, Heritage writer
The Automated Multiphasic Examination
Second part, follows “Screening for Better Health: Medical Care as a Right”
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.
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.”
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.’”
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.
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:
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
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
, Heritage writer
Change rarely comes easily. People get used to doing things a certain way, and physicians are no exception. One such shift was a technology Kaiser Permanente adopted early on, creating patient medical records electronically rather than on paper.
In 2013 I interviewed Jim Gersbach, senior hospital communications consultant for Kaiser Permanente’s Northwest region. As their unofficial historian, Jim had accumulated many stories during his 28 years of service. This is an edited version of one of his learnings.
Prior to that, we had computerized lab records, computerized this, computerized that. But you had to go and get those records sent to you, and it was not all integrated the way it is now. It was interesting, from that one discussion of them beta testing in that one medical office, to then see that it later succeeded, and they made the decision to roll it out to the Northwest. Then they gradually put all of Kaiser Permanente’s systems onto EpiCare.
I can remember some of the older doctors didn’t even know how to type. That was the biggest barrier; they were doing the old hunt-and-peck because they had never needed to type. They just did dictation, or their nurses would type it up for them. The younger physicians were very eager to adopt computerized medical records, because they were a little bit more familiar with computers.
But after 1998 the Northwest Permanente Medical Group had done some survey work – [which had some] pushback— and heard that ‘This is adding to our day; it’s 45 minutes more a day to try and enter all this stuff in.’ People were complaining that ‘When I did paper, I didn’t take so long to do all this stuff, so it’s not a time saver for us.’
We started looking at that, and found was that sometimes when doctors would get busy, they would just sort of scribble something illegible in the chart, and send it off, because they could get out of their office faster. EpiCare was forcing them to actually enter data on every patient; they couldn’t just leave it blank. That was a major ‘Aha!’ moment. What became evident was, ‘Wait a minute; we’re not necessarily charting everything we’re supposed to.’ And the computerized system actually helped.
Not only did it make everything legible, but it forced clinicians to put something in; you had to type something in, or it wouldn’t advance you forward. It definitely improved the quality of the data.
In the Northwest, at the time EpiCare was being adopted, the doctors were very free to say what they didn’t like about it. But despite all the grumbling about ‘It’s adding to our length of day,’ when we asked, “Would you ever want to go back to paper?” they said ‘Absolutely not! I couldn’t live without the system, because it actually provides me everything I need to know for the patient.’ They very quickly saw the value of it as a clinical aid.
Short link to this article: http://k-p.li/1NDdUjM
By Ginny McPartland, Heritage writer
In a highly technological world, paper medical charts no longer show up in Kaiser Permanente doctors’ hands when they interact with today’s tech-savvy patients. These collections of hand-written notes of our medical complaints, drug prescriptions, lab tests and more, are going the way of fax machines and typewriters.
They’ve been replaced by Kaiser Permanente’s award-winning electronic medical record system, Kaiser Permanente HealthConnect®, which brings patients much closer to their providers.1
But preserved paper patient records going back to World War II will continue to be a valuable asset for research, even as we trade in the old cumbersome model for the new.
Gary Friedman, MD, retired director of the Kaiser Permanente Division of Research in Oakland, Calif., says Kaiser Permanente’s medical records – whether the original hard copies or digital files– are valuable assets to allow groundbreaking research.
In a 1998 article in The Permanente Journal, Friedman wrote: “Our collection of manual charts going back over 50 years is a national treasure and must be preserved despite the storage and retrieval costs entailed.”
In his 2006 oral history, Friedman said the highly touted study on the value of sigmoidoscopy in preventing colon cancer relied on paper records going back to the 1970s.2
He added: “(In) a recent study I did on the early symptoms of ovarian cancer (we found) by going into the charts (paper records) we could get much more of what the physicians recorded in text about the symptoms these women were having . . . Who knows what question might come up in the future (that could be answered) by looking at these charts that go back to the mid-1940s?”
Kaiser Permanente’s early foray into digital world
Kaiser Permanente’s journey into electronic record keeping started around 1960 and took advantage of emerging computer technology. A desire to prevent chronic disease through pre-symptom screening supplied the motivation to automate routine tests and to compile anonymous patient data for population-based research.
Barbara Breen, a medical assistant at Kaiser Permanente Oakland Medical Center in the early 1970s, had her hands on paper charts as well as on the pioneering electronic medical records of the day. She often stood by as lunch-time relief to ensure the computer ran fluidly as it processed punch cards that coded the results of patient visits for Kaiser Permanente’s complete physical (multiphasic) examination.
She was on the cutting edge of computer technology of the time and was in awe. “I got to see all these brand new machines and they assigned me to the spirometer (to test lung capacity),” Breen recalled recently. “The patients filled out a medical questionnaire (health assessment) and had 90 minutes to go around to all the cubicles where they had the tests.”
Data collected by Breen and others in the multiphasic unit were fed into early computers that took up the basement at 3779 Piedmont Ave., just off of MacArthur Boulevard near Kaiser Permanente’s flagship medical center in Oakland, Calif.
Tracking members’ health over decades
Over the years, these records, now considered invaluable and precious, have been the basis for many Kaiser Permanente longitudinal research projects. Collection of detailed patient data from 1964 to 1972 was made possible by the pioneering computer work of Morris Collen, MD, largely funded by the federal government.
Breen, who worked for Kaiser Permanente for 30 years mostly in the northern San Francisco Bay Area, recalls having the duty to retrieve charts for patients scheduled to come into the San Rafael facilities in the 1970s.
“I got a job down on Fourth Street, which was an old motel . . . General Medicine was downstairs and Internal Medicine was upstairs, and the garage next door is where all the charts were. And in those days, we didn’t have (access to) computers yet, so if you needed a chart ASAP you would order it by phone.
“The chart room didn’t always have an extra person to bring the chart over. So the medical assistant or other (staff person) went out, rain or shine, across the parking lot, into the remodeled garage and picked up your chart.”
Today, Kaiser Permanente medical centers are constructed without medical chart rooms, indicating a confidence that the electronic chart is here to stay. With KP HealthConnect® in place, patients get their routine test results much quicker, and they can discuss their care with their physicians via secure email and mobile devices.
For member convenience, patients who travel can have their medical data downloaded on to a memory stick to take wherever they go. For quality of care, physicians have access to patients’ medical information in any of Kaiser Permanente’s facilities nationwide, enabling better care and avoiding duplication of tests.
1 Kaiser Permanente has been awarded Stage 7 honors by the Health Information Management Systems Society Analytics for 36 of its hospitals. Stage 7 is the highest award in the category and recognizes environments in which paper charts are no longer used to deliver patient care. KP was also honored with the HIMSS Davis Award for excellence for 2011. The 2013 annual HIMSS conference is under way in New Orleans through Thursday, March 7.
2 Selby, JV, Friedman, GD, Quesenberry CP Jr, Weiss NS. A case-control study of screening sigmoidoscopy and mortality from colorectal cancer. New England Journal of Medicine 1992.
Also see: “Screening for Better Health: Enter the Computer”
By Ginny McPartland
Seventh in a series
In 1989, Southern California quality guy Sam Sapin, MD, made a prescient plea to KP leadership: invest in information technology to improve quality of care. Having worked on quality issues for decades, Sapin saw the need for a KP database to be shared among all regions.
“This would allow us to compare ourselves to each other,” Sapin told a gathering of KP quality professionals. He continued: “The data must be accurate, otherwise one loses credibility and effectiveness. The data must be timely, not two to three years old, because the environment changes quickly these days. . .We need to develop data that will show the outside world – the public, employers and legislators – how good we are.”
Twenty-two years later, KP is positioned to capture detailed patient data across all KP regions and to analyze it in many different ways to learn what’s working and what isn’t. With an abundance of data, KP can not only record adherence to best clinical practices, but also potentially figure out more precisely how treatment affects outcomes.
Halvorson’s big initiative to improve quality with data
In 2002 when George Halvorson took over Kaiser Permanente as president and CEO, the Care Management Institute was well on its way to performing the essential function of developing and sharing best practices among all KP physicians. But Halvorson, acutely interested and knowledgeable about medical information systems, was not satisfied that KP was on the path to develop a patient data system that would support his vision for quality improvement.
He brought in Louise Liang, a physician, medical director and quality professional who had worked closely with Total Quality Management expert Donald Berwick at the Institute for Healthcare Improvement (IHI). She led the program-wide monumental task of finding an appropriate vendor, figuring out the best software and driving the implementation of KP HealthConnect, ultimately the data collection and interpretation system that would transform Kaiser Permanente’s ability to assess and improve quality.
In 2005, KP reorganized its quality management structure, creating the KP National Quality Committee (KPNQC), which took the place of the Medical Directors’ Quality Committee. The NPNQC oversees all quality activities for hospitals, outpatient clinics, and outside care for all KP regions.
Value of data to quality measurement
“Having data is extremely important,” Halvorson told the editors of the NCQA 20th anniversary report. “Whenever you have data you can reach conclusions and you can change process, you can re-engineer, you can make things better. But if you don’t have data, you don’t have any particular direction to go.”
He adds, “There is an evolution from process to outcomes, and measuring the mortality rate for different conditions is a wonderful measurement, sort of the ultimate definition of outcome. Measuring process is good, and a far better thing than not measuring quality at all, but organizations really need to focus on what happens to each person. How many people have failing kidneys is a great measurement.”
NCQA president validates KP success in quality improvement
In her 20-year assessment of NCQA’s success in improving quality of care, President Margaret E. O’Kane concludes: “Our hard work has led to many gratifying and exciting results. In Northern California, for example, Kaiser Permanente has demonstrated that aggressive management of patients with coronary artery disease (CAD) pays off in the most important ways: fewer deaths.
“CAD is the leading cause of death in every other county across the U.S., but for Kaiser (Permanente) patients in Northern California it is second. This confirms that when quality measurement and science meet, patients benefit,” she wrote.
KP’s electronic medical record system also makes it possible for physicians to access a patient’s full medical history anytime in any KP facility.
“You never ever have to make a clinical decision about a patient without information,” Andy Weisenthal, KP pediatrician and quality expert, told Charles Kenney, author of Best Practices: How the new quality movement is transforming medicine.” He adds, “I cannot tell you what that means to me as a doctor.”
Has Kaiser Permanente been successful in demonstrating its high quality of care? The abundance of accolades showered onto the KP medical care program over the past decade speaks for itself.
In the fall of 2011, KP received the highest rating in 11 effectiveness measures – more than any other health plan in the nation – in the 2011 NCQA’s Quality Compass results.
KP also won J.D. Power & Associates first place awards, as well as the prestigious Davies Award for KP HealthConnect, the patient data system.
KP also distinguished itself by garnering Medicare five-star awards in five regions, outstripping other health plans in California, Hawaii, Colorado and parts of the Northwest. Only nine Medicare plans in the country earned five stars for the overall 2012 Medicare star quality rating.
Next time: Sam Sapin: Southern California pediatrician’s career parallels KP’s quest for best quality
To learn more about KP current quality honors:
By Tom Debley
Kaiser Permanente today is arguably the most advanced non-governmental health care organization in the country, and perhaps in the world, in the use of computers in medicine. A key historic reason for that leadership is its pioneering role. So this week we recognize the moment this work all began exactly 50 years ago.
The big lesson is that innovation did not occur through magic. It took vision, openness to new ideas, and dedicated work by thousands of people over the ensuing decades.
The result is that, at a time when electronic medical record systems have barely scratched the surface of American medicine, they are pervasive throughout Kaiser Permanente. All 8.6 million members have their own electronic medical records, which are also available throughout the organization’s 36 hospitals.
What’s more, the system’s Web-based member portal enables members to view most portions of their own medical record on line, send secure messages to their doctors, order prescriptions, make appointments, view lab results, and much more.
The critical moment when the futuristic vision of computer-enabled medical care came together with an organizational willingness to embrace new ideas came in May 1960. At a four-day leadership meeting, Sidney R. Garfield, our founding physician, was giving a report about hospital designs. Then, he shifted gears and announced, “I would like to use my remaining minutes on a more important, new concept. I want to throw this idea on the table for your consideration. Please accept it in the spirit it is given. It is a controversial idea, but please keep an open mind.”
It was a whopper.
“Let us conceive a building for health—designed, streamlined and geared to serve our healthy members. This health institute could conceivably function in this fashion. Each new health plan member would automatically and periodically be called in for service. On his first visit, a history would be taken and fed in a computer.
“A duplicate of this history would be sent to his service area. On each periodic visit or service visit, further data would be taken . . . and fed into this record. This would not only develop records never before available, but might do so at a great savings in time of physicians.”
The late Dr. John G. Smillie, who was at the meeting, commented on the discussion at the time that physicians who were there felt Garfield’s proposal “had exciting merit,” adding they said “it should be studied from many angles, and designed and redesigned… (and) should be made flexible to meet new developments…”
Over the next decade, the 1960s, research and testing headed by Garfield’s colleague, Morris F. Collen, MD, propelled Kaiser Permanente into a leadership role in the emerging field of medical informatics.
Within that decade, more than one million patients had early versions of electronic medical records and became more involved in their own care because of the new levels of knowledge available to them and their doctors.
“It was the first transformational aspect of looking at how the system of caring for patients could change,” recalls Dr. Marion J. Ball, author of “Consumer Informatics: Applications and Strategies in Cyber Health Care” and adjunct professor at The Johns Hopkins University School of Nursing.
Dr. Collen recognized in the early years of his work that the computer would be an incredibly important tool in modern medicine, declaring in 1966: “The computer will probably have the greatest impact on medical science since the invention of the microscope.”
Dr. Cecil C. Cutting, the first executive director of The Permanente Medical Group, challenged all physicians in 1965 to embrace the future in a talk to the American Association for the Advancement of Science.
“. . . The great challenge,” he said, “will be the willingness of traditional medicine to accept these new concepts and reorganize to provide these services. The future . . . in medicine may well rest on the open-mindedness of the doc¬tors of the country to anticipate inevitable trends and lead the way. We earnestly hope they will.”
That Kaiser Permanente was changing from a pioneer to a continuing leader in health information technology (IT) was well established by 1968, when its annual report stated: “The computer cannot replace the physician, but it can keep essential data moving smoothly from laboratory to nurses’ station, from X-ray department to the patient’s chart, and from all areas of the medical center to the physician himself.”
This early embrace of health IT – and persistent work in the half century since – explains why, as I’ve mentioned in earlier blogs, 12 of the first 13 American hospitals to be rewarded by HIMSS, the leading health IT association, for having the highest level of e-connectivity were Kaiser Permanente hospitals. This year, 24 Kaiser Permanente hospitals have achieved that status, with more on the way. Meanwhile, less than 1 percent of America’s hospitals are at this stage.
What was said of Dr. Garfield two decades ago is just as true today: “Sidney Garfield…had a way of always operating on the cutting edge of the future.”