By Ginny McPartland
First of a series
It’s 1970 and Kaiser Foundation Health Plan’s operation in Sacramento is just five years old. The state of California and the federal government have both recently set up health benefits for their employees with Kaiser Permanente as a popular option.
The Northern California Health Plan is quickly approaching its million members mark, and the Sacramento facility is overflowing with patients.
Meanwhile, Mildred “Millie” Kahane, BS, MS, a New York transplant teaching nursing at California State University, Sacramento, thinks her students are bright enough to contribute more in the burgeoning field of health care. The destiny of nurses, she believes, is to rise above the traditional hospital bedside role and to take on more responsibility in an outpatient setting.
She believes her students can learn new skills that could eventually be included in a bachelor of science nursing program and that these advanced nursing capabilities would provide the core content upon which to build clinical specialties.
John Mott, MD, physician-in-chief at Kaiser Permanente Sacramento, is facing increasing pressure to welcome and serve new members. His resources for providing primary care and new member health assessments can’t keep up with the demand. What is he to do?
Fortuitously, Mott and Mrs. Kahane have occasion to meet – through her husband Kaiser Permanente Sacramento chief of OB-GYN Albert Kahane – and their collaboration sets in motion a revolutionary program to elevate the nursing role and to solve Mott’s shortage of primary care providers.
Some of Millie Kahane’s students will become “nurse practitioners,” a title unheard of at the time in Sacramento County, and Kaiser Permanente members will get comprehensive evaluations in what will become known as the Department of Preventive Medicine.
Origin of advanced practice nursing
The story of Mrs. Kahane and her hand-picked nurse practitioner pioneers was not unique in the 1970s health care landscape. Indeed, medical providers throughout the United States were looking for solutions to a manpower shortage. In that era, the federal government provided special funding to identify ways to maximize health care dollars.
Within Kaiser Permanente in particular, physicians in Southern California, Oregon and Hawaii began to train nurses to examine seemingly well patients and identify any abnormalities for follow up with a physician.
Pediatrician Sam Sapin, MD, in Panorama City worked with Southern California Permanente Medical Group Director Raymond Kay, MD, to train nurse practitioners to provide well-child check-ups, along with physicians.
In Oakland in the early 1970s, Drs. Morris Collen and Robert Feldman employed NPs in the “Multiphasic,” an annual physical program originally set up for the longshoremen’s union in 1951.
After nurse practitioner programs were well established in Northern California, The Permanente Medical Group developed a certification process for those who were to work as nurse practitioners within the organization. This process later helped Kaiser Permanente nurses meet California nurse practitioner requirements.
The first formally educated Kaiser Permanente nurse practitioner was Linda Lee, who was one of Mrs. Kahane’s students at Sacramento State. Upon graduation, she attended the nurse practitioner program established by Henry Silver, MD, at the University of Colorado in 1965.
Silver’s program was the first university-based pediatric nurse practitioner program in the United States. After completing the program, Lee came back to California and worked with Sacramento Kaiser Permanente Chief of Pediatrics Clifford Skinner, MD.
Synergistic forces converge in Sacramento
Why is the story of the Sacramento Kaiser Permanente Nurse Practitioner and Preventive Medicine Program of the 1970s remarkable? Looking back after 40 years, the program’s pioneers – many still working for Kaiser Permanente – marvel at the phenomenon of a close-knit group of advanced practice nurses who loved their mentors and their patients and whose lives were marked indelibly by the experience.
Nurse educator Mildred Kahane and Physician-in-Chief John Mott’s alliance to develop a nurse practitioner program found fertile ground in the hearts and minds of certain of Mrs. Kahane’s graduates. In 1970, Mrs. Kahane set completion of a bachelor of science degree as the basic program requirement and recruited four candidates to begin work (and training) in the Health Appraisal Evaluation center to be located in an older Kaiser Permanente building at 3240 Arden Way, Sacramento.
Kaiser Permanente allergist Carl Henriques, MD, formerly a general practitioner in Susanville, Calif., became the center’s physician leader and primary teacher. As the program progressed, the University of California at Davis Medical School was developing a mid-level practitioner master’s in Health Services program for nurses.
UCD lacked clinical facilities, which Kaiser Permanente had. Eventually KP and UC partnered, and UC students were able to enhance their clinical experiences at Kaiser Permanente with Mrs. Kahane and Dr. Henriques as members of the UC clinical faculty. Kaiser Permanente nurses were given the opportunity to apply their education and training toward the master’s degree.
Next time: Kaiser Permanente preventive care patients benefit from more time with their provider.
This blog is dedicated to the memory of Eileen O’Hagan McCauley and Linda Lee (both deceased), two of the first NPs at KP Sacramento, and the late Carl Henriques, MD.
By Lincoln Cushing, Heritage writer
Kaiser Permanente and the University of California are two major California-based institutions that share a long history of partnership. The collaboration started right after World War II with UC securing Health Plan coverage for its employees beginning in 1945, the year the plan opened to the public.
From the beginning, Permanente physicians joined UC for many medical research projects, and over the decades many have taken on professorships at UC campuses in Northern and Southern California. By all accounts, the partnership has been a fruitful one.
Professor touts KP care
A 1949 feature story in the Kaiser Permanente member newsletter Planning for Health pointed out that the University of California was the Health Plan’s fourth largest group, starting in 1945 with 59 members and reaching 1,961 members by 1949.[i]
The article included an interview with electrical engineering professor Charles F. Dalziel and his wife, who were early members of the university plan.
“During much of the period the family have been members of the group, Mrs. Dalziel has had many opportunities to evaluate the Plan in action. Like so many otherwise healthy children, their charming daughter, Isabelle, aged 8, is allergic.
“Mrs. Dalziel is enthusiastic in her comments on the results Permanente doctors have achieved in determining the child’s allergies and combating them,” the interviewer wrote.
Permanente educator adapts UC fight song
In 1972, Kaiser Permanente’s Jack Chapman wrote the “Kaiser-Permanente Marching Song,” an authorized adaptation of the UC Berkeley athletic fight song “The Big C.” Chapman was the first Kaiser Permanente Walnut Creek hospital administrator and later the Northern California regional director of training and management development.
Chapman’s first two lines:
“We are Kaiser-Permanente, finest plan in all the land
K-P stands for qual-i-ty and doing all we can.”
UC graduates lead Health Plan
Notable UC alumni include Eugene Trefethen, Jr., longtime Kaiser Industries president, James Vohs, longtime Health Plan president, Henry J. Kaiser’s son, Edgar F. Kaiser, and many others.
Edgar spent 3½ years at UC Berkeley majoring in economics. But in 1930, one semester short of graduation, he quit college and headed for Texas where he had been offered a chance to work as a pipeline construction superintendent.
His father gave him his blessing. “I talked it over with my father,” he once recalled, “and we agreed that I had learned about as much as I could in college, and that two months more of class work would not matter.”[ii]
Physicians join university faculty
Many Permanente physicians have associated with UC to teach and conduct research on various campuses. Morris Collen, MD, taught a public health course at UC Berkeley. Mark Binstock, MD, MPH, a Kaiser Permanente physician at Woodland Hills, was an assistant clinical professor at the UC Los Angeles School of Medicine in the 1990s. Monte Gregg Steadman, MD, was a lecturer at UC San Francisco.
UC Berkeley’s venerable Bancroft Library houses the Henry J. Kaiser Papers collection, a massive trove of Kaiser’s personal and business correspondence, memoranda, speeches, and papers. Kaiser’s documents from his Oakland, New York, and Hawaii businesses, principally from the period after World War II, are archived at the Bancroft.
The collection includes material on the Kaiser Industries corporation, the Kaiser Permanente Medical Care Program, the Kaiser Shipyards at Richmond, Calif., and other Kaiser industries.
UC’s Bancroft archives Health Plan pioneers’ interviews
UC Berkeley’s Regional Oral History Office staff has interviewed dozens of Kaiser Permanente pioneer physicians, administrators, and board members to document their roles in the development of this innovative health maintenance organization.
The initial interviews were conducted between 1984 and 1999 as the series: “History of the Kaiser Permanente Medical Care Program—Founding Generation.” A second series of interviews started in 2005 to look at Kaiser Permanente and the transformation of health care in the U.S. from 1970 to present.
Short link to this article: http://ow.ly/pvoLk
By Ginny McPartland, Heritage writer
Fans and benefactors of the Rosie the Riveter World War II Home Front National Historical Park gathered April 13 to get the latest on the park’s outreach programs and additions of artifacts and interpretive displays.
The Rosie the Riveter Trust, which helps support the park, sponsored “Rosies – Then & Now,” a fundraising event that drew about 200 revelers of all ages to the site of the former Kaiser Richmond Shipyards.
Some guests toured the 11-month-old National Park Service Visitor Education Center museum for the first time, and some took in the park’s “Home Front Heroes” film before dinner.
The tone was set early on with the energetic harmonies of the Honeybee Trio, three Vacaville (Calif.) high school girls who performed nostalgic songs from the era, many of those made famous by The Andrews Sisters.
The trio hit the right note with the audience: with five years’ experience on stage, their act is polished and could be mistaken for the original.
In one of their numbers, the Honeybees brought back the irreverent “Six Jerks in a Jeep,” calling on three Richmond girls from the audience to take a seat on stage in an imaginary jeep.
Young Rosies on stage
The selected guest performers are part of “Rosie’s Girls,” a six-week summer program supported by the trust. The program for girls from designated disadvantaged neighborhoods focuses on teaching the students traditionally male skills, such as carpentry, welding and fire fighting, and introduces them to positive female role models they call SHeroes (female heroes).
The girls, Hadassah Williams, 11, Ariel Norwood, 16, and Malaih Ware, 16, took center stage for the evening as modern-day “Rosies,” along with the wartime shipyard Rosies who were honored as well with special introductions.
Another honored guest was Morris Collen, MD, a Kaiser Permanente physician and researcher who started with the medical group in the Kaiser Richmond Shipyards in 1942. Dr. Collen, who spoke a few words at the podium, will celebrate his 100th birthday on Nov. 12.
Lucien Sonder, NPS community outreach specialist, presented a recap of the “Rosie’s Girls” 2012 summer camp; NPS Ranger Matt Holmes gave a report about “Hometown/Richmond,” a year-round park program that helps youth faced with environmental risk factors such as crime, violence and poverty.
Community support for event
The Rosie Trust got support to produce the event from many businesses and individuals in the community. Among the sponsors were: the International Brotherhood of Boilermakers, Iron Ship Builders and Blacksmiths, Forger and Helpers, AFL-CIO, and Local 549; Kaiser Foundation Health Plan; Chevron; the Coalition of Kaiser Permanente Unions; Northern California Carpenters Regional Council; The Permanente Federation; and PG&E.
Eddie Orton and the Orton Development company donated the use of the Craneway Conference Center for the evening’s event.
By Lincoln Cushing, Heritage writer
One of the major academic figures in American public health was Lester Breslow, MD, who passed away last year at the age of 97. Dr. Breslow was a former dean of the Fielding School of Public Health at UCLA and director of the California Department of Public Health from 1965-1968.
He was also president of the American Public Health Association from 1968 to 1969. Central to Dr. Breslow’s research was mathematical support for the premise that improving personal habits such as reducing smoking, eating better, and sleeping well could have a significant impact on life longevity and quality.
Dr. Breslow was also a pioneer in multiphasic screening and an advocate for the Automated Multiphasic Health Test developed by Kaiser Permanente’s Morris Collen, MD, an early medical informatics guru who turns 100 this November.
National Public Health Week, April 1-7, is a good time to revisit Kaiser Permanente’s role in the early recognition of preventive care as a way to address public health issues.
Breslow had developed the original multiphasic screening (the examination of large numbers of people with a series of tests for detecting diseases) during the 1940s, and Collen improved upon it with new technology. The first beneficiaries of Collen’s multiphasic process were members of the International Longshoremen’s and Warehousemen’s Union in 1951.
The AMHT was a battery of tests, administered in an efficient routine by medical professionals and supported by then-new mechanical and chemical analytic devices. The results were funneled into a powerful mainframe computer.
From a public health perspective, the ability to efficiently diagnose communicable and noncommunicable diseases not only benefitted the individual patient, it also helped to stem public health risks as well.
In Breslow’s 1973 Preventive Medicine article, “An Historical Review of Multiphasic Screening,” he noted: “Automated multiphasic screening opens the possibility of extending the health-maintenance type of health care to all groups of the population, particularly including those most likely to suffer from the conditions now responsible for the greatest amount of disability and death.”
Dr. Collen taught two semesters at UC Berkeley’s School of Public Health during the spring and fall of 1965; much of the curriculum explored the uses of multiphasic exams. Students included physicians engaged in their continuing medical education.
Final papers for the classes included such subjects as “Evaluation of Environmental Toxins Utilizing Automated Methods” by David R. Brown, “Obesity and its Measurements as it Relates to a Multiphasic Screening Program” by Clarence F. Watson, MD, and “Biological Effects of Magnetic Fields” by Earl F. White.
Although the multiphasic screening as it was developed in the 1960s has been replaced by other diagnostic methods, the efficient application of medical diagnostic tools – and the enormous Kaiser Permanente patient database that has accumulated over the years – continues to advance public health.
Also see: “Screening for Better Health: Medical Care as a Right”
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 Laura Thomas
First in a series
Despite Kaiser Permanente’s early emphasis on preventive health care, pervasive 20th century American attitudes about alcohol and drug abuse curbed Health Plan leaders’ willingness to tackle addiction as a bona fide treatable illness.
“Very few physicians or even psychiatrists are willing to treat the chronic alcoholic, just as few lawyers go into the specialty of bankruptcy law,”
Paul Gliebe, MD, of the University of California medical school, told Kaiser Permanente physicians in 1953. “The chronic alcoholic is in most instances looked upon as a bankrupt personality.”
The American Medical Association (AMA) was also reluctant to empathize with alcoholics, stopping short of declaring alcoholism a disease in 1956, while encouraging hospitals to admit patients suffering from the symptoms.1
“Since the earliest era, (Kaiser) Permanente (KP) physicians had resisted the idea of comprehensive care for alcoholism, self-inflicted wounds, or other self-induced illness,” the late KP San Francisco pediatrician John Smillie, MD, wrote in his 1991 book, Can Physicians Manage the Quality and Costs of Health Care?
This resistance existed despite some early voices in Kaiser Permanente who pointed out what the Permanente organization accepts today – that social and behavioral imbalances lead to disease and the symptoms include addiction and depression, now being recognized as diseases in themselves.
KP psychiatrist Kahn warns addicts need early care
One early KP psychiatrist, Bernard Kahn, MD, sounded an alarm at a Permanente Medical Group planning meeting in Monterey in 1960. From that vantage point, Kahn described the modern, ever-present pressures of managing technology, work and leisure:
“Our national consumption of tranquilizers and alcohol prove we are a nervous nation. Let’s face it: the internist, the surgeon, the general practitioner, our Drop-In (Clinic) physicians are treating this kind of illness – the intangible, aggravating, emotional upsets, day in and day out – regardless of what the Health Plan contract reads.”
Kahn asserted that the Health Plan needed to extend its preventive care to include alcoholics because they would surely develop chronic disease without treatment for their addiction. “(In this area) we’re already too late, and we are covering end-stage disease (caused by alcoholism).”
Dr. Kahn, a retired Navy psychiatrist, was helping to craft a cost-effective and practical psychiatric program, along with The Permanente Medical Group (TPMG) pioneer Morris Collen, MD, in the 1950s. Collen was concerned that traditional psychiatric appointments were too long at 50 minutes and would add unduly to Health Plan costs. He wanted Kahn to develop a program based on a 30-minute appointment. Unfortunately, Kahn died of a heart attack before he could accomplish the task, Dr. Collen said in his 1986 oral history.
KP institutes psychiatry program in late 1950s
In the late 1950s, Kahn and psychologist Nicholas Cummings had been successful in establishing a KP psychiatry program. But treatment for alcoholism and other addictions was kept at arm’s length until it was pushed by the federal government for its employees in 1969, physician leader Raymond Kay, MD, wrote in his 1979 book on the history of the KP Southern California medical group.2
The AMA also took its time to define alcoholism as a disease. It waited until 1967 to declare it a “disease that merits the serious concern of all members of the health professions.” By then, President Lyndon Johnson had publicly called for more study and treatment for alcoholism, and health insurance plans had begun to respond.1
Richard Merrick, MD, then a young internist at KP’s Harbor City Medical Center in Southern California, said he was approached by the department chief in early 1971. “They needed at least one physician from each area to start an alcoholism program.
“There were 12 or 15 doctors in the department at the time and he came to me last because he had been turned down by everyone. There was zero interest at that time in having anything to do with ‘those people’. That was the common mentality at the time.”
There was little understanding of the functional alcoholic or socialite imbibing wine, he said, only of the “stinking drunk. There was hardly any concept of addictions being diseases. They were defects of character. It was a matter of choice. These people were ‘bad’ so how could you treat that?” he said.
Dr. Merrick hired a recovering alcoholic to help him organize a one-night-a-week outpatient clinic, which lasted for three-and-a-half years. But if a patient was going through withdrawal symptoms, he or she could not be admitted easily.
“They had to have a seizure to get admitted. That’s how crazy it was for a while,” he remembered. “Once in a while I would sneak somebody in, and I would take all kinds of heat from the Health Plan because they would tell me it wasn’t a covered benefit.”
But industry and the government were determined to extend addiction treatment to as many American workers and their families as possible. Recognizing the need, KP regions began instituting coverage in the late 1970s, usually offering outpatient treatment services through the psychiatry department with a copayment and yearly cap on the number of counseling appointments or group meetings a member could use.
By the early 1980s, alcoholics were no longer falling “through the cracks at Kaiser (Permanente),” according to Andrus Skuja, MD, then chief of the alcohol and drug abuse program in South San Francisco. His comments in an interview in the KP Reporter employee newsletter in December 1982 reflected Merrick’s early experience in Southern California:
During the 1980s as the nation recognized cocaine as a new addiction problem, KP saw the need to treat many other drug addictions. It was a little tough at first. Many alcohol counselors were not comfortable with “heroin addicts or pill users, and they didn’t seem to realize that the dynamics were all the same. Addiction is addiction,” Merrick recalled. “In the San Fernando Valley, one clinic treated alcoholics and another treated addicts other than alcoholics . . . that lasted for a while.”
Kaiser Permanente resisted the initial trend of sending people to 30-day inpatient treatment programs even though many large employers and well-off unions, such as the longshoremen, were pushing it. KP established inpatient detoxification programs at KP Fontana for Kaiser Steel Mill employees in 1978 and in Carson just south of Los Angeles in 1988.
Thirty days was the gold standard based on the Minnesota model of alcoholism treatment that health insurers recognized and were willing to pay for. It got a large push when Betty Ford, wife of President Gerald Ford, spoke of her alcoholism in 1978 and later lent her name to the Betty Ford Center for alcoholics and drug addicts.1
Merrick, who was never convinced of the need for the month-long inpatient stay, noted: “We never kept them in for 30 days . . . As it has shaken out, I was right.
“It was just common sense. If you are a functioning alcoholic and not going through detox, why on earth do you need to be in for 30 days when you can do equivalent work on an outpatient basis over a longer period of time, because treatment for alcoholism or any drug is a lifelong thing . . . There is nothing magical about the 30 days.”
This inpatient treatment model died off everywhere in the early 1990s and was replaced by less expensive residential treatment as an alternative for patients with special needs.
Next time: 1990s spawn research and refinement of addiction care
1 Slaying the Dragon: The History of Addiction Treatment and Recovery in America, William L. White, Chestnut Health Systems/Lighthouse Institute, 1998
2 Historical Review of the Southern California Permanente Medical Group, Raymond M. Kay, MD, 1978, publisher: the Southern California Permanente Medical Group.
By Lincoln Cushing
Kaiser Permanente has a well-deserved public reputation for providing top quality health care, but less known is the health plan’s long and illustrious record for conducting high-caliber medical research. Kaiser Permanente is widely considered the leading non-university-based health research organization in the United States, with Kaiser Permanente Northern California’s Division of Research amassing more than $100 million in 2011 to conduct research.
This research has a direct effect on health care in this country, influencing the way physicians care for patients and refining broader policies that support medical services. Kaiser Permanente researchers, often partnering with academic institutions, successfully compete for federal research grants, and develop lines of research whose results translate to improved patient outcomes at the local, state and national levels.
Centers for Disease Control and Prevention (CDC) Research Director Jeffrey Harris, MD, put it this way: “If you look at who the leaders in research are and who the folks are that have been doing research… to improve care, it’s a very short list. And Kaiser Permanente is clearly at the top of that list.” [i]
This year, The Permanente Medical Group, the oldest of the eight Kaiser Permanente regional medical groups, celebrates the 50th anniversary of the founding of its Division of Research.
In the past five decades, Kaiser Permanente researchers have conducted thousands of studies and helped to solve many medical mysteries – from the best way to cure pneumonia in the World War II shipyards, to making discoveries leading to the mapping of the human genome, to learning the most effective use of drugs to prevent heart attacks.
The DOR (under its original name, Medical Methods Research, or MMR) was established September 21, 1961, by the Northern California medical group’s Executive Committee. Morris F. Collen, MD, one of the Health Plan’s founding members and a pioneer in the emerging discipline of medical informatics, led the group, which occupied offices in the old Kaiser Permanente headquarters at 1924 Broadway in Oakland.
Ten years earlier, Dr. Collen had met with Lester Breslow, MD, then a public health officer in San Jose who had recently completed a trial of “multiphasic screening.” This battery of thorough and efficient examinations was a practical solution to the problem of providing care to large populations despite the post-war shortage of physicians.
This approach was put to the test when labor leader Harry Bridges insisted that all members of the International Longshore and Warehousemens Union (ILWU) be given annual check-up exams as part of a negotiated care package with the Permanente Health Plan. Importantly, this exam approach provided a critical evidence base to empirically determine what screening methods are and are not clinically beneficial for patients.
In 1962, Kaiser Permanente Northern California received its first grant from the U.S. Public Health Service to develop, automate, and evaluate the multiphasic exam. Within three years, the Health Plan’s Oakland and San Francisco clinics began offering the Automated Multiphasic Health Testing to all members. In 1968 Dr. Collen dismissed some of the resistance to this use of technology:
“Many physicians are concerned that the computer is depersonalizing medical care,” he said. “Just the opposite is true. Because of the computer, the physician will have more individualized information about his patient—more complete and more accurate than he could possibly have gathered before.”[ii]
Antecedents to Permanente medical research
Even before the Health Plan went public in 1945, Henry J. Kaiser articulated research as one of its goals at the August 21, 1942, dedication of the Permanente Foundation Hospital in Oakland. As former Kaiser Permanente historian Tom Debley observed:
“From prepaid dues it collected, the Permanente Foundation paid for the medical care of Health Plan members and accumulated funds for such charitable purposes as medical research and the extension of medical services to larger population. . .The idea that research would be a tool to bring advances in medicine to the plan’s dues-paying members thus was embedded in the medical care program from the outset.”[iii]
In 1943, founding physician Sidney R. Garfield received $25,000 from the Permanente Foundation to study new methods of curing syphilis[iv] and he launched the Permanente Foundation Department of Medical Research under the leadership of Franz R. Goetzl, PhD, MD. He also started the research journal Permanente Foundation Medical Bulletin, edited by Dr. Collen from 1943–1953.
The Department began to receive national recognition for outstanding work in the study of peptic ulcers, human appetite, and pain. By 1949 the name was changed to The Permanente Foundation Institute of Medical Research to clarify that the research was not only a department within the hospital.
In late 1958, research involving basic medical sciences was shifted to the Kaiser Foundation Research Institute (KFRI), established by Kaiser Foundation Hospitals to coordinate long-term basic research projects supported by grants from sources other than the Kaiser Foundation Medical Care Program.[v] At first this just covered Northern California’s MMR and the Northwest research center (established in 1964.)
Today, all Kaiser Permanente regions – Hawaii, Georgia, Ohio, Colorado, Northwest, Northern and Southern California, and Mid-Atlantic States, conduct research under the auspices of the KFRI.
By 1961 KFRI’s domain included more than 50 long-range clinical research studies exploring such medical problems as cardiovascular and renal diseases, adenovirus infections, cancer, diabetes mellitus, and psychosomatic medicine. More than 70 staff physicians and residents conducted these investigations, often in collaboration with laboratories at nearby medical and scientific institutions.
Clifford H. Keene, MD, chief executive officer of Kaiser Foundation Hospitals and Health Plan, was named director of KFRI.[vi] A wing of Kaiser Foundation Hospital in Richmond was remodeled to bring together several disparate research projects under the KFRI umbrella.
These included a Laboratory of Comparative Biology (under Ellsworth C. Dougherty, PhD, MD) studying the basic physiology of microorganisms; a Laboratory of Medical Entomology (under Ben F. Feingold, MD) investigating the role of insects in causing human allergies; a Laboratory of Human Functions; a study of the Epidemiology of Human Cancer; and a Child Development Study and Blood Grouping project that investigated congenital abnormalities and childhood diseases.
KP Northern California research evolves
During the late 1960s Edmund Van Brunt, MD, a project director for MMR, piloted the San Francisco Medical Data System, a computer-based patient medical record system with a database that supported both patient care and health care delivery research. By 1973, Health Plan members in San Francisco had a computerized “lifetime” medical record, and pivotal work was conducted to begin to understand the safety of prescription drugs.
But by the early 1970s researchers were forced into a different avenue of research when the Nixon Administration abruptly canceled the department’s funding. The loss of $500,000 per year led to shutdown of the hospital computer system in San Francisco, but the application of computers and databases in medicine and health research continued, supporting new investigators and new areas of research.In 1979 Dr. Van Brunt succeeded Dr. Collen as the second director of the research department (MMR), and in 1986 he changed the name to the current Division of Research (DOR) to more accurately reflect the expanded mission and scope of clinical and other types of research that were being conducted there. Recently he described his vision of the program:
“[We] conducted high quality health services and biomedical research, epidemiologic and vital statistical analysis of the whole variety of medical care processes. . . of different collections of people drawn . . . from the Health Plan membership and by different collections of people . . . males, females, different ethnic groups, young and old.”
Van Brunt continued: “. . . The mission is to use these resources to conduct the kinds of health services research that we feel are important not just to the organization but important in a larger sense.”[vii] Dr. Van Brunt expanded DOR’s research agenda by adding a department of Technology Assessment headed by Director Emeritus Collen.
In 1985 Kaiser Permanente Northern California opened its first research clinic to support the heart disease research study CARDIA (Coronary Artery Risk Development in Young Adults). Within a year it was looking at a group of 5,115 black and white men and women aged 18-30 years in four centers – Birmingham, Chicago, Minneapolis and Oakland. Also in 1985, MMR began the Vaccine Study Center as a way of responding to numerous requests to use Kaiser Permanente’s large population for vaccine efficacy studies.
The center currently operates 31 sites in Northern California and collaborates with Kaiser Permanente’s Northwest, Hawaii, and Colorado regions and participates in several Centers for Disease Control and Prevention and National Institutes of Health studies.
Studies to better understand HIV/AIDS impact
During the AIDS crisis in the 1980s, DOR proved its worth in analyzing the impact of the disease. Kaiser Permanente Northern California was second only to San Francisco County’s public health services in the number of people with AIDS it treated in the initial years of the crisis.
Consequently, Kaiser Permanente researchers knew how many patients were actively seeking treatment, but they didn’t know how many of its members were infected yet untreated. Anonymous analysis of blood samples taken during routine checkups of 10,000 Kaiser Permanente patients in late 1989 told DOR researchers that 1 in 500 of its members was infected with HIV/AIDS.[viii]
Gary Friedman, MD, succeeded Dr. Van Brunt as director in 1991. During Dr. Friedman’s seven-year tenure, the DOR conducted important research on the etiology, prevention and early detection of cancers; on prevention and treatment of cardiovascular disease and diabetes; on the determinants of health care utilization; and on population approaches to chronic diseases.
Early research on the effects of socioeconomic status, race and ethnicity on health care and outcomes laid the foundation for the DOR’s ongoing involvement in health disparities research.
In 1994, Kaiser Permanente Northern California became a founding member of the Health Maintenance Organization Research Network (HMORN), ushering in an era of large-scale collaborations seeking to integrate research and practice for the improvement of health and health care in diverse populations.
Long chain of clinician-researcher leaders
Joe Selby, MD, MPH, took the helm in 1998, and former research investigator Tracy Lieu, MD, MPH, was appointed director in 2012, continuing DOR’s unbroken line of leadership by clinician-researchers.
Currently, 58 researchers and over 500 research staff continue DOR’s work in health care delivery research, outcomes research, clinical trials, epidemiology, genetics/pharmacogenetics (how individuals react to drugs), effectiveness and safety research, sociology, qualitative research (conducting patient interviews to better understand study data), and quality measurement and improvement.[ix]
Kaiser Permanente’s massive member database and consistent medical record keeping, maintain medical informatics as the cornerstone of Kaiser Permanente research in fields such as cardiovascular disease, cancer, metabolic disorders, dementia, autism, infectious diseases, osteoporosis, maternal and child health, chemical dependency and mental health. Dr. Friedman, Division of Research scientist emeritus, touts Kaiser Permanente data as offering “the best epidemiologic workshop in the world.”
Kaiser Permanente Northern California research also leads or co-leads several national research collaboratives sponsored with federal funds involving multiple Kaiser Permanente and non-Kaiser Permanente organizations, including the Cardiovascular Research Network (CVRN), Cancer Research Network (CRN), Vaccine Study Datalink (VSD), Developing Evidence to Inform Decisions about Effectiveness (DEcIDE), Accelerating Change and Transformation in Organizations and Networks II (ACTION II), among others.
Overall, DOR has a remarkable history filled with contributions to the health of Kaiser Permanente members and the broader community. DOR is committed to expanding its impact through better understanding of the underpinnings of risk factors and diseases, determining methods for effectively preventing and detecting these conditions, delineating the natural history of diseases, identifying ways to improve outcomes and the overall delivery and organization of health care.
Thanks to Alan Go, MD; Maureen Mcinaney; and Marlene Rozofsky Rogers at DOR for their contributions in the preparation of this article.
For an introduction to DOR research scientists and their work, please visit:
For more information, including all of the published work of DOR authors, please visit The Morris F. Collen, MD Research Library, 2000 Broadway, Oakland, CA.
Also see “Something in the Genes: Kaiser Permanente’s Continuing Commitment to Research,” by Robert Aquinas McNally, Permanente Journal, Fall 2001
short permalink to this article: http://bit.ly/RM39iE
[i] “Perspectives – Research,” [videotape] [Oakland (CA):] Kaiser Permanente MultiMedia Communications; 1998, quoted in “Research in Kaiser Permanente: A Historical Commitment and A Future Imperative,” Robert Pearl, MD, Permanente Journal, Fall 2001.
[ii]Kaiser Foundation Medical Care Program Annual Report 1968.
[iii] The Story of Dr. Sidney R. Garfield: The Visionary Who Turned Sick Care into Health Care, by Tom Debley, The Permanente Press, 2009.
[iv] Correspondence November 1, 1943 from E. E. Trefethen, Jr., Trustee of the Permanente Foundation, to Dr. Garfield; letter is an appendix to the Cecil C. Cutting Regional Oral History Office interview 1985 by Malca Chall, <http://www.oac.cdlib.org/view?docId=hb8p3006n8&brand=oac4&doc.view=entire_text>
[v]Kaiser Foundation Medical Care Program Annual Report 1961.
[vi]KP Reporter, September 1959.
[vii] Interview June 13, 2012 by Bryan Nadeau, Senior Producer Northern California Multimedia.
[viii]“AIDS research among Kaiser’s quiet studies,”Carolyn Newbergh, Oakland Tribune, 10/8/1991. The published medical research finding is: Hiatt RA, Capell FJ, Ascher MS.; Seroprevalence of HIV-type 1 in a northern California health plan population: an unlinked survey.; Am J Public Health. 1992 Apr;82(4):564-7.; PubMed PMID: 1546773; PubMed Central PMCID: PMC1694106.
By Ginny McPartland
Millie Cutting was the wife of Kaiser Permanente’s pioneering chief surgeon Cecil Cutting, but her influence on the fledgling medical program during World War II contradicts any cliché prescribing the role of a doctor’s spouse. She was a vibrant, energetic force in her own right, a good woman behind a good man, but much, much more.
The Cuttings met in Northern California at Stanford University in the early 1930s. He was training to become a physician; she was a registered nurse with a degree from Stanford. They met on the tennis courts and married in 1935.
During her husband’s nonpaid internship, Millie Cutting worked two jobs – for a pediatrician during the day and an ophthalmologist in the evenings – to pay the bills. He was making $300 a month as a resident when Sidney Garfield, MD, contacted him about joining the medical care program for Henry Kaiser’s workers on the Grand Coulee Dam in Washington State.
Millie was at first reluctant to leave San Francisco to relocate in the desert. But when Cecil convinced her that he would have more opportunity as a surgeon with Garfield than in San Francisco, she was game. “Oh, she was willing to go along; she had a lot of spirit and enthusiasm,” Cecil Cutting said in his oral history.
“I think with a little reluctance, perhaps of the unknown,” he told interviewer Malca Chall of UC Berkeley’s Regional Oral History Office in 1985. “We didn’t have any money. She had worked during my residency as a nurse, to keep us in food.” Sidney Garfield was able to match the $300 Cutting was earning at Stanford to get him to Coulee.
A rough start at Grand Coulee
Unfortunately for Millie, things at Coulee didn’t start out too well. John Smillie, MD, writes: “Cecil and Millie Cutting resided in the company hotel. They were flat broke. The young couple had exhausted their resources getting to Washington. Neither of them thought of asking for an advance.”1
“My wife couldn’t take the heat very well,” Cutting told Smillie. “She would lay on the bed with a wet sheet over her; and we didn’t have enough money to eat, really. She would go to the cafeteria and see how far she could stretch a few pennies to eat. Of course, I ate well at the hospital and had air conditioning and everything.
“She finally learned to come over and sit in the waiting room on the very hottest days. Since then, Dr. Garfield laughed at us and said, ‘Why didn’t you ask me for money?’ We didn’t know enough to do that!”
“At the end of the first discomforting month, Cutting received his first paycheck for $350,” Smillie writes. “He and Millie moved into a remodeled schoolhouse, the largest home in the community, and it soon became the social center for the physicians and the Kaiser executives.”
Millie gets her groove back
During the rest of their time at Coulee, Millie not only got her energy back but she exhibited her strength as a staff nurse and as a community volunteer. Probably her most significant contribution was the development of a well-baby clinic in a community church. As a volunteer, she organized the clinic and went door to door soliciting funds for its operation. She had no qualms about knocking on the portals of the town’s brothels.
“The madams were very friendly,” Cecil Cutting told Smillie. “The community church provided the space, and the houses of ill repute the money – a very compatible community.”
Garfield’s right hand ‘man’ at wartime shipyards
The Grand Coulee Dam was completed in 1940, and the medical staff and their families scattered. The Cuttings settled briefly in Seattle where Dr. Cutting set up a surgery practice. But it wasn’t very long before World War II broke out and Dr. Garfield was called upon again to assembe the medical troops.
Cecil Cutting was the first physician to arrive in Richmond, California, where Henry Kaiser set up four wartime shipyards. Millie Cutting volunteered to work side by side with Sidney Garfield to get the medical care program up and running and to take charge of any job that needed to be done.
She recruited, interviewed and hired nurses, receptionists, clerks, and even an occasional doctor, to staff the health care program that was set up in a hurry in 1942. She smoothed the way for newcomers and helped them find homes in the impossible wartime housing market.
Thoroughly adaptable Millie drove a supply truck between the Oakland and Richmond hospitals and the first aid stations and served as the purchasing agent for a time. As she had done at Grand Coulee, Millie set up a well-baby clinic for shipyard workers’ families, and she opened her home in Oakland as a social center for the medical care staff.
Perturbing postwar perceptions
After the war, Millie and Bobbie Collen, wife of Morris Collen, MD, started a Permanente wives group in 1949. The association created a support system against an often hostile medical establishment that shunned prepaid group practice of medicine as “socialist.” The physicians were not allowed in the local medical society, and the women felt socially ostracized.
“They organized themselves as the Permanente Wives Association, which had a nickname, ‘Garfield’s Girls,’ ” Smillie wrote. “They had dances, parties, picnics and social outings several times a year that were really a lot of fun. The auxiliary. . .became famous for its rummage sales.”
The Cuttings became good friends with Sidney Garfield, and in fact, he spent periods of time living with them in their Orinda home in the 1940s and 1950s. Cecil Cutting credits Garfield with the couple’s decision in 1948 to adopt their two children, Sydney and Christopher. “He talked us into it,” Cutting said.
Garfield often went to them for advice about business matters, as well. “I think he talked over a lot of things with Dr. Cutting and Millie,” said Smillie in his oral history. “He had a great deal of confidence in their judgment. If they told him he was wrong, he was able to accept it.”
The Cuttings were the friends Garfield chose to share the happy moment of burning the mortgage papers once the renovated Fabiola Hospital (the first Kaiser Foundation Hospital in Oakland) note was paid off. The private celebration took place in the Cuttings’ home with just Garfield and Millie and Cecil present.
Dr. Cutting worked his way up to become the executive director of The Permanente Medical Group in 1957 and retired in 1976 after 35 years as a major figure in the organization. Millie Cutting continued to volunteer at the Oakland Kaiser Foundation Hospital all of her life. She had to quit in 1985 when she became too ill to leave her house. She died that year at the age of 73. Cecil Cutting received a flood of condolence notes from all the people whose lives Millie had touched.
One woman wrote: “When life seemed just too much, Millie’s unforgettable laughter would ring in my mind’s ear, and the will to tackle life again would be there like a gift from her. She didn’t just give. She was a gift.”
1 John Smillie, MD, Can Physicians Manage the Quality and Costs of Health Care? The Story of The Permanente Medical Group, McGraw-Hill Companies, New York, 1991
By Ginny McPartland
First in a series
In the beginning of the modern era of medicine there were doctors and patients. To judge the quality of care was to ask: Did the patient live? Is the patient thriving? Doctors had little science to back up their methods. They followed conventions and did what they thought was best for the patient. If a doctor went wrong, no formal mechanism existed to correct his (or her) ways.
Hard to imagine how we got from such early simplicity to today’s complicated state of quality affairs. Our 2012 definition of quality encompasses a myriad of considerations: timely access to care, science-based treatment, adherence to well-defined practice protocols, and appropriate use of technology. Preventive care screenings, such as mammograms and colon studies to catch cancer early, and access to health education so patients can learn to avoid disease are key factors in assessing the quality of care of a provider organization.
Figuring out the best way to judge quality of care has been a monumental quest pursued by health care providers and consumers alike since the early 1950s. This pursuit has been embraced by numerous medical, government and consumer agencies in the past 50-plus years, creating a veritable alphabet soup of regulatory and review/rating organizations with varying degrees of effectiveness and longevity.
Further complicating the issue of quality is the fact that everything doctors, hospitals and health plans undertake – staff recruitment and education, research, and technology upgrades – affects quality. So it’s difficult, if not impossible, to talk about quality without looking at these topics as well. So the subject of quality is all-encompassing and, at times, overwhelming.
A case study of Kaiser Permanente’s initiatives over the decades to assess and improve quality of care reveals many different approaches and different boards and committees formed to respond to industry trends and to ultimately crack the quality nut.
In many instances, Kaiser Permanente was in the forefront of the various quality movements, often with the intention of proving its own worth to a skeptical world of traditionalists who didn’t like prepaid group practice. At other times, Permanente was pioneering new methods of care delivery and conducting crucial quality research that would lead the way for what came to be called quality assurance, initially for health maintenance organizations (HMO) and later for all forms of managed care.
Permanente physicians came from academic tradition
Garfield hired like-minded contemporaries, such as surgeon Cecil Cutting, internist Morris Collen, and gynecologist Hannah Peters, all socially conscious and oriented toward innovation, to carry out the wartime program. Learning all the time, these physicians developed new treatments and published their results during and after the war.
Inundated with pneumonia patients, Collen uncovered new ways to treat the often deadly condition. Treating pneumonia patients with horse serum and sulfa drugs, Collen was able to save many lives, even before the “wonder drug” penicillin became available to treat civilians at war’s end.
Hannah Peters, a German native who migrated to New York in 1934, studied women shipyard workers’ ability to adapt to heavy, industrial work. She noted how a woman’s menstrual cycle was affected by the carbohydrate-rich diet necessitated by the physical demands of welding and other shipyard jobs.
She and her colleague gynecologist Duncan Footer published their results in a 1946 issue of the Kaiser Foundation Bulletin, as well as in national medical journals. Peters went on to become the leader of the Laboratory for Reproductive Biology in Copenhagen and published many articles on women’s health.
Postwar health plan set aside funds for research and education
After the war when the Permanente health plan was opened to the public, quality of care continued to be a top priority. With 5% of Kaiser Foundation revenues guaranteed by its charter for education, research and community benefit, the Permanente physicians continued to form bonds with academic institutions to learn, teach and conduct research.
Sidney Garfield always put an emphasis on research and continuing education. Dr. Collen recalls: “When he (Garfield) set up the Department of Medical Methods Research (1961 in Northern California), he always maintained a close association with it. He always had important projects that he wanted our department to carry out because he was very self-critical of our organization. Although he was of course very proud of what he had conceived and accomplished, he always felt we should try to do better.”
Collen adds that having a robust research program helps attract good physicians to KP. “The best quality of care involves a simultaneous interest in teaching and in research, in addition to patient care.”
Southern California pioneers had eye on the quality ball
In Southern California, the physician group was also diligent in the selection of physicians from its beginnings in the early 1950s. Sam Sapin, quality pioneer, explains: “The SCPMG (Southern California Permanente Medical Group) had many intrinsic or built-in quality assurance mechanisms.”
These included: careful selection of physicians and imposing a probationary period of two to three years before election to partnership; and an informal but very effective form of physician peer review because of KP’s group practice model. Group practice also provided the opportunity for collaboration with colleagues and specialists to avoid inappropriate care and mistakes.
Sapin says other quality ensuring factors included mandatory physician continuing education, ongoing sharing of inpatients and outpatients and their medical records as well as the accountability for quality of care vested in chiefs of service and medical directors who could withhold merit and longevity salary increases. Another key factor: there was no incentive for overutilization or performance of unnecessary procedures and no incentive to withhold appropriate care.
Henry Kaiser triggers review of KP hospitals in 1959
Aside from the original and sincere intent to be the best in care, the Permanente physicians’ first stab at quality assurance came in 1959 when Henry Kaiser asked the question of Permanente health plan executive Clifford Keene, MD: “Do our hospitals provide quality of care? John Smillie, MD, an early KP San Francisco physician, recounts in his oral history: “Dr. Keene thought for a moment and he said, ‘I don’t know. I don’t know how we can judge how good the care is in our hospitals, but I’ll find out for you.’
“So Dr. Keene then commissioned Dorothea Daniels (KP’s first female hospital administrator) to do a study of hospital quality of care in all Kaiser Foundation Hospitals, not just Northern California, but in Southern California, and Oregon and Hawaii. She came back, I think in a year, with a very thorough report, which showed that in some hospitals the quality of care could be improved, and in other hospitals it was excellent. But it was a very honest and straightforward report,” Smillie said.
At that time, formal external quality assessment and documentation did not yet exist. The Joint Commission on the Accreditation of Hospitals had formed in 1952 and begun a voluntary accreditation program, but before the advent of Medicare in 1965 no government, employer or consumer influence had made itself felt in the regulation of medical care. That situation would soon change and the age of innocence for physician and hospital quality review was giving way to a much more complicated and anxious time.
Next time: The late 1960s and 1970s bring much conversation, soul-searching and anxiety about quality of care.