The Center for Total Health (@KPTotalHealth) is Kaiser Permanente’s Social Innovation Center.
This presentation was given to the American College of Preventive Medicine (@ACPM_HQ) Corporate Roundtable, meeting in Washington, DC, to introduce the Center, Social Innovation, and Total Health for individuals and communities.
I also included a little information about the “Why” of prevention at Kaiser Permanente. Thanks to a little help from our friends at the A History of Total Health (@KPHistory) blog.
Thanks for having me!
Facilitating: Livable Communities : Healthy Neighborhoods National Building Museum.
An honor to facilitate:
- Scott Ball, planner with Duany, Plater-Zyberk & Company
- Terry M. Bellamy, mayor of the city of Asheville, North Carolina
- Irene H. Yen, PhD, MPH, associate professor, University of California, San Francisco
Studies show that our homes and neighborhoods play a large role in public health, especially for an aging population. Walkable, safe, and connected communities promote exercise, access to healthy food options, and an active social life. Panelists discuss how planning, design, and community engagement help create livable communities for older adults and everyone.
September 12, 2013, 6:30 pm – ticket purchase required (support the National Building Museum) @BuildingMuseum
#PreventionisthenewHIT – see you there
Route: “The Citizen” (click to enlarge) Get this app here
Route: “The Presidential” (click to enlarge)
This is just one of the photographs I tend to enjoy taking of people engaged in active transportation, while I am engaged in it as well, and usually in my favorite place, the most walkable city in the United States…..Washington, DC.
And now, it’s easy to track your walk quickly, and frictionless-ly with the relaunched Every Body Walk! (@everybodywalk) app, available for Android and iOS.
When you download and use it, you’ll see what I mean. When you are on the move, it’s hard and unrewarding to spend time tending to your smartphone for tracking purposes, and this redesigned app doesn’t make you do that. There’s just a big huge button that says “Start”. Press it, and keep going.
The sharing part is really easy, too. This comes in handy when you are going on a walking meeting (which you are doing, aren’t you), and it’s helpful to share with the person who you introduced this to (you are introducing walking meetings to others, aren’t you) how you did, where you went etc.
My approach is to walk a different route every morning, depending on how many social determinants of health I would like to study. I’ve named my routes accordingly in the images on the right. Feel free to do the same and post your results – tag them #activetransportation.
Here’s a gallery of past routes / images I’ve taken. Isn’t Washington, DC, beautiful?
Prevention is the new HIT.
Photos of/from #activetransportation
Spring B, Schneider K, McFadden HG, et al. Make Better Choices (MBC): study design of a randomized controlled trial testing optimal technology-supported change in multiple diet and physical activity risk behaviors. BMC public health. 2010;10(1):586
The quick answer is: don’t focus on the technology.
This is not one, not two, but three papers published in the last six months, the last one last week, encompassing an impressive body of work around behavior change and weight loss, from the same research group led by Bonnie Spring, PhD, at Northwestern University.
There’s a lot of stuff in here – everything from financial incentives to the way you coach people about behavior change to the use of mobile devices. If you don’t read them all (or don’t read any of them all the way through), it’s highly likely that you’ll come to the wrong conclusion, in my opinion, so I’m going to break it down here:
1. The way you counsel people about behavior change makes a difference
This is actually the most important part of the first two papers linked here, not the up to $730 incentive (more on that later). What the authors studied was competing theories about how to talk to people. They looked at four different ways, which I’m going to summarize, because it’s important – these are things that are cost-free and don’t require any capital expenditure to deploy 🙂
- Theory 1: Familiarity hypothesis, I’ll call it “MOTS: More of the Same” – “Decrease your saturated fat intake, increase your physical activity”
- Theory 2: Behavioral Economic hypothesis: Crowd out an unhealthy behavior with a heathy one – “Eat more fruits and vegetables, decrease your sedentary activity” <- This was the winner
- Theory 3: Low Inhibitory Demand, I’ll call it “Don’t be a downer, tell people what they CAN do rather than what they CAN’T” – “Eat more fruits and vegetables, increase physical activity”
People coached with the winning theory had significantly higher changes in a calculated “Diet-Activity” score compared to others. If you break it down a little more, it looks like it was far more likely that they could eat more fruits and veggies, than that they could increase their physical activity, across all groups. The winning group, though, dramatically decreased sedentary leisure, almost by half, which persisted 20 weeks later.
2. Paying people is a background activity to the above
In the first two papers, people were paid $175 to go through 3 weeks of intervention and point incentives along the way up to 20 weeks of follow up, for a total of $730. It seems like this got them through to recording their information. I don’t think it’s the most important feature of the study, and as the authors point out, probably not a realistic approach moving forward.
3. The mobile technology itself doesn’t help in isolation
Notice, I keep saying “mobile technology” not “smartphone.” That’s because these studies used PalmPilots (!) to support entry of data and target feedback. All of the study participants in the behavior change theory study improved their diet-activity score. There was no control group there, the goal was just to compare the theoretical approaches. The first study relied on self report of food intake and physical activity, which the authors sought to keep accurate by deploying a “bogus pipeline” approach where they told people to submit their grocery receipts and accelerometer data that were actually not used – clever.
The second study, which is in the third paper linked to this post, was more focused on weight loss itself rather than behavior change, and in it, the authors planned at the start that the mobile technology would be part of intensive coaching for all study subjects – they didn’t even try to have the mobile device make this happen for people. And in fact, the mobile device by itself didn’t make it happen for people – the one group who were randomized to get the mobile device and didn’t go to class actually gained weight. They gained more weight than the control group who had no mobile device.
What did happen for people was weight loss when they (a) used the mobile device to track and get feedback AND (b) they went to classes, in person. That was the requirement – that both happen, and when it did, this group lost more weight initially, and kept it off – average of 6.38 pounds at 12 months. The people with the mobile devices that didn’t go to classes, gained about 5 pounds at 12 months, which is more than the people who went to classes by themselves, and more than people who didn’t do the classes or get mobile devices.
There’s another really important piece of information in all of this, which is that the people who were
selected to get mobile devices randomized into the study were selected after a two week trial of recording their information. About 35% of the people that went into this gate didn’t make it, so in the end, this was a study of people who can use mobile devices to record their information.
As I said, there’s a lot here
I’m looking at this from a population/social determinants perspective, and I would ask the question, “Should mobile devices or apps be deployed to the entire population to make weight loss happen compared to other approaches?” The answer for me would be “no.”
I think what the authors are demonstrating is the answer to this question, “Should mobile devices or apps be deployed to people who are motivated to use apps to lose weight and participate in intensive behavioral interventions?” to which the answer is more of a “yes.”
Also, “Should we get smarter in communicating with people, with technology and not, about their choices? – answer is “yes.”
I think we still need to think about technology as an enabler at the right time / place , everyone is necessary, and the hard work of looking at the causes of the causes of poor health is not going to go away (see: Now Reading: Why a focus on lifestyle behavior change may not improve health: The Marmot Review | Ted Eytan, MD).
The reason I love technology and have been invested in it for so long (and will continue to be) is because of its role in facilitating communication and connecting people to people. The best.app.ever is the human brain, the most important innovation in health information technology is listening. Oh, and prevention is the new HIT.
I communicated with Dr. Spring before writing this post to help me understand what we can take away from this research, which is very important/timely/useful (and I of course invited her to Washington, DC to the Behavior Change Summit in 2013 🙂 – More info on that here: Behavior Change: What can we learn from other industries? – EXAMPLES | Ted Eytan, MD). I learned a ton here that I didn’t know before, which makes me happy that talented behavioral scientists are working in this area.
This is the reality of climate change in our cities. At one drug store:
And at another:
Allergy season started 3 weeks earlier than last year. The shelves are cleaned out. You can imagine that the consumers of these products are probably not as productive, happy, or with the same sense of wellness they usually have. To me, this is an image of suffering.
This is not the reality of climate change in our cities, from a display at Reagan National Airport, in Arlington, Virgina
The problem with the iceberg image is that it doesn’t connect people to the impact of climate change in their lives; research has shown that the polar bear / iceberg imagery is less effective in describing a problem that affects people. The drug store image connects climate change to our lives. Images and messages that focus on the impact of climate change to people are more effective, which is I why I wrote this post.
And, it’s a vicious circle. Health care in the United States accounts for 8 percent of our nation’s CO2 emissions. In the United Kingdom, health care accounts for 3 percent. Pharmaceuticals are accountable for 14 percent of those emissions in the US ( 21 percent in the UK ).
More allergies = more medications = more CO2 production = more allergies = more suffering.
More allergies also means more loss. In this great study by Ron Goetzel, PhD, et. al: “Health, Absence, Disability, and Presenteeism Cost Estimates of Certain Physical and Mental Health Conditions Affecting U.S. Employers“- the productivity loss of allergies has been estimated at 0.9 hours a day from an 8 hour work day, with a total cost of $271.04 per employee per year in direct and indirect costs (medical treatments and productivity). The annual cost of diabetes is $256.91 per employee per year. I’ll call these numbers “dramatic.” More allergies also means less physical activity, less resources for people to reach their everyday and ongoing life goals.
I’ve posted my own allergy journey on here previously (See: “Why Health2.0 is a great idea: The Case for Allergies”). I never had seasonal allergies until I moved to Washington, DC. I’ve become incredibly knowledgeable about how to manage mine, but I still move a little slower, take a little more time to get things done, spend a little more time indoors. I now understand why someone with pet allergies might have a cat or a dog. I call this time of the year, “the time that DC tries to reject me,” but I still <3 DC. Love knows no bounds I guess.
Someone might say, “this is good, promoting the health care economy through the production of these medications.” However, the goal of health care is not to put more resources into health care, it is to liberate the resources people have to achieve their life goals instead of paying for unnecessary treatments.
I’ve never been an environmental activist and I don’t see myself becoming one in the future. Probably more of a health activist. Climate change, like the other things I’m interested in, such as diversity, and patient access to information, is a health issue. Climate change, like the other things, is also a social determinant of health. Its impacts, including the ones above, disproportionately affect people across the social gradient.
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:
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….
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 – “big in europe”
Acronyms out of the way: HIMSS12 is the premier Health Information Technology Conference and Exhibition, put on by the Healthcare Information and Management Systems Society. ACPM2012 is the American College of Preventive Medicine’s annual meeting, and the is premier event for professionals in disease prevention and health promotion.. Las Vegas (HIMSS), Orlando (ACPM2012).
Around this time of year I await HIMSS time because the urban centers empty out, the traffic clears, and e-mail traffic abates. The tweets and messages fly as well about who’s going for this huge event. It’s beyond comprehension in my opinion. With the permission of Leonard Kish ( @LeonardKish ), I’m reposting a Twitter DM conversation we had about this.
Our back and forth is a bit tongue in cheek, and I think he’s right, collaboration will have an impact on the “greenness of health care.”
That’s what my talk is about at ACPM2012, and what the next series of blog posts are going to be about, because
- It was a steep learning curve, but one that completely fascinated and drew me in….because,
- I learned in the end that it’s the same conversation that we have about patient empowerment, diversity, and social determinants of health.
- And not only those things above, also health information technology, efficiency, preventive care, and total health…and, it’s measurable
- I think I’m ahead of my time
- I could use help on the narrative that goes with the story before I give the presentation on Feb 22
- I’d like a place to refer people to who ask me if I’m going to HIMSS 🙂
If you are going to HIMSS, Leonard’s eCollaboration Forum is happening there, and you can register for it.
In the meantime I’ll just use the tag #greenhealthcare because my discussion is part of a whole day of experts talking about climate change and health.
Here goes, these slides are not in order, I’ll show a few each day (this is supposed to be 15 minutes), feel free to comment. Let’s start with the patient.
For whom…the patient
In the medical profession and in health care, we have become numb to the amount of waste we generate. I can remember the first time I scrubbed into a surgery or saw/performed a procedure and saw how much “stuff” we opened, used, and threw away. Some was cleaned, much was not. All in service to the patient.
Our patients aren’t numb, though, as you can tell from the quote above (See: The Greening of Medicine). They are at times horrified, and they want us to lead. And…it turns out all is not needed in service to the patient. From this blog post from the Centre for Sustainable Health Care:
“But everything we use is needed!”
Are you sure? Other units have found that they are opening whole dressings packs but really only needed some gauze swabs, or that a smaller bicarbonate cartridge would do just as well…
In fact, we aren’t sure. The blog post in the slide above (“The Zero Waste Challenge for 2012″“) talks of the significant savings of materials, supplies, money, and CO2 ultimately that comes from making sure. Without compromising performance, this is a way for our patients to see that we want to save their money, their time, and the communities they go back to. And actually, it’s not the communities they go back to, it’s the communities that we share together. Health care is part of the environment, too.
In Green Health care, this extends to the reprocessing of single use devices. Reprocessing of SUD’s (single use devices) is regulated by the Food and Drug Administration, has been extensively studied, and can save enormous amounts of materials, time, money, and…CO2 emissions. The devices are carefully cleaned, recommissioned, tested, and in some cases can perform better than when they were used the first time.
You can read an excellent primer on the reprocessing of single use devices here: Kwakye G, Pronovost PJ, Makary MA. Commentary: a call to go green in health care by reprocessing medical equipment. Academic medicine : journal of the Association of American Medical Colleges. 2010;85(3):398-400.
Reprocessing medical equipment is part of Kaiser Permanente’s target to reduce waste. By 2015, Kaiser Permanente aims to reuse, recycle, or compost at least 40 percent of its waste system-wide, diverting all of this material from landfills. Kaiser Permanente arranged for the safe reprocessing of 274,000 pounds of medical devices in 2010, with a savings of $8 million compared to buying these devices new each time.
Tomorrow, we’ll talk about the safer use of chemicals in health care, then we’ll get to food.
Medicare To Cover Obesity Counseling Without Cost Sharing – Kaiser Health News.
Since I’ve mentioned this to more than a few people recently, I’m writing a post about it.
This is significant for two reasons:
- For changing the way health care is paid for, from procedures to counseling, which talking AND listening.
- For changing the way we think about obesity treatment, from thinking about it as untreatable (which is a myth), to thinking about it as treatable (which the science supports)
#1 has potential implications above for other things in health care that have been underemphasized (by they way they are reimbursed) such as advanced care planning (think “Engage with Grace
“). It’s worth checking out to see what the parallels are.