I was alerted to this editorial by Susannah Fox’s post about it on e-patients.net, and I really liked that this topic (generational issues) is getting coverage in the medical literature:

JAMA — Web Searching for Information About Physicians, July 9, 2008, Gorrindo and Groves 300 (2): 213

The medical community is experiencing the same GenX, GenY, Baby Boomer challenge that everyone else is. I’ve written about it on this blog (See these posts, and these posts) quite a bit, as it took me awhile in my own professional work to realize what was going on - many of the discussions I was having seemed to be themed to the generation of the person I was talking to rather than the specific person. This turned out to be really helpful in creating understanding and collaboration.

I think we need each other, and if anything, my discovery (glass half-full) is that many baby boomers have the desire and ability to have their creativity unleashed. GenX-Y can and will help with that by stimulating the conversation (See my most recent read for a great example). I enjoy being sandwich guy (Gen X), it’s kind of like being a family physician, coordinating with all of the other medical and surgical specialists, all of whom add value to everything I do and (hopefully) vice versa.

Acknowledging the tension, and creating some more

I’m glad to see the authors call out that the tension exists, at the same time they create the tension they speak of in their advice, which is centered around the concept of being “aggressive” about “protecting” the physician:

Talking to Patients About How They Are Using the Internet. If a physician suspects that an Internet-savvy patient is engaged in seeking personal information about him or her, we recommend that the physician talk with the patient about the garnered information. This is particularly relevant when treating young adults or adolescents who commonly use the Internet. Physicians should clearly inform patients that the Internet is not a substitute for face-to-face conversation.

It’s not? Patients need to be talked to? We need to clearly inform them about how to use the Internet?

There’s a very cool alternative paradigm where we protect the patient, by clearly informing them about everything we are doing for and to them, and listen to them about how they use the Internet, so we can use it with them. It’s completely possible. The best part is that I’ve seen many a baby boomer embrace it. The future’s bright for our profession and those we serve….

As a leader in an organization, imagine reading this description of an employee’s workday:

A typical day for me includes waking up when my room is too bright from the sun and I can no longer sleep. I check my e-mail to make sure there are no pressing issues and respond to anyone who needs my input. I will typically watch an episode of South Park on the Internet, then walk to my local grocery store and buy some breakfast, even though it’s closer to lunch at this point. After eating I will work in front of my television with ESPN on in the background. At this point I will choose to go into the office or continue to work from home, or maybe not even work at all and go for a bike ride or jog. If there is still work to do later that night, I’ll do it then and it’s no big deal.

I’ll admit it - it kind of made me gulp when I read it.

At the same time, though, I have been in a lot of conversations with a lot of personal and professional colleagues over the past 3-4 years or so, where the question we’re asking ourselves is, “Is this how work life is supposed to be?” Spoken or unspoken, the answer is “we don’t think so.” Various companies’ data also show a trend toward less vacancy in their physical locations.

In the middle of that self-discovery, I read about BestBuy, Inc., (see “Smashing the Clock“). This is the book about their journey.

It’s time to let go and see what our employees can really do - BestBuy Manager

A Results Only Work Environment (ROWE) is as it says - one where results are measured, not time spent. There are no timeclocks, no discussion of time, and no “Sludge” as the authors refer to it. “Sludge” are the comments people make to each other about time, whether it’s about being late to a meeting, or working late at night. Simply put, the authors state, an employer is trading work for money. Why not give them what they pay for?

Reading beyond the BusinessWeek article was very useful - this is not flextime, it’s not “working from home,” it’s a different philosophy altogether. That includes the vignette above. Totally allowed, if you have the results to show for it. The concept can appear challenging; however, it makes sense, in the context of strong leadership committed to respecting employees and customers. That’s where I found similarities to the work I have done.

About respect

When I first read about this work, I asked about how this was similar or different from the LEAN transformation I participated in, in the area of health information technology. Some of the things were consistent, some seemed less so, like having technology teams physically present alongside doctors and nurses, guiding care and feeding of an electronic health record system.

My reconciliation of all of this rests with not comparing individual tools/approaches between ROWE and LEAN. What they both have in common is respect for the customer and staff, and strong leaders. It’s impressive that at the heart of the ROWE movement was (at the time) a 24 year old employee of BestBuy (Cali Ressler), who was dissatisfied with the status quo. The authors also explicitly reject war analogies in business as I have. In my own situation, there was not just a desire to change the way we worked, it was clear that not changing would be unsafe. Healthcare organizations across the country are now learning this, thankfully, but it’s a slow transformation, and the transformations that are happening are nowhere near as radical as ROWE, which is why I am interested in the movement (not because I want to be radical, but because the threats to our patients and their families’ health are so significant).

Just because you can no longer be late doesn’t mean you can be lame

Preliminary data from the University of Minnesota’s Flexible Work and Well-Being Center are showing that voluntary terminations are down, involuntary terminations are up.

Mea culpa and, as usual, I see analogies to health care

I liked the concepts in the book a lot, and have done a self-inventory of my own sludge and the sludge that’s been directed my way. The kind of sludge I get nowadays is really from people who want to understand better how technology can be used to help patients stay healthy. I welcome it as an opportunity to teach and learn. As the authors discussed, people can learn to live sludge-free, and they really want to live sludge-free. It starts with us.

I could see myself promoting ROWE in health care settings, and I think physicians, primary care ones especially, would benefit. The work I do to change health care is completely connected to the idea that health is a means, not an end, and people who go into health care want to support our patients where support is needed, mostly where they live, work, and play. I don’t believe people in health care are any more attached to time than Cali and Jody’s (former?) colleagues at BestBuy are. When I read the stories of BestBuy employees before and after, I reflected on some of the conversations I have had with health professionals (at all levels) who have really been challenged to juggle their passion for helping people and their ability to provide for themselves and their families, physically and emotionally. What would it be like for a family medicine or internal medicine specialist to provide their cognitive services to patients and families using a combination of virtual tools and office (or even home presence) when the situation called for it? Look at what HelloHealth is doing. It’s possible.

A Results Only Patient Experience (ROPE)?

A came upon this table in the book, and curiously, I found it extensible to our health care system. I hope I won’t get in trouble for using it to think about what our health care system were like if our patients experienced it the way a BestBuy employee experienced their work life. The edits are mine.

Published! The report I co-authored with Josh Seidman, Ph.D. from the Center for Information Therapy is now online. It describes our experiences out “in the rest of health care” understanding the environment that supports patient centered health information technology. My conclusion: we can make it happen.

Helping Patients Plug In: Lessons in the Adoption of Online Consumer Tools - CHCF.org

It has become fashionable to say farewells in person, over e-mail, and now in the blogosphere. Since the e-mail has already gone out to all of the staff at Group Health Cooperative, this is my blog farewell. I have decided to leave my position as Medical Director of Health Informatics and Web Services; my last day with Group Health Permanente, providing direct service to Group Health Cooperative, will be June 30, 2008.

Without realizing it, I wrote a little tribute to my wonderful experience as a Group Health physician and patient empowerment advocate in my book review of “Overtreated,” by Shannon Brownlee. I definitely share the feelings of another blog farewell I read along time ago - I leave with gratitude and appreciation for every Group Health member and staff member who supported me in becoming a better physician and servant leader every day. I was rebooted often, and reprogrammed/upgraded regularly by these awesome teachers.

People who know me know that the glass is at least 3/4 full. Fortunately, Group Health is a great place to be optimistic about improving the health of patients and their communities. I’m certain that health care across the United States and beyond has been improved through Group Health’s contributions; the innovation that will continue to come from Group Health will also continue to help every patient in every care system.

Keep in touch, Group Health, and all the best.

This photograph was taken on the National Mall, at an event celebrating the 60th Anniversary of the birth of the State of Israel. The women in the picture are tracing the roots of their family across the globe, along with other attendees.

I learned at the event that I am here because of Operation “Ezra & Nehemiah” - a massive, emergency airlift of 125,000 Jews from their homes in Iraq in 1950-1951, to the only country that would accept them. My parents were a part of that airlift, and eventually emigrated to the United States, where I was born.

My life experience as a social/cultural minority has, in a great way, connected me to people and ideas that I think I wouldn’t have appreciated otherwise. I am always drawn to stories about people, of all backgrounds, finding their home and belonging, whether it’s in their health care, or where they live and work.

As I posted previously, I was honored to present at the Institute for Family Centered Care’s intensive training seminar, on the leveraging of health information technology to promote patient and family centered care. Bev Johnson, the Institute’s CEO continues to impress me with her boundless energy - I include her in the class of individuals that probably has more energy than I do.

I enjoyed great interaction with the rest of the attendees, many who came in teams, with either a record of change in their institutions, or about to create one. What I haven’t really appreciated to date is the fact that this type of care is still not the norm in most medical institutions. I should say that I appreciate it, but maybe I don’t have the best understanding of the challenges of transforming to a system that involves patients and families in all aspects of care. This includes family presence in all rounds (physician and nursing), 24 hour access to their loved ones in the hospital, ability to access all information generated as part of the care experience. A lot of the seeds of this transformation come from the pediatrics arena; it is slowly making its way into adult health care. There is a significant leadership presence in the nursing community. Imagine a family being present during nursing rounds where a nurse discovers that a scheduled dose of antibiotics has not been given. This seems challenging on its face, but turning it around to create an opportunity for Poka-yoke is far less challenging than allowing an event like this to happen again. I noticed that a lot of nurses and physicians understood this, and it is terrific.

In my own environment, I also reflect on the fact that I’ve been supported in promoting patient-centered health information technology. Yet at the same time, if even a greater percent of the organization’s activities was devoted to promoting this method of care, there are things I might not have to “nemawashi” about that I do now. Regardless, I am happy to do this; if IT is going to be the nidus of patient and family centered care in some organizations, so be it (for now). In the end, though, I’m going to continue to work for IT be the support for patient and family-centered care philosophy, rather than the lever.
Thanks to Bev and the IFCC team for continuing to move into ambulatory care, and to understand the changing landscape of HIT and the opportunities to use it for its true customer, the patient.

I’ll be honest, the first thing that went through my mind when I saw the Visible Human, and the caption (in another display) that said, “A 39 year old convict, executed by lethal injection,” was “that’s my age.” It was a little flash of the reminder of my mortality. I usually use these to think about what I am dedicating myself to, as I have done here and here.

One of the blogs I enjoy following, Health Care Renewal, had this quote in one of the posts:

Please acknowledge that medicine has a 100% failure rate at keeping people alive for their desired lifespan.

In that context, the donation of his body to science is a great gift to maximize the lifespan of others.

I also visited the Library of Medicine itself this week twice, the second time to meet with Clement McDonald, MD, Assistant Director for Program Development in the Lister Hill National Center for Biomedical Communications. As his biography says, he’s an international expert in electronic health record systems, and I consider him one of the parents of the field of Informatics. Needless to say, it was great to talk with Clem and share ideas about patient centered health information technology. Many of the ideas in place in today’s health information technology efforts come from his work.

In the wake of the controversy surrounding the Troll Tracker blog, which was managed anonymously by a Cisco Systems patent attorney who recently was unmasked, I found the Sun Microsystems Corporate Blog Policy. What I like about it is that it provides information to help staff make decisions as professionals. It even encourages good technical blogging practices. At the same time, it does not suggest a blog free-for-all for employees, just that they understand what the impact of a blog can be for Sun’s customers, staff, and shareholders:

Advice: By speaking directly to the world, without benefit of management approval, we are accepting higher risks in the interest of higher rewards. We don’t want to micro-manage, but here is some advice. 

In my opinion the blog policy itself brands Sun as an employer of choice in promoting innovation of ideas in its industry. I think this is a policy that would promote safe and productive blogging in the health care industry as well.

This is a community where there are visible reminders everywhere to recommit yourself to what’s important.

I just read that at the exit of the headquarters of the business maverick ING Direct National Bank, employees see a sign that says, “Did Today Really Matter?”

This is a nice analysis of solutions from the Family and Community Medicine Team at University of California, San Francisco, to support diversity in the health professions, which unfortunately have not yet reached levels comparable to the general population, especially in allopathic medicine.

There are two concepts that reinforce that this is not just an issue for health care, it is an issue for society, and the people and businesses that depend on a strong health care system:

The business case highlights the customer service and competitive advantages to the health industry of having a workforce that is culturally and linguistically attuned to the increasing diversity of the nation’s health care consumers.

and

A wide group of organizations—including the AAMC and other health professions educational organizations, higher education institutions, consumer groups, and Fortune 500 companies—contributed amicus briefs and other documents in support of the University of Michigan in Grutter v. Bolinger, signifying a more concerted effort to identify and organize stakeholders interested in supporting diversity efforts.

Many physicians, myself included, work in the most downstream parts of this ecosystem, and it’s therefore helpful to consider that there are places we can be to create a more effective care system for everyone. From my travels to date, it’s clear to me that these are worthy investments of my physician colleagues’ expertise. None of us enjoy waking up to a world where the quality of health care is dependent on things other than the fact that you are a human being.