Posts Tagged ‘public health’

Screening for Better Health: Enter the Computer

posted on March 15, 2017

Lincoln Cushing
Heritage writer

 

The Automated Multiphasic Examination
Second part, follows “Screening for Better Health: Medical Care as a Right

 

IBM 1440 computer processing room at Kaiser Permanente, circa 1964

Last summer a major medical news story splashed across the world: “Historic Kaiser Permanente Data to Aid in Long-Term Study to Determine Extent of Ethnic Disparities in Brain Health and Dementia; new $13 million study funded by National Institute on Aging will revisit patients who were first screened as long as 50 years ago.”

Where did this remarkable trove of data come from?

In 1961 the U.S. Public Health Service awarded the Kaiser Foundation Research Institute a grant to study the automation of the multiphasic health testing it had been conducting manually for 10 years. Members would now go through the screening stations with computer cards that got marked along the way.  At the end of the session, which took a couple of hours, there would now be a computerized medical record of their current health status. The Automated Multiphasic Health Test was born.

Multiphasic stations, from “The Multitest Laboratory in Health Care,” by Drs. Morris Collen and Lou Davis, Journal of Occupational Medicine, July 1969.

The first AMHT center was at a new building on the Oakland Hospital campus at 3779 Piedmont Ave. By the end of 1966, Kaiser Permanente had enlarged and updated its testing facility and laboratories nearby at a state-of-the-art center at 3772 Howe Street, and expanded the computer center and offices in the Piedmont building. A second center in San Francisco was linked to the mainframe computer in Oakland.

Dr. Collen, in the Journal of the American Medical Association (1966), accurately predicted that “The advent of automation and computers may introduce a new era of preventive medicine … [The computer] will probably have the greatest technological impact on medical science since the invention of the microscope.”

AMHT questionnaire card about occupational health

The AMHT continued to be seen as a vital tool in the diagnosis and treatment of occupational and industrial illnesses. A 1967 article in the Archives of Environmental Health discussed the employment data gathered, which included a list of 170 occupational titles and a battery of work-related health questions. “The computer storage of data on more than 40,000 adults annually permits extensive epidemiological research, especially directed toward the preventive aspects of chronic disease.”

It wasn’t just union members who benefitted. The Modern Hospital, May 1966 called the periodic health examinations to more than 4,000 patients monthly “… an impressive investment in the concept of ‘health medicine.’”

AMHT station 4 skin fold thickness test, a much more accurate indicator of obesity than BMI.

The test expanded to about 20 stations, measuring everything from hearing to heart function. It even went beyond mere testing – if recommended, a patient could get a tetanus booster via the new high-pressure injector system.

A 1970 article by Dr. Garfield in the prestigious New England Journal of Medicine with the provocative title “Multiphasic Health Testing and Medical Care as a Right” began with this abstract:

Although no long-term evidence exists that the course of disease is influenced by multiphasic health testing, this is largely irrelevant. Such programs are essential for other very important reasons. The existing and spreading concept of medical care as a right, with its elimination of personally paid fees, is creating a demand for periodic health checkups and health appraisals. This demand cannot be met by traditional methods totally involving the physician without great waste of doctor time.

Multiphasic health testing can help separate the entry mix of patients into the well, the asymptomatic sick and the sick. This separation makes possible optimum use of physicians’ services, which can be devoted to the area where they are most needed: the care of the sick.

The efficiencies of the AMHT were sufficient that these programs were sometimes adopted by private practice, large companies, and public health agencies. Dr. Collen remarked:

It is still of great interest to me and much personal satisfaction that the AMHT is still flourishing in Japan, Taiwan, and in China; and in the past when I visited them I found the AMHT centers in Japan to be primarily employer-sponsored for employees. I found the newest AMHT centers in Taiwan and China to be for-profit, marvels of efficiency and associated with health education centers open to the public, and with a high level of provider and patient satisfaction.

“Multiphasic Screening Comes to Portland,” Healthgram, Winter 1976

But despite the AMHT’s popularity, it was discontinued by Kaiser Permanente by the late 1970s when a federal grant supporting the work dried up and Kaiser Permanente declined to commit further resources.

Dr. Collen himself noted some of the challenges to quantifying the benefits of screening:

…Epidemiologists required us to report on gross mortality, and since the potentially postponable conditions comprised only about 15 percent of all the causes of death, most people died from other conditions … some of the criticism of urging checkups is based upon the fact that one does not decrease total gross mortality. That is, everyone eventually dies from something.

Gary Friedman, MD, former director of Kaiser Permanente’s Division of Research, recently explained additional medical limitations to the AMHT:

Kaiser Permanente silent film showing the Automated Multiphasic Health Test process, circa 1970. Click to play.

Initial enthusiasm for multiphasic health screening was tempered by experience in using it and by scientific studies that did not confirm benefits vs. costs of specific screening tests.  For example, it was initially hoped that routine chest x-rays, included in AMHT, would lead to early detection and increased curability of lung cancer.  Studies did not confirm this benefit.  A yes/no question about chest pain provoked by exercise and relieved by rest was included in the AMHT symptom questionnaire.  Although a yes answer seemed almost diagnostic of angina pectoris, this often did not prove to be the case in the follow-up examination by the physician, who could question the patient in greater detail, consuming valuable time.

Clearly however, the value of some screening tests has been amply confirmed.  Finding and treating high blood pressure in asymptomatic individuals prevents strokes.  And screening for colorectal cancer by the various tests available can lead to early detection and cure, or the removal of polyps that could later progress to cancer.

Despite these issues, Dr. Collen defended the value of the AMHT in a 1986 UC Berkeley oral history by Sally Smith Hughes:

…The study [on AMHT] did clearly demonstrate that for those conditions that are potentially postponable, there is a significant decrease in mortality.

He went on to note larger policy and commercial impediments to the AMHT:

Blue Cross/Blue Shield and other indemnity insurers to this day still do not pay for checkups. They take the position that periodic health checkups are schedulable and elective, so are not insurable events. Medicare to this day does not pay for checkups. The contrast, in other countries, like in Japan and in France, their social security and governmental supportive systems pay for periodic health checkups for well people, but do not pay for sick care. Just the opposite from the U.S. So if our Public Health Service is so interested in

Dr. Morris Collen at Multiphasic registration counter, circa 1966

preventive medicine, why do they fail to support the financing of checkups? A very key reason that multiphasic testing has not proliferated in the United States is because it is not reimbursed by any of the insuring agents. That has been reported by vendors who try to sell the systems.

I should point out that the Public Health Service had asked us to patent the system because it was an invention. Whether I was right or wrong, I refused to do so. I felt that it should be in the public domain, and it is. It’s never been patented.

Dr. Collen concluded with deep pride in the accomplishments:

We actually developed the most comprehensive inpatient and outpatient medical information system in the world. And this book, Hospital Computer Systems, describes that. There were only a half-a dozen others in the world that were doing that.

 

As the 2016 medical news story about the persistent value of the AMHT data shows, this was a significant accomplishment in medical practice. Thank you, Dr. Collen.

 

 

Short link to this article: http://k-p.li/2n00mcW

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Kaiser Permanente’s Innovative Spirit of Prevention and Health

posted on July 23, 2015

Lincoln Cushing
Heritage writer

Fourth in a series on Kaiser Permanente’s 70th anniversary

 

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“Patients hospitalized at the Northern Permanente Foundation Hospital received a meal and all medical care as part of their 50 cent weekly premium.” Circa 1943.

“Problems are only opportunities in work clothes.”
– Henry J. Kaiser.

Innovation has been a part of Kaiser Permanente’s culture from the beginning. While many people think of a new technology or exotic surgical device when they hear the term “medical innovation,” Kaiser Permanente’s view is much broader.

From its very beginnings, Kaiser Permanente proposed a radical – and innovative – shift in the delivery of health care.

When Henry J. Kaiser and Sidney Garfield, MD., were taking care of the almost 200,000 workers on the Home Front during World War II, few of them had ever experienced routine medical care. People feared the expense of seeing a doctor, and delayed seeing caregivers, thus guaranteeing a more difficult treatment and a less positive result. But because the prepaid Permanente Health Plan was affordable and run under the same system that was already handling their industrial care, it changed how people accepted early treatment. Dr. Garfield himself was amazed by this phenomenon during his “dress rehearsal” of medical care for worker families at Grand Coulee Dam in 1938:

One of the most impressive lessons we learned was, prior to the family plan, you would go walking through our hospital and you would see quite a few very sick women and children – ruptured appendices, bad pneumonias and so forth, even diphtheria cases. Once the plan was in operation for a while, that changed. You no longer saw ruptured appendices, we saw early [inflamed but not ruptured] appendices. Never saw bad pneumonias, we would treat them early. And diphtheria entirely disappeared. In other words, people, once the barrier of cost was removed, were coming to us earlier and we could treat them earlier and keep them from getting complications and, I’m sure, keeping them from dying.[i]

Later, in the World War II shipyards, Dr. Garfield experienced the same conditions but on a much larger scale. He reflected on the challenges of treating the rookie workers:

Some of them were in such bad condition we jokingly would refer to our shipyard workers as a walking pathological museum. But in spite of all of that fact, they really built ships and built ’em fast. And not only that, but our plan was able to succeed and work and be sustaining with that tremendous load of all those sick people to take care of. It was a tremendous demonstration of the merits of our health plan and of its value of its economics.[ii]

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Sample page from Physical Demands and Capacities Analysis, published by the Region XII War Manpower Commission, Bureau of Manpower Utilization, Division of Occupational Analysis and Manning Tables, San Francisco, CA, and the Permanente Foundation Hospitals; May 1944

Other preventive features of the shipyard health care plan included a rigorous process for assigning workers to suitable job classifications, training for the women in the industrial workforce, and extended child care services. And during the war, some of the more conventional medical innovation took place as well – such as Morris Collen, MD’s groundbreaking work on using penicillin to treat pneumonia cases.

Fast forward to the present, and Kaiser Permanente is continuing to promote preventive health services while also conducting high-quality, innovative research. Kaiser Permanente is coordinating a national health initiative to improve colon cancer screening rates to 80 percent by 2018, with a special emphasis on screening minorities and those without health insurance. And when a screening does detect cancer, a progressive Oncology Clinical Trials program selects promising new medications and techniques for members to consider, even before they are FDA approved and commercially available.

In Portland, Ore., Kaiser Permanente led a study showing that mailing test kits to patient homes improved colon cancer screening rates by 40 percent in underserved communities. Sometimes basic delivery systems — like the U.S. mail — can deliver innovative health care solutions.

As Henry Kaiser noted, not all medical innovations need to come forward as bright, shiny objects. Some of the most important ones appear in simple work clothes.

 

Short link to this article: http://k-p.li/1KmGi87
[i] “Sidney R. Garfield in First Person: An Oral History,” by Lewis E. Weeks, Hospital Administration Oral History Collection, 1986.

[ii] Dr. Sidney Garfield interview by Dan Scannell, 9/1978.

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Henry J. Kaiser on veteran employment and benefits

posted on December 16, 2014

Lincoln Cushing
Heritage writer

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Henry J. Kaiser presenting Kaiser-Frazer car to veteran owned and operated G.I. Taxi company, promotion for Kaiser Community Homes, Panorama City, Calif., 1948

Over the past year, dedicated professionals across the Kaiser Permanente have taken steps to position the organization as a destination employer for veterans. Kaiser Permanente’s goal is to ensure it provides a supportive and inclusive environment for all individuals within its current and future workforce, including those with military backgrounds.

But for a health plan born in the crucible of the last world war, support for those who served is not a new idea.

On October 17, 1944 – less than a year before the war neared its end – Henry J. Kaiser addressed an audience at the Herald Tribune Forum in the Waldorf-Astoria Hotel, New York City. The topic? Jobs for all.

On this one fact, there is unanimous agreement: every man in the American Forces has the right to come home not only to a job, but to peace. Anything less would be a denial of the true American way of life. Peace means so much more than a cessation of hostilities! Peace is a state of mind. It is based on the sense of security. There can be no peace in the individual soul, unless there is peace in the souls of all with whom we must live and work. Jobs for all could well be the first slogan for a just and lasting peace.

…I have always believed that the future belongs to youth; it is theirs to build. Here is an opportunity to help youth see the pattern emerging out of a great surge of social forces. There must be purpose in the cause to which a whole generation of youth is giving their lives.

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Billboard for Highland Estates, a Kaiser postwar housing development connected to the Panorama City hospital; sign advertises discounts for veterans, circa 1950

Often I am classified as a dreamer, particularly when I talk about health insurance. To live abundantly and take part in a productive economy, our people must have health. This is not only a matter of medical science, but of facilities. Health service can be rendered on a self-sustaining insurance basis, at a price well within the reach of all. The cost of such medical care might be incorporated in the monthly payments on the home, freeing the American family from the fear of illness and the loss of income!

We can go further and insure the payments when illness overtakes the head of the family. If American industry builds and equips modern hospitals in one thousand American communities in the first year after the war, prepaid medical service could then be organized around these facilities. The five hundred million dollars so spent will generate employment for two hundred and fifty thousand workers. I am speaking from the experience of operating seven hospitals on this basis. It is encouraging to read recent announcements that public health authorities are now thinking along these lines. Organized medicine is beginning to see the wisdom of this sound principle…

Remember, youth will not be handicapped by the prejudices or blindness of an outmoded past. The men and women who have accomplished the impossible in defense, in war, and in sustaining a war effort throughout the world, are not apt to be afraid. Our nation was created by men of faith, against obstacles such as you and I have never known. Our country is sustained by men of faith today in the midst of battle. There will be jobs for all if the men of faith have their way.

Short link to this story: http://bit.ly/1xpJn3D

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Get those flu shots!

posted on January 28, 2014

It’s “that time of year” again when physicians and other health care professionals are strongly encouraging members to get flu shots. It’s the sort of common-sense public health education message that Kaiser Permanente has been promoting for decades. Here are some examples from previous member newsletters – 1951, 1960, and 1974; to see the current campaign, click on this video link. And join the Vacci Nation!

Short link to this item: http://bit.ly/1ftLA1i

flu shot video still

“Protect Yourself and Your Family with the Flu Vaccine” video, posted November 11, 2013.
Click on image to load video.

SC Planning for Health, 1951-spring

“Defense against disease” illustration, Planning for Health newsletter (KP Southern California) Spring 1951

SC Planning for Health, 1960-fall

Flu shot illustration, Planning for Health (KP Southern California) Fall 1960.

Healthgram 1974-Winter

Sick child who didn’t get her flu shot, KP Healthgram newsletter Winter 1974

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Public health exhibition at Centers for Disease Control and Prevention

posted on November 4, 2013

By Lincoln Cushing, Heritage writer

Health is a Human Right: Race and Place in America September 28, 2013 – January 17, 2014

Health is a Human Right:  Race and Place in America
Health is a Human Right: Race and Place in America
click on photo for more information

This exhibition examines some historic challenges of the past 120 years in achieving health equity for all in the U.S. We know that “race and place” are as important as personal choices in achieving our full potential. People with low-incomes, minorities, and other socially disadvantaged populations face significant inequities in opportunity for optimal health. This can lead to inequities in health, along the lines of race, ethnicity, and place.

From the exhibition introduction:

As this year marks the 25th anniversary of CDC’s Office of Minority Health and Health Equity, it is timely to reflect on the evolution of minority health over the last century.  Looking back at how minority groups have experienced health problems differently helps us understand “why” these disparities persist. Though we have not yet been able to achieve our goal of the best health for all, we have as a nation made important strides in identifying the problems and implementing solutions. There is still more to do, and this historical reflection helps us examine what other vital changes are needed.

In addition to viewing historic photographs, documents, and objects, visitors can check up on the health of their communities through interactive atlases. Videos, including one of Michelle Obama talking about access to fresh food and vegetables, will be integrated throughout.

Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, Georgia 30333

Short link to this story http://ow.ly/qyoFE

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“Mujeres embarazadas! Pregnant women!” screenprint poster for Proyecto de Salud, San Diego, by Lincoln Cushing, 1979. Click on photo for larger view.
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“Health Care is a Human Right” poster by Juan Fuentes, 1995

 

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Kaiser Permanente joins officials in tackling 1960s public health issues

posted on April 2, 2013

By Lincoln Cushing, Heritage writer

Lester Breslow, Director of the State Department of Public Health, reported in 1967 that the death rate from coronary heart disease was dropping in California while the national rate was still rising. Photo published in the December, 18, 1967, issue of the LA Times. LA Times photo

One of the major academic figures in American public health was Lester Breslow, MD, who passed away last year at the age of 97. Dr. Breslow was a former dean of the Fielding School of Public Health at UCLA and director of the California Department of Public Health from 1965-1968.

He was also president of the American Public Health Association from 1968 to 1969. Central to Dr. Breslow’s research was mathematical support for the premise that improving personal habits such as reducing smoking, eating better, and sleeping well could have a significant impact on life longevity and quality.

Dr. Breslow was also a pioneer in multiphasic screening and an advocate for the Automated Multiphasic Health Test developed by Kaiser Permanente’s Morris Collen, MD, an early medical informatics guru who turns 100 this November.

National Public Health Week, April 1-7, is a good time to revisit Kaiser Permanente’s role in the early recognition of preventive care as a way to address public health issues.

A longshoreman is greeted by staff of the Kaiser Permanente multiphasic health screening program in 1961. Photo from the KP Reporter, May 1961.

Breslow had developed the original multiphasic screening (the examination of large numbers of people with a series of tests for detecting diseases) during the 1940s, and Collen improved upon it with new technology. The first beneficiaries of Collen’s multiphasic process were members of the International Longshoremen’s and Warehousemen’s Union in 1951.

The AMHT was a battery of tests, administered in an efficient routine by medical professionals and supported by then-new mechanical and chemical analytic devices. The results were funneled into a powerful mainframe computer.

From a public health perspective, the ability to efficiently diagnose communicable and noncommunicable diseases not only benefitted the individual patient, it also helped to stem public health risks as well.

In Breslow’s 1973 Preventive Medicine article, “An Historical Review of Multiphasic Screening,” he noted: “Automated multiphasic screening opens the possibility of extending the health-maintenance type of health care to all groups of the population, particularly including those most likely to suffer from the conditions now responsible for the greatest amount of disability and death.”

Dr. Collen taught two semesters at UC Berkeley’s School of Public Health during the spring and fall of 1965; much of the curriculum explored the uses of multiphasic exams. Students included physicians engaged in their continuing medical education.

Final papers for the classes included such subjects as “Evaluation of Environmental Toxins Utilizing Automated Methods” by David R. Brown, “Obesity and its Measurements as it Relates to a Multiphasic Screening Program” by Clarence F. Watson, MD, and “Biological Effects of Magnetic Fields” by Earl F. White.

Although the multiphasic screening as it was developed in the 1960s has been replaced by other diagnostic methods, the efficient application of medical diagnostic tools – and the enormous Kaiser Permanente patient database that has accumulated over the years – continues to advance public health.

Also see: “Screening for Better Health: Medical Care as a Right”

http://bit.ly/10wyozK

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