Just Read: Can Physicians Manage the Quality and Costs of Health Care? The Story of the Permanente Medical Group

To know where you’re going, it’s important to know where you came from….

This book, published in 1991, gives a physician’s eye view of one of the most significant health movements in the United States – prepaid, integrated health care with a social mission.

Before reading the book, I already knew that part. I didn’t appreciate its scope in American consciousness, though:

On one occasion, Avram Yedidia, the Health Plan representative, observed a distinguished looking man working quietly on some papers while waiting for an appointment with his physician at the Permanente Hospital in Oakland….Yedidia asked him if he were satisfied with the medical attention he was receiving from the Plan. The gentleman said that he was. Yedidia then asked if he minded the waiting. No, he did not, the gentleman replied. He understood how busy the doctor was. Yedidia then introduced himself, and asked the man’s name. He was Enrico Fermi, a professor of physics at UC Berkley and a winner of the Nobel Prize.

A few more quotes about the genetic code, revealed in the book:

On April 14, 1941, the first keel of the first freighter, the Ocean Vanguard, was laid…that freighter was the first of 1490 vessels to be constructed in Kaiser Shipyards over the next 5 years. in the case of the Robert E. Peary, launched in November, 1942, less than 1 year after Pearl Harbor, the time between keel laying and launching was reduced to 7 days, 14 hours and 29 minutes.

This level of social organization and cooperation was matched by a program of medical care equally organized and disciplined. The intense social cooperation of the shipyards inspired and sustained a practice of medicine comparably characterized by innovation and social cooperation. When it was over, a new way of practicing medicine had emerged.

As early as April 4, 1945, Sidney Garfield outlined them (the genetic code) in a speech to the Multnomah County Medical Association in Portland, Oregon

(here they are, summarized)

  • Prepayment
  • Group practice
  • Adequate facilities
  • A new economy of medicine (“By having the healthy pay to maintain their own health, capital coaslesced with which to care for the sick”)
  • Voluntary enrollment with dual choice
  • Physician responsibility in management as well as medical matters

Medical education, not a new idea…

There was even talk of establishing a medical school in San Francisco after the Stanford Medical School moved south to Palo Alto.

Kaiser Permanente did not mature with ease. There were lots of conflicts along the way, detailed in the pages throughout. This is in large part why people who say the core element is prepayment don’t understand what Kaiser Permanente is.

In the end, this is the place people came to. The answer to the question in the title is an unqualified yes.

No matter how the principles of our plan our meant…if you don’t have the physician group who have it in their hearts to make it work and who believe in prepaid practice, it won’t work. This is the thing that makes me wonder about HMOs all over the country. They aren’t going to work unless they get men in those operations who really believe in giving service to the people. – Sidney Garfield, MD

I am suggesting, (Cecil) Cutting reported to the partnership on October 13, 1969, that they not put their foot in it unless they can put their heart in it also. That is, first to be convinced of the principles, philosophy, and desire to provide good medical care at reasonable cost – to take pride being part of an organization that is making the medical dollar go a little bit farther.

Yes, that is a 90% Hypertension Control Rate

The results are in from what is considered the report card for health plans in the United States, and these results are kind of amazing.

I was reminded of this when I was at the #DesignForAction conference in Washington, DC, where in one of the sessions about health, the current United States’ rate of blood pressure control was bemoaned to be around 50%. This figure is sadly true.

Except at Kaiser Permanente.

Like I said, amazing. The number is 86% across Kaiser Permanente, 91% for the number one health plan in the nation, Kaiser Permanente Mid-Atlantic States, which is also number one in 7 other measures.

In the Medicare population, it’s even higher, 94% across Kaiser Permanente, 95% in Kaiser Permanente Mid-Atlantic States.

-> 95% <-

That means that 5% of Medicare members do not have their hypertension under control. Unheard of.

The 50th, 75th, 90th, and 95th percentiles for blood pressure control are


Every Kaiser Permanente region is above the 95th percentile.

Breast cancer screening, similar story

Kaiser Permanente Mid-Atlantic States is #1 in the nation at 90%, every Kaiser Permanente region is number one in the state it operates, except for Kaiser Permanente Northern California (88%). It’s #2 to Kaiser Permanente Southern California (88%) 🙂 .

Overall, Kaiser Permanente is number 1 in 21 measures, out of 83 total measures, across 5 domains of care.

News, Views and Moves from Kaiser Permanente

Source: Kaiser Permanente Share | Being the Best Saves Lives: Kaiser Permanente Leads the Nation in 21 Quality Measures

Photos from “Which Health Care Metrics Matter?”

Which Health Care Metrics Matter? Explored gaps between quality data and its use by the public to improve health and health care. (View on Flickr.com)

With great thanks to the team from Mid-Atlantic Permanente Medical Group, Kaiser Permanente Mid-Atlantic States (@KPMidAtlantic), NCQA (@NCQA), National Quality Forum (@NatQualityForum), and the medical directors/health officers of the health authorities of Maryland, Washington, DC, and Virginia: Joshua Sharfstein, MD (@DrJoshS), Joxel Garcia, MD (@HealthDiplomacy), William Hazel, MD (@VaSecofHealth)


And, congratulations Kaiser Permanente Mid-Atlantic States for its 2014 ranking of #13 out of 500+ health plans in the United States.

FWD: emr (a conversation with my brother about the RAND study on EHR adoption and quality improvement)

I received this e-mail from my brother, who is an (excellent) ophthalmologist practicing in a fee-for-service environment:

Hey ted,

Just saw this on the net, kinda confirming what my conversations have been with doctors (though can’t speak for hospitals).  The study didn’t address cost savings though, as I’m sure some duplication of tests can be avoided.

There has been some (very slow) integration of emr into offices here.  My main contention is still the focus on data collection by the govt,


what do you think?

As I mentioned in my last post about conversations with my brother (FWD: More on HIT and cost saving (NOT!), Arizona is a long way from Washington, DC, and as I have always said, the reality of health care is what happens where the patient is.

He was referring to the study recently released by folks at RAND. I reviewed it, provided some commentary, and here was his response.

I agree with you, that the cost savings and quality improvements depend on implementation.  The few docs I know that are going emr, are in it for the govt discount, and of course, chose the cheapest, most basic system that is clearly worse than paper charts at this point.

Also, a good point with the duplication of tests.  Even though a test was normal 3 days ago, we’re still legally liable to repeat it.

Integration with physicians is surely the way to enhance our health care delivery; as long as it’s done right.

There were some doctors elected to the new congress.  Hopefully, that will help.

So what did I think?

I think the article makes a good argument that an EHR by itself is not transformative (you can read commentary on it here). There’s an important clue embedded within:

Sixth, our study may not have been long enough to fully estimate the relationship between EHr adoption and quality improvement. Institutions with “homegrown” EHrs that have been developed and refined over decades typically report that their EHrs have significantly improved clinicians’ adherence to recommended practices. In fact, our analyses are some- what illustrative of this phenomenon, as we observed that hospitals that had a basic EHr in place at the outset of the study realized significantly higher gains in heart failure quality scores.

In other words, there’s the data, and then there’s what you do with it. Quality does improve with leadership experience, and that will happen over time.

Not just technology, leadership, Kaiser Permanente, Tualatin, OR

Look at the data in this study – the first of its kind – showing the impact of measuring and introducing “care gaps” into clinical practice, at Kaiser Permanente, Northwest. The study looked at 13 different care recommendations and found that after 20 months, the PST improved performance from 72.9 percent to an average of 80 percent.

That’s a very different conclusion. Why? Look at the photograph on the left. You could only understand how an EHR helps by physically going to the place where it is used. When you do, you discover all the things in the environment around the technology that makes it work, like leadership and commitment. And it does work, with results to show for it. You can read more about my experience here: The ability to know – Population care facilitated by health information technology at Kaiser Permanente Tualatin, Oregon.

I suggest looking beyond the data, just like the design thinkers do – the value of observation.

I don’t want to imply that the hospitals studied in the RAND article lack leadership or commitment – referring back to what my brother asked, it’s the goal of EHR implementation to open the physician and patient community to the commitment they have always had, enabled by great tools.

In Conclusion, I don’t know what to tell my brother, yet

I need to sip my own champagne and “observe what people don’t do, listen to what they don’t say,” so I’m going to shadow my brother in his practice of medicine, where his patients are. 🙂

I’ll report back; in the meantime, what would you tell him?

How provider competition can improve health care delivery – McKinsey Quarterly – Health Care – Strategy & Analysis

How provider competition can improve health care delivery – McKinsey Quarterly – Health Care – Strategy & Analysis – A good overview of some of the evidence around the benefit of competition in specialized and not so specialized care. Relevant to those interested in reducing information assymetry. Of relevance to those interested in personal health records: “We believe that it is time for health systems to shift their focus toward unleashing competition in primary care; that is where competition is likely to make the greatest difference.”

Presentation: Using Technology to Achieve Total Health – Aligning Forces for Quality #af4q

Here is this morning’s presentation for the Aligning Forces for Quality meeting in Orlando, Florida ( @AligningForces ). I’ll follow up with another post with links, etc. See everyone in a bit!

I have posted images and links from this presentation in this post, if you would like to access the resources mentioned below.

Data Graphic: Patient-Physician E-mail improves care

When I decided to toss most of the slides I was going to show at the Consumer Health Congress in Washington, DC, I knew that I would be able to share that information here, in the social media world, where the conversation never ends.

Here is some impressive data regarding the impact of patient-physician e-mail.


Technology does not replace us…

We use it to improve the care we provide

Key points:

  • People ultimately rely on health professionals as their primary source of health information. Therefore, “getting information online” and “getting information from your doctor” should not be considered mutually exclusive (and surveys should not present this dichotomy – I have good information that @SusannahFox is totally on top of this :))
  • At a place where patients get information from their doctor AND online, Kaiser Permanente, you can see a significant improvement in blood pressure control on the part of patients who did e-mail their doctor versus those that didn’t.

This data comes from the online appendix to this study published in Health Affairs in July. I decided to pull out blood pressure specifically, but you can see from the article that overall this was the case with all of the quality measures studied (with a nod to the nice people at Health Affairs who allowed me to leave the table in after I published it before checking with them – at least I am easy to train).

All of this put together is, kind of huge. A condition that affects 1/3 of American adults, is accountable for 27 % of CVD events in women, 37 % of CVD events in men, is the #1 reason for physician office visits in the United States, can be managed by patients and physicians together, with the help of electronic systems that provide information online WITH (not instead of) from doctors and nurses.

At this point in the presentation, when the audience might be thinking, “Kaiser Permanente can do that, I can’t,” I would show this slide. And I believe it. Enjoy.

And you will, too.

Now Reading: Improved Quality At Kaiser Permanente Through E-Mail Between Physicians And Patients

This article, published in Health Affairs today, adds to the body of information we already have about patients and physicians enjoying the benefits of secure e-mail access to each other, with information about impacts on health care quality.

Thanks to the scale of Kaiser Permanente (and even in just one region of Kaiser Permanente), it is possible to look at the use of secure e-mail between patients and the 3,092 primary care physicians (there are 6,000 total in this multi-specialty group) who had used it with at least one patient, by December, 2008.

And…in a comparison between patients with diabetes and/or hypertension who did and did not exchange e-mail with their physicians two months after the service was available, there was a statistically significant (better) improvement of all of the Healthcare Effectiveness Data and Information Set (HEDIS) measures for this population.

Not just one of the measures analyzed, all of them.

In addition, the more messages sent resulted in more improvement for four measures (HbA1c and cholesterol screening, HbA1c control, and nephropathy screening).

The patients with e-mail use were compared to patients similar to them based on baseline measures (where they started disease-wise), age, sex, and primary care provider. In other words, this takes care of differences between doctors who may practice differently in terms of working with patients to improve health.

What this matching does not take care of, as the authors point out, are patients that are more likely to use secure e-mail in the first place, because they have more resources, they are more engaged, etc.

On this note, I have been having conversations of late about the “engaged in their health” person. I know that a lot of people are taught to promote the idea that many patients don’t want to be engaged in their health, but really, this is an idea whose origin is not clear to me. How many people do we know that want to be engaged in being sick? Comment from the patient community?

One thing to notice – look at the rate of blood pressure control across all the patients – 90%. This is unheard of in most of health care, where the average control rate is less than 40%, in a condition (high blood pressure) that accounts for 27% of total CVD events (stroke, heart attack) in women and 37% in men. That by itself is huge, and it actually makes a study like this very difficult, because unlike the rest of health care, in this system there is almost nowhere to go but down.

One note from the authors that I agree is worth considering, an unintended consequence of a system that still thinks “in person” is more important than “accessible”:

Nonfinancial barriers to the use of e-mail should also be addressed. Current quality measures, such as those used by HEDIS and the National Committee for Quality Assurance, rely on face-to-face visits as the standard of care. For example, an office visit is now required to document the ongoing presence of hypertension.

These are impressive findings, and I think ready (and useful) to be replicated in health environments where the quality numbers are not as good to begin with. I do not say this pejoratively, all health systems can be this good for their patients, and every tool helps. If you are a health care provider or patient using an online system to communicate, please post your experiences in your perceived quality of care since you began, even anecdotally, what do you think?

I feel the need to paste in Exhibit 1, showing the p values of improvement for each measure checked. Looks good.

courtesy Health Affairs

FW: More on HIT and Cost Saving (NOT!)

Health Information Technology is becoming a bit of a family affair, since my brother, who is an (excellent) ophthalmologist practicing in a fee for service environment, has been pondering electronic health records. His practice is far from the halls of the US Capitol, so I think his viewpoint is an important view of the reality of the overwhelming majority of medical practices in this country. It’s worth a read, so I’m reposting it here. Our conversation was stimulated by two pieces of research recently published (linked on the right).

Sure, you’re welcome to publish anything you want.

I agreed with your assessment. Just as a computer at home or having a smartphone doesn’t really save any time or money, it does make us more productive.

I have no doubt a well written emr will be beneficial to medicine, but I doubt it would be any huge time or money saver.

I dont know any doc with emr, that is more than marginally happy, and no one that saves money or time. And, the records I get are useless, as they are all macro’d out and two pages for a 30 second exam.

In fact they may cost insurers more, because some are marketed as ‘printing money’ for being able to tell you what you need to add in order to upcode the visit.

Right now, I think it is the quality of emr’s that is the problem, at least for ophthalm as we do alot of drawing and do alot of tests that need to be digitally incorporated.

But, I can’t imagine not having an employee file and pull charts wouldn’t save money. And, I would just love for a referring doc to just transmit a patient’s history to be incorporated into my records when they are referred. Likewise, instead of sending an email regarding a patient I am sending a retinal doctor, (which they probably forget), I would love to just send my records over so they know what I had the question about.

The big issue now is the privacy/audit issue. There are now companies that specialize in auditing charts for medicare and private insurers, and getting commission. Much easier to do with emr, as we can just transmit the chart. But, with paper charts, they can’t read them well, and they don’t plan on doctors copying dozens of charts, so they kind of give up.

What do you think? If we believe (as I do) that all doctors are driven to perform well for their patients, what’s the gap here, and what needs to be fixed?

Click below to see what my original response to him was….

Continue reading “FW: More on HIT and Cost Saving (NOT!)”