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.

Network Citizens: Power and Responsibility at Work

Not long ago I was ordering coffee and needed to wait a few seconds for the person taking my order to end a personal cell phone call. Once the call ended, she was extremely courteous, warm, and service oriented. I now realize that she was tapping into her social network, using her own information technology, at work.

There’s an ongoing conversation in many workplaces that starts with “(name your social network) is blocked by by my employer.”

This white paper, written by Demos, which bills itself as the think tank for every day democracy, delivers a broad look at social networking, and goes beyond, “your company should allow access to social networks.” On that point, though, here is what is said:

First, smart businesses recognise that ‘social’ networking is not neatly separable from ‘professional’ networking. Attempts to control employees’ use of social networking software in the office may end up damaging the organisation in the long run by depleting its network capital. Of course, bans on Facebook or YouTube are in any case almost impossible to enforce; firms may as well try to put a time limit on the numbers of minutes allowed each day for gossiping. A network permissive culture requires a degree of trust on the part of managers and responsibility on the part of employees; but to the extent that networks add internal economic value, this is usually a risk worth taking.

So, controlling access to networks in the workplace is futile (think about the coffee employee’s cell phone) and has negative consequence on recruitment, retention, and innovation among other things. At the same time, there’s an interesting conversation about the risks of networks, and not the kind of risks most people commonly think of:

Networks can build meritocracy, openness and democracy – but then can also exclude and discriminate. They can help to diffuse power away from hierarchical structures – but they can hoard power for themselves, too.

The authors point out that most social networks are opaque, compared to the transparency of the organizational chart. It’s easy to look at these and see who is connected. This is where responsibility comes in. Organizations should “go with the grain” of social networks and those engaged in social networks should be good network citizens and use the power they get from the network to further the goals of the organization. This comes together in the creation of a kind of network “constitution” or social contract, which supports good relationships, rather than hard rules. I think some companies, like Sun Microsystems, are starting on this journey through the creation of progressive social networking policies.

Some organizational approaches are to create Bespoke services, which are internally supported social-networking-like applications, and these carry some risk, as pointed out in one of the case studies:

The issue with our company is that the answer to every problem is a database. The problem is actually time – this utopian vision of being able to look up all this information and draw it down from the database is a bit unrealistic. – Interviewee, large professional services firm

I think Bespoke services can be successful if their purpose is thought of carefully and not as the solution to every problem. Every organization will likely need a portfolio of tools to support the needs of employees of today and tomorrow. The paper has a high philosophical tone, and the social networking analysis is very interesting ( I have to try that soon ). The idea here is to support the exploration of what those are in an open environment.

In this context, the fact that the person taking my order for coffee after tapping into her social network doesn’t bother me at all. I have a feeling it will help them and the organization they work for provide even better service in the long term. I hope this paper and blog post might help some have the conversation about whether (social networking tool) should be blocked or not.

Feel free to comment with your experiences in your organization, of course.

de Brantes F, Wickland PS, Williams JP. The value of ambulatory care measures: a review of clinical and financial impact from an employer/payer perspective [Internet]. Am J Manag Care. 2008 Jun ;14(6):360-8.[cited 2008 Oct 1 ]

The subtitle of this article might be, “what performance measures should employers be tracking and paying for in ambulatory care”

The article was passed to me by Sophia Chang, MD, at the California Healthcare Foundation, who has been advising and supporting on our Connectivity for Californians work, and is a nice economic study of 62 performance measures used in specialty recertifcation program and pay-for-performance initiatives.

The measures will look familiar to anyone who works in quality improvement – everything from blood pressure management, to retinal eye screening, all the way through to some measures that have less data associated with them, such as “plan of care for hypertension.” What the authors did was grade the evidence of effectiveness, add cost and benefit data based on meta-analyses and derive a “savings per patient” for each measure.

There are a few critical assumptions made, including full adherence to therapy (they used the term “compliance” which is no longer recommended), and most importantly, no quantification of indirect costs. In other words, this is not a study of presenteeism, only direct medical costs.

What came out near the top of measures with the most impressive savings profile? Hypertension management. Here’s the detailed analysis:

This study has a specific informative value in my mind – which is to encourage employers’ engagement around the performance measures that will likely result in a return on investment for them. This is not a call to action for the health system to reorient its priorities for maintaining community health. I think the idea is that if an employer has an interest in promoting efficient use of the health care dollars they spend on behalf of employees, an analysis like this provides an idea of where to start.

Incidentally, when I did the same analysis using my own literature review, but without the complex analysis employed here, I came to the exact same conclusion around hypertension, which surprised me. I thought I would become an expert in remote monitoring of congestive heart failure or coronary artery disease. The data led me a different way.

See what you think.

From the AAFP press release:

“Comprehensive, continuous, patient-centered, personal and holistic primary care which is based on strong relationships between patients and their physician — this is foundational to good health. Practice and payment reform are the prescriptions for achieving it,” Grundy recently told health care blogger, Ted Eytan, M.D.

I am happy to be told anything, anytime by Paul Grundy – his energy and interest in doing the right things for patients everywhere make him a fine addition to the community of America’s Family Physicians. Welcome, Paul!

Shai, Iris, Dan Schwarzfuchs, Yaakov Henkin, Danit R. Shahar, Shula Witkow, Ilana Greenberg, et al. “Weight Loss with a Low-Carbohydrate, Mediterranean, or Low-Fat Diet.” N Engl J Med 359, no. 3 (July 17, 2008): 229-241.

“The Employer as Health Coach,” October 11, 2007.

I initially reviewed this article for my interest in the question, “What kind of diet is best for losing weight?” (with good news for low carbohydrate and Mediterranean dieters), but I quickly became fascinated with the way this study was performed – on the worksite, at the Nuclear Research Center Negev, in Dimona Israel.

To quote:

As Okie recently suggested, using the employer as a health coach could be a cost-effective way to improve health. The model of intervention with the use of dietary group sessions, spousal support, food labels, and monthly weighing in the workplace within the framework of a health promotion campaign might yield weight reduction and long-term health benefits.

I think this is as significant as the weight loss intervention itself – that the study authors worked to modify the work environment to support the study aims. In the supplemental materials (linked here), you can see an example of the signage placed in the cafeteria to alert employees to the different food choices available, depending on which arm of the study they were in.

I think this fact of the study design is under-emphasized and marks an important trend in supporting interventions like this moving forward. With thanks to the Research Center in Dimona for teaching the world about more than nuclear science.

Paul Grundy, MD – “Think huge”

Purchaser guide – there have been many of these, but the first time one prepared with consumers and providers

Health Information Technology – help educate, advocate, demonstrate around PCMH the technology that will be necessary to help physicians make the transformation

Panel – What Does it Cost to Become a Patient Centered Medical Home?

Bob Berenson, MD, Senior Fellow, The Urban Institute

“A good medical home”- patient with superficial phlebitis treated via one office visit, 6 phone calls, 6 e-mails, including hematologic consultation, one reimbursement for in-office care

Julia Pillsbury, DO, Alternate RUC Representative, American Academy of Pediatrics

New G codes for Medical Home-type work. Crosswalked to currently existing codes, some subsume current G codes, some do not. Tier 1, 2, and 3, between 6.5 to 9.2 minutes per patient per month, may be around $50/member/month.

Patient Partnership

Sabrina Corlette, Director of Health Policy, The National Partnership for Women and Families

Grant from the Wellpoint Foundation to introduce consumer advocates to PCMH and involve them and shaping it. Environmental scan, Focus Groups, Develop consumer/patient principles

Debbie Peikes, Ph.D., Mathematica Policy Research

We should involve patients and providers in primary care assignment, using claims retrospectively is expedient perhaps but has difficulties

Patient Centered Primary Care Collaborative, Washington, DC

I’m resuming life in the cloud by attending the Patient Centered Primary Care Collaborative Stakeholders Working Meeting, here in Washington, DC. I hope to post updates throughout the day – we are all fortunate that this group operates with an impressive level of openness and interest in collaboration (just as its name implies). The agenda and materials are online for others to peruse.

By the way, here’s what an Internet Holiday looks like.

A3 (Project Plan). Click here to learn more about what an A3 is

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.

United Hospital Fund, Empire State Building, New York City

On our last day in New York City, Rachel and the United Hospital Fund arranged for a presentation on patient-centered health information technology to the New York Business Group on Health, at UHF-NYC headquarters in the Empire State Building.

As I do with most presentations, I started with a thought provoking question, and this day’s was “When was the last time you looked at your medical record?” The responses, as expected, were extremely varied. Most had never seen their medical record, or seen it in disconnected parts. There were some answers that went like this: “I have seen my claims data in a PHR, but not my medical record.” I thought it was interesting that people were able to differentiate between claims data and a medical record.

At the same time I said, “I wouldn’t be here talking about this if I didn’t think you could do it,” and I meant it. As I posted previously, New York is having great success implementing EHR’s through their PCIP project, and are about to add patient access to these systems. A strong purchaser community can bring the next level of integration – that of a wellness ecosystem.

Several audience members pointed out, accurately, that there are things that can be done in an integrated health system that cannot be done in a dis-integrated one. At the same time, there was sharing of some innovative projects that are happening in the health plan community as well as the purchaser community. I left as impressed with the possibilities as I was when I came.

When I looked out the window at the brewing snowstorm at the end of my talk, Rachel reminded me, “You’re still going to Queens.” Of course I was, and I’m glad I did. More on that in the next post.