• The Health Care Blog: Kaiser tiptoes into HealthVault & tells THCB about it, with UPDATE - The title says it all. Nice interview with Anna-Lisa Silvestre from Kaiser Permanente.

Congratulations Kaiser Permanente.

While many PHRs in the market are finding it difficult to attract users, Kaiser Permanente has long offered its members access to key features in managing their health online at kp.org.

This is a very important statement. The experience of Kaiser Permanente members challenges the idea that “patients don’t want PHRs.” They absolutely do - if the PHR helps people manage their health and connect to their health care team.

Two Million People Using Kaiser Permanente’s Personal Health Record

The quote in the title is from Mark Snyder, MD, Associate Medical Director, Information Technology, Mid-Atlantic Permanente Medical Group, who once again, volunteered to demonstrate how Kaiser Permanente improves medical care for patients using the latest technology. This happened at Kaiser Permanente North Capitol Medical Center, which takes great care of a community that includes the United States Capitol.

Mark was demonstrating the After Visit Summary, in this case, to a group of leaders from the District of Columbia Primary Care Association, which is currently undertaking an impressive program to implement health information technology in safety net medical centers in Washington. Senior Project Specialist Lauren Mardirosian was in attendance, along with Tracy Knight, NW Social Services Director from Bread for the City, and Deborah Parris, Health Information Manager from Family and Medical Counseling Services.

I set up the visit, with Kaiser Permanente’s help, because I am excited by the fact that our members’ experience can help patients in every care system, locally and nationally. It’s a virtuous circle - sharing our experience brings other experience back that we can use to do even better, and the cycle continues. I have really learned the reinforcing power of sharing in this journey. It’s even more enjoyable when I get to work with colleagues like Mark and Medical Center Chief Doug VanZoeren, MD, who willingly give their time alongside me.

What about the After Visit Summary? Mark showed that by involving the patient in its development, he makes the creation as important as the delivery in achieving its goals - involving patients and families in their care. In an era where we talk about Web2.0, Health2.0, and focus on user generated content, I think this is a great example - we create the record of what happened today, together.

DCPCA is implementing a modern electronic health record system, manufactured by eClinicalWorks, that has this capability. A care system that I visited in Sonoma, California, is already generating these for patients. Sometimes a piece of paper (albeit one that is also available on the Web in real time, on Kaiser Permanente’s personal health record, kp.org) can be as revolutionary as the people who put it together.

Thanks again to DCPCA, Mark, Doug, and Kaiser Permanente North Capitol Medical Center members and staff for their interest in helping patients everywhere.

Pictures: Click on any to see larger. Note: The patient displayed is a test patient. No actual patient information was demonstrated during the visit.

The recent story in the Los Angeles Times has sparked some helpful commentary about a transformed medical system, which is great. I thought it useful to write about one commentary I read recently on the Health Beat blog. I would characterize the tone on the cautious, maybe negative side about “virtual medicine.”

Health Beat: The Downsides of Virtual Medicine

While the focus of the commentary was on commercial providers of messaging services, there’s a whole other practice of patient-centered care supplemented by technology that is going on in integrated and progressive non-integrated care systems. This was the feature of the Los Angeles Times article, which highlighted a colleague of mine, Christine Calderone, MD, from Kaiser Permanente’s Whittier Medical Office.

On the topic of low-income populations, it’s interesting that the 58 percent figure that is cited for having computers in these households is called low, was actually a very high figure in 2000, when organizations like Group Health Cooperative and Palo Alto Medical Foundation began offering these services. From my perspective, 58 percent is very compelling. I’d disagree with the statement that “those most likely to benefit from the web-doc movement are the young, affluent folks who are already plugged in.” Our experience has shown that there are many non-affluent, non-young folks are plugged in, and receiving great benefit. We shouldn’t assume or build a system around the idea that they will not, and our experience going to practices demonstrates that we don’t have to.

Another issue worth pointing out is the question about whether online visits drive up volume. The excellent study at Kaiser Permanente Northwest answers this question well. They do not. In fact, they are associated with both a drop in face to face visit volume and a reduction in trend for phone calls, meaning that the demand for care that is currently unreimbursed in both fee for service and integrated systems is less.

I applaud the careful critique of the trend to involve patients more in their care. At the same time, I keep coming back to the idea that there aren’t very compelling arguments for limiting patients’ access to their care providers or their medical information. I’ve practiced medicine in both worlds, and now around 2 million patients and counting (if you look at Kaiser Permanente and Group Health Cooperative) have received care in both. For me, I can finally be the kind of physician I hoped I could be, and I don’t plan to go back. Does anyone else?

This post began as discussion of my reacquaintance with the work of theSidney R. Garfield Health Care Innovation Center, which happened when I was in California recently. I was happy to find that they have put up an Internet site for those who want to learn more. I especially recommend looking at the photos. It’s an impressive place - I was able to go on a tour in August, 2007, and I was especially interested in their “mock home.”

What I remembered, though, was that I had wanted to read a landmark publication written by the Center’s namesake, Sidney Garfield, MD, “The Delivery of Medical Care,” which was published in 1970. I believe that learning about where I/we came from as physicians and informaticists is important - the dreams of those who came before us inform our dreams. I was happy see that the article is now available online.

Sadly, the challenges that Dr. Garfield mentioned in 1970 health care ring true today: “In 1967, the National Advisory Commission on Health Manpower reported that medical care in the US is more a colletion of bits and pieces (with overlapping, duplication, great gaps, high costs and wasted effort) than an integrated system in which need and efforts are closely related.”

After reading the piece, I think that his vision is a compelling one today, and much of what he dreamed of has come true today, in certain health systems, such as the ability to administer a health risk appraisal and leverage it as a productive entrance into the health care system (even saying “the entire record is stored by the computer as a health profile for future reference” - this is the name that Group Health has given its health risk appraisal). He understood that poorly informed actors in health care resulted in people entering through the wrong door and

The entry of healthy people into the medical care system should not be considered undesirable. It opens the door to a great opportunity for American medicine: if these well people are guided away from sick car into a new, meaningful health care service, there is hope that we can develop an effective preventive-care program for the future.

There is a heavy reliance on computing power for this new vision, and I might argue perhaps too heavy a reliance; however, what’s remarkable about his models is that they place the patient at the top, with the medical system underneath in support. This is significant, even in 2007.

What’s especially influential for me is his idea that he was a proponent of the Kaiser Permanente model, but was not hoping to make this approach exclusive to Kaiser Permanente. He was open source before anyone knew what that was:

We believe any group of physicians, or a foundation working with physicians, can easily duplicate the Kaiser Permanente success….freedom of choice is important; we believe that the choice of alternate systems, including solo practice, is preferable for both the public and physicians.

I think this is great, and it’s a reason I cite for doing what I’m doing during this experience - helping the entire system succeed in guiding people “away from sick care into a new, meaningful health care service.”

There’s a cautionary note in what I read about over-reliance on technology, and I need to continually check in that I am not promoting technology at the cross purpose of leadership. There is also an energizing note for me about focusing on medical education in this journey - where Sidney talked about the need of medical school faculties to educate about different ways of practice so “these young men can choose wisely.”

The diversity advocate in me appreciates that Sidney Garfield did not predict in his writing in 1970 was that it would be “women and men of all ages and backgrounds” choosing wisely. At the same time, this is a welcome change in our profession that Kaiser Permanente the organization has actively fostered in its work.