Shadow Dancing – going to be where the patient is

One of the greatest things I heard from a CEO of a health care company I really admire was, “Sometimes I go back to my office and ask myself what the heck I am doing.”

And, sometimes I go back to my office and ask myself what the heck I’m doing.

I am just finishing up a week (more or less) of visiting a total of four different health care organizations, in the San Francisco Bay Area. It was a great week. I never know what I’m going to see or learn when I do this, and I learn a lot. The reason for this is that I do shadow – asking to go into the exam room with patient and physician (after proper consent). I typically don’t sit down with people at meetings, and instead talk to them on the fly, in the context of patient care. Sometimes I will give a presentation, on request, which I am happy to oblige.

It’s a bit of an unusual way to learn, and it can be challenging to get there in the first place. This includes everything from knowing my tuberculosis status (to protect patients I may come in contact with) to understanding privacy practices and protecting the security of medical information.

When I visit a practice, there is invariably a conversation that starts with, “who are you and why are you here?” I have a bit of an elevator speech that I’ve developed over time. The reality is, that in medicine, it’s not the “norm” to perform quality improvement a little at a time. People are used to data-driven quality, which can take months to compile and more months to release as people discuss methodology. They don’t really watch each other practice and critique and improve on the fly. So, I sometimes find myself in a situation where I have to represent my value very quickly.

The good news is that I have been uniformly welcomed, even by busy clinicians, which has been so impressive to me. Some of the clinicians I am following are not having the smoothest days, and some may not be having the smoothest weeks or smoothest months. And, that’s okay. I’m a visitor serving them, not the other way around.

In a health care system where quality happens every day, a bit at a time, it would be more likely that a physician (or nurse) would be shadowed by a colleague, and so my presence wouldn’t be a novelty. But that’s not the case, so every new request to shadow is going to bring a challenge with it. It would be much easier to acquire information by setting up meetings, but I think the quality of information would be inferior. So, I’m not going to do that, but I will set myself up for disappointment and maybe even failure, if an organization or practice feels that there isn’t a need to have me observe what they do.

The reason why it’s okay, to do this more complicated thing, is because of all of the things I have seen and heard, the moments of “the heart of family practice” that I have had in every place I’ve been. Maybe one day all patients will expect to see another physician in the exam room with their own who is working to help their colleague to be a better doctor.

Such is the life of the change agent….

Presentation: Blogs in Health Care; Council of Accountable Physician Practices

Eytan-Chcf Web2 2007-2

PDF: Web 2.0 for Planning, Communication and Change Management, Ted Eytan, MD

California Healthcare Foundation

Given at California Healthcare Foundation’s new headquarters, Oakland, CA

It was a busy week in California, starting with a visit to the California Healthcare Foundation’s new headquarters in Oakland, California. I was honored to lead a discussion on the use of “Web 2.0” (mostly focusing on blogs) in health care. This blog itself is an experiment, partially funded by the Foundation. I think the basic message is “If you don’t, they will,” and “being transparent and accountable as a health system can inspire confidence.”

I first gave this presentation with Andy Wiesenthal, MD, who leads the Kaiser Permanente HealthConnect project, at a User Group meeting for Epic Systems clients, later within my own health system, Group Health Cooperative, and now this public version.

I am a bit of an evangelist now of using Web 2.0 in Healthcare, and consider myself “very available” when it comes to the opportunity to give this presentation to other audiences. It’s been a great journey, as you can see in the slides.

We had a nice discussion about the value of blogging and transparency in different environments. The presentation is meant to be informational, without any particular recommendation for the philanthrophy community. Of interest, though, was a question posed about how to move to Web 2.0 in a large organization. My answer was, “Slowly” and “not to shock the system.”

What was really great was that Holly Potter, the Director of Communication for the HealthConnect project was in attendance, and her response was, “It would be nice to have the luxury of being that deliberate. We don’t have that option anymore.” Holly’s team supports a project that touches millions of lives. She related her experience as the person accountable for ensuring that the communities that are touched by this project have the most accurate information about it, all the time. It was very powerful to have Holly present in the discussion, in my opinion.

Council of Accountable Physician Practices (CAPP)

Speaking of accountability, I was also fortunate to meet Nancy Taylor, the Executive Director of CAPP, which is an affiliate of the American Medical Group Association. The medical group I belong to, Group Health Permanente, is a member of CAPP, and these are the medical groups that are working to promote a health care system that is “more accountable to patients, consumers, and purchasers.”

I actually didn’t know about CAPP before I started this work, but as I look at the roster, it’s a who’s who of innovators in the personal health record / patient-centered care world.

This is not to say, though, that CAPP groups are the only ones innovating. As I discussed previously on this blog, there is a lot going on in smaller practices supported by the American College of Physicians and the American Academy of Family Physicians. At the same time, this consortium represents another nice touchpoint for those who ask, “Who can I talk to about implementing patient centered health information technology?”

Of course, in the shadow of the talk I had just given, I thought about which of these medical groups have blogs where they are communicating their work to the public. I don’t know the answer to that question (and if any of them are reading this, please post your comments here about that). I hope at some point to interact more with the Council and maybe discuss the opportunity to be even more transparent using Web 2.0 technology

I am wrapping up my time in California, with just a few more posts to go, and I wanted to again thank the California Healthcare Foundation and The Council of Accountable Physician Practices for their support of patient centered health information technology.

Cardiorespiratory Fitness and Adiposity as Mortality Predictors in Older Adults

I think this study:

JAMA — Abstract: Cardiorespiratory Fitness and Adiposity as Mortality Predictors in Older Adults, December 5, 2007, Sui et al. 298 (21): 2507

deserves its own post, and is significant when thinking of patient-centered health information technology. Why? Because in demonstrating an association with fitness and mortality (death) that is independent of adiposity (fatness – I love medical terminology, don’t you?), a change in focus of our health system is suggested, in my opinion.

Instead of tracking a measure that’s potentially hard to move, and with slow fluctuations, it’s possible that we should be tracking a different measure that’s easy to move, and with significant fluctuations – physical activity. It may be more important that patient-centered health information technology allow patients to track steps per day or some other proxy for active movement, on a regular basis, rather than a periodic weight check. And it may be more important to have a PHR implemented in the first place, because coming to see the doctor for a periodic weight check may not be good enough anymore.

One thing that this study supports in my own practice of medicine is my response to the patient who states that they have stopped exercising due to a symptom or medical condition (physical or emotional). I consider a history of “I’ve stopped exercising because of X” as dangerous as “I have chest pain” and treat it as serious as that.

I think that in the long run, stopping exercise is probably as dangerous as chest pain, if not more dangerous. I think this study backs up that idea.

Pictures and Quotes: Kaiser Permanente Oakland Medical Center

I am adding images from Josh’s and my visit to Kaiser Permanente Oakland Medical Center in this post, plus a few quotes from Victor and his Medical Assistant, Monica.

I’ve just got these two things and it (the system) prioritizes them nicely – Victor Silvestre, MD

Victor said this as he pointed to the home screen of the electronic health record, HealthConnect. On the left were his day’s visits, on the right was his electronic In Basket, which included patient secure e-mail, right within his workflow.

I loved this quote because it echoes perfectly what my medical partner David McCulloch, MD, Medical Director of Clinical Improvement and Education, says about the patient view of health care:


Instead of many many things we need to give to patients, it’s just two things, illustrated above and in Victor’s quote.

I used to check for patient e-mail’s exactly 4 times per week. Now I do it millions of times a day – Victor Silvestre, MD

In this quote, he was referring to the impact of integrating secure e-mail into his workflow, as part of the EHR he uses to care for patients every day. The “millions of times” was in jest of course, but the idea is that as he touches the system many times a day to support patients who come to visit him in person, he can also simultaneously touch patients who are not in front of him, and blend that into his support of a whole population seamlessly.

It’s better than all…..this (waving a paper chart) – Monica, Medical Assistant

This was the answer when I asked what Monica thought of the EHR she’s using in practice with her care team. What I was that the staff was eager to use the new technology to do more for patients, and in several instances, to support physicians in using it better. That’s the nice thing about patient-centered health information technology – everyone gets to help everyone use it better for people.

Images: click on any to see larger. I’m including a bonus of myself and Ed Cohen, MD, who’s the Physician Lead for for The Permanente Medical Group and who helped arrange today’s visit in the interest of sharing knowledge.

Into the Future at John Muir Health

John Muir Physician Network (20071205)

Josh and I spent our day yesterday at two leading edge health organizations in the Bay Area, Kaiser Permanente, and John Muir Health. This post is about our time at John Muir Health. Like Kaiser Permanente, John Muir Health is a big place – out attention was focused on the John Muir Physician Network, which provides multispecialty care within owned and operated practices as well as within an Individual Practice Association.

And…it was very valuable. My background is as a family physician within an owned and operated multispecialty group, so even though I understand the implementation of both an EHR and PHR at an enterprise level, I am not acquainted with the environment of physician-owned practices. To this end, Michael Schierman, MD, hosted Josh and I at his practice at Blackhawk Medical Center, in Danville, California.

Michael is a family physician, originally from Calgary, Alberta, who shares his full time practice with two physicians who are general internists. His practice is leading the way for a transformation to electronic health records using the NextGen platform. In my work, I have also never seen the NextGen product, which is a fully CCHIT certified electronic health record, in action. Michael’s practice has only recently gone live, and he’s pretty facile with the system in practice, from my view. They are now doing the hard work of converting paper charts to the electronic work, and a great metaphor for this was Michael’s office. Before we visited, he apologized for any messiness in his office, which comes as a result of the paper charts he is diligently reviewing as part of the transition. Again, the value of being there is made apparent, because I could see that the transition to an electronic health record means everything from changing your workflow to uprooting your physical practice environment.

In the patient rooms themselves, the story was a very pleasing one. Michael was able to tell his patients that laboratory studies could be obtained without needing a paper lab slip, and prescriptions would be sent electronically from his laptop during the visit. His patient population, which is a busy and professional one, seemed impressed. In reference to my presence, he asked several of his patients what they would think about e-mailing their doctor. The comments that came back were very interesting, and tracked what we’ve heard at Group Health. There was a measured concern and respect for their doctor’s time that came with each response – “I would want to keep things to the point.” At the same time, Michael showed me his work list that was nicely displayed on his laptop. The question would be how this other avenue of communication would fit into this portion of his practice life.

Pictures: Click on any to see full size

Continue reading “Into the Future at John Muir Health”

Time at Lifelong Medical Care, Part 2

In yesterday’s post, I talked about my day shadowing with Dr. Pete Lovett, who’s the Medical Director of Berkeley Primary Care, which is part of LifeLong Medical Care. Today, a few more observations based on my time with his other patients, plus my time with Frances Herb, MD, Berkeley Primary Care’s HIV Specialist.

Other patient perspectives

As I mentioned yesterday, I learned that “uninsured” does not mean “uninformed.” Another of Pete’s patients indicated that he was very actively using the Internet to learn more about his condition. He was very interested in complementary healing remedies and satisfied with the results he had achieved so far. As with other patients, there was a challenge here in terms of integrating information from other specialty care providers in the visit. There was not ready access to treatment information. And as with the other patients, this one had a good fund of knowledge about his care in other venues. I asked about this patients’ support system and he indicated that he did share information about his health with a colleague, over the Internet. He also indicated an interest in gaining assistance from his physicians about information he was seeing online about treatment options.

Other connectivity issues

For the rest of my afternoon, I was able to shadow Frances Herb, MD, who is a general internist and specialist in HIV care. I asked Frances what made her decide to practice medicine in this medical center. She told me that she remembers being in the same situation (being uninsured) that many of her patients are in now and wanted to support those that came after her. As with the rest of the Medical Center, charts are primarily on paper. She introduced me to a few of her patients, and noted in each case that she had a written record of their care back 10-13 years. It was an impressive show of continuity.

(side comment: One of the most enjoyable parts of using the paper chart when we had it at Group Health was visiting a member who had been with the organization since 1947 – reviewing their paper chart was like looking at an encapsulated version of the history of medical care. No EHR can duplicate the social experience of paper…)

In HIV care, there is an exception with regard to charting – there is a functional EHR that is interconnected with other medical centers in the area, thanks to Ryan White funding. But only in these patients. As far as I could tell, there is no PHR attached to this record. However, I did see Frances print laboratory values, chart them, and give them to patients – Information Therapy.

At one point I asked Frances how she would feel about securely e-mailing her patients. She said, “Secure e-mail to my patients? I would love to be able to securely e-mail other physicians about my patients’ care.” Good response.

Watching myself

LifeLong Medical Care is the fifth safety net care provider I have visited so far in this project. In true LEAN tradition, I can’t help but reflect (through a process known as hansei) on how I got here. My past experience involved rotation in residency at the Country Doctor Community Health Center in Seattle, Washington, which is not in the Country (it is right around the corner from one of Group Health’s largest medical centers) but does have great doctors. I haven’t been in a safety net medical center since, and I realize that I have lost touch with the disparities in technology that are now existing in modern medical care. This doesn’t mean that I have come to a conclusion that a PHR doesn’t make sense here – just the opposite actually. I can see an even greater benefit here, and maybe more than the EHR itself (or at least as powerful). Now that I have been involved with an ideal care system with the ability to transform, I want to think about ways to support LifeLong Medical Care and organizations like it – I think they are ready and their patients will benefit.

Today, I am going to visit a Kaiser Permanente Medical Center in Oakland, California, a medical center at John Muir Mount Diablo Health System in Walnut Creek, and tomorrow, La Clinica de La Raza, also in Oakland.

Baby Boomers and retirement; Case for Informed Optimism

November 27th through December 2nd:

I deactivated my Facebook Account. Is LinkedIn next?

I am a big fan of everything Web 2.0, including social networking. I just decided that the negatives of Facebook outweighed the positives and deactivated my account. Why? First, what I liked about Facebook was that it was a “professional” social networking community. A person used their real name and real interests. Facebook at the same time did a very nice job of creating exquisite privacy controls, so that your friends could know about what they needed to know, and professional contacts could know what they needed to know.

Then Facebook opened up the world of applications, which was interesting enough. Except that applications begat applications. I couldn’t find someone’s Wall to write on. I had to find the super-duper-neon-Wall 3.0. And then the requests came from friends to add application x or application y to my account so I could rate them, compare myself to them, etc etc. I think we need to get back to a time and place where we sit down and tell each other how we feel in person. Perhaps I am revealing my GenX-ness in that comment. But maybe not.

And finally, the news that maybe the monetizing application isn’t going so well made the decision a relatively easy one.

I have an identity here that people can find just by Google-ing me. All the applications I need I have added.

I’m a little worried that there’s going to be a bump in the social-networking road at this point.

And I’m still trying to figure out what the value of LinkedIn is.

“I want my doctors to meet me half way” : Lifelong Medical Care, Part I

Berkeley Primary Care

Lifelong Medical Care, Berkeley Primary Care, Berkeley, California

These were the words of a young man who stayed for a few minutes after his primary care visit at Downtown Berkeley Primary Care, to talk to me about his care experience. In fact, this was a new experience for me, too, because it was the first time that a physician whom I was shadowing asked me to do more than observe the visit. Pete Lovett, MD, is the Associate Medical Director of the Berkeley Primary Care Clinic and my guide during the visit.

A little background, first, and a good illustration of why there is more to an organization than their Web site. I am going to break this description into 2 posts for readability.

I was connected to Lifelong Medical via the California Healthcare Foundation, which has a strong interest in supporting the safety net medical providers in the communities it serves. On, it says, “LifeLong is known as the primary “safety net” provider of medical services to the uninsured and those with complex health needs in Berkeley, North Oakland, Albany and Emeryville. In 2004, LifeLong provided approximately 101,000 primary care visits to over 17,000 people, nearly half of whom were uninsured.” I knew prior to visiting that LifeLong does most of its charting on paper, and does not have an online personal health record for its patients. My presumption then, was that I would be here as a comparison for other safety net medical centers I am working with on the East Coast, many of whom I am working with because they have full EHRs or who are in the process of getting them.

Pete is a family physician trained in the National Health Service in the United Kingdom, with experience as Family Practice Faculty at University of California, San Francisco. As a physician in the NHS, he has experience with paperless practices, and in fact told me that his work in the United States has meant a return to less developed ways of moving information around. It turns out that LifeLong Medical does have experience with an EHR that it uses exclusively for its HIV patients.

Continue reading ““I want my doctors to meet me half way” : Lifelong Medical Care, Part I”

Photo Friday 2: Kaiser Permanente visibly supports diversity

I am sneaking in another set of photos this week, because I was so taken (and impressed) by these images I encountered in the San Francisco Powell Street BART station. The commitment shown here echoes reports from other national organizations, most notably the Human Rights Campaign (which awarded KP a perfect 100 rating for corporate equality). These reports show that Kaiser Permanente sets a very high bar for supporting staff and members from different backgrounds.

Even though I am not officially an employee of Kaiser Permanente (I am a Permanente physician in an affiliated medical group), I have great respect for an organization that emphasizes leadership in this area. Protecting our vital populations by reducing disparities is one of the most important goals (actually the most important goal) I have as a physician.

Kaiser Permanente Thrive

Kaiser Permanente Thrive