Innovation in Collaboration: What 18F and Kaiser Permanente South Bay have in common

18F , where collaboration happens View on

I think I’ve mentioned a few times here that I’m guest lecturing in colleague Carol Cain’s (@ccain) summer course, Stanford BioInformatics (Stanford University Biomedical Informatics 207), aka “Digital Medicine: Designing IT Innovations that Improve Healthcare.”

Since I’m coming from Washington, DC, Carol asked me to include something about health policy, and what do I know about that, so I asked my very knowledgeable colleague Ann Kempski (our Director for Government Relations) for a few ideas. She gave me some, which I put into the double-rainbow machine for further processing, and the one of the examples that’s fresh in my mind are actually two examples, from two different places, in very large organizations, who are working to improve health for a lot of people.

That’s the actual URL -> and there’s a really simple twitter handle that goes with it (@18F). I heard about it from Adam Dole (@AdamDole) , most awesome (recently) Presidential Innovation Fellow, who went on a walk with me (which is where all discoveries happen) to a meeting hosted by the General Services Administration and asked me, “Is it affiliated with 18F?” To which I replied, “What’s 18F?”

Here’s 18F:

It’s in the middle of a very government-ish building on 18th and F streets (get it?) in an organization that’s not supposed to innovate. Except that they’ve discovered that you can innovate in a large organization (and I believe you can only innovate in one). It’s where the Presidential Innovation Fellows are housed, and where presentations are given including ones about hacking bureaucracy.

What’s special about 18F and health policy? Well… 18F is where a lot of fixing of happened, by a lot of talented people. I’m not going to tell that story here, instead I’d focus on the environment that allows innovation to flourish.

I was told that GSA is one of the few agencies that is using a web-based email and document collaboration platform (I’ll avoid using vendor names for the purpose of this post, since I don’t think it’s relevant). You know, the kind that allows you to not attach documents to messages and send them to people who don’t know what to do with them. This alone caught my extreme attention…more collaboration, less e-mail.

Notice the sign: “Get Excited and Make Things.” Innovation is ideas AND execution.

Kaiser Permanente, South Bay Medical Center

All the way across the country, in Harbor City, California (near Los Angeles), is a pretty large, technologically superb, clinically excellent medical center, Kaiser Permanente South Bay Medical Center  physician led and professionally managed, where I went with our Digital Workforce Team in late June, 2014, to learn about…collaboration.

They don’t have a “big room floor plan” like 18F (although they are constructing a brand new hospital which will open in 2015) because they’re actually preventing illness, saving lives, producing health. What they do have is a focus on connecting the people who are delivering high quality medical care.

They are also using one of those web-based social collaboration platforms with the specific intent of connecting people, supporting purpose….and reducing email. There are medical directors of physician wellness and the Area Medical Director, Barbara Carnes, MD, is supporting the use of this technology to connect all staff, including doctors, and nurses. This is a complement, of course, to the system that already connects members/patients to everyone, the world-class, now surpassing 4.5 million members online.

Orthopedic surgeon Abtin (“Abi”) Foroohar, MD, showed us how he’s using the platform to connect with his fellow physicians. As he pointed out to us, there’s an inherent increased collegiality and collaboration in a multispecialty group practice in an integrated system that is not matched in fee for service medicine. At the same time, working on staying connected brings huge gains in people’s perception of their purpose and mission.

Commonalities, Health, Policy

Why the focus? Isn’t it obvious that people should collaborate and therefore they will?

They should, but it turns out that in the era of Health Information Technology, and technology in general, sometimes they don’t. Physicians who used to have combined hospital/outpatient practices now have one or the other, which reduces their exposure to their colleagues. They chart on computers with fixed locations, they communicate via messages sent in text, test results, and digital progress notes.

Both of these teams are solving huge problems for people with great need. Electronic Health Record systems are not going to automate all communication and web sites aren’t going to build themselves, and not certainly using old methodologies, that’s definitely what I see in this post-EHR organization and at 18F. The policies that create the environment where more people can get health care that’s of a quality not previously imagined will also create the need to think differently to make this happen. With a combo of changing technology, changing behavior, changing minds. That’s what I saw at 18F and Kaiser Permanente South Bay Medical Center.

By the way, Kaiser Permanente also has an 18F-type floor in Oakland, called iThrive (don’t you love all the catchy names of these places). Come by and see it sometime 🙂

Dialogue about #hcsm at the 2013 #AAMCJtMtg – Academic Medicine and Social Media

Ask us about @wingofzock, or about the future in general. #hcsm breakout at the 2013 AAMC Joint Meeting, Phoenix, Arizona, USA.

Jennifer Salopek, Bryan Vartabedian, Vinny Arora, Ted Eytan, Sarah Sonies – View on Flickr

Luckily, there’s a comprehensive Storify record of the dialogue I had the opportunity to co-lead yesterday. Bryan Vartabedian, MD (@doctor_V), Vinny Arora, MD (@futuredocs), and I (@tedeytan) were at the 2013 Association of American Colleges (@AAMCtoday) joint gathering of…. essentially the leaders of our academic medicine institutions.

A few things

  • Vinny, Bryan, and I are so aligned in our drive to communicate and promote communication, even if we are not in the same environment or passionate about the same thing at the same time. That to me is a good model for the medical profession. We are part of the same community, the same society, dedicated to making lives better.
  • Really great audience and hosting by the WingofZock team (@wingofzock), specifically Jennifer Salopek (@jsalopek) and Sarah Sonies (@ssonies), and a few special guests, most notably my mother (producer of not one but two University of Arizona-trained physicians) and Anita Samarth (@anitasamarth) – it takes a community!
  • Sponsorship courtesy of Joanne Conroy, MD (@joanneconroymd), who is the Chief Health Care Officer of AAMC. Transforming an organization requires sponsorship, and it shows great foresight to bring this conversation to this group.

Like most humans, I love to learn. I enjoyed learning from these leaders.

Slides and Storify below. Thanks for following along.

@Futuredocs & @Doctor_V" target="_blank">Social Media / Academic Medicine – co-presentation with @Futuredocs & @Doctor_V from Ted Eytan

What innovation looks like in the medical offices of the future, Kaiser Permanente, La Mesa, California

What innovation looks like – View on

Like this. Click on the image to see larger size.

These are not medical charts (this is Kaiser Permanente, remember….no paper charts), they are folders of innovation projects being supported by La Mesa Medical Offices Physician in Charge, Martin (“Marty”) Bartolac, MD, who is also a practicing family physician. He is part of one of the largest (he says the largest, so the hedge is mine) primary care physician groups in the United States, in Kaiser Permanente, San Diego.

Marty told me that members of the staff will come to him with problems they would like solved, and he’ll advise them to do some analysis, propose solutions, and do a test of change. That’s where the folders come from. Imagine the opposite of this situation – a leader with a clean desk and no innovation projects going on, which would you prefer?

Our group continued our shadowing yesterday, switching between primary care and specialty care. The half of the group that was not in dermatology went there, under the guidance of Jeff Benabio, MD (@dermdoc) and the other half went to primary care, including me.

Here are some more images of what innovation looks like, plus a group shot of all of us, click to enlarge.

By the way, that’s Charles (Chuck) Miller, MD, sitting across from Jeff Benabio, MD, in the photo above. He’s the Chief of the Department, and is beyond ready to innovate not just in this department, but in the dermatology specialty itself.

I shadowed Vu Pham, MD, another family physician, member of the Southern California Permanente Medical Group for 4 and a half years. Like other physicians in his cohort, he has never practiced medicine at Kaiser Permanente in the absence of KP HealthConnect, the comprehensive electronic health record.

Because I can recognize these things 🙂 I can say it – he exudes the spirit of family medicine. He talked to us about how he really knows his patients, and he doesn’t just know his patients, he knows their families, and integrates the knowledge about their life journey into every visit. He knows them so well (and vice versa), he actually has trouble referring some of them to specialists for needed care, in a good way. The patients want to understand what a specialist knows about treating a condition that he doesn’t, and he explains it carefully – they see him as their steward through the health system.

Photographs of his family are posted on the wall of the exam room. At one point, Vu’s family comes to see him in person, because his son has just received well child care. We watch as the other doctors come to say hello and he hugs his children. Vu jokingly tells us that they really do work hard here. We’re not really hearing him because our hearts are melting all over the floor. This is the kind of hard work that technology supports – genuine social networking.

We’re are here, the Digital Workforce Capability team, to understand how a modern clinical workforce collaborates and communicates with each other in the process of clinical care and in leading the health system. In 2013, there is no shortage of modern social networking tools available to help people communicate in thousands of different ways. What we’re interested in is the right tools, deployed the right way, to support what physicians and nurses are doing well. We gained tons of insights about the how, what, and why that we never (never) would have understood without observing the care at the level of the patient.

I just have to show this photograph one more time. It’s the solar panel array that sits atop of La Mesa, generating 1 megawatt of electricity, supplying 75% of this medical office building’s power. Imagine practicing medicine or receiving care in the shadow of innovation like this, and what it does to encourage your drive to heal not just inside the building, but everywhere you live, work, learn, pray and play. And, La Mesa is not unique, not at Kaiser Permanente, maybe not in health care (well maybe a little unique in health care :)). Before you assume physicians, nurses, and patients don’t want to innovate, go shadow them.

Thanks again to the primary care, dermatology, pediatrics, departments at Kaiser Permanente La Mesa, as well as the members and their families, who took the time to give us the gift of their teaching. Also to our superstar host Jeff Benabio, MD (@dermdoc), and special shootout to Susan Russo (@Susan_Russo) , our culinary expert and food steward extraordinnaire who ensured that our shadowing was as healthy as the excellent care we observed.

Collaborating and engaging in the post-EHR era – A visit to the @dermdoc

Jeff (@dermdoc) and Jackie, at your service – View on

When you want to learn about medical practice in the era of online social collaboration, social media, in the post-EHR world of a connected, integrated, member-centered health system, where do you go? Easy answer, Jeff Benabio, MD, aka @dermdoc

Luckily for me and a lot of others, Jeff is part of our health system. He and I have known each other since I began working at Kaiser Permanente in 2008, and he’s been a physician member of the Southern California Permanente Medical Group for 7 years now. However, I have never shadowed him, until now. I came to see him and his colleagues with member of our digital workforce capabilities team, who are designing next-generation collaboration and information tools for our 180,000+ workforce. To help people use technology to collaborate, you must first watch them collaborate, and also luckily for all of us, this is a team that takes advantage of the fact that we work in a system that finances AND delivers the care by going to see it in action.

Jeff works at Kaiser Permanente La Mesa Medical Offices in La Mesa, California, which I didn’t realize until I arrived that is famous in my world for another reason – it is a world leader in using natural energy. Take a look at the parking garage – it’s covered with solar panels, which provide 75% of its annual energy. This medical office exemplifies “To heal, you must first do no harm.”

As his twitter handle implies, Jeff’s a dermatologist, a specialist working alongside primary care physicians to integrate skin care, technology, teaching, learning, service, and engagement, all at once. He’s pioneering work in teledermatology that allows him and his colleagues to facilitate the care of the 400,000 510,000 people that Kaiser Permanente San Diego (@KPSanDiego) serves. He asks his patients to follow him on twitter. He posts QR codes of helpful information resources for his patients to scan and learn more, all in the flow of a busy practice that includes biopsies, cancer removals, and full body skin exams.

I may enjoy being a family physician, but I am also deeply impressed at the dermatologist’s ability to examine complex skin patterns quickly and make judgements quickly. As Jeff explained to me, he and his colleagues like doing this, and they are leveraging technology to the fullest to be there for patients who may be (a) in his office (b) in the office of a peer in primary care (c) at home (d) on their way to or from any of the previous places. What I observed is that they do it with a bit of excitement, as we noticed when members of the team are pulled in to watch how service is given with these new tools. 

Jeff and his team also do more than dermatology. Kaiser Permanente is the home of complete care, which includes advanced tools that guide clinical staff here to counsel on preventive interventions, including colorectal cancer screening, and the famous exercise as a vital sign. The system is smart enough to know how often these questions are asked of patients and decides when the answers need to be refreshed.

It’s worth repeating – in this dermatologist’s office, medical assistants are as comfortable coaching people about FIT kits (to screen for colon cancer) as they are about skin biopsies. 

What we’re seeing as this team and medical group push the boundaries of what technology can do for members is that they’re doing the same for their own colleagues. The challenge in the post-EHR era, that I think most health systems are not experiencing yet (and my not for several years) is to keep teams and groups who provide the care, up to date on their skills, communicating with each other, moving ahead together. My own semi-foolproof shadowing system involving two shadowers and one practice team started to break down a little because the team is so sync, it was hard to keep up. This type of actualization achieved in the delivery of care makes for a great learning environment about the future. And why wouldn’t it be, this is @dermdoc we are talking about here.

Thanks again to the members, staff, and physicians at La Mesa Medical Offices. We’re sticking around for one more day, this time I’ll be seeing primary care in action.