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
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”
Kaiser Permanente Heritage Resources has started a regular column in the labor-management partnership publication Hank about the rich labor history of the organization.
The Summer 2012 issue includes a story about how Bay Area longshore workers participated in a groundbreaking medical program—the Multiphasic Screening Examination, the first comprehensive health assessment conducted in cooperation with a union, way back in 1951. One aspect of this relationship was understanding that good medical care requires knowing about a patient’s living and working conditions. Even after a remarkable record of offering health care for workers in the shipyards during World War II, further physician education was called for.
Recognizing traditional medical services were not well attuned to the health needs of working people, the ILWU newsletter The Dispatch noted “Local 10 is going to put five Permanente doctors through a course of indoctrination on the waterfront, so that they will learn first-hand the conditions under which longshoremen work and will be better able to interpret the tests.”
Read the whole story at http://www.lmpartnership.org/stories-videos/longshore-start-total-health
short permanent URL for this item – bit.ly/RVK5RY
By Ginny McPartland
When I first heard Kaiser Permanente was offering its employees a $50-to-charity incentive to take the THA, I wasn’t that impressed. I didn’t think the donation would convince people to participate in KP’s initiative to build a healthier workforce. I also didn’t think $50 would go that far. I have to admit I was WRONG!
By mid-December, more than 22,000 (14.5%) KP employees nationwide had taken the THA and by that small action collectively raised an impressive $1.1 million. Now that will go a long way. How far? For starters, each $50 could buy 700 pounds of fruits and vegetables or 77 dozen eggs for the hungry. Or it could provide 10 pediatric flu shots for needy kids. Multiply those items by 22,000 donors and you get the picture.
The money raised by the 2010 THA incentive program will go to community healthy eating initiatives and to support health care for disadvantaged people and families, especially the homeless, the disabled and those living with HIV/AIDS. The KP region whose employees raise the most money will receive an extra $50,000 for charities in their communities. The winner will be announced in January; the money will be awarded in March.*
I think it says something about the KP culture that so many employees were motivated to raise money for others less fortunate than themselves. If they hadn’t felt compelled to take the assessment for their own sake, they were motivated to help others. Of course, Kaiser Permanente has given millions to good causes over the years through its Community Benefit programs.†
Total health assessment by any other name
Given our history as a preventive care organization, it shouldn’t come as a big surprise that Kaiser Permanente has been a champion of the total health assessment for over 60 years. In 1950, such an assessment was called the “multiphasic examination,” and it was initiated when labor leader Harry Bridges of the International Longshore and Warehouse Union (ILWU) demanded it for all members of the union.
These records, still accessible today, have supported long-term health research related to heart disease and other chronic diseases. One such study, “Characteristics of Longshoremen Related to Fatal Coronary Heart Disease and Stroke” by Paffenbarger et al., was published in the “American Journal of Public Health,” in 1971.
In the late 1960s, Permanente founding physician Sidney Garfield launched a program called “The Total Health Care Project” to expand the multiphasic programs in Oakland and San Francisco. Garfield and Robert Feldman, MD, hired and trained KP’s first nurse practitioners to run the program that included the use of computerized lab machines that yielded results while the patient was still at the clinic. Their goal was to collect baseline health data that could be used to identify health risks and to prevent disease.
Today’s iteration of the multiphasic exam is a system of chronic disease screening programs designed to detect symptoms early and identify risk factors. The total health assessment questionnaire challenges participants to scrutinize their lifestyles and work with their doctors to figure ways to head off diseases such as diabetes, heart disease and cancer.
For me, the THA results are a reminder of what I need to do to stay healthy. I’m also hoping I can improve my sleep by following through with the online insomnia program. But most of all, I feel glad that my co-workers saw fit to get involved for themselves and to raise money to improve the health of others less fortunate.
*Benefit-eligible Kaiser Permanente employees and physicians may earn the $50 charitable donation by taking the THA by Dec. 31. Go to the Healthy Workforce site to participate.
†Click here for more information about Kaiser Permanente’s Community Benefit Program.