I attended the 29th annual Management of Change (MOC) Conference with Dr. Val. The conference is sponsored by the American Council for Technology and the Industry Advisory Council. MOC brings together government and industry leaders to share knowledge, collaborate, and develop actionable technology management strategies. As a physician, attending this conference for the first time, I assumed a great deal of the conference topics would be over my head and in very “techie” terms. My hope was to get a glimpse of some of the technology solutions the government was considering as they relate to health care IT.
Vivek Kundra, first Chief Information Officer of the United States, addressed the audience early in the day in language that even a doc could understand. He spoke about the need to simplify government, and connect people to solutions, instead of “endless bureaucracies.” The same of course goes for medicine. How great would it be to connect our patients to systems that actually had interoperable medical data?
I was able to catch up with Mr. Kundra after his talk for a few minutes and ask him how technological simplification would apply to physicians such as myself, operating in a haphazard infrastructure with varying PAC systems, EMR’s and paper charts. He said the key would not only be investing in technology, but investing in training healthcare personnel to master new technologies. He acknowledged that different generations of physicians would embrace technology differently, but ultimately, if a physician says he “can do a better job on paper” then we have a problem.
I was very impressed by Mr. Kundra’s answer namely because it was so insightful for a man who’s expertise lies primarily in the technology field. He does not come from a healthcare background, and yet had hit the nail on the head. There has been so much talk about HIT being the “key” to cost savings and the next “breakthrough” in medicine. With very little discussion on how physicians feel about it. For some docs – particularly those that come from an older generation – the thought is quite terrifying. They are happy with their paper charts and manual dictations. Health technology is almost viewed as an impediment to those set in their ways, and accustomed to a system that has worked for them and their patients for years. This upheaval will not come without it’s challenges even after we find the best technologies for the tasks at hand. It will be imperative for government leaders to understand that the mission of HIT implementation may be just as difficult as finding the technology solutions they are currently seeking.
As Mr. Kundra and his team embark on this huge task, it will be important for physicians and health care personnel to engage with the government and serve as a guide for what docs need from technology, and what will and will not work for our patients. I hope next year’s conference is attended by more physicians such as myself and Dr. Val.
At Health 2.0, Ted Eytan, MD, and I talked for a bit about why Kaiser Permanente’s “virtual health care system” has had such great success. According to his bio, Ted is a family doc from DC with a background in “working with large medical groups, patients, and technologists to bring health care consumers useful information and decision-making health tools, to ensure that patients have an active role in their own health care.”
Ted is Permanente’s Medical Director for Delivery Systems Operations Improvement. Permanente’s online system strives to bring the doctor and patient together online via the electronic health record (EHR), decision making tools and communications tools such as email. It further empowers the patient to be an active participant in the health care system by having access to the EHR and being able to book appointments online, renew prescriptions, contact health providers, and see labs and tests. Eytan has a wonderful summary of the system and the demonstration they did at Health 2.0 on his blog here.
Here are the highlights of our chat:
Dr. Gwenn: What makes Kaiser work so well compared to other areas of the country, for example Massachusetts?
Dr. Eytan: The key difference between Kaiser and here (MA) is adoption.
Dr. Gwenn: Why is that?
Dr. Eytan: The important point to teach doctors is the customer service approach. We do things because the members want it. That should be the reason for all change in health care. If places focus on quality not customer service, the system won’t work well and nothing will change.
Dr. Gwenn: What has helped Kaiser be so successful?
Dr. Eytan: Three major points that have worked well in Kaiser’s system: accountability, physician leadership and valuing members.
1. At Kaiser we have 100% accountability over everything. We own up to mistakes when they occur and help physicians learn from them.
2. Kaiser encourages physician leadership to spark reform and help IT departments facilitate change: Physicians do have value and can create the clinical vision. They work with IT to facilitate the technological changes that need to occur to make the doctor-patient encounter work better and to make the physician’s work life more manageable.
3. Kaiser listens to members… members have advisory groups, teen groups: they are involved and their voices are heard at all levels and all ages.
Dr. Gwenn: How do you oversee the online world with patients?
Dr. Eytan: The patients are the customers and the EHR must be usable to them – that is the MO of the entire system. In addition, there is an online, full time medical director responsible for the patient interface. There is no other way to have a patient-involved online system without a dedicated staff overseeing that system lead by a physician.
Dr. Gwenn: What problems do you help the clinical staff anticipate with online care?
Dr. Eytan: With virtual care, patients will see lab results and parts of the EHR they are not used to seeing and that could prompt questions or concerns. There has to be commitment from everyone to be ready to answer those questions fro the system to work well for the patient. They provide a great deal of training and support so the clinical staff will be prepared for questions from patients they may not have had when patients were not so involved in their care and seeing so much of their EHR.
Dr. Gwenn: How does virtual care help the system?
Dr. Eytan: There are a number of important ways virtual care helps the system on many levels:
1. It builds confidence in the doctor patient relationship by fostering conversation.
2. There’s a database to give patient’s article-based information (Permanente uses the “healthwise knowledge base”).
3. They use true medical terms with patients and in the EHR that patients will Google. This helps patients be more savvy in the health care system and know what terms to search for should they seek more information or have questions to ask of the clinical staff.
Dr. Gwenn: What are the benefits of virtual care for the patients and the physicians?
Dr. Eytan: There are three primary benefits:
1. Online care helps empower the patients to be part of their care and shapes use with guidance from the staff.
2. Patients become so involved they become invested in making sure the EHR is accurate and often point out mistakes they note, such as typos.
3. Doctors can be more efficient by using pre-visit emails to organize their time.
Dr. Gwenn: What’s your take on the Health 2.0 vs. Ix (Information Therapy) debate during this conference?
Dr. Eytan: Useful, accurate information is the goal. Give people what they want, when they want it. All systems need to use more health 2.0 tools member to member. Ultimately the goal is to connect to the doc.
Dr. Gwenn: How can docs be more health 2.0 savvy?
Dr. Eytan: All docs should ask patients if they use the internet. It’s the 6th vital sign.
Dr. Gwenn: Many patients don’t live in a virtual health care system like Kaiser, how can they get from their system what you offer at Kaiser?
Dr. Eytan: Ask and demand! Most electronic medical record systems have the tools in place, like email, and just have to start using them. Patients need to ask for what they want. Physicians want to do a great job and hate waste.
My final thoughts:
With such great models such as Permanente in many areas of our country, it’s frustrating we can’t get similar systems everywhere. Perhaps it is not just the patients who have to “ask and demand” for what they want in the health care system. Perhaps it’s time docs everywhere stood up and demanded a system where docs were compensated well, treated respectfully, and had a system that actually supported good care.
*This blog post was originally published at Dr. Gwenn Is In*
In honor of National Nurses Week, the National Museum of Health and Medicine hosted a discussion about the history of nursing at Walter Reed. Debbie Cox, former Army Nurse Corps Historian, initiated the conversation by describing what nursing was like at the turn of the 20th century. Steam-driven ambulances transported patients out of “mosquito-infested” Washington, DC to fresh-aired Fort McNair. A leading controversy of the time involved the intention of the hospital administrators to place the nurse baracks near the horse stables rather than the main hospital. In a dramatic twist, Jane Delano (cousin of Franklin D. Roosevelt) saved the nurses from relegation to the stables. However, it wasn’t until 1920 that nurses were given rank by the army.
Entry into nursing was through the Red Cross exclusively until the first nursing school was opened at Walter Reed in 1918. From there, nurses grew in numbers and prestige, until they became a cornerstone of medical research in the 1950s, leading the way in understanding how to reduce the spread of infections in the OR, decubitus ulcers in the hospital wards, and radiation damage related to nuclear war.
Jennifer Easley, a nurse who works in the pediatric intensive care unit at Walter Reed, described her experiences as a nurse leader for a team of soldiers in Iraq. She derived great satisfaction as an officer in her unit, and said that the team spirit and camaraderie was unlike anything she experienced in civilian nursing. She had this to say:
“I only made it 18 months as a civilian nurse. When I was called back to serve in the army, I had my paperwork in so fast you could hardly blink. I found out that in the private sector, no one ‘has your back.’ There’s no protection for those who raise safety concerns and nurses don’t have the authority to request back up in cases where units are dangerously understaffed.
I remember one day when several nurses called in sick and there weren’t enough of us to cover the children and babies in the ICU safely. I reported this to my nurse supervisor and she told me that maybe I wasn’t cut out for a challenging work environment. I was shocked, and really feared for the patients.
Another problem with private sector nursing is that there are glass ceilings. If you apply for a job as a staff nurse, you can’t work your way up to nurse manager. You’d have to leave that hospital and apply for a nurse manager position elsewhere. In the army, I had many more opportunities to contribute, grow, and lead.”
The final speaker was a nurse who returned from Iraq with head and neck cancer. He (LTC Patrick Ahearne) was an inpatient at Walter Reed for many months, losing 35 pounds and experiencing severe nausea, vomiting, and depression. At his lowest point, when he had lost hope of recovery and wanted to die, he was met with kindness by an experienced nurse who knew how to ask the right questions and reframe his perspective:
“This wonderful nurse stayed with me for 2 hours, watching me vomit and talking me through it. I remember her asking me what I’d learned about myself through my illness. I thought it was a strange, and medically irrelevant question – but it was just what I needed at the time. I realized how strong the human body can be, and the inner strength I had to endure my cancer. In those two hours nurse McLaughlin took me from wanting to die to wanting to live. She taught me that it was ok to be angry. It was ok to be sick.”
Many thanks to the unsung heroes out there who touch lives like nurse McLaughlin. We couldn’t do it without you.
I recently interviewed the CEO (Bill Reed) and SVP (Stuart Segal) of AllOne Health at the World Health Care Congress. Their enthusiasm for mobile technology rivals Better Health’s own Dr. Alan Dappen. Will mobile technology get people more engaged in healthy behaviors and assist with disease management? I hope so.
Dr. Val: What is “All One Health?”
Reed: All One Health provides a bundle of customized offerings to small employers – including insurance and health and wellness programs. We provide the same kinds of benefits that large insurers offer to large employers except we spend a lot of time analyzing the specific needs of small companies before initiating a health program for them. Some small companies have employees with diabetes-related challenges, and others might be more concerned about asthma. We also use predictive modeling (health risk assessments) to help the companies customize preventive health strategies for their employees.
Engagement and compliance are very important in bringing about substantive changes in healthcare – and good health can be incentivized by employers. All One Mobile is our means for connecting patients (or employees) with health coaches and nurses, which we believe is critical for affecting lifestyle changes.
Dr. Val: What does your “menu of services” look like from the employee’s perspective?
Reed: Each employee begins the relationship with a health risk assessment (HRA). That HRA recommends programs for the employee based on their risk factors, and prioritizes the top three things for them to work on. There are performance trackers linked to employer incentives for health improvements and the programs are available via the phone so that employees don’t have to be in front of their PC to interact with their health coaches. We have proactive outbound calling with an opt out feature. We believe that the mobile phone is critical for encouraging consistent participation in health programs. Our services center on phone-based reminders and personal relationships with coaches.
In the near future we’ll include blue tooth technology to have patients upload data from their home monitoring devices for their coaches to review. This is a more proactive approach to health management.
Dr. Val: And Stuart, tell me about the All One Mobile program for the Department of Defense (DOD).
Segal: The DOD was having difficulty with follow up care for military personnel returning from Iraq and Afghanistan with traumatic brain injuries (TBI). Once they returned to their communities, it was very hard to reach them. All One Mobile won a contract with the army to provide constant messaging services to soldiers with TBI because they need regular reminders to keep their rehabilitation on track. Army case managers can push out questionnaires to soldiers and depending on how they answer, the case manager might be triggered to give them a call while they have the phone in their hand. So the phone-based communication tool is the primary tracking device for soldiers who return to the US with TBI.
Dr. Val: What are the educational qualifications of your coaches?
Reed: Registered nurses, dieticians, and psychologists.
Dr. Val: And what if the patient needs to see a doctor?
The coaches are trained to refer patients to their doctor when it appears that they need it. We can also track their prescription patterns and send the patients a “gaps in care” letter to remind them to fill their prescriptions. Non-compliance with medications is a major problem that All One Health can address.
Dr. Val: How would a doctor use All One Mobile?
Segal: We’re currently working on making EMRs accessible via phones – so that no matter where a physician is, he or she can review patient records and track their progress remotely.
Dr. Val: Or better yet, when one doctor is taking call for her group, she can have access to patient records so that when she’s called in the middle of the night, she’ll be fully informed about the patient problem list and understand the context of the concerns much better.
Segal: Yes, and All One Mobile can be used in the Emergency Department setting – so that when patients are discharged home, they receive 30 days of our service. The hospital can send them their lab results (that were drawn in the ER) and easily contact patients to bring them back in if necessary. In addition the patients can take photos of their wounds, for example, and have the physicians see how they’re progressing.
Dr. Val: Any closing thoughts?
Reed: This kind of health communication is incredibly convenient. Patients don’t need to carry around a smart card, a thumb drive, or a paper record. They’re already carrying around what they need – their own cell phone. And almost everyone in the US, regardless of economic class or age, has a phone.
Sam Solomon over at Canadian Medicine, did a great job of introducing our recent interview. Please check it out.
Educated in Nova Scotia before she moved to the United States to do degrees in biblical studies and medicine, Dr Val Jones is now one of the most popular physician bloggers. Her work has appeared in MedPage Today, Revolution Health, a now-defunct blog called Dr. Val and The Voice of Reason and, most recently, her own internet company Better Health.
Last year, Dr Jones was accredited as a member of the National Press Club in Washington, DC, and has focused much of her recent reporting on health policy reform efforts. She still practises medicine part-time as a rehab specialist at Walter Reed Army Medical Center. Dr Jones is also a talented cartoonist and her cartoons‘ take on medicine displays a sharp, wry sense of humour.
This week, Dr Val agreed to answer some questions for Canadian Medicine:
Canadian Medicine: Did you know as an undergrad at Dalhousie University, in Halifax, Nova Scotia, that you wanted to be a physician?
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