, 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
June is National Safety Month, during which we are asked to pay particular attention to something that we usually don’t think about – our own personal safety and that of our loved ones. Yet reducing our risk for injury at work, on the roads, and in our homes and communities is as vital to our health as diet, exercise, and regular checkups.
Kaiser Permanente has a long history in working to protect its employees from harm and injury in the workplace, a commitment that goes back to the World War II home front. At precisely the same time that the conventional industrial workforce of healthy young men went off to fight, everyone else stepped up to produce the materials to arm the Arsenal of Democracy and win the war. Among these unsung heroes were the almost 200,000 people in the seven Kaiser shipyards. Most of them had never engaged in heavy industrial work before. They were housewives, farmers, the disabled, and those too old to serve in the military.
This January 14, 1944, article from the weekly Oregon Kaiser shipyard newspaper The Bos’n’s Whistle does a good job of explaining the challenges:
Safety pays dividends in shipbuilding production. That is apparent in the safety record of the three Kaiser yards during the past year. In all three yards, from superintendents to laborers, men and women showed more interest in observing safety rules. As a result, sizeable cuts were made in the two major causes of time loss injuries – handling tools or materials, and eye injuries- bring the total percentage of injuries in these two classifications down from 64 per cent to 53 per cent. National Safety Council figures show that, in terms of production, industry last year lost 380 million man days of work because of accidents. And the death rate on the war industry front is still four times higher than on the nation’s battlefronts. First Aid stations in the Vancouver and Swan Island yards treated a total of 704,435 cases during the year.
While hundreds of workers manage to stay on the job after an accident, their efficiency is impaired.
That steady progress is being made in the war on injuries is shown in the drop in accident insurance cost. At the start of the program, the cost was $3.75 per $100 of payroll, and the three yard average is now down to less than $1.00 per $100 payroll.
Before the war was over, the successful health plan for Kaiser shipyard workers was opened to the public. Today at Kaiser Permanente is a leader in occupational health as well as employee and patient safety. “Kaiser On-the-Job,” first started in the Northwest Region in 1991, incorporates prevention, case management, clinical protocols, and return to work programs with impressive results.
Safety still pays. Work safe, be safe.
Short link to this article: http://k-p.li/28Ywcw2