Today I gave the first official presentation in my new skin as a physician with The Permanente Federation. I was a little nervous leading up to this (as the tweet said) because this is earlier in the tenure of an organization than I would want someone to represent me.

I did this because it was National Partnership for Women and Families and the groups they work with. I am a huge fan of their work promoting friendly workplaces and blogged about this previously. I managed the newness to Kaiser Permanente by weaving in basic information about Kaiser Permanente’s onilne services (the slides in the middle) and including the names of the leaders involved and taking questions to provide more information later. I also planted a little seed at the end for the innovation potential of Washington, DC.

Today I also got to go on walking meetings with the famous (to me) Jacob Reider, MD , a family physician and health information technology innovator, and now Medical Director at Allscripts-Misys Healthcare Solutions., and soon to be famous (to me, but already to his fellow New Zealanders) Professor Jim Warren, Chair in Health Informatics and Chief Scientist for the National Institute for Health Innovation at the University of Auckland. Both Jacob and the Country of New Zealand have a lot of innovation up their sleeve, all involving patient centeredness in health care. Let’s cheer them on.

Click on any slide to see the images closer up. If you don’t know what the point of any image is, let me know in the comments.

Oh, last thing, the video I showed at the end is Kaiser Permanente’s latest TV commercial, launched in tandem with the 2008 Olympics. Kaiser Permanente now regularly uploads its media to YouTube. Sharing is healthy.

Denham C, Dingman J. Are You Listening…Are You Really Listening? Journal of Patient Safety, September 2008 [Internet]. [cited 2008 Nov 2 ]

This paper stands up really well on its own as a call to action around listening to patients and their families. It does a nice job of discussing the contribution of communication (or lack thereof) to a safe care experience, with some great quotes included, like this one, attributed to Julie Ann Morath, RN, MS, COO of Children’s Hospital and Clinics of Minnesota:

When you listen, it’s a demonstration of respect, and listening in itself is a healing practice.

The data presented are dramatic : in 77 % of patient/physician interviews, the patient’s true reason for visiting was never elicited. Patients are “redirected” by physicians on average, within 23 seconds.

This is also the hook for Web2.0/Health2.0 because what technology does is allow people to be heard, relative to their Web1.0/Health1.0 counterparts, and this is the action that the authors did not write about:

Actions that CMIO’s/CIO’s can take.

In that section, they would advise these leaders to consider carefully who the customer of their newly funded (maybe legally mandated) electronic health record is.

When they decide that the ultimate customer of the electronic health record is the patient, they would allow access to all of the information about that patient to themselves and those that care for them, privately, securely on line, inpatient or outpatient.

How does a personal health record promote listening?

When care providers open their electronic doors to questions about care, or questions about anything based on facts in their care that they can now access, listening becomes less of a choice - patients will ask questions about what they see and we’ll want to make sure they understand what we’re presenting to them in their electronic health records. This is what my colleague at Kaiser Permanente, Mark Snyder, MD, describes when he says the printed After Visit Summary “is a process, not a souvenir.” I wrote an example of this process here - I like that it gives you no option but to listen.

I found myself agreeing with a lot of the ideas written here, especially the one that the patient and their family are one of the most powerful barriers to harm in health care. The authors state it here:

“The hospital’s deepest resource of care information is patients and their families; this is because these people have the ability to share core root cause information, from symptom to outcome, that can drive the quality and safety of care in hospitals.”

And I said it almost exactly the same way in this month’s AHRQ Web M&M Spotlight Case.

Toward the end of the article, the authors write that this is not another paper that should collect dust on the shelve of a few “Safety Geeks.” Based on what I’ve been doing and what I saw most recently at the Health 2.0 conference, I can be reassuring that there are a whole lot of Geeks out there working to make listening happen. Come join us!

(click any image to see it larger) This is Anna, she’s 12 years old, and I got to meet her because her mother is Jane Sarasohn-Kahn, author of one of my favorite heatlh care blogs, Health Populi, and came to DC and wondered if I might walk to meet them today, at my favorite Smithsonian museum. Twist my arm on many levels…

Those of you who are parents (or near Anna’s age) might not think this observation is that unique, so excuse my lateness to the game, but look at how Anna is interacting with the art in the museum. When we came to the exhibit she was interested in, she immediately grabbed her cell phone camera and started taking pictures. I asked Jane if she would look at them later and said she absolutely would. “It’s her scrapbook,” Jane said.

Anna goes to a school where she’s required to write a blog post every day, covering her assigned work, with one “free day,” each week, where she and her fellow students can write about whatever they want.

In Anna’s case, instead of passively taking in the art, she immediately begins creating content with it. And this is what she is being trained to do every day at school. What will Anna expect when she is 18 from her health care system? If Anna decides to train to be a physician, what will she expect from the systems (electronic and not) that are set up to enable her to care for patients?

In 2003, it was a pretty amazing thing to have a tethered PHR in place, for patients to see their health information on line. In ushering this new world, I could be heard to say to fellow physicians, “…and patients’ e-mail messages are limited to 3,000 characters, and no attachments!”

It’s very possible that Anna and her cohort won’t be looking to provide and receive care in systems that limit how much content patients can contribute to their health care experience. They may expect just the opposite, and want that the systems that support them help them manage this intelligently.

This example should give us some energy to think about really supporting participation in Health 2.0, the real thing.

With thanks to Jane and Anna for being great teachers, on and off stage. Come back to Washington anytime!

This question was posed to me by Ann Barber, MD, who I just spoke with. Ann reached out to me because she has been following the work of the group at e-patients.net, and specifically their call to recruit physicians to support the patient empowerment movement. Ann is an internist who specializes in hospital medicine, and has recently relocated to New York.

Ann asked me the question in the title of this post, and in talking with her, I decided to ask it here as well, because I’m unsure of the answer.

I wondered if this is because I/we have assumed that the majority of physicians are not interested in empowering patients, and therefore we don’t know how to support those that are?

I did a mini-check in with myself on this, and although I have alluded to some physician groups still feeling challenged by the idea of patient empowerment on this blog, the majority of my writing here points to the idea that physicians are very interested in empowering patients, because they want to perform well for them. The overwhelming majority of my posts here point to that idea, and here’s just one example.

Back to the question - where should a physician start when they have the energy and drive to make a difference in this area? When they interview for positions, what vocabulary should they use to describe what they are looking to do? How do they find the institutions in their communities that are already forging ahead in this area? If there are no institutions identified, how do they find the ones that are open to new ideas/thinking in this area?

My suggestion was to walk the hallways of any potential medical center employer and observe and ask questions - how are patients and families involved in their care? Do nurses and doctors round at the bedside (like they do at Medical College of Georgia, and hospitals in the Kaiser Permanente system [article in Harvard Business Review describes this] )? Are there visiting hours? How does the institution keep families and informed throughout a hospital stay?

I recommended a few resources, including the Wachter’s World Blog, written by hospitalist expert Bob Wachter, MD, the Institute for Family Centered Care, to find institutions in a community that are practicing patient and family centered care in New York, and of course, HelloHealth in Wlliamsburg.

I think the inpatient setting is the next frontier of patient and family involvement in their care, enabled by technology, and welcome the creativity of Ann and other hospital medicine specialists who want to make a difference for patients and famlies everywhere, which is why I wanted to think about this more.

Are there other ideas for Ann and the physicians in our profession who are among the “already recruited?”, in New York (and beyond)? Post them in the comments, please!

And thanks to e-patients and all the patients who have made it easy to remember who I am accountable to.

Kolodner RM, Cohn SP, Friedman CP. Health Information Technology: Strategic Initiatives, Real Progress [Internet]. Health Aff. 2008 Aug 19;hlthaff.27.5.w391.

Kibbe DC, McLaughlin CP. The Alternative Route: Hanging Out The Unmentionables For Better Decision Making In Health Information Technology [Internet]. Health Aff. 2008 Aug 19;hlthaff.27.5.w396

Diamond CC, Shirky C. Health Information Technology: A Few Years Of Magical Thinking? [Internet]. Health Aff. 2008 Aug 19;hlthaff.27.5.w383

When I read these I thought about what my opinion was about them, and what I might write in a blog post about them. I didn’t really want to critique their opinion or lay mine on top, because I think the pieces stand up well on their own, and I am no more connected to the facts than these authors are.

So I thought I’d just end up writing a post that said that I read these articles (I know, uncharacteristic of me).

Then, I stepped on the Washington, DC Metro, and this advertisement, for a local hospital stared me in the face:

I looked at it several different ways - on the one hand, the implication is that if your child has a serious spine problem, they will take care of it. However, if you do not have a child with a serious spine problem, should you go elsewhere for primary care, or are they good at that, too?

Is 3-D imaging today’s marker for quality health care? That’s what brought me back to the point of these three pieces.

In my travels, I don’t often see advertising for health care organizations that say, “Come to us for your primary care, your child is more likely to be immunized by us.” Or, “Come to us for all of your care - we’ve been rated the best listeners in DC.”

Here’s another example from my Twitterfeed. How did health care come to this?

What these pieces do for me is support the work to move to a system where the customer is the patient. The care experience should be as good as any a person can get from any other industry, online or offline, and one that is accountable to it for the things patients care about. It’s not how many personal health records there are, but how often patients and families make meaningful decisions to stay healthy because of them.

For me, this is where the energy comes from around patient access, patient and family involvement in care, and in the design and improvement of the health system.

Finally, I just re-acquainted myself with this quote yesterday, from my reading of A Fortunate Man, by John Berger about a country doctor in 1967. Here’s what the author said about computers in medicine back then.

It may be that computers will soon diagnose better than doctors. But the facts fed to computers will still have to be the result of intimate, individual recognition of the patient.

Was he right? (rhetorical question)

Where the magic happens

I had the opportunity to talk about participation (of patients, families, and communities) in health care and the design of the health system today at the Agency for Healthcare Research and Quality (AHRQ) headquarters in Rockville, Maryland, at the invitation of AHRQ’s Director, Carolyn Clancy, MD, with attendance of experts including Jon White, MD, Director of the Health Information Technology Portfolio for AHRQ.

What can I say except it was a great experience at a place I and many people who do what I do have thought highly of for a very long time.

The slides I presented are below. I want to thank the students in the University of Washington eMHA program for doing a run-through with me. One of the suggestions I was given was to know what I “wanted” in giving this presentation to AHRQ. I told the group that I thought about this, and it was - to inspire them. I think that’s both enough to want, and a lot to want.

The session is/was a reminder to me that in 2008, people who are studying health information technology (a) have a good grasp of the idea that it’s a tool to improve health and health care and (b) the importance of involving patients and families in their care. That, and we should look outside our borders, to places like Africa, to think about innovation in IT beyond the computer.

Inspiration is a 2-way street. Thanks again Bill, Carolyn, Jon and AHRQ for the warm welcome.

“Why Work Sucks and How to Fix It: No Schedules, No Meetings, No Joke–the Simple Change That Can Make Your Job Terrific” (Cali Ressler, Jody Thompson)

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.

I started off a presentation-in-the-works to students in the University of Washington Executive MHA program, led by David Masuda, MD (who, sadly, doesn’t have a blog, just a Twitterfeed, it’s a journey…), with the words, “This is a beta test,” and I’m glad I did.

The beta test part is true, since I was asked by Carolyn Clancy, MD, from Agency for Healthcare Research and Quality to reprise and elaborate on a talk I gave at the American Board of Internal Medicine Forum in July for a seminar at AHRQ later this month. That was a 10 minute presentation, the one coming up is a little more full. The way I like to do these when the presentation is in evolution is practice to myself, of course, but also to test with a smart audience to read the feelings/emotions that are created (which is what I think a presentation is for - read more about this here) and see what ideas resonate well and which ones don’t. I usually tell the test audience that I’m testing, and it really helps, because it engages the discussion beyond the content, to how to make the content help other people after this group. Synergy.

Luckily, Dave and his co-students gave me the opportunity to do this.

Before it was my turn, I got to see Rick Rubin, President of Washington’s OneHealthPort in action, talking about community collaboration in the health information technology space. In my travels, I have seen that OneHealthPort is really a gem in the area of health information technology (when people find out about it). It’s company that supports collaboration among potential competitors who jointly have a business need for this collaboration. Whenever I mention that it exists on the East Coast, I have always gotten a good amount of interest in it (which I in turn forward on to the OneHealthPort folks).

I didn’t know before this day that Rick is from Boston, which probably accounts for some of my draw to his style. I think OneHealthPort should get more exposure nationally as a functional model for community collaboration and I reflected on the fact that doing business behind the Cascade Mountains in the Pacific Northwest sometimes shields the nation from some really good ideas. Place matters.

My turn - I worked to combine my work at Group Health with my work at California Healthcare Foundation, and beyond, with Participation as a theme, which is really where I have come to in terms of what I am about professionally. I think it went okay as a first run. I got great feedback from the students (all accomplished health professionals in their own right). I included some information about the 60 Minutes piece about Cedars Sinai and heparin. Luckily someone in the audience had first hand experience with this situation, and I need to adjust the presentation about this - it’s a reminder to be careful about telling other people’s stories, they know their stories better than I do (and vice versa).

One of the physicians in the class, who’s an Infectious Disease specialist, let me know that this approach to health care resonated with him as a physician supporting HIV patients, and how it was when his cohort of specialists began practicing a new way based on the needs of his patient population. I thought this was great to hear - I tell people that my cohort of physicians (Generation X) went through medical school during this time, and as a result we (I) graduated with the idea that I would work with patients who would know more than I would about their condition (which I embraced).

As far as the presentation I need to tighten it up more, and link every section to the concept of participation, and maybe a little leading on what should be done to foster it (study it in the leadership context among health providers? study it in the leadership context among patients guiding health systems? Going beyond studying participation of patients in their care). One of the parting commenters said to me, “It was very entertaining, it needs more substance,” and then, “you asked for feedback, so I wanted to give it to you.” I’ll take it, and since I’m now an East Coaster, directness really works.

I’ll wait to post the slides at the end of the month, so I can work up these ideas a little more.

Thanks again, Dave and University of Washington eMHA students for allowing me to continuously improve my continuous improvement!

Rickerby, J, and J Woodward. “Patients’ experiences and opinions of home blood pressure measurement.” J Hum Hypertens 17, no. 7 (0): 495-503.

Pare, Guy, Mirou Jaana, and Claude Sicotte. “Systematic Review of Home Telemonitoring for Chronic Diseases: The Evidence Base.” J Am Med Inform Assoc 14, no. 3 (May 1, 2007): 269-277

Little, Paul, Jane Barnett, Lucy Barnsley, Jean Marjoram, Alex Fitzgerald-Barron, and David Mant. “Comparison of acceptability of and preferences for different methods of measuring blood pressure in primary care.” BMJ 325, no. 7358 (August 3, 2002): 258-259.

Not pictured: Port, Kristjan, Kairit Palm, and Margus Viigimaa. “Daily usage and efficiency of remote home monitoring in hypertensive patients over a one-year period.” J Telemed Telecare 11, no. suppl_1 (July 1, 2005): 34-36.

There’s a potentially serious gap in the Connectivity for Californians initiative that we are addressing. Here’s a quote that illustrates it:

It is very clear from the interview data that patients have their own ideas, and spend a lot more time thinking about their BP than is apparent in the average 10-min consultation in general practice.

The gap is patient involvement in the design and planning of this initiative, or any healthcare initiative for that matter. Patients have many more ideas about what the problems are to be solved than can be gleaned even from articles like this - the articles simply show that the ideas are out there. Fortunately, we are committing ourselves to have a patient representative involved from the beginning, and that is coming together before any work is started.

The quote above is from the first paper by Rickerby, et. al (click on the images to the right to review any of the papers yourself), which described a qualitative study to look at a small number of patients’ attitudes toward monitoring their own blood pressure, in a practice that routinely recommends this.

The question (#1)

The reason I have reviewed these particular papers is because of the commonly posed question to me over the past several months, in the form of, “Ted, will/are patients really motivated to check their own blood pressure?” with the implication that they are not and they won’t. It’s a fair question that deserves an informed response. Several of the readers on this blog have given me some information from their own lives. These papers add to that knowledge.

The answer (#1)

They are and they will.

The question (#2)

This came up during reading of the papers. Does patient engagement come from having knowledge? Or does knowledge come from being engaged? This came up because patients in the first study who did not have knowledge about why they should monitor their blood pressure or how to do it seemed less engaged.

The answer (#2)

Unclear, with the implication being about whether to work to engage patients with more knowledge or use knowledge as a means test for engagement. I think regardless of the answer, there’s no reason not to provide information to patients. That answer is good enough in this case.

Read on for more conclusions….

Read the rest of this entry »

Personal Health Record PHR Advisory Task Force - CCHIT Certification Commission for Healthcare Information Technology

Minutes from the first two meetings are also on this page. I believe the discussion regarding patient involvement happened after these meetings happened (at least, it is not in the minutes posted)