By Ginny McPartland,Heritage writer
Since the launch of Kaiser Permanente’s online member portal on kp.org, four million of the organization’s 9 million members have become My Health Manager users and racked up 116 million visits; they’ve retrieved 32 million test results, ordered 11.8 million prescription refills, and communicated with their physicians via secure email more than 13 million times.
More than 400,000 members have downloaded Kaiser Permanente’s mobile app since it debuted in January of 2012, and these members have clocked up more than 19 million mobile-optimized website visits.
It’s with this member e-engagement prowess that Kaiser Permanente information technology leaders participate in the annual conference of the Healthcare Information Management Systems Society in New Orleans next week.
Kaiser Permanente’s digital success stems from its early adoption of computers beginning in 1960 – and to its medical care model that integrates physician offices, hospitals and health plan administration into one system of care.
As an integrated health system, rather than a fee-for-service model, Kaiser Permanente was able to complete its deployment of its electronic health record system, Kaiser Permanente HealthConnect®, in early 2010. Consequently, KP providers can access health information about any member at any of the organization’s locations.
Informatics pioneer saw it coming
Forty-five years ago, in 1968, Kaiser Permanente’s digital guru was Morris Collen, MD. He was a physician and electrical engineer, an unusual career combination in his generation. At that time, he was hot on the trail of one of the first electronic medical records systems, at the cutting edge of computer technology. Dr. Collen will turn 100 on Nov. 12.
Dr. Collen started something big many years ago, and his successors have kept moving forward as pioneers in the medical digital world. When Dr. Collen took KP’s first step into computer technology in 1960, the industry was in its infancy.
KP’s first computer took up an entire room in Oakland, Calif. Since then, through the magic of technology, digital devices have shrunk, and shrunk, and shrunk some more until they can fit in your pocket. Amazing! But Dr. Collen predicted as much in 1998.
“By 2008,” he wrote: “Plan members will hold personal smart cards that will contain their basic health care information, including genetic information, for the predictive practice of medicine. . . Information technology will penetrate every aspect of professional practice, as very small, inexpensive computers pervade clinicians’ offices and examination rooms, nursing stations, procedure rooms, bedsides, clinics and patients’ homes.”
Dr. Collen also predicted – in Kaiser Permanente’s 1966 Annual Report – that patients would welcome a computer between them and their doctors. He said members would be happy their provider could glean instantly so much about their health from a robust and up-to-date electronic record.
Mobile users connect on the fly
The advanced connectivity of Kaiser Permanente’s electronic health record system means that members can go online any time of day or night – on a desktop or virtually anywhere else using a smart phone or other mobile device – and securely access their health information.
They can retrieve test results, order prescriptions, find health information, and make appointments. They can even enroll in online programs that will help them stick to an exercise regimen such as walking, or a nutritional program prescribed for diabetes or other chronic condition.
Perhaps most popular, patients can contact their doctor directly via secure email for advice or follow-up. This access eliminates unnecessary office visits and phone queues.
Getting KP HealthConnect up and running in all facilities, including 37 hospitals and 533 medical offices, makes it the largest non-government electronic health record system in the United States today.
KP well-represented at HIMSS
At HIMSS, a number of Kaiser Permanente experts will present talks on a variety of topics. Among them will be: Shawn Jackman and Nico Arcino who will discuss “Technology and Trajectory of Mobility in a New Health Care Model.” They’ll talk about how providers can stay ahead of mobile technology trends and plan for how their use affects workflow, policy and security.
Also on the bill are: Kate Christensen, MD, and Geeta Nayyar, MD, MBA, who will address the growing use of mobile applications to access health information and discuss how use of these apps can affect patient health and provider practices, and evolve patient-physician relationships.
As a health IT pioneer, Kaiser Permanente will have a strong presence at the HIMSS conference, having received 36 Stage 7 Hospital Awards – the highest level for successful electronic health record implementation. The award recognizes a hospital’s ability to deliver patient care without paper charts.
Since the award was instituted in 2005, HIMSS has bestowed the Stage 7 designation on only 104 of the nation’s more than 5,800 hospitals; 36 of those awards have gone to Kaiser Permanente hospitals.
By Lincoln Cushing, Heritage writer
The image of Kaiser Permanente founding physician Sidney R. Garfield as a hammer-wielding workplace safety diehard has been passed down through the decades from his early days as a desert doctor. But is the legend true? Did Garfield really charge out into the dust and dirt himself and pound down rusty nails, shore up tunnels to prevent rock showers, and insist workers wear hard hats?
This story of Dr. Garfield’s passionate preventive practice on the Colorado River Aqueduct project has endured for eight decades, since about 1933. The oft-told tale conveys the young doctor’s commitment to worker safety and preventive care once he instituted the unconventional prepaid model of health care that saved his little hospital from extinction.
Garfield was certainly committed, but his allegedly active role in the cleanup of aqueduct work sites is a stretch of the imagination. And he was not alone in promoting workplace safety.
Fact or fiction?
The story has sometimes been presented as fact:
“There was a funny little story that Dr. Garfield, on the first day in which prepayment began in the desert, got up early in the morning with his hammer, and went around the worksite pounding down nails. . . The notion is that if you can keep the patients healthy, then it’s a good thing not only for the patient, but it’s a good thing, financially, for the program.” [i]
Sometimes it’s told as legend:
“There (in the Mojave Desert) he also discovered the importance of preventive medicine, and he strove to remove potential health hazards for the workers – although it is only legend that Garfield would go to the construction sites and pound down any protruding nails himself.”[ii]
And at least once the story has been cited in a novel about the desert doctor’s operations, where a fictional Dr. Sidney Garfield speaks to a fictional nurse:
“I picked up another nail. ‘Look at all these dirty nails. Just lying around, waiting for someone to step on them and end up with a puncture wound, tetanus, or worse.’ ”[iii]
In his own words
When we examine the historical record and let the doctor speak for himself, as in this circa 1934 quote in which he describes a disquiet of conscience from collecting fees from illness and injury, we see his true role.
“We had been anxious to have sick men or injured men come into the hospital because that meant income and that we would continue to exist. . . It was embarrassing to me to want people to get hurt. So we started to do safety engineering. . . We would get a bunch of nail punctures from a job and we would go out there and get them to clean up the nails. Or we would get a lot of head injuries . . . and we would get them to shore up the tunnels better.”[iv]
Garfield’s commitment to worker safety was genuine, but it was his nurse, Betty Runyen, RN, who actually went to the work sites to speak to the importance of taking salt tablets and drinking water to avoid sunstroke, and of donning gloves to prevent the spread of impetigo from pick axes and shovels. The competent nurse was also the visage of an angel in those hostile environs with her blonde curls and pretty smile.
Water district’s safety efforts
It should also be noted that Garfield and Runyen had help as well. The Metropolitan Water District of Southern California, the builder of the aqueduct, and Workmen’s Compensation insurance companies all placed their own safety engineers in the field to remedy dangerous job situations.
The 1937 Colorado River Aqueduct project manual describes their role thusly: “It is the duty of the safety engineer and members of his organization to visit all work on the aqueduct at frequent intervals to see that the work is being carried on in accordance with established safety rules, to offer advice and instructions to those in charge of construction operations, and to assist in the elimination of dangerous operations and equipment.
“In addition, each division engineer is charged with the responsibility of reducing accidents to the minimum. Special safety meetings are held at various points along the aqueduct at frequent intervals and a regular plan of safety education is maintained.”[v]
All of these efforts apparently had an impact – accident frequencies were reduced to a point well below the average rate experienced in that class of construction during that period.
In the desert years (1933-1938), Garfield did not wield a hammer or gather stray nails at the job site. But it is still fair to say that he overturned the conventional wisdom that a physician must derive his income from illness and injury. In the desert he realized the incentive to keep people well and on the job. Thereafter, preventive care became paramount, first in his imagination, then in reality when he partnered a few years later with Henry J. Kaiser at Grand Coulee Dam project in Washington State.
Kaiser Permanente Core Values,” conducted by Martin Meeker in 2007, Regional Oral History Office, The Bancroft Library, University of California, Berkeley, 2007.[ii] Can Physicians Manage the Quality and Costs of Health Care? The Story of The Permanente Medical Group, by John G Smillie, MD; book review by Morris F. Collen, MD, The Permanente Journal, Summer 2001
by Tom Debley, the Permanente Press, 2009, p. 21
By Marc Klau MD Kaiser Permanente Southern California
The Southern California Permanente Medical Group has taken giant steps in recent years to enhance our physician training curriculum so we can better meet the needs of our communities. Since 2007, we have instituted new programs to address a looming nationwide shortage of physicians, and we’ve launched two new programs to broaden the scope of our charity care.
Started in 1955, the SCPMG graduate medical education program has grown to include eight different specialties and 27 independent residency programs at six Kaiser Permanente medical centers in Southern California. With this flourishing GME program serving as a springboard, we have added community medicine fellowships and a KP-UCLA internal medicine/master of public health degree program.
These enhancements are designed to prepare new physicians to practice in today’s ever-changing and progressively challenging world of medicine.
Community medicine fellowship
The community medicine fellows practice in safety-net clinics in the greater Los Angeles area and study topics essential to the understanding of community health needs and the allocation of resources. The fellows learn how to approach the care of people of different cultures and to identify special needs in the community.
They also learn to develop and foster partnerships with safety-net providers and to find ways to share KP’s evidence-based practice with clinic staff. One goal of the program is to inspire new physicians, residents and students to take part in community care opportunities and to share their new knowledge through teaching.
The community medicine fellowship, begun as a pilot with one resident at the Kaiser Permanente Woodland Hills Medical Center, has grown to six positions shared among Woodland Hills, Los Angeles, Fontana and Orange County medical centers.
The fellows, new graduates of residency programs, spend half of their time in community settings, providing care and supervising residents and medical students. They collaborate with site leaders to identify needs and plan development of new systems or programs.
The other half of their time is at their home medical centers, providing care to Kaiser Permanente members or mentoring/teaching residents and medical students.
In recent years, the fellows have accomplished much: putting Kaiser Permanente’s pediatric weight management program into practice at Saban Clinic at Hollywood High School; and charting improvements in blood pressure measures and screening assessments of diabetics at the Inland Family Community Clinic.
Kaiser Permanente community medicine fellows have also taken medical care to a number of non-traditional sites, including a mobile clinic set up outside of court for homeless people in trouble with the law, as well as a diabetes clinic on an Indian reservation near Indian Wells. They’ve also offered care at the Motor Inn in Costa Mesa and in Duroville, the largest mobile home park in the Riverside County desert.
Connecting internal medicine with public health
The person who participates in the SCPMG internal medicine-public health program has the opportunity to train with Kaiser Permanente and then directly enter the UCLA School of Public Health to complete the coursework and earn a master of public health degree.
The goal of this program is to enhance the training of future Permanente physicians and leaders by developing a broader knowledge base in the public health arena, including biostatistics, epidemiology, chronic disease management, injury prevention, health promotion, health policy and management, and disaster preparedness.
We also hope to gain an in-depth understanding of the interaction of biological, psychological, economic, cultural, and political factors that contribute to health outcomes and to share this knowledge with community clinics.
Addressing a nationwide shortage of physicians
Statistics from many sources predict in the near future a severe shortage of primary care physicians, general surgeons, emergency room specialists and psychiatrists. The American Association of Medical Colleges estimates a shortfall of 150,000 physicians by 2025.
To attack this shortage, medical schools and hospitals need to step up efforts to produce new physicians. To properly meet demand, 45,000 of the new physicians should be trained in primary care.
Other sources predict shortages of emergency room doctors and psychiatrists, particularly physicians trained to care for children with mental health problems. In the San Diego area, the supply of psychiatrists dropped by 27 percent between 1990 and 2002 while the demand for these services increased by about 16 percent.
Also in San Diego, where there is no county hospital to care for disadvantaged patients, primary care clinics and emergency rooms are seeing a rising number of patients. In 2009, 32.7 percent more patients were seen in San Diego community clinics than in 2005.
Adding specialties to the curriculum
To address these trends, SCPMG is adding new residency programs in disciplines where the need for more well-trained physicians is greatest, and enlarging the enrollment in many of its existing residency programs.
In San Diego, Kaiser Permanente is launching new pipeline programs in family medicine, emergency medicine and internal medicine. Family medicine is starting with six residents and increasing to 18 by 2014. Emergency medicine will have six residents when it opens in 2014 and is expected to increase to 18 by 2016. Internal medicine will open in 2015 with six residents with plans to increase to 18 by 2017.
In Fontana, we are opening a new internal medicine program, to begin with six residents in 2013 and increase to 18 by 2015. A psychiatry residency program will launch in 2014 with six residents and increase to 18 by 2016.
Existing programs to grow
Also, our Orange County family medicine program will increase its number of residents from 18 to 24 this year. Los Angeles Medical Center has added one resident in general surgery, bringing its total to 29; in neurology, the number of residents will increase to 12 by 2014; and in diagnostic radiology, the number will increase from 10 to 15 by 2016.
We continue to discuss plans to open a general surgery program at Riverside with a complement of 10 residents by 2015 and an internal medicine program at Antelope Valley with five residents from Olive View–UCLA Medical Center.
In the past, between 30 and 40 percent of Kaiser Permanente residency graduates have chosen to continue their professional careers with us. By the expansion outlined above, we are ensuring a supply of well-trained young physicians both for Kaiser Permanente and the general community.
Through its graduate medical education programs, Kaiser Permanente Southern California has responded to community needs for better care for the uninsured, as well as planning ahead to ensure we have enough qualified physicians to care for our patients now and in the future.
Marc Klau, MD, is chief of head and neck surgery and former director of medical education at KP’s Orange County Medical Center. He is also chair of the Institutional Graduate Medical Education Committee, Physician Director of Medical Education and Designated Institutional Official providing administrative oversight for all GME and continuing medical education programs for the Southern California Permanente Medical Group.
By M. Rudolph Brody MD and Sam Sapin MD Kaiser Permanente Southern California
First of Two Parts
Permanente’s pioneering physicians started out in the 1940s with the idea of developing an academic environment in which to practice medicine. Accustomed to the university-based hospitals in which they got their training, these not-so-traditional doctors relished the idea of keeping their strong connection to academia. Group practice, which allowed for convenient consultation with colleagues, was the perfect vehicle.
In the late 1940s, Southern California Permanente Medical Group physicians presented interesting and challenging cases for their peers twice per week at the medical centers. More in-depth discussions took place at half-day departmental educational activities that included organized rounds at various hospitals, teaching and research. Often the medical group hosted visiting professors who presented and led discussions.
In Northern California, The Permanente Medical Group physicians were taking a similar route. Doctors were given a half day a week to pursue academic opportunities, including teaching, learning and research. By 1969, San Francisco and Oakland medical centers had graduate medical education programs, and each facility had a chief of staff for education.
Beginning in 1955, SCPMG invited medical experts renown in their fields to lead specialty symposia and share new clinical information. Research, mainly on clinical topics, flourished. Without knowing it, SCPMG physicians were practicing in an environment that met the definition of an academic medical center.
Cross-pollinating medicine and academia
What is an academic medical center? Let us take you back one hundred years in American medicine to explain:
In 1910 the Carnegie Foundation asked educator Abraham Flexner to review the quality of the 155 medical schools then operating in the United States and Canada. Flexner visited each one of the schools and prepared a voluminous report that would result in all but five of the schools being declared deficient and forced to close.
The Flexner Report spurred a revolution in medical education, and the academic standards set at the time of its release are still pertinent today. In his investigations, Flexner identified Johns Hopkins University School of Medicine as the model for all institutions qualified to train new physicians.
The Johns Hopkins model set down three must-haves for an institution qualified as an academic medical center: 1) a clinical setting where new physicians can gain experience treating patients, 2) high quality teaching and 3) a research program.
Academic bent attracted like-minded colleagues
Starting out a few decades after the Flexner Report’s release, Kaiser Permanente pioneers understood the value of high-quality physician education. Our early physician leaders created educational opportunities at the medical centers and encouraged all doctors to participate. Many physicians taught at local medical schools. With this academic mindset, SCPMG attracted many new physicians who had recently finished their post-graduate residency and/or fellowship training.
With a large clinical practice and excellent continuity of care, Kaiser Permanente medical centers also began to attract medical students looking for a clinical rotation. Next, residents from local university residency programs came to Kaiser Permanente for an elective experience. This led to residents affiliated with medical schools rotating through the Fontana and Los Angeles Kaiser Permanente medical centers.
In the mid-1950s, SCPMG physicians began to ask themselves: Why not develop our own independent residency programs? The three assets that Johns Hopkins University saw as vital to an academic medical center – opportunities for clinical experience, education, and research – all existed within Kaiser Permanente Southern California.
First SCPMG residency program launched
Led by OB-GYN physicians T. Hart Baker and Jack Halett, the first independent residency program was begun in 1955 at Kaiser Permanente Los Angeles. Dr. Baker, who later became the Southern California regional medical director, had a strong academic background and proven administrative abilities. He teamed up beautifully with Dr. Halett, who had an upbeat personality and a passion for research.
During the early years, a number of the graduates of our OB/GYN Residency Program stayed on after their residencies and devoted their professional careers to SCPMG. These included Ruth Nicoloff, MD, Fred Miyazaki, MD, Harry Richards, MD, and Doug Taguchi, MD.
Started in 1971, the pediatrics program initially had one resident, Richard Mittleman, MD, then added Daisy Dolorfino, MD, Jim Heywood, MD, Mary Ellen Friedman, MD, and Phil Mattson, MD. All but one of these pioneer pediatric residents continued their careers at what later became the Baldwin Park Medical Center. Dr. Mattson continued his career at SCPMG in San Diego.
Graduate physician education expands
In the ensuing years, residency programs were started in several other KP medical centers: family medicine at Fontana; internal medicine, general surgery, pathology, urology and pediatrics at Los Angeles; internal medicine at West Los Angeles; and family medicine programs in Orange County, Riverside and Woodland Hills.
Vince Roger, MD, was key to the development of the Family Medicine Residency in Fontana. Dr. Roger also oversaw the launch of the Sports Medicine Fellowship in Fontana, which Aaron Rubin, MD, and Bob Sallis, MD, have directed since 1990. Our sports medicine program was among the first 20 that were accredited in the United States in 1993.
Today, SCPMG trains more than 300 residents and fellows in 27 independent residency and fellowship programs in six of Kaiser Permanente’s Southern California medical centers. About 150 residents at various GME programs in Southern California, including UCLA, University of Southern California, UC Irvine and Loma Linda Universities, rotate through our medical centers for a portion of their training. We can afford to be highly selective because we receive more than 7,500 applications each year for 100 available positions.
Many people have contributed over the decades to the success of our residency programs. Our list includes our longtime Los Angeles residency program directors: Jack Braunwald, MD, Steve Woods, MD, Ted O’Connell, MD, Thomas Tom, MD, Jimmy Hara, MD, Aroor Rao, MD, Craig Collins, MD, and Scott Rasgon, MD.
Also deserving recognition are: Tim Munzing, MD, program director, Orange County; Walter Morgan, MD, program director, Riverside; Dennis Kim, MD, physician director of the Center for Medical Education; and A. Robert Kagan, MD, an internationally known radiation oncologist.
The growth and prestige of our educational programs result from the work and support of many professionals. We have mentioned some of them in this article, but we realize that many more deserve credit and praise for their contributions.
Next time: Southern California Kaiser Permanente residents take their care to the community.
M. Rudolph Brody, MD, is the retired director of the Center for Medical Education at the KP Los Angeles Medical Center. A pediatrician, he helped create and develop SCPMG’s Pediatric Residency Program and was the first pediatric residency program director (1970-1990). He was the regional coordinator for all the Southern California Residency Programs from 1983-1992.
Sam Sapin, MD, a retired pediatric cardiologist, was SCPMG’s associate medical director for Clinical Services from 1982 to 1990 and consultant for Clinical Services until 1994. Sapin was SCPMG’s first director of Education and Research, taking on that position in 1972. Sapin was also a major influence in the development of quality assurance methods.
Lincoln Cushing, Heritage writer
Organized labor played a big role in Kaiser Permanente history, and Heritage writer Lincoln Cushing contributes a column to the quarterly
Labor Management Partnership magazine Hank about that rich legacy.
The Winter 2013 story is about the Health Plan’s postwar struggle for survival, and the crucial support it got from labor.
“In the boom years after World War II, the Kaiser Foundation Health Plan (KFHP) faced an uphill battle. It had expanded to the public in 1945, but the wartime truce between fee-for-service (medicine) and the prepaid, group practice model developed by Dr. Sidney Garfield had faded.
The gloves came off in 1953.” Read more here.