Pleasure to Host: Health Care and Climate Change tweetchat #GreenHealthChat 11/12/13

As I mentioned in a previous post:

I felt a little lonely on social media – they (The White House Champions of Change) talked about social media, but I didn’t get the sense they are using it themselves to communicate and lead, and I wish they would.

That was three months ago, times are changing!

Please join myself and a distinguished group of experts on twitter on Tuesday, 11/12/13 at 11:00 am PST, 2:00 PST for a Health Care and Climate Change tweetchat.

Hashtag will be #greenhealthchat

Experts include

Kaiser Permanente will also be unveiling its brand new twitter voice for environmental stewardship: @KPGreenHC

and several of my colleagues:

  • Kaiser Permanente Environmental Stewardship (@KPgreenHC)
  • Susannah Patton (@susannahpatton), communications manager for sustainability at Kaiser Permanente, 
  • Catherine Brozena (@catbrozena), senior communications consultant for community benefit at Kaiser Permanente, 
  • Kaiser Permanente Thrive (@kpthrive), the voice for total health at Kaiser Permanente
  • Rame Hemstreet, chief energy officer at Kaiser Permanente

This tweetchat will explore the role that health care providers can play in addressing and mitigating climate change. We will learn how many health care organizations are already working to reduce their carbon footprint in order to address this crisis.

Join us!

Community Health Needs Assessment includes the Environment, and Green Health Care Resources

After I had the opportunity to write this post on the Robert Wood Johnson Pioneering Ideas blog (see: Pioneering Idea: Your Patient’s Community Health Needs Assessment on the Desktop – Robert Wood Johnson Foundation), I learned courtesy of the Environmental Stewardship workgroup that I serve on at Kasier Permanente that one of the indicators in the main indicator library is Poor Air Quality, reported at the level of the census tract. I ran that map in a few clicks for the east coast.

It’s a great addition to the main indicator library, especially since it’s known that an unhealthy environment disproportionately affects those with greater health inequalities. It’s a reason why this whitepaper, How doctors can close the gap | Royal College of Physicians, has such a strong emphasis on environmental stewardship.

And speaking of environmental stewardship in health care, here’s a list of resources to access to learn and participate more, also courtesy of the Environmental Stewardship workgroup. Prevention is the new HIT. Enjoy.

Green Health Care Resources

Photo Friday: Climate Change is about People, not Polar Bears

Top image (March 2012): Ineffective

Bottom Image (November 2012): Effective

If you fly through DCA airport to get to Washington, DC, you’ve probably seen one of the images above on your way to the baggage carousel. I’m there enough that I was able to snap the image on the top, in March, 2012, and the image on the bottom, in the same space, in November, 2012. Note how the focus has changed – from “Polar Bears” to “People.”

I noticed the first image back in March because of the research I was exposed to about this phenomenon in learning about Green Healthcare. (see: Not using stock photography: Better images to talk about green in health care #greenHCTed Eytan, MD | Ted Eytan, MD)

The two together are great examples of ineffective (top image) and effective (bottom image) means of creating awareness about climate change, which is impacted by environmental stewardship, which is impacted by Green Health Care, which is impacts health.

Not harming people at the same time you are working to heal them is part of total health. A few more images related to climate change and green health care (or lack thereof) are below. Click to enlarge. Prevention is the new HIT.

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 6: Are LEAN hospitals green hospitals? – Measuring CO2e in health care

Healthy environments and people eytan  23

My presentation is today, and just one more section to go after this one. This post is about measurement.

The question in the title of the post came from ePatientDave (@ePatientDave). He asked me, “I wonder if hospitals that are well advanced with LEAN are any different in the behaviors you cited – because everything you said sounded like a LEAN post.”

The answer is, I don’t know for sure. In theory they should be, because LEAN is about respecting your customer and those who take care of them (it’s a mistake to think that LEAN is about efficiency, it’s about respect).

Imagine you could measure the impact of what you do in your own operations as well as society

This is the advantage of looking at CO2 equivalents (or CO2e). As part of this work I have had to get rapidly up to speed on the nomenclature, and you can do this too, here (on Wikipedia) and here (at the EPA, with handy conversions). The difference between measuring this versus something like “profit and loss” is that it can take into account societal impact for what an organization does. Apple, Inc., is a great example here. It states that 2% of its carbon footprint comes from manufacturing, the other 98% is from the use of its devices by consumers. England’s National Health Service is the same, it measures CO2e output comprehensively, including the travel that its patients incur ( The NHS is responsible for 5% of all journeys made in the UK ), as well as that from its supply chain (the bulk of its CO2 output comes from this).

Kaiser Permanente was the first health care organization to report its green house emissions to the California Climate Action Registry, in 2007. I watched how this work has progressed and it’s not easy. It started with understanding how much energy was consumed at individual facilities. This starts with the simple question, “who actually pays the electricity bill?” Next all types of facilities in one region were accounted for, and then in multiple regions.  Things are to the point now where Kaiser Permanente can state what its national carbon footprint is, and have it listed in a public registry, now known as The Climate Registry.

Even with all of this work, though, we are not as advanced in understanding our impact at the NHS is – we do not yet include the output from travel of members and staff, and procurement of supplies. The slide above shows a comparison of just energy use. The NHS’ estimates its total footprint at 21 Megatons of CO2e. Interestingly, when I compared the CO2e footprint of energy use between Kaiser Permanente and the NHS, the proportion, 17%, is equivalent to the proportion of people being cared for (9 million vs. 52 million, 17% also).

Regarding The Climate Registry, go, check it out, look up a few reports.

The Climate Registry: In good company, when will the rest of health care join us?

The good news is that many large private and public organizations are reporting their CO2 emissions in a single place. The bad news is that few health care organizations are. Here’s the list of health care organizations in the registry. Considering health care generates 8% of the United States’ CO2 load, shouldn’t we see more than 4 or 5  listed here?

Back to Dave’s question….

If you look on specific health care organizations’ web sites, you’ll see links to green health care efforts. For example, I found this page at one of Dave’s favorites, Beth Israel Deaconness (See: Going Green – BIDMC ). There are a lot of good things happening there. I don’t see numbers or targets, though. This doesn’t mean they don’t exist, it just means I can’t find them (and if I looked in the wrong place, please post in the comments!). Kaiser Permanente also has a Green Center, that links to its annual CO2 output analysis.

I am clearly just learning about this, and so is American health care. However, comparing us to other organizations nationally and internationally and to other industries helps health care establish that it is part of the community that it serves. Or as I have quoted on here previously, “Health care should not face the hospital, it should face the community.”

Thought provoking question: Does your organization report its CO2e footprint? Publicly? In a registry? How does it compare? How does it help you understand your respect for the people you serve, the community you and they live in, and the people you employ to take care of them?

These are the questions that make LEAN and Green a good match, and CO2e a measure to understand where you are at and where you want to be.

Next: The “Why?” for me.

#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.

#greenhealthcare part 4: Health Information Technology helps health care be green

This is part 4 in a series on health care and climate change, or “Prevention is the new health information technology,” based on my learning prior to ACPM2012. You can see all the posts here.

A goal of health information technology may be prevention, however, health information technology can support prevention by making health care more green. A very useful paper: Turley M, Porter C, Garrido T, et al. Use of electronic health records can improve the health care industry’s environmental footprint. Health affairs (Project Hope). 2011;30(5):938-46. was published in HealthAffairs last year which examines the ability of health IT to replace paper (in charts), water and toxic chemicals (in imaging), reduce energy use (transportation to office visits) and reduce waste (imaging plastics). In a comprehensive way, it also included energy use increases from computers, and waste increases from plastics used in personal computers.

And…the news is good, with a huge caveat. The carbon sequestration savings estimated nationally at 1.7 Megatons of CO2, or the amount of CO2 sequestered by 362,473 acres of pine or fir forests.

The caveat is that health information technology must reduce transportation of people to and from health care. If it does not, then the carbon savings becomes a carbon spend..

Therefore health information technology by itself is not enough. Leadership is required too. This is one of many areas where the conversation about climate change and health is a lot like the conversation about patient empowerment, and in this case, it’s about patient access to online records. The slides below the carbon saving calculation show what Kaiser Permanente has done. There are now 3.8 million members (59% of the eligible population) using kp.org, with steady use – almost 11 million messages sent by members from January – October, 2011. The slide below it puts it in focus around the experience – new medical offices are built:

  • Without medical records rooms
  • Without X-ray processing or file rooms
  • With smaller foot prints, and more importantly,
  • Less parking lots, the most toxic structure you can build