How do you handle medical testing and care in a remote location? A really, really remote location – such as outer space?
This was one of the challenges that the National Aeronautics and Space Administration faced in the early 1970s – and it got help from one of our founding physicians and Kaiser Permanente, through what was then the Kaiser Foundation International[i] program.
“KFI to Help Develop NASA-Sponsored Health System”
Kaiser Permanente newsletter, August 9, 1972
Kaiser Foundation International became a major ($1.8 million) subcontractor to the Lockheed Missiles and Space Company to help design, develop and test a ground based remote health care delivery system.
The ground-based test unit will be installed at a sparsely populated site on earth to provide medical care to local residents. Trained physicians’ assistants will employ the unit to transmit medical information on residents of the area to physicians at an established facility many miles from the remote site. If the test program is successful, it may provide system technology to improve health care and medical services to remote areas on earth. Part of a four year NASA sponsored program, this concept, as applied to a remote area on earth, will be evaluated by NASA for possible use in advanced, long-duration, manned space missions.
The back story is that in late 1970 Morris Collen, MD, attended a Northeast Electronics Research and Engineering Meeting in Boston that included a session on medical electronics. At that conference he served on a panel with Dr. Walton Jones, Director of Biotechnology and Human Research at NASA.
Kaiser Permanente’s Dr. Collen, in addition to being a brilliant physician in the Kaiser Richmond shipyards during World War II, was also an electrical engineer and considered one of the fathers of the field of medical informatics. He pioneered the use of the “multiphasic” examination, a battery of prescriptive medical tests for incoming health plan members, which later became the Automated Multiphasic Health Test.
By late 1971 J.P. Nash, the assistant general manager of Lockheed, told Dan Scannell, Kaiser Permanente’s director of public relations, some exciting news:
“Very shortly NASA is expected to solicit proposals for the design, development and testing of a Test Bed System for an Area Health Services Field Unit. This requirement has grown out of a NASA program for which [Lockheed] has been under contract for about four years called Integrated Medical and Behavior Laboratory Measurements System. IMBLMS is a four-phase program leading to the development and operation of a space flight biomedical laboratory, for research experiment in long-duration manned space flight in post-Apollo programs . . .”
On Jan. 4, 1972, Dr. Collen wrote to Sam L. Pool, MD, at the NASA Manned Spacecraft Center in Houston:
“Of special interest to us . . . would be the development of a completely automated self-administered multiphasic health testing laboratory in which a person in space could perform everything himself, utilizing automated equipment which enters the data into the computer which is programmed to provide advice and instructions. We believe that it is now technically feasible to develop such a prototype and with our experience we estimate such could be done within two to three years at a reasonable cost.”
The project, as noted in the 1972 news story, would use a “sparsely populated site on earth” to test equipment, systems, and personnel. That location would be the Papago Indian Reservation [now known as the Tohono O’odham Indian Nation] in southwest Arizona, with the catchy space-age title “Space Technology Applied to Rural Papago Advanced Health Care,” known as STARPAHC. Lockheed issued a summary report in June 1974 that explained the “Part 1 – Design and Definition” of the project:
STARPAHC will prototype a ground-based demonstration of IMBLMS space technology with two primary program objectives: (1) to obtain data for application to future spacecraft design and (2) to improve health care delivery through application of space technology. STARPAHC is designed to improve the capability for delivering health care to the Papago Indians located on the Papago Indian Reservation in southwest Arizona.
The STARPAHC operational concept was based on utilizing the professional staff of the Sells Hospital, where the Health Services Support Control Center will be located, to provide direction and consultation to paramedical and technical personnel stationed at the remote clinics, Local Health Services Center, and the Mobile Health Unit. The interchange of information between the HSSCC, LHSC, and MHU will be accomplished by voice, data, and video communication links. Computer-based data management techniques will implement record keeping, data retrieval, and data analysis.
STARPAHC ended in 1977, and resulted in several advances in the nascent field of telemedicine. A 1979 article in Medical Care interviewed 47 individual care providers in the program, and concluded that the major problems were the unreliability of equipment and the time required for television consultations. The major benefit cited was improved access to health care for a population not previously receiving such care near their homes. Another positive outcome noted by non-physician providers was the linkage to physicians via television and voice communications from remote areas.
In 2001 the Arizona Health Sciences Library acquired important archival materials documenting the STARPAHC project and established the Arizona Archive of Telemedicine.
Telemedicine – terrestrial and beyond – has evolved considerably since the early 1970s. In 1980 Dr. Collen would serve as a member of the NASA Workshop on Space Shuttle Studies. And Kaiser Permanente is as deeply committed to exploring its applications now as it was when the field was brand new.
[i] In 1964 Kaiser Industries established the not-for-profit Kaiser Foundation International to administer foreign medical care programs. With Kaiser Permanente’s reputation on the rise, requests for consulting help started to come from places where Kaiser Industries didn’t already have a presence. Between 1964 and 1969, the international group was engaged for medical care projects in 15 African countries. When it closed down in 1975, KFI had been hired and paid for projects in 30 countries around the globe, including rural locations in California, Utah, and West Virginia. KFI was replaced by Kaiser Permanente International in 1996. Today KPI is a self-supporting subsidiary that offers educational programs about the Kaiser Permanente model and provides speakers at international conferences.
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In addition to supporting the Affordable Care Act, one of President Barack Obama’s most notable achievements has been to begin normalizing diplomatic relations between the United States and Cuba. It’s been a rocky relationship ever since the Spanish American War of 1898, but the long arm of Kaiser history offers some positive examples.
In 1927 Henry J. Kaiser took on a $20-million contract to build 200 miles of roadways in Cuba. This was the beautiful and modern Carretera Central (Central Highway), running almost the entire length of the island.
It was a huge opportunity for Kaiser, and its success would help catapult him into the national area. He’d already worked on projects in Canada, and was eager for the challenges and rewards of the Cuban project,
Building the road
The total contract was for approximately 692 miles of highway, 481 of which was awarded to the Warren Brothers Company of Boston, Mass. (with whom Kaiser had partnered with in 1927 rebuilding Mississippi River levees), and 211 miles awarded to Compañia Cubana de Contratistas (Cuban Contractors Co.). The portion of the highway subcontracted to Kaiser Paving Company was about 200 miles.
The Warren Brothers/Kaiser Paving Company portion included the provinces of Pinar del Rio, Havana, Camagüey and Oriente, while the Compañia Cubana de Contratistas were to build the highway in Matanzas and Santa Clara provinces.
The pavement constructed under the Warren Brothers contract was 20 feet wide, with a 6-inch base covered by a 2-inch Warrenite surface. Warrenite was a dense and durable proprietary road surface material, composed of stone and bituminous cement.
The plans for the Central Highway, prepared by a firm of consulting engineers working in collaboration with the Cuban Department of Public Works and its chief engineer, called for the construction of a highway with a minimum gradient and restricted curvature. This necessitated the excavation of deep cuts through hilly sections and exceptionally heavy fills across valleys and depressions. In many sections the back fill material was of an unstable clay nature and it was necessary to put in a broken rock reinforcement between the native soil and the base of the pavement because the alternating wet and dry seasons created such a shrinkage that often broke the pavement.
One of the most unique features of the highway was the absence of railroad crossings, and the insertion of reinforced grade crossings for… bull carts. Roads used by carts laden with rural goodness were built along the main road, with granite blocks inserted at crossing points to protect the pavement.
The highway also required approximately 500 bridges. Some of the steel bridges along the highway were prefabricated in the United States under the supervision of the H.C. Nutting Co., of Cincinnati, Ohio.
The contract between the Warren Brothers Company and Kaiser Paving Company was dated February 19, 1927; Kaiser Paving started work on March 4, 1927. Although the contemplated completion date was July 31, 1931, in classic Kaiser fashion they finished a year ahead of schedule.
Kaiser put his most trusted men in charge of the operation. Alonzo B. Ordway was the general manager and Clay Bedford was the office engineer (later the general manager). Kaiser also hired George Havas, a Hungarian expatriate working as a banana plantation supervisor, as the office engineer. Havas was such an excellent part of the team that he was promoted to chief engineer, and went on to serve Kaiser Industries for many years.
The terms of the contract required that most of the labor be done by the Cuban workforce, with foreigners only staffing key positions. This proved to be a complicated blessing. Henry Kaiser was an early adopter of mechanization in the roadbuilding industry, but the conditions in Cuba thwarted his plans. It was soon found that in many cases using local hand labor and burros was a cheaper and faster method of construction than using the mechanical equipment imported for the purpose. The experience supported Kaiser’s trust in the human factor in production. He summarized the Cuba job this way:
We learned you can’t get fine talent into your organization by simply offering high salaries. You and the men you work with have to build yourselves up to the capacity to tackle bigger and bigger jobs.
Kaiser Permanente and Cuba now
Henry J, Kaiser’s biggest legacy, the Kaiser Permanente Health Plan, has replaced road building with health care – and there’s a Cuba connection. Since 2012, a Kaiser Permanente Community Benefit grant has supported Oakland-based Medical Education Cooperation with Cuba in their MD Pipeline to Community Service program. The “pipeline” seeks to increase the number of diverse and socially committed physicians in underserved communities, and has provided support to more than 50 low-income, minority U.S. medical students trained at Cuba’s Latin American Medical School in the form of summer observerships and clinical placements. Sacramento student Sarah Hernandez commented on the experience:
There are a lot of things to learn, but it pushes me to work harder and find those niches where I can apply my excellent Cuban medical education with my U.S. clinical training…exposure to a U.S. clinical setting is essential to my training and possible residency placements.
Special thanks to Leandro Torrella and the University of Miami Libraries for help in identifying Carlos Miguel de Cespedes in the top photo.
Escritor por património de Kaiser
English version of this article
Además de apoyar la Ley de Cuidado de Salud Asequible, uno de los logros más notables del president Barack Obama ha sido el comienzo de la normalización de las relaciones diplomáticas entre Estados Unidos y Cuba. Ha sido un relación difícil desde la guerra hispano-estadounidense (llamado por los Cubanos la guerra hispano-cubano-norteamericana) de 1898, pero el brazo largo de la historia de Kaiser ofrece algunas historias positivas.
En 1927 Henry J. Kaiser adquirió un contrato de $20 millones para construir 200 millas de carreteras en Cuba. Esta fue la hermosa y moderna Carretera Central, corriendo casi toda la longitud de la isla.
Fue una gran oportunidad para Kaiser, y su éxito ayudaría lanzarlo en el área nacional. Él ya había trabajado en proyectos en Canadá, y estaba ansioso para los retos y beneficios del proyecto cubano.
La construcción de la carretera
El contrato total fue para aproximadamente 692 millas de carretera, 481 de las cuales se concedió a la Warren Brothers Company de Boston, Massachusetts (con quien Kaiser se había asociado en 1927 reconstruyendo los diques del río Mississippi), y 211 millas otorgado a la Compañía Cubana de Contratistas. La porción de la carretera subcontratado a Kaiser Paving Company (la empresa de pavimentación de Kaiser) era de aproximadamente 200 millas.
La porción hecha por Warren Brothers y Kaiser Paving Company incluye las provincias de Pinar del Río, La Habana, Camagüey y Oriente, mientras que la Compañía Cubana de Contratistas se ocupó por construir la carretera en la provincias de Matanzas y Santa Clara.
El pavimento construido bajo el contrato de Warren Brothers era de 20 pies de ancho con un base de 6 pulgadas cubiertas por una superficie Warrenite de 2 pulgadas. Warrenite era un material patentado de superficie de carretera denso y resistente, compuesto por piedra y cemento bituminoso.
Los planes de la Carretera Central, preparados por un gabinete de ingenieros que trabajan en colaboración con el Departamento de Obras Públicas de Cuba y su ingeniero jefe, pidieron para la construcción de una carretera con un mínimo de pendiente y una curvatura restringida. Esto exigió la excavación de cortes profundos atravesando secciones montañosas y rellenos excepcionalmente pesados a través de valles y depresiones. En muchas secciones el material de relleno era de barro inestable y fue necesario poner un refuerzo de roca quebrada entre la tierra y la base del pavimento debido a que las estaciones húmedas y secas alternadas crearon una encogimiento que frecuentemente rompía el pavimento.
Una de las peculiaridades de la carretera fue la ausencia de cruces de ferrocarril, y la inserción de cruces reforzados para… carretas de bueyes. Los caminos utilizados por los carros cargados de bondad rural se construyeron a lo largo de la carretera principal, con bloques de granito insertado en los pasos para proteger el pavimento.
La carretera también necesitaba aproximadamente 500 puentes. Algunos de los puentes de acero a lo largo de la carretera fueron prefabricados en los Estados Unidos bajo la supervisión de la empresa HC Nutting Co., de Cincinnati, Ohio.
El contrato entre el Warren Brothers Company y Kaiser Paving Company fue fechada el 19 de febrero 1927. Kaiser Paving Company comenzó a trabajar el 4 de marzo de 1927. A pesar de que la fecha de finalización estaba prevista el 31 de julio 1931, en el estilo clásico de Kaiser terminaron un año antes de lo programado.
Kaiser puso a sus hombres de mayor confianza a cargo de la operación. Alonzo B. Ordway era el director general y Clay Bedford fue el ingeniero de oficinas (más tarde el director general). Kaiser también contrató a George Havas, un expatriado húngaro que trabajaba como supervisor de una plantación de banano, como el ingeniero de la oficina. Havas era tan excelente en su equipo que ascendió a ingeniero jefe y sirvió a Kaiser Industries por muchos años después.
Los términos del contrato exigían que la mayoría de la mano de obra se hicieron por la fuerza laboral cubana, con los extranjeros solamente tomando las posiciones claves. Estro resultó ser una bendición complicada. Henry Kaiser fue uno de los primeros en utilizar la mecanización en la industria de la construcción de carreteras, pero las condiciones en Cuba frustró sus planes. Pronto descubrió que en muchas ocasiones utilizando burros y la mano de obra local era el método más barato y rápido de construir en vez de importar equipo mecánico. La experiencia apoyó la confianza que Kaiser tenía en el factor humano en la producción. Resumió el trabajo en Cuba de esta manera:
Nos enteramos de que no se puede conseguir buen talento en una organización simplemente ofreciendo altos salarios. Uno y los hombres con que trabajan en conjunto deben capacitarse para abordar obras más y más grandes.
Kaiser Permanente y Cuba ahora
El legado más grande de Henry J. Kaiser, el plan de salud Kaiser Permanente (Kaiser Permanente Health Plan), ha sustituido a la construcción de carreteras con el cuidado de salud – hay una conección con Cuba. Desde 2012, una subvención de Kaiser Permanente Community Benefit ha apoyado Cooperación de Educación Médica con Cuba (MEDICC) con sede en Oakland cómo un canal para médicos para el programa de Servicio Comunitario. El “canal” busca aumentar el número de médicos diverso y socialmente comprometidos en la comunidades marginadas, y ha prestado su apoyo a más de 50 estudiantes de medicinas estadounidenses, que son minorías y de bajo ingresos, que han entrenado en la Escuela Latinoamericana de Medicina en Cuba en la forma de pasantías de verano y colocaciones en clínicas. Sarah Hernández, Estudiante de Sacramento, comentó sobre su experiencia:
Hay un montón de cosas que aprender, pero me motiva a trabajar más duro y encontrar aquellos nichos donde puedo aplicar mi excelente educación médica cubana con entrenamiento clínico estadounidense… ser expuesta a un ambiente clínico en los estados unidos es esencial para mi formación y mis oportunidades de especialización.
Gracias a Leandro Torrella y la University of Miami Libraries por apoyo en identificar Carlos Miguel de Cespedes en el foto superior.
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In sleepy San Leandro, California, a non-descript warehouse building is ground zero for innovative health care designs that are changing care delivery around the world. Named after an innovator who was ahead of his time in many ways, the Garfield Center is a place where the people of Kaiser Permanente – members, physicians, staff and experts – envision the future of health and are empowered to create it.
Dr. Sidney Garfield (1906-1984) may be most well-known as the founding physician of the health care system we now call Kaiser Permanente. What many don’t know is that he was a passionate innovator of architecture and hospital design, care delivery, technology and the computerization of health care, and the concept of total health. His spirit of curiosity and drive to improve systems are reflected in the mission, projects, and future-minded vision of the Garfield Center today.
An opportunity wrapped in a challenge
The Sidney R. Garfield Health Care Innovation Center’s beginnings were sparked by some specific problems arising from a technology-induced shift in health care delivery and design. Around 2005, an avalanche of new technology was burdening nurses and other clinicians with devices that were disrupting their workflows and ability to provide care. At the same time, Kaiser Permanente’s HealthConnect®, a massive electronic health record system, was readying for deployment and would affect every aspect of the organization. Moreover, facilities teams, architects and designers were redesigning and building new facilities to accommodate technologies such as MRI and CT scanners, and to meet new seismic standards.
Key leaders at Kaiser Permanente saw that these huge shifts would soon start upending workflow and systems organization-wide – and would ultimately impact the ability of teams to deliver care. They also realized that such changes to technology, physical space, and workflow could not be assessed in existing care settings or at isolated sites. So as is perhaps fitting, they launched an experiment: an innovation center they hoped would help Kaiser Permanente lead the coming transition in health care.
A center for cross-functional innovation
The Garfield Center was given the green light in 2005 – a mere 21 years after Dr. Garfield’s death. It was an idea championed by Jennifer Liebermann, the Center’s founding director, and Marilyn Chow, vice president of National Patient Care Services and Innovation.
Naming the Center after Dr. Garfield was a natural choice since, as Liebermann said, “Our mission and work scope continue his legacy of innovation in the name of health care improvement.” The naming process was a collaborative one, with Liebermann and Chow reaching out to the Kaiser Permanente’s Heritage Resources department for input.
Tom Debley, the department’s founder, recalled how Kaiser Permanente’s institutional history and contemporary vision of innovation intersected in the naming of the Sidney R. Garfield Center:
When I was approached about a possible name for the center, after reviewing the details I recommended considering naming it after Dr. Garfield. This suggestion was also in the context of the celebration of the centennial of Garfield’s birth, in connection with the Garfield biography I was writing at the time.
Bryan Culp, archivist with Heritage Resources at the time, explained how the historical fusion went further:
We worked with the Center’s leadership on the naming of their rooms. For this we prepared short biographies and photographs of key figures such as Morris Collen, MD; Francis Bobbie Collen, RN, MPH; and Cecil Cutting, MD. We also arranged conversations for the Garfield Center team with doctors Collen and Cutting, and even held a 95th birthday celebration for Dr. Collen at the Center in 2008.
Covering 37,000 square feet, the Garfield Center is a labyrinth of mocked-up rooms (some complete with equipment and furnishings, others simply of moveable plywood walls), wandering robot prototypes, walls of interactive screens, and futuristic simulation environments. Installations include a surgical suite, labor and delivery area, patient home, hospital ward, consulting room, and nurse workstations.
The Center is a place where the introduction of technology into the workplace can be studied in a simulated, safe environment away from the patient. Front line teams are able to investigate the intersections of space, technology and workflow and find ways to align them to improve care. Using tests, prototyping and simulations as near to real world conditions as possible, technologies and new designs can be tested in a hands-on, mocked-up environment before being implemented.
This process allows project owners to test innovations before investing significant resources in capital improvements, and provides a way to get systematic input from the clinicians, care teams and patients who would actually use the space. Bringing users and stakeholders together in the testing space is invaluable because their diversity of views and perspectives allows the center to assess issues from multiple angles, ultimately strengthening the ideas or revealing insurmountable problems.
When the Center opened June 26, 2006, current Chairman and CEO Bernard J. Tyson (then senior vice president of Health Plan and Hospitals Operations) made these remarks:
I’ve had a chance to take an early look at the Garfield Center. It is a wonderful facility and clearly the embodiment of everything I’ve learned about Dr. Garfield’s commitment to improving people’s lives by providing forward-thinking health care.
How will this benefit the … members of Kaiser Permanente? After the initial testing at the Garfield Center, successful initiatives may undergo additional testing in live patient environments at various Kaiser Permanente medical centers, medical offices, and clinics across the nation. Kaiser Permanente physicians, labor representatives, and management will use the research and information produced at the Garfield Center to serve [our] members. Like so much of the work done on behalf of our members, the center is a strong reminder that we are fully committed to making lives better.
Projects and clients
In the last decade, the Garfield Center has tested, mocked up and simulated hundreds of projects. As should happen with good innovation testing, many have failed, but a good number have grown legs, are now in practice, and are improving health care both within Kaiser Permanente and at large. KP MedRite, a successful and now widespread initiative that has significantly cut down on medication errors, began at the Center. So did recently-launched micro clinics in retail spaces, as well as the Interactive Patient Care system – a screen-based technology hub in the hospital patient’s room that lets them communicate with their care team, browse the web, learn about their procedure, and prepare for discharge from day one.
The Garfield Center is one of several Kaiser Permanente innovation entities, serving a unique role as the physical place where Kaiser Permanente employees and groups can go to “greenhouse” new ideas tangibly. In large organizations, and especially within health care, it’s easy to dismiss new ideas before they’re able to be tested – the Center is a safe place to nurture innovations, test them, and give them the space and time to play out.
The Center does not initiate its own projects, but selects them from submitted project proposals from client groups across the organization. They work with groups at the national, regional and medical-center level, at three levels of engagement: use of the space and tools for project exploration, coaching/guidance through a project, and – for strategic initiatives – a hands-on role in driving the project. According to Lieberman, “Our projects represent a combination of those that are aligned with organizational goals and those that are off the strategic radar enough to push boundaries or be game-changers.”
Imagining the future of health care
In ten years, the Garfield Center has evolved from a testing lab to a place that provokes people to think about the future. This is how those “game-changers” happen. For example, Imagining Care Anywhere (ICA), a groundbreaking approach developed in 2012, stretches teams to think about the future and bring in provocative outside trends. Combining telemedicine, smart technology and an entirely new model that lets members access personalized care anytime, anywhere, ICA is taking care delivery to the next level.
Serene Lau, innovation storyteller at the Center said, “I lead a lot of tours at the Center, and I always love seeing peoples’ minds open up to the possibilities of the future. Sometimes it takes being in a physical space where innovations are tangibly explored to really drive out-of-box thinking.”
The greater good
The Garfield Center is mission-driven to help launch health care innovations that benefit members, patients and care teams throughout Kaiser Permanente – and ideally, ones that impact health care on a larger scale. Their mission goes one step further, by cultivating and spreading the idea of innovation itself. The Center offers innovation coaching services and supports employees throughout Kaiser Permanente with training, toolkits and abundant resources. And by hosting tours to outside organizations, its reach and influence is even greater: more than 75,000 people from hospitals, health plans and academic institutions from 44 countries have visited the Center to learn more about health care innovation.
Some of Dr. Sidney Garfield’s pioneering ideas for the future of health care were perhaps too early to actualize in his time, but through the work of contemporary innovators and the Garfield Center, they are gaining ground and taking shape in this new frontier of health care.
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Labor Day is an opportunity to celebrate workers and their contributions. But often the workers that don’t get visibility are the very ones too busy writing about it – labor journalists.
In the World War II Kaiser shipyards, a revolution took place in industrial production – massive numbers of ships were turned out in record time by ordinary/extraordinary Home Front citizens, many of whom had never even seen a ship before. But telling that story was also work, and it fell to the editorial team of the weekly shipyard magazines. Fore ‘n’ Aft reached those in the four Richmond, Calif. yards, while The Bos’n’s Whistle was for the three yards in the Portland, Ore. region.
Traditional journalism was simply not capable of reaching the new workforce. The editorial staff had to evolve to reflect the views and interests of women and people of color. The biggest change was bringing women on board. Writers and illustrators such as Virginia Olney and Emmy Lou Packard brought a fresh perspective to industrial journalism, and their pioneering was supported by external media partners such as African American photographer E.F. Joseph.
Fast forward to Kaiser Permanente now, with a diverse staff producing content for publications such as Hank (named after Henry J. Kaiser) aimed at both a labor audience and its management and physician partners. The ground broken during World War II continues to this day.
There’s an old expression – “Nothing about us, without us, is for us.” That holds true for authentic journalism as well as anything else, and this blog honors those unacknowledged workers who get the message out.
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