Just Read: In a health system where patient-physician email is actually used, how it impacts care

In an American health system, where, for the most part, patients *still* do not have access to their online medical records or access to their physicians (see: Patel V, Barker W, Siminerio E. Individuals’ access and use of their online medical record nationwide. Office of National Coordinator for Health Information Technology and Majority of Americans don’t use digital technology to access doctors | CAPP), this is a study conducted by the research team at Kaiser Permanente (@KPDOR) where patients mostly *do* have this access.

Of interest, they looked at how patients who had higher co-pays thought of using email as their first contact with providers, and how it may have shifted their use of services. This article on the @KPShare web site summarizes things nicely so I won’t repeat here: Patient-Initiated E-mails to Providers: Associations With Out-of-Pocket Visit Costs, and Impact on Care-Seeking and Health

I do want to clarify that the study is not asking about cost-sharing for email interactions. It asked what people would do if they didn’t have email at all. Totally different question. And no less interesting at this stage of adoption.

Speaking of adoption, the national numbers are 30% of people are offered their online medical record, and 46% viewed it at least once. That’s super low.

At Kaiser Permanente, 100% of people are offered their online medical record, 69% of the eligible population (as of 2Q2015) have signed up to use it, and 68% have viewed it at least once in the last quarter. 40% accessed it 5 or more times in the last quarter. By definition this is patient directed activity because there aren’t any organizational barriers to this access. These numbers are much better 🙂 .

Read the study to find out more what they do with it once they have it, which is a much more interesting question than, “when are they going to get it.”

Just Read: Patient & Family Health Care Leadership: A Resource Compendium from the National Academy of Medicine

So you would like to learn about patient and family health care leadership, where it’s happening and what the results are (and why wouldn’t you, I always want to).

This compendium has just been published as a body of work of the participants in the Patient & Family Health Care Leadership Network convened by the National Academy of Medicine, part of the National Academies of Sciences (@NASciences). So while not a report of the NAS, sometimes, like this time, compiling what is known is a great thing. And this compendium has both the leading institutions and the leading people represented – I was fortunate to join a meeting of the Network, and it was fantastic.

Thanks to Deidtra Henderson (@dee_henderson) at the NAS for being a part of this, sharing it with all of us, and posting it so others may enjoy.

This Compendium was created to assist and to inform volunteer patient & family council leaders and such leaders have contributed valuable feedback from its inception to its completion. It presents summary information on available evidence and information about the impact of patient and family engagement on health care outcomes and care improvement. It is intended to be a continuously updated living resource, and suggestions for inclusion are encouraged.

The compendium also has links to short video testimonials like this one, from one of the nation’s leaders in respecting patient and family involvement, Georgia Regents’ University, who I’ve spent time with previously, and where I was fortunate to be exposed to the leadership of Pat Sodomka, F.A.C.H.E., who I will always remember as the person who involved patients and families not because she had to, because it was the thing to do as a leader (see: Remembering Pat Sodomka, F.A.C.H.E.).

When people are ready to promote patient empowerment/engagement, what can they do?

The title of this post is a variant of the title of another post (“When physicians are ready to promote patient empowerment/engagement, do we want them to do?“). That post came about from a conversation with another physician. This one is coming about with a conversation with a person, not a physician, Erica Brand, who works in silicon valley and is interested in the same idea.

We got in touch because Erica has been following the work of myself and the e-patients.net group, and on reflection of her own experience with health care is interested in making a difference.

We talked about different opportunities for someone with talent in an industry that is not health care could help health care succeed, and there are lots of them. For example, depending on who a person’s employer is, they may belong to a coalition of employers focused on health issues. In California, this might be The Pacific Business Group on Health, or in silicon valley, the Silicon Valley Employers Forum is an affiliate of PBGH, which is also a place to get involved in transforming health care.

As I look back at the original post, though, the advice/recommendations are generally the same, which says to me that we all have as much if not more in common as fellow patients than we do being in health care / not being in health care. I still think health care can learn a lot from other industries and we should welcome all of the help we can get, and I think talent is talent regardless of the industry that it comes from. In the era of Health 2.0, the improvement of health is truly democratic.

It is nice to discover in these conversations that there are many people who want to bring their professional and personal experiences forward to help us improve. Come join us!

Now Reading: 25 Percent of Large Medical Groups Use Data from Patients to Improve Care

Only 10 percent reported that most of their physicians would strongly agree with statement that the group regularly incorporates feedback from patients in improving care and developing new services.

This is among the largest medical groups, the ones with the greatest infrastructure.

This figure comes from the attached article, published in Health Affairs , which is a survey of a sample of the largest medical groups in the United States (those with 20 or more physicians), with the exclusion of Independent Practice Associations (due to theoretically less infrastructure present), and via self-report of the CEO’s/Presidents/Medical Director. In other words, this is best case.

With regard to online access:

Thirty percent of medical groups use group visits for patients with chronic illnesses at a majority of their practice sites (data not shown). A similar proportion reported that most of their physicians communicate with patients via e-mail “occasionally,” although only 1 percent reported that physicians use e-mail with patients daily. Nine percent said that a majority of their patients could access some part of the group’s EMR online.

Unfortunately, the performance of the medical groups surveyed lessens as the size of the group does. I thought it might be possible that smaller practices in this group might employ greater efforts to incorporate patient feedback. That could still be the case, since groups with less than 20 physicians are not included here (and those are the overwhelming majority of places where Americans receive their ambulatory medical care).

What about measuring “Medical Home-ness”?

Although some argue that “ medical-homeness” is better evaluated from the patient’s perspective than from the physician’s, others balk at all attempts to measure aspects of the PCMH as overly reductionist. Regardless, the demand for clinical practice “ transparency” remains a reality of the current policy environment, and success of the model will depend in part on continued multistakeholder involvement in the development of standardized, comprehensive assessment tools.

How, in a Health 2.0 world, could we combine the significant expertise of NCQA and lighter weight solutions to support patient involvement in the measurement of medical home-ness? Would this approach also guide medical groups to select the right infrastructure improvement projects for themselves and implement them quickly? This fits in nicely with the LEAN concept of “seeing the impact of what you do,” by getting smaller bits of feedback soon, combined with more comprehensive feedback over time.

Maybe a parallel iPhone Medical Home measurement application will surface …. see what you think.

My AHRQ M&M Case & Commentary – The Promise of Patient and Family Involvement

AHRQ WebM&M: October, 2008, Case & Commentary: Recurrent Hypoglycemia: A Care Transition Failure? Commentary by Ted Eytan, MD, MS, MPH

I wrote this month’s spotlight case in AHRQ’s Web M&M.

At first glance, this article looks like a traditional M&M (“Morbidity & Mortality”) review of an internal medicine case, replete with lab values, diagnostic discussions, and the like. However, the cases on this site stretch beyond diagnostics, as I found.

Bob Wachter, MD and his team invited me to write a commentary on a case about recurrent hypoglycemia that was about system supports rather than diagnostic and clinical errors. This included putting together all the thoughts on having an accessible EHR, patient and family involvement in care, and in the design of the system. The whole thing is in there, wrapped in a package for clinicians and those who support them to review and ponder.

It’s the spotlight case this month, and as I review it, I remember all of the people along the way who added this idea or that idea (and there’s many more to add). You’ll probably recognize yourselves in there….

With thanks to Bob and team for envisioning that a difficult medical case could be the foundation for a discussion about what Health 2.0 will do for our nation. See what you think.

When physicians are ready to promote patient empowerment / engagement, what do we want them to do?

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.

Now Reading: “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.


Moving Closer to Patient Centered Care in Yountville, California


I think word has gotten out that I am something of an urban dweller; Susan Edgman-Levitan was nice enough to ask me, “Ted, are you hanging in there?” as we spent several days in Yountville, California at the American Board of Internal Medicine Foundation forum on Achieving Patient-Centered care.

I ended up doing just fine – it’s about the content, not the place, and a scenic jog through the vineyards of Yountville can’t be argued with.

And the content was right up my alley, with thanks to the ABIM Foundation for hosting this discussion. The discussions at the Forum are being compiled by the ABIM Foundation, so I will let them report on that rather than me, but I can share my perceptions of the event here.

First of all, patients and families were involved throughout, as faculty and equal participants. This continues an important precedent in helping health care leaders achieve comfort with this idea.

One of the most powerful moments was Margaret Murphy sharing the story of her son Kevin’s death (You can read more about it here) within the Irish health system. I really appreciated Mrs. Murphy’s use of images in her storytelling – in the future, a presentation without at least 50 % images and a video or two is going to be minimum bar to go in front of an audience. There was discussion about Kevin’s death being the result of diagnostic error. I think that’s true, and I also think that if the family had access to all of his medical information from the beginning, it might have changed the diagnostic approach or caught the fatal series of errors before they happened.

For my part, I presented the following slides in the 10 minutes I had alotted, around the topic of the use of health information technology to put patients, families, and communities in the center of care.

Enjoy (I hope) and thanks to the ABIM Foundation for hosting this discussion and follow-up.

Click on any image to see them larger

Running a hospital: The message you hope never to send

Running a hospital: The message you hope never to send

As with many stimulating blog postings, the comments are as interesting as the post itself. Kudos to Paul Levy for doing his best to handle this differently than is the norm in health care – that’s an important role for a CEO who wants to change health care for the better.

I’m particularly drawn to the comment(s) by Ray Poses, MD about doing a “5 Why’s” type exercise to see what is happening upstream (why are teams being pulled in so many different directions regularly) that causes protocols to be slipped.

I also think there’s an opportunity for BIDMC to bring in patients and families to own the solution together. What would care be like if there was a family member in the operating room during surgical prep (Medical College of Georgia does this)? Or if the family had access to the patient’s electronic medical record in real time while in the hospital? Preventing this for another patient may be less about “what” to do in the operating room, but “how” teams (that include patients and families) are involved in the design of the system.

Given the work BIDMC has been doing to be transparent and involve more, rather than less, people in designing and improving their care system, it seems that they’ll do their best for their patients this time, too.