• HealthVault : Conference presentations now available… - If you weren't in Bellevue, Washington, in early June, you can do a little catching up on HealthVault. I’ve reviewed these presentations, and the amount of thinking that has gone into the health ecosystem is very impressive. And I’m critical of these things. Of significance, there’s some nice thinking displayed regarding bringing small practices online. Well done.

• 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.

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.

I have been intrigued by EMC’s work in managing an employee personal health record - it seems above and beyond (in a good way) how an human resources function and grow and support talent. Also, time to upgrade Office for Mac. It went OK. I’ll update “my own CIO” tools list in the near future.

• Employers Find Benefits with PHRs - More info about EMC and its employee PHR
• News - - Gainesville.com: Dean admits student without backing - It’s interesting that this is posted in the entertainment section. That aside, this looks concerning. I don’t understand how a student is admitted to medical school on a personal recommendation, and without taking the MCAT. How will we have a diverse medi
• Event Calendar - A way to put upcoming events on a wordpress blog
• TimeDriver - Coming Soon! A revolutionary online personal appointment scheduler - A very high potential meeting scheduling package. Given that Timebridge only allows 5 slots to be determined, this looks very interesting.
• GE Healthcare-Press Release-NCHL and GE’s Institute for Transformational Leadership - I didn’t know about GE’s work in this area. It looks like they are doing work in LEAN as well as Six-Sigma, which they are known for.
• Report cites UA med school crisis | www.azstarnet.com ® - Sad news from my alma mater, related to the difficulties medical schools are having balancing revenue and their mission.
• D.C. Not-for-Profit Offers Model for IT Adoption - iHealthBeat - More progress in DCPCA’s EHR adoption efforts
• Burlington Free Press.com | Fletcher Allen’s new EHR - Fletcher Allen in Vermont gets approval to go ahead. I believe this is an Epic Systems install, bringing with it the possibility for excellent patient engagement with their health system as a result.
• Database Problem with Office 2008 for Mac - Office 2008 Install problems, just in case

April 5th through April 8th:

• Headzoo » WP Anti-Wares - Now it looks like we have to worry about insecure wordpress themes, too.
• Electronic Prevention - washingtonpost.com - Nice writeup of the New York PCIP program. What the writer doesn’t realize, is that a patient portal is coming, so a visit isn’t always going to be required….
• Jack and Suzy Welch: Leader vs. Manager - ‘We’d wager it only comes into play when you don’t want to offend an employee who crosses t’s and dots i’s but couldn’t excite a busload of kids bound for Disney World. In such a case, what do you say? You got it. “You’re a good manager.”‘
• Generation Y’s Bad Rap - It’s not really that bad, according to Jack Welch. I agree.
• The National Physicians Alliance encourages all doctors to join our Unbranded Doctor Campaign — a national network of physicians committed to reducing the influence of pharmaceutical marketing on our profession. - NPA appears to be a grown up version of AMSA. They include consumers in their governance
• Macworld | Mac OS X Hints | Add more power to 10.5’s screen sharing - Economical screen sharing alternatives using Leopard
• Total Value, Total Return: Invest in Health Management Programs -
• Office 2004 for Mac Solution Center - Office 2004 downloads for Mac. Time to upgrade

• Topics - e-Visits @ TransforMED - Transforming Medical Practices - Article on whether the tipping point has been reached for e-visits
• WordPress Plugin: SIMILE Timeline at freshlabs journal - Nice visualization tool
• Doctor-Patient ‘Web Visits’ Spur Privacy Concerns : NPR - Should the American Medical Association always present the contrarian view around patient access? I don’t agree with the implication that cell phone / telephone is “most secure.” Anyone who has been in an airport recently would probably agree.
• WSJ.com/Harris Interactive Study Asks: Are There Fair and Reliable Ways to Assess Healthcare Quality? - Patients are saying that having an EHR is a “fair” assessment of quality
• Expansion of CCHIT Certification for 2009 (PDF Presentation) - Overview of CCHIT’s work to date and future strategy. Disclaimer: I am on the Foundations Workgroup
• Meet the Press — Robert Scoble — The Blogosphere | Fast Company - How Tim Ferriss used the blogosphere to his advantage
• News - Diversity gap found among state’s doctors - sacbee.com - “Not just a civil rights issue, a public health issue”
• YouTube - Microsoft Surface Parody - Why not use the device the size of a small car? The peril and promise of on demand video in shaping your message.

Health 2.0 is now over, and it was a great experience. I am not the only person in the room that remarked that they felt less innovative than ever in this room of innovators. The patient experience was front and center. I / we need to see that, often.

The post-lunch surprise was a demo of Microsoft’s HealthVault, accompanied by a post-demo comparison of the HealthVault and Google Health product by Missy Krasner. Overall a great discussion. I’m happy that more, rather than less, is happening here.

From my perspective I thought a big splash was made by the new EHR platform that Jay Parkinson, MD, demonstrated, manufactured by Myca. It has a compelling patient portal aspect as well. Interesting to see what happens when people start from scratch and build things the way they want to use them.

Veterans Affairs Medical Center, Washington

Veterans Affairs Medical Center, Washington

I was fortunate to spend time with Hank Rappaport, MD, the principle PM for the Microsoft Azyxxi Team, to fill a few big gaps in my EHR knowledge recently. Hank is a critical care specialist and has extensive experience building and maintaining electronic health records within the Department of Veterans Affairs, and now will do the same as a leader at Microsoft.

I sought Hank out originally because I wanted to learn more about what the Department of Veteran’s Affairs is doing with patient access to their highly regarded electronic health record. The Washington, DC, VA Hospital was a pilot site for the MyHealthEVet program, which allows those served in this system access to their medical records online. What’s special about the pilot sites is that they allow patients access to the entire record, without any filtering. This includes progress notes. More on that later.

Hank simulated access to both systems for me to get a sense of each systems’ strengths. Azyxxi was actually born at Washington Hospital Center, where Hank showed it to me, and is an excellent aggregator of clinical and other data, in a very accessible way. It seems to fill a niche that some electronic health records lack, which is a population view of data. The heritage of Azyxxi was the emergency room; at the same time, the utility is very relevant to primary care. With Microsoft supporting its future development, it should continue to add to innovation in health information technology. Of course, wearing my patient-centered hat, I thought there could be very interesting applications of this tool for patient access.

Following the tour in Washington Hospital Center, we walked across the way to the VA Washington to look at a simulated view of CPRS. The system is of course very capable (it lives up to its stellar reputation), specifically in the areas of order entry and decision support. It’s able to capture structured and unstructured text data, for example in progress notes. Like Azyxxi, I think there are rich areas for expansion for the system. The capabilities of this development team are different, though, and there are some changes being made in the way that the VA manages its health information technology.

There is currently not much interaction between the physician / staff view of the medical record and the patient view. However, it’s remarkable that patients have full access to their entire medical record, and has Hank indicated to me, this has not been a problem. I understand that the production (non-pilot) versions of MyHealthEVet do not have full patient access in them. In the meantime, I think the experience here in Washington deserves further attention in terms of its innovation.

I appreciate the value of the experience of seeing these two very competent systems a little closer.

Now, on to California and Heatlh2.0 to see some other cool stuff up close!

February 23rd through February 24th:

• Headlines - Mike and the Mad Dogs | The Daily Show | Comedy Central - Jon Stewart illustrates “Powerpoint Chart Junk” based on the work of FEMA
• Electronista | MS to publish free APIs for Windows, Office - Bravo, Microsoft. Might we soon see an Exchange-Apple Mail client? Great direction.
• Chez Pazienza: Say What You Will (Requiem for a TV News Career) - Media on The Huffington Post - CNN Producer fired for blogging. Will choice of employer soon revolve around whether they allow blogging or not? I assume the fact that my boss comments on my blog means I am okay. (Right?)

• Business Writing: A Great Letter from My Doctor - Good written communication makes a difference. From a Group Health patient.
• Blackwell Synergy - Family Process, Volume 37 Issue 1 Page 3-15, March 1998 (Article Abstract) - Article by Kathy Weingarten on Postmodern Narrative Therapy
• Treatment Dedication Project - Empowering patients undergoing cancer treatment through dedication.
• Microsoft customizes its workspaces - I suppose sliding glass doors are becoming the norm. Video of new Microsoft Research Facility. Note the Metro-type entrance gates.
• 60 Minutes - Here Come the Millenniels - GenY - All Carrot, No Stick. GenX - forgotten….