

I’d like to say that it doesn’t take having an EHR, a PHR, or even a lot of technology to participate with patients (these things can help a lot, though). It just takes a desire to want to.

As I said in my comments the next day, I don’t believe Kaiser Permanente is the national leader in patient participation in the design and operation of the health system. This is good news, because there are lots of leading edge organizations who doing this work (you can find many of them here), and in them, you will find scenes just like this.

I should say that due to an unfortunate coincidence, Dave and Kate’s presentation was at the same time as a discussion being led by Health 2.0’s Matthew Holt and my favorite economist Jane Sarasohn-Kahn, so even in the same meeting, you’ll find many scenes like this!

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!

This week’s photograph was taken right after the snowpocalypse, and I am using it to add an image to the idea of “Total Health,” which is part of the presentation that Holly Potter and I are giving at HIMSS next week.

I like taking photographs like this because they show what the success of a health system looks like – people achieving their life goals through optimal health.

I learned to think this way because of the personal health record, which allows us to care about what our patients do when they are not in the medical office. From that perspective, the workplace of a health system that supports total health is where people live, work, and play.

I considered a few other images for the slide that this one is on (see below). They’re included here in the event you think they are a better fit than this one (let me know in the comments, please). I’ll post all the slides here after our presentation (and truth be told, when they are actually completed).

Click on the link for more details, and just in case, the job # is 012631. I am not the hiring authority; however I can pass questions on and/or feel free to post your resume at the site above for consideration.

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

_________________________________________________________   

These roundtable discussions connect attendees with industry bloggers and give them a behind-the-scenes look at the responsibilities and dedication required to develop and maintain a successful blog and following. Each discussion will have a different focus and will be moderated by Cesar Torres, Manager, Web Services, HIMSS. I’m up on Wednesday, March 3 at 3:30 pm.

I knew this had to be this week’s photograph the minute I saw it (and cross posted it in various places…). It is what it looks like, a beautifully created couch made out of snow, in Dupont Circle, Washington, DC. This is just the tip of the iceberg reminder of what comes from a community that embraces diversity and new ideas.

Not everyone lives in/works in a place that is brimming with or tolerates diversity (ahem, Virginia), so the creativity and new ideas may not be as apparent, but they are there. I think people should always stop to notice them – creativity, innovation, and diversity potentiate each other.

Here’s a view of the furniture from different angles. Enjoy.

Some time ago, I used to teach a class at the University of Washington School of Medicine on diversity in the health professionals, and I reminded students that in most parts of Washington State (at the time), it was still legal to fire someone from their job for no other reason than that they were lesbian, gay, bisexual, or transgender.

This is no longer true in Washington State, however, this is a reminder that such discrimination is still legal across most of the United States, in 2010. And this is just employment.

The words of Mildred Loving, whose case, Loving v Virginia, ended racial discrimination in marriage in 1967 are appropriate here, considering that she sued the State of Virginia. Here’s what she said on the decision’s 40th Anniversary:

“Not a day goes by that I don’t think of Richard and our love, our right to marry, and how much it meant to me to have that freedom to marry the person precious to me, even if others thought he was the ‘wrong kind of person’ for me to marry. I believe all Americans, no matter their race, no matter their sex, no matter their sexual orientation, should have that same freedom to marry.”

Meanwhile, Washington, DC, is barelling toward the end of marriage discrimination, set to end in less than a month, in March, 2010, and many Virginia employers, including mine, respect the value of diversity. People are excited and happier to live in a place that supports equality. See for yourself:

Washington, DC is the #epicenter of equality, too. Come join us.

Feder JL. Cell-Phone Medicine Brings Care To Patients In Developing Nations [Internet]. Health Aff 2010 Feb;29(2):259-263

Kahn JG, Yang JS, Kahn JS. ‘Mobile’ Health Needs And Opportunities In Developing Countries [Internet]. Health Aff 2010 Feb;29(2):252-258

As I alluded to in my post yesterday, this month’s issue of Health Affairs is devoted to E-Health in the developing world, a great validation of the importance of learning from this trend, given this journal’s ability to attract the best authors.

With that in mind, I eagerly approached these two.

The first, Kahn JG, Yang JS, Kahn JS. ‘Mobile’ Health Needs And Opportunities In Developing Countries [Internet]. Health Aff 2010 Feb;29(2):252-258. , attracted me because its lead author, James Kahn, MD, is an innovator in the developing world, through his work to support patients with AIDS in San Francisco. I was fortunate to meet Jim in previous work (and blogged about it here) and think his perspective is very valuable to people thinking about mHealth.

This article is particularly useful for the mHealth inexperienced (that’s me) as well as the mHealth and eHealth inexperienced. For those of us that live in the stew of innovation, we forget that most people don’t know what we mean when we say, “mHealth,” so starting off with a helpful definition is great (“the use of wireless communication devices to support public health and clinical practice”).

Beyond basic definitional elements, the article has a nice table of mHealth applications listed, along with their potential benefits and risks. The article also links to a report that was mentioned in the HealthAffairs briefing that also seems worthwhile. You can find that report here. The most important thing that the authors state is this:

“We found minimal formal evaluation of m-health.”

So, as much as it excites me/us for its potential, we have to remember that it doesn’t yet excite us for its outcomes. I/we have been here/there before with eHealth and the web, so we understand the dance, and in retrospect it seems that in the absence of hard evidence, these technologies will be used; however, they may be more strongly used to provide better service and access rather than hard clinical outcomes. And, this is okay, service and access to health care (and let’s say, prevention and primary care specifically) do improve health. But why not be aspirational this time around, right?

The second article,  Feder JL. Cell-Phone Medicine Brings Care To Patients In Developing Nations [Internet]. Health Aff 2010 Feb;29(2):259-263., is a description piece about some of the innovation that’s happening in Mexico City. As I remarked yesterday, the article dropped a big bomb for me when it mentioned that giving patients access to their medical records is prohibited by law. It’s part of the description of the background that results in the innovation that is seen there, and, as usual, I see lots of parallels to our health system here.

I did notice one review article mentioned here that was not mentioned in the Kahn article above, that you can see the reference for here, which reviews some outcomes from SMS.

Specific services are discussed covering the areas of cardiovascular disease and HIV, co-created with Voxiva, who I also met last year (and who are behind the new Text4Baby service). When it comes to the next service, Diabetes, there’s an implication in the article that this is taking longer to launch, and maybe (or maybe not) this highlights some of the limitations of text-based mHealth services.

Whether there are limitations or not, however, the environment that this work is happening is going to push toward removing hurdles, not creating them. In this sense, discovery about how to use mHealth is more likely to be global, which can only foster the best kind of innovation, the kind crosses borders, not just physically, but nationally and experientially as well.

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.

This week’s photograph shows a diverse group of people enjoying a recreational snowball fight in specially built snow-bunkers, at Malcolm X Park, in Washington, DC. In between them, is, I believe, the “black diamond” sled run, or at least it looked black diamond to me. Elsewhere in the park there is a green run and a blue run, formed from the snow covered steps of the park.

Despite the difficult week weather wise, there were a lot of smiles to be seen.

Here is another view from the top of the park, with the Washington Monument in the distant background. At one point in Washington, DC’s history, this was going to be the site of a “colossal presidential mansion to replace the White House.”