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

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

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

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

Feedback and comments welcomed.

When in California last week, I went to visit Larry Leisure, President, North America, and Deryk Van Brunt, DrPH, Senior VP of Business Development for iMetrikus.

images: click on any to see larger size

iMetrikus is part of the Continua Alliance, and has expertise in collecting and processing patient derived biometric data using FDA-cleared gateways, and in presenting the data to support clinical workflow. Here are a few images of the devices. The MetrikLink device connects many different devices via a phone line or PC, but it is not required if the device has standard connectors. There is also a mobile platform, especially interesting for patients who may rely on a cell phone for Internet connectivity.

This weeks’s photographs come from San Francisco’s Legion of Honor, which is currently hosting and exhibition of Annie Leibovitz’s photographs. I came here because this was the suggested venue for a walking meeting with Sophia Chang, MD, MPH, one of my advisors at California Healthcare Foundation.

Besides the beautiful scenery, there was significant relevance to health care in the exhibit itself, which included photographs of Ms. Leibovitz’ father and her partner Susan Sontag’s last days. These included a haunting image of her parent’s living room, almost completely taken over by a hospital bed, and photographs that relayed the different ways they died, from the intensity of Susan’s fight to that of her father, who died at home, in the arms of his wife.

This post contains the A3 Document, or the Project Plan, for Connectivity for California Consumers. I have been posting some of the data that supports this plan on this blog (click here to see them all). In addition, I have been working with staff at California Healthcare Foundation and potential stakeholders to improve the plan.

For those of you unfamiliar with the A3 format, it is designed to (a) tell a story and (b) incrementally improved to the point that the actions are clear at the time a project is launched. It may be revised once a day or even more often. The process of discussing the project and making improvements is called “nemawashi.” I am using this blog for extended nemawashi, so please post your comments.

Since an A3 tells a story, starting on the left, going down, and then on the right, I will summarize the story here. Feel free to print out the A3 and follow along (A3 means “11 x 17″ paper. You may have to shrink to fit on letter size).

Issue & Focus

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

Current Condition

1. There are well known gaps the care of people with high blood pressure
2. The impact of these gaps is distributed across stakeholders differently compared to other chronic illnesses, which includes a strong productivity-loss component, due to the high prevalence of the condition in employed populations (see charts).
3. There are examples of employers and technology companies approaching these gaps in hypertension and other chronic illnesses that can be studied.

Problem Analysis

1. Lack of access to care accounts for only 10% of poor blood pressure control; there is a physician component in setting goals, and a patient component in operationalizing those goals, that may not be accomplished in physician visits alone.
2. Patients who are not seen at least every 12 months are at greater risk for non-adherence
3. The societal costs of inadequate management are spread diffusely; few organizations are able to to see the total harm from this perspective
4. There are few models outside of integrated care systems of using non-visit-based approaches to managing chronic illness.
5. We are just entering an era of interoperability, with many solutions not yet integrated into the value chain of patients and payers

Target Condition

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

Action Plan

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

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

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

Cost / Cost-Benefit / Waste Recognition

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

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

Followup / Unresolved Issues

Points of concern and planned countermeasures

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

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

In my fielding of this data to various people, this part of the analysis has been by far the most controversial. Let’s first start with indirect costs added on top of direct costs, from the societal perspective, just for California. By indirect costs, we mean lost time from work (absence and short term disability), presenteeism (impairment while at work, to avoid being absent), and caregiving (21 million working men and women are caregivers in the US)

The indirect cost data is only for employed persons reporting the condition, which means it is a subset of the population (doesn’t include indirect costs for the non-employed, doesn’t include costs for the undiagnosed). The graph above is therefore a little bit off, because the medical cost is for all people, productivity costs just for employment related losses.

Now, a different look at the data, which averages costs across the entire employee population, from the employer perspective.

This is different because it takes into account prevalence, and spreads that cost over all employees, whether they report the condition or not. My explanation for the different way this data looks is that the medical cost per person for hypertensive employees is far less than for heart disease, but there are many more hypertensive patients in a population. In the employee samples used to derive this data, there’s a factor of 2 difference compared to heart disease (12.4 % vs 6.4 %).

The sources for this data are the same as previous charts (formatted for Zotero, below).

I have already been asked, “Ted, how can high blood pressure cause presenteeism at all?” and I welcome the skepticism. I reviewed the study below, which defined the term for our profession, and it includes a combination of employee studies, some done quite well, that ask about employee impairment and absences due to multiple conditions. This includes things like side effects of medications (which are a cornerstone of hypertension therapy). Questions, based on the study, were things like whether an employee performance was reduced by ‘losing concentration, repeating a job, working more slowly than usual, feeling fatigued, or generally “doing nothing”‘. The authors specifically chose tools that measured multiple conditions at once, so that comparisons could be made.

One novel study worth mentioning specifically is one by Bank One, that used administrative and computerized productivity records of its employees to explicitly measure productivity losses, in addition to using a health risk appraisal and claims data to come up with estimates. For hypertension, the estimate was 0.4 % in this one, which was right in the middle.

Based on my reading of the paper, I am accepting the methodology as supportive. As a student of LEAN, though, I know that the facts are best obtained on the factory floor, so my next interest is in working with an employer, and ultimately and employee, who experiences these conditions first hand. And I do mean on the factory floor, rather than the health system.

After creating this post, I realized that my A3 (coming next) has one inaccuracy. Fixing that, posting it soon.

1. An Unhealthy America: The Economic Burden of Chronic Disease: California. Take a look at the methodology here.

2. Goetzel, Ron Z, Stacey R Long, Ronald J Ozminkowski, Kevin Hawkins, Shaohung Wang, and Wendy Lynch. “Health, absence, disability, and presenteeism cost estimates of certain physical and mental health conditions affecting U.S. employers.” Journal of occupational and environmental medicine / American College of Occupational and Environmental Medicine 46, no. 4 (April 2004): 398-412.

Comment away, this can only improve with input.

Continuing on the case for connecting Californians, here is a look at the direct costs of hypertension (high blood pressure). There are several sources for cost data, the sources I used here typically rely on the Medical Expenditure Panel Survey (MEPS). The references are below.

The first chart shows things from a societal perspective, for California residents, the cost per person reporting the condition. It does not include costs for people who do not report the condition.

The second chart shows things from an employer’s perspective, and is calculated differently - it is the total cost of the condition spread across the entire employee base, per year. On this one, you’ll note that the prevalence of hypertension makes it formidable from an employer’s perspective relative to the other chronic conditions.

There’s a whole lot more to be said about this, but I’ll keep it brief and open things up for comments.

Additional cost estimate (not charted): $US 1,131 direct medical expenditures, prescriptions &gt 50 % of expenditures

Next, a profile of indirect costs.

Sources (Zotero format):

First Chart

1. An Unhealthy America: The Economic Burden of Chronic Disease: California. Take a look at the methodology here.

Second Chart

2. Goetzel, Ron Z, Stacey R Long, Ronald J Ozminkowski, Kevin Hawkins, Shaohung Wang, and Wendy Lynch. “Health, absence, disability, and presenteeism cost estimates of certain physical and mental health conditions affecting U.S. employers.” Journal of occupational and environmental medicine / American College of Occupational and Environmental Medicine 46, no. 4 (April 2004): 398-412.

Additional Estimate

3. Balu, Sanjeev, and Joseph Thomas. “Incremental expenditure of treating hypertension in the United States.” American journal of hypertension : journal of the American Society of Hypertension 19, no. 8 (August 2006): 810-6.

This is simply a redrawing of yesterday’s graphic, based on California population data. This site has an excellent overview of the impact to California. It understates prevalence because it speaks of patients who have had hypertension diagnosed and does not include undiagnosed Californians.

I found a more recent article and updated proportions accordingly ( see, I did find something wrong with the previous diagram )

Click on the images to enlarge

I added a new source, #3 below, since yesterday. This paper has newer control data with a more optimistic point of view:

The prevalence of hypertension has not increased significantly since 1999. At the same time, there has been increasing control rate of hypertension, especially in Mexican American men, elderly, and obese people - Ong, et. al (see below)

(formatted for Zotero):

1. Fang J, Alderman MH, Keenan NL, Ayala C, Croft JB. Hypertension Control at Physicians’ Offices in the United States. Am J Hypertens. 2008;21(2):136-142. Available at: http://dx.doi.org/10.1038/ajh.2007.35 [Accessed May 8, 2008].

2. Rosamond W, Flegal K, Furie K, et al. Heart Disease and Stroke Statistics–2008 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2008;117(4):e25-146. Available at: http://circ.ahajournals.org [Accessed May 7, 2008].

3. Ong KL, Cheung BM, Man YB, Lau CP, Lam KS. Prevalence, Awareness, Treatment, and Control of Hypertension Among United States Adults 1999-2004. Hypertension. 2007;49(1):69-75. Available at: http://hyper.ahajournals.org/cgi/content/abstract/49/1/69 [Accessed May 15, 2008].

Tomorrow, a look at costs, direct and indirect, for the nation and California.

In April of this year, I swtiched gears slightly, from spending time to discover the determinants of patient access / connectivity to their care system through personal health records, to examining the possibilities of creating connectivity with the California Healthcare Foundation.

We’ve been talking to several people and the Foundation is allowing me to present our ideas in sequence, here, for critique, improvement, and interest among potential partners. The goal is to launch a project that will connect multiple stakeholders in the health ecosystem, to improve chronic care management, in California. Timeline and details are going to be posted over time.

Let’s start with the case for hypertension as a chronic illness worthy of examination, though. Take a look at this graphic. What does it say to you about the state of high blood pressure care in the United States? What are the opportunities using HIT and Health 2.0? Are there corrections to be made?

Welcome to my PDCA cycle. Sources are underneath - feel free to ask questions about any of this data. I’ll begin posting regularly under this category.

Update: After finding an error in the image, I decided to leave it in, with this note that it’s incorrect, and a corrected version is in this post. PDCA is about iteration.

Quote: “…undiagnosed hypertension and treated but uncontrolled hypertension occur largely under the watchful eye of the healthcare system.” - Hyman and Pavlik

Sources (formatted for Zotero):

1. Fang J, Alderman MH, Keenan NL, Ayala C, Croft JB. Hypertension Control at Physicians’ Offices in the United States. Am J Hypertens. 2008;21(2):136-142. Available at: http://dx.doi.org/10.1038/ajh.2007.35 [Accessed May 8, 2008].

2. Rosamond W, Flegal K, Furie K, et al. Heart Disease and Stroke Statistics–2008 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2008;117(4):e25-146. Available at: http://circ.ahajournals.org [Accessed May 7, 2008].

Tomorrow: Impact to Californians

This photograph was taken from the headquarters of the Pacific Business Group on Health, when we were meeting with David Lansky, Ph.D. the President and CEO, and Ted von Glahn, MS, to talk about consumer engagement in health care. The second photograph is the wall of fame of PBGH membership and associate membership.

David has been a great proponent of patient and family involvement ever since I have known him and is bringing this approach to his work at PBGH, and both gentlemen have a lot of experience interacting with employers interested in an improved health care system. David contributed a very useful perspective in this California Healthcare Foundation Report on the Future of Personal Health Records last year.