The Green Doctor Office Program – helps medical practices across the US prevent care before it’s needed

In the last 2-4 weeks I’ve reflected on a consistent theme that I’ve encountered in the area of health care that goes beyond what the industry traditionally sees as its role, and that is the leadership of individual, dedicated physicians.

It’s a bit like the Apple, Inc. “misfits” commercials because these people push the boundaries. The place where I work places a heavy emphasis on developing physician leadership, but (and fortunately) there are many of these people across health care that think different, too.

I got to meet Todd Sack, MD, ( @toddsack ) a gastroenterologist in Jacksonville, Florida, who is one of those people.

I first heard about the program that Todd is leading out of the Florida Medical Association, the Green Doctor Office Program, at as I was doing my reading on climate change in health care.

The Green Doctor Office Program  makes it easy for smaller teams and practices (where the overwhelming majority of health care is provided) to create green teams, eliminate wasteful practices, and save money in the process. It’s laid out really well, there’s no registration requirement, and there’s a path to recognition by the Florida Medical Association. It’s also a gift to all of health care – you don’t have to be a Florida-based practice to take these steps or receive recognition.

Why Florida? It turns out that Todd is a native Californian and has always had an interest in the physician’s responsibility for the environment and health. He’s Past Chair of the Jacksonville Environmental Protection Board, Past Chair, Climate Change Advisory Group for the Florida Energy Commission, Past Member, of the Florida Energy Commission, and current Chair, Environmental & Health Section, Florida Medical Association.

It’s possible to imagine that a medical association might not be the place where leadership comes from in this area, given the many issues brought to them by their membership. And yet, it’s happening here.

A passionate physician leader can understand that health professionals don’t want to provide care in a way that makes the community less healthy. They can go farther and create an approach to change this situation that’s relevant to her/his colleagues. From this work, I can see how it’s possible to create medical care where health care doesn’t undermine itself, with some knowledge, and some tools, and the built-in thought for the people we serve.

Just as in the diversity / patient empowerment movement,  a program like this also  promotes leadership at all levels of a practice team (even the patients!) to provide their ideas, expertise, emotional equity. Caring for the community is health care, too, and it doesn’t require a medical/nursing/professional degree.

As I posted previously, if we think our patients don’t notice waste in health care (of our resources, their resources, the environment, our time, their time), think again. The converse is that they notice when we take steps to reduce waste, save their communities, save their health before they need health care.

If you look at the CO2 footprint of an organization the size of Kaiser Permanente, it’s easy to see how the impact adds up. Thanks, Todd, and Florida Medical Association, for supporting every patient in every practice in receiving care in a way that helps their community be healthy, too.

Oh, and Todd is just getting up to speed on Twitter, but go ahead, follow him, he’ll be a great resource 🙂 : @toddsack

My slides from presentation : #GreenHC – Healthy Environments, Healthy People

I really enjoyed putting these together because I learned so much in the process. And I thank the American College of Preventive Medicine ( @ACPM_HQ ) for allowing me to practice it for the first time to an understanding audience.

Slide share version plus click through version below (I like the slide table view so I can go right to what interests me).

I worked to put together all the sources in one place, and you can find those here:

Not using stock photography: Better images to talk about green in health care #greenHC

I (and many others in the social media space) don’t really like stock photography. The problem with it is that it isn’t real, so what does it illustrate except that someone somewhere was in a studio pretending to do something. I wrote about this previously: (See: Health care is usually not a stock photo (of rainbows and butterflies)

Regina Holliday ( @ReginaHolliday ) has even set up a group on Flickr where people can add “Reality Stock Photography” photos (which you are welcome to use because they are copyright free).

When I thought about what image should represent “Green” in health care, I realized it should not be a plant, or the “marble shot” of Earth, or glaciers.

Here’s the photo that comes with the slide template that we use where I work, The Permanente Federation:

The photo is not great because it doesn’t show anything real (and it’s designed to be a placeholder, the template designers encourage us to swap it out :)), and it’s also the wrong way to introduce the topic of climate change to a medical audience.

This learning came about because I was invited to speak on behalf of Kaiser Permanente on the topic of the “greening” of medical practices at American College of Preventive Medicine ( @ACPM_HQ )  2012, through our (very talented) Green Team.

This was a stretch for me on some level. On another level when I dug into the content and data (so helpfully supplied to me including from the Green Community on our internal social network), I realized the concepts and philosophy are not that different from what I know much better, patient-centered health information technology.

Back to the photos, I always take time to pick a cover photograph that’s:

  1. Not a stock photograph, which means something I’ve taken or has been taken of real people/things.
  2. Has some meaning to the topic

So after some thinking I used a series of images, that I took myself, of parts of the city I live in that illustrate the importance of a healthy environment. And guess what, they are the same images I would use to illustrate : Total Health, Prevention, Health Information Technology, Patient empowerment, etc etc.

Next photos, better choices (click to enlarge):

From top to bottom, they are: View of the US Capitol from the Eckington neighborhood, Washington, People sitting on Dupont Circle, People doing the LIndy Hop on Dupont Circle, People using bike share bicycles on 17th Street, Washington, DC.

All of these photos are Creative Commons licensed, you are free to download them, and you can get them here. I’ve also set up a Pinterest Board on the topic of Climate Change and Health.

In the all day session at American College of Preventive Medicine, that we were exposed to research that shows that it is in fact a mistake to talk about Climate Change as an issue of polar bears rather than as an issue of people. You can access this research here.

And yet…as I got off the plane at National Airport there was a huge poster showing two images, of an Alaska glacier 20 years ago, and today, to illustrate the problem of climate change. I wish I had takean a photo of it, however, thanks to Google you can see it here. This approach does not resonate with Americans.

What does resonate is the fact that my allergies look like they are starting almost a month earlier this year….talk about increasing the cost of health care and our CO2 footprint.

I’ll put the rest of the presentation up in another post. I learned in this process that climate change is a serious health issue for humans, and that health care should do what it can to mitigate the effects. Not doing anything means undermining ourselves.

Do you have any favorite images that you would use to illustrate climate change and health? Post in the comments!

#greenHC Part 7 (last one): Why am I interested?

From my LEAN training, I’ve learned to always ask “Why?” and this topic is no different for me. I did not train at a place where sustainability was emphasized, so I asked why it’s emphasized where I work now, Kaiser Permanente.

Answer: this is in our DNA, too

The first images are from the Sidney Garfield, MD, designed Walnut Creek hospital, which opened in 1953. Family could access patient rooms from an outside walkway, leaving the central corridor of the nursing wing free for nurses. There’s a video reel on the Kaiser Permanente History blog that shows just how ahead of its time this hospital was, and yet, the benefits of mother nature were well respected.

Sidney Garfield’s industrialist partner, Henry J. Kaiser, was similarly genotyped:

In 1942, Kaiser built the first steel mill west of the Rocky Mountains, and insisted that his engineers make it the cleanest in the United States and Kaiser Steel installed the most sophisticated smokestack and furnace emission screening devices available. (See: Kaiser Permanente and Earth Day 2010: It’s in Our DNA)

Flash forward to 2008 and 2012: The image on the left is of Kaiser Permanente Modesto, one of the greenest health care facilities in the United States:

  • Vinyl flooring has been replaced with rubber
  • Carpeting is PVC free
  • Partially energized by solar power
  • All cleaning and maintenance materials have a lower toxic footprint
  • 80% of the materials used in the building process were recycled

The image on the right is a depiction of a parking structure covered with solar panels. Kaiser Permanente agreed in 2010 to install solar power systems at 15 California facilities, a total of 15 megawatts of solar energy, which would power 15,000 homes in one year.

Kaiser Permanente’s San Diego Hospital went live on January 25, 2012 with 4,958 solar panels, which will provide 25 % of its energy. Kaiser Permanente’s La Mesa Medical Office Building went live with 4,926 solar panels over its parking structure, providing 75 % of its power.

The next two slides quote the Kaiser Permanente Vision for Environmental Stewardship & Guideline for Climate Change. A vision doesn’t make people do things, it describes what they are like and where they want to be. The first image is of the 2009 Environmental Protection Agency Award for….

Green Health Care and Social Determinants go hand in hand

The image on the last slide is a personal story, which I wrote about previously on this blog. I am not an environmental activist. I am not sure I ever will be. What I am is a patient activist, a diversity, activist, and a health activist. On this particular day, I was at “work” encouraging colleagues attending a conference to not ride in the gas guzzling hotel shuttle, almost standing in front of the boarding doors. Was it easy to do this? No. Was it fun to do? Not particularly (the walk was awesome, however). Did anyone try and stop me? No. Did my colleagues take myself and my co-conspirator on the offer? Yes.

And then we happened on the gentleman in the middle of the photograph. He, along with others around Washington, DC, that day were mourning the 1 year anniversary of the worst man-made environmental disaster in history (guess which one…). None of us realized what day this was, I realized that we were fully supported in thinking of health broadly. Because of that support, we would find ourselves in the company of people who think of health broadly, too, and we would support them as well.

Some of those people don’t have the kind of voice that physicians have.

The Royal College of Physicians has written a wonderful white paper (See: How doctors can close the gap: Tackling the social determinants of health through culture change, advocacy and education) that speaks to the issue of social determinants of health and what physicians can and should do to reduce inequalities. Becoming active in green health care and sustainability is one of the key places they recommend action, because people at the lower end of the social gradient are disproportionally affected by environmental threats.

Reducing health and social inequalities, giving people a voice when they don’t have one, thinking of health more broadly than health care, that’s why I went into health care :).

By the time this post is published, I will have presented all of these slides at ACPM2012.  I am on a roll, though, because tomorrow I’ll be on a panel at the Bipartisan Policy Commission talking about healthy institutions. Prevention is the new HIT….

#greenHC part 5: An ounce of preventing preventive care equals megatons of CO2 saved

Deliberately avoiding the term “greening” as too much like “tree-hugging,” Dr. (David) Pencheon (head of NHS’s Sustainable Development Unit) argues that whole new models of care are needed, with new financial incentives that reward medical behaviour that benefits both human health and the environment. (Moynihan R. The greening of medicine. BMJ. 2012;344(jan16 1):d8360-d8360.)

#greenHC is a better hashtag – Meredith convinced me that shorter-but-clear wins every time. – ePatientDave (@ePatientDave) via Meredith Gould (@MeredithGould)

So, again, as in the last post (#greenhealthcare part 4: Health Information Technology helps health care be green), the support of a healthy environment that does not undermine/defeat what we are doing in the health care system is connected to how we enable and involve patients and families in their health and health care.

A big thanks to ePatientDave for the shiny new hashtag. He understands that these posts describe a leading edge concept for many in health care and wants to help me communicate it well. I’ll take all the help I can get!

The slides above are meant to demonstrate a shift in the model of health care to make it more efficient – people who communicate electronically with their doctor are much more (significantly so) likely to have their blood pressure controlled, their blood sugar levels controlled (not pictured), their cholesterol lower (not pictured), and their eyes and kidneys checked for damage before they go blind or go on dialysis (not pictured) (See: Now Reading: Improved Quality At Kaiser Permanente Through E-Mail Between Physicians And Patients).

Performing preventive care OR treatment increase the CO2 footprint of health care, prevention more than treatment. This is okay, health care is supposed to be an investment in a longer, higher quality of life. In cardiovascular care, the one exception is smoking cessation, which is cost saving. Everything else costs money:

If all the recommended prevention activities were applied with 100% success, those costs would be reduced by $904 billion, or almost 10%. However, assuming the costs shown in Table 2, the prevention activities themselves would cost $8.5 trillion, offsetting the savings by a factor of almost 10 and increasing total medical costs by $7.6 trillion (162%).(Kahn R, Robertson RM, Smith R, Eddy D. The impact of prevention on reducing the burden of cardiovascular disease. Circulation. 2008;118(5):576-85

Almost any health care activity, then, generate CO2 (in the US, about 8% of the greenhouse gas footprint, in the UK, 3%). In the United States, 14% of the CO2 generated by health care activities come from prescription drugs. In the UK, it’s 22%. These may actually go up if all prevention activities were applied uniformly to the population, so the prevention part that saves CO2 comes from delivering these services more efficiently, or not requiring these services at all.

The “delivering more efficiently,” example is in the slides above. The not requiring these services at all comes from prevention of nutritionally related diseases. Just four of these (cancer, high blood pressure, diabetes, and heart disease) are estimated to account for 1/3 of the US health care carbon footprint, and the estimate is that half of these could be mitigated by dietary changes. By “mitigated” we mean not requiring any preventive care or treatment in the health care system.

This is extensively modeled in the white paper “Harvie J, Schettler T, Mikkelsen L, Flora C. Common Drivers Common Solutions. 2011.

Next post in #greenHC – measurement, an advantage of understanding green house gas emissions in health care.

These blog posts are a series connected to an upcoming presentation at American College of Preventive Medicine 2012, on February 22, 2012. You can see the whole series here.