When Conventional Wisdom Becomes Outdated: How new perioperative guidelines can save time, pain, and cost

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Maurice Cates, MD, is an Orthopedic Surgeon at Kaiser Permanente’s Fredrick Medical Center. He is the chief of orthopedic surgery for the District of Columbia and Suburban Maryland as well as the regional medical director for musculoskeletal service.

Surgery has been around for thousands of years. The advances in technique, pain management, and outcomes have been remarkable. Since the advent of modern anesthesia, one thing has stayed pretty consistent; those dreaded pre-operative instructions not eat or drink anything after midnight the day of your surgery. Here is to hoping you’re scheduled in the morning, right?

qem2The thing about those instructions is that they may not be helping – especially in several types of cases, one of which is total joint replacement. While improvements in minimally invasive techniques have helped reduce length of stay for something like a knee replacement from well over a week to about 3.4 days in the past couple of decades, our work at the Mid-Atlantic Permanente Medical Group (MAPMG) is validating that it could be as short as 1-2 days in most cases. Several cases are achieving “same day discharge” and we have even completed a total knee replacement in our free standing ambulatory surgery center where the patient had no need to be admitted to a hospital at all.

One in 25 adults over 50 in America lives with a knee replacement. With that kind of volume, cutting length of stay by some 2 days per case, and potentially moving cases from hospitals to ambulatory surgery centers, could deliver a tremendous cost savings for American health care with no detriment to quality. To get there, more physician practices and hospitals need to embrace the mantra of evidence-based medicine and examine how to safely apply ERAS®, as MAPMG does, to its joint cases.

ERAS stands for Enhanced Recovery After Surgery. It represents a shift in care involving all aspects of the patient’s journey through the surgical process, from preoperative care through recovery. The whole idea is to reduce surgical stress and disruption to a patient’s baseline physiology. ERAS protocols, in brief, focus on: (1) allowing the patient to have liquids prior to surgery, (2) narcotic pain medicines are minimized (we use intravenous acetaminophen instead), and (3) eating and walking/ambulation as soon as possible after surgery. Implementation requires thoughtful development of end-to-end care pathways, decision trees, and detailed post-operative outcome measurements. Doctors, support staff, and administrators must be invested in patient-centric care, and having a cadre of talented surgeons helps too – just the ingredients we have at Kaiser Permanente.

Medical evidence in the modern world of health care is an ever-growing body of knowledge. The more organizations continuously look to new studies and those producing the best outcomes (even if it comes from outside the United States, as ERAS initially did), the more people can receive the best care possible. After all, who wants to lie in a hospital bed for 3-plus days when there is the possibility of going home the same or next day? Our patient satisfaction data bump for those having surgery with ERAS and getting early discharge versus the traditional approach suggests the answer is nearly no one.

Can you see me now? Video Visits at Kaiser Permanente

By | Care Delivery, Uncategorized | No Comments

Dennis Truong, MD, is an emergency medicine specialist and the telemedicine director for the Mid-Atlantic Permanente Medical Group.

Smart phones and tablets are everywhere. Adoption of these devices now largely spans age, income, race and ethnicity. Americans, of all stripes, are emailing, tweeting, posting, banking, gaming, navigating, checking weather and so much more almost nonstop. Yet when it comes to using those nearly ubiquitous devices, only 2 percent report having access to video visits with their doctor.

In stark contrast, almost 9 in 10 family physicians believe telehealth – the suite of technologies and tactics to deliver virtual medical, health, and education services – is a way to increase access to care. Putting two and two together, that means far more than 2 percent of people should have access to video visits – a core component of telehealth.

Dr. Truong conducts a simulated video visit with a member.

Dr. Truong conducts a simulated video visit.

Why this disconnect? Telehealth regulatory policy for one. From the patchwork of state by state rules to privacy protections to reimbursement rules. Doctors (and some patients) also worry that telehealth has limited diagnostic and treatment value relative to face-to-face care and will adversely impact the day-to-day practice of an office. Not only does it interfere with the routine of quickly moving from one prepped patient to the next, it changes how you chart, plan for space in your office, bill and collect, and so much more.

The regulatory and payment framework must evolve, and technological advances in remote capabilities can help validate telehealth as a reliable solution. But it is easy to overlook the fact that none of it matters if doctors don’t want to change their norms. And, that adoption will fail if the consumer satisfaction barometer is not met as a result of a fragmented experience. At the Mid-Atlantic Permanente Medical Group (MAPMG), and all the Permanente groups of Kaiser Permanente, video visits have become a key part of our clinical offering. Making it work has been a case study in careful planning rather than chasing a “sexy” concept without judiciously working out all the details.

Since launching video visits three years ago, we carefully worked through the legal and regulatory steps. We put in the necessary equipment, trained every provider, collaboratively chose the specified set of clinical chief complaints that should be eligible for video, and slowly built video visit appointments into the schedule that gave physicians dedicated time for the care. The “competition” isn’t other providers. It is the doctor’s frame of reference. Is this as easy as when the patient is sitting in the exam room ready and waiting with forms completed, vitals collected, and nursing tasks done?

As the industry saw more platforms and pure-play video offerings emerge, we worked to stay true to a principle that says video care shouldn’t be fragmented from the normal care patients receive. Patients do not want to repeat themselves, pay for redundant tests, or fail to get a diagnosis because the doctor doesn’t have enough information to definitively make one. Nor do they want to have their “regular” doctor fail to provide care in consideration of what is known from any previous video encounters.

We purposefully integrated our solution into the same integrated electronic medical record we use for every face-to-face visit, telephone, or email visit. All the information is there to make the right clinical call. The ordering and referring process is identical (and can be done for the patient by the provider). The activity is visible to the patient’s regular provider(s).

When practiced right, it becomes as clear as the face on that smart phone screen that video visits are a powerful tool to improve access and patient satisfaction. The medical community needs to invest in making it not simply available to more patients, but making it available in a way that allows them to integrate that care with their overall primary and specialty care.

Minority Women with HIV or AIDS May Suffer From Violence at the Hands of Intimate Partners, Delaying Necessary Treatmen

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Today concludes the 2015 National HIV Prevention Conference – a national conference to share advances, strategies and accomplishments in HIV prevention and care. You can follow along with a number of interesting talks and presentations on social media #NHPC2015. Similarly, Kaiser Permanente’s Institute for Health Policy recently published findings regarding women who are a growing risk group that suffer from the illness and face barriers in seeking and receiving care.

Minority Women with HIV or AIDS May Suffer From Violence at the Hands of Intimate Partners, Delaying Necessary Treatment

Brigid McCaw, MD, MPH, MS, Medical Director for Kaiser Permanente’s Family Violence Prevention Program

An interview with Brigid McCaw, MD, MPH, MS, Medical Director for Kaiser Permanente’s Family Violence Prevention Program.

Although the U.S. has made progress in identifying and treating HIV and the late symptoms of the infection, AIDS, women are a growing risk group that suffer from the illness and face barriers in seeking and receiving care.  Recent studies have shown that violence against women – specifically violence at the hands of an intimate partner – may be an important cause of this gender-based disparity in care for people with HIV/AIDS.

In 2013, out of more than 47,000 newly HIV-positive individuals in the U.S., nearly 20 percent were women, with 86.6 percent of their infections coming from heterosexual contact. Those from minority backgrounds were disproportionately affected, with close to 6,000 new diagnoses in African American women and 1,400 in Hispanic/Latinas. And while the number of women with HIV/AIDS is growing, only 45 percent of women living with HIV are engaged in care, and even fewer, 32 percent, have the virus under control.

– Read the full article here.

Organizing Care for the Future: A Live Broadcast from the Kaiser Permanente Center for Total Health

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On September 30, 2015, The Kaiser Permanente Center for Total Health (@KPTotalHealth) hosted “Care Redesign: Creating the Future of Care Delivery” with The New England Journal of Medicine Group (@NEJMGroup) and Harvard Business Review (@HarvardBiz).

Featured speakers included Robert Pearl, MD (@RobertPearlMD), CEO of The Permanente Medical Group and Mid-Atlantic Permanente Medical Group, who addressed “The Health Care Value Chain.” The event was broadcast to an estimated audience of 9,000 people worldwide, in addition to a smaller (obviously) in-person audience spanning the spectrum of health innovation locally and regionally. The nice thing about our collaboration with the New England Journal of Medicine Group is (a) the experience they bring in producing live events like this, (b) their extensive reach – including that of their parent, New England Journal of Medicine (@NEJM) and (c) their ability to put the multimedia together in a useful package. That’s what they’re going to do for this event, which will be published as a product of the NEJM Group, on the web. The presentations were tight, followed by panels, and carefully choreographed for the broadcast. In his comments, Dr. Pearl was emphatic and animated about the value for the amount of money spent on health care in the United States. Hint, it’s not high….

At the same time, with physician leadership, integration, the harnessing of technology (and in Kaiser Permanente’s case, “good genes” as Dr. Pearl said on the broadcast), the United States can lead in quality. For example, 5-star programs today could deliver 20 to 30 percent of visits to a person’s physician via video. Robert Pearl MD CEO The Permanente Medical Group - CareDesign1510

In terms of live reach, this event was both a record for the Center for Total Health, and we are told, for the New England Journal of Medicine Group.

We already knew that our physician-led vision of the future is compelling and this was confirmed. Putting these together, we’re eager to bring the platform of the Center for Total Health and Permanente Medicine together again to radiate what’s possible to the people and communities we serve and the leaders of other organizations who want to serve their communities well, too.

CareDesign15 09481

First two photos above courtesy Leigh Vogel

What Is Blue Button? Why Do I Care?

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RevisedBlueButtonlogowithmarkEditor’s Note: This post is authored by guest blogger Mary Anne Sterling. Mary Anne has been a thought leader in health information technology and health policy for over a decade. She serves on several healthcare advisory panels, a Federal Advisory Committee, and recently served as Executive in Residence for the Healthcare Information Management and Systems Society (HIMSS) Foundation, Institute for e-Health Policy.

  • Are you caring for an elderly parent? Are you trying to keep your child’s vaccination records up-to-date?
  • Do you have a health issue? Do you want to feel more in control of your personal health information?
  • Do you need to share your health information among several doctors? Are you changing doctors?
  • Do you need to find the results of a medical test? Do you need a current list of your medications?

If you answered “yes” to any of these questions, you need access to your health information or the health information of someone you care for. You may not be aware that you have the right to access it and healthcare providers must allow you to do so. When you have access to your health information, you can partner with care providers on improving the quality and safety of care that you or a family member receives.

To help you better understand why this should be important to you, I’ve asked Aaron Seib of the National Association for Trusted Exchange (NATE) to help me break down what this means and what you can do to help.

MA: Why would someone want access to their own health information?
AS: You have a legal right to receive your personal health information. Many people are not aware of this. When you have your health information, you can:

  • Share it with your doctors or trusted family members or caregivers
  • Check to make sure the information, such as your medication list, is accurate and complete
  • Keep track of when your child had his/her last vaccination
  • Have your medical history available in case of emergency, when traveling, seeking a second opinion, or switching health insurance companies
  • Plug your health information into apps and tools that help you set and reach personalized health goals.

These things are just too important to leave to others to manage for you. It’s time to take command of your health information. After all, it belongs to YOU.

MAS: It’s one thing to have access, but will the information be in an understandable format?  Will medical jargon be translated?  How will someone know what to do with the information?
AS: Our medical information is often difficult to understand and we don’t always have easy access to people who can explain it to us. Right now, it is imperative that people have access to their health information first and then we can work with patients, family caregivers, and app developers to ensure this information is presented to them in a way that they can better understand and use. The good news: we see multiple services already emerging that assist in translating complicated health data into accessible information for patients and family caregivers.

MAS: If I want to share my health information, can I choose what parts of my information I allow to be shared?  For example, will my mental health notes from my psychiatrist or therapist be made available to my primary care doctor?  Is it all or nothing as far as what is made available?
AS: Working in partnership with your doctors, you can decide what information is shared and for what purpose. But you must be actively engaged in managing your health information in order to do that. You may decide to share some information, all of your information, or nothing at all.

BlueButton-Logo-withtextandmarkv2 (2)MAS: How is my information protected? With all the hacking of retail, credit cards and even insurance accounts, how can I be sure my information is being kept safe, especially when I download it?
AS: Using ‘Blue Button” is one good way you can access your health records electronically. Millions of Americans can get easy, secure online access to their health records thanks to Blue Button. Health information about you may be stored in many places, such as doctors’ offices, hospitals, drug stores and health insurance companies. Ask your health care providers or health insurance company if they offer you the ability to view online, download, and share your health records via Blue Button and look for the Blue Button logo.

MAS: How do I talk to my doctor about getting access to my health information?
A: NATE has a letter that you can download from our website to make that conversation easier. The hardest part is getting the conversation started! But you will be glad you did when you have the peace of mind of knowing your health information is at your fingertips.

MAS: If someone is interested in knowing more about this topic, what are the best resources for more information?  
AS: NATE is not the only organization working to get patients and family caregivers access to their health information. Additional sources of information are:

Blue Button:

Other initiatives that you may be interested in learning more about:

Overall, having access to your personal health information, or the health information of someone you care for, is an important step in maximizing your health and the health of others. Now is the time to get involved in the discussion and request access to your own health information. Being a more informed healthcare consumer could save your life!

ILN Day 2: Innovation Safaris

By | Center for Total Health, Health Innovation | No Comments
Capital Bikeshare -- Innovating active transportation.

Capital Bikeshare — Innovating active transportation.

This morning, ILN in-person attendees got the chance to visit DC-area companies embodying innovation in their everyday work. Safari destinations included:

  • Capital Bikeshare – Technology to change the way we move, for health
  • NPR Headquarters – Disrupting broadcasting, building for health
  • Consumer Financial Protection Bureau  (CFPB) – Financial health and behavior change at the 
  • National Intrepid Center of Excellence at Walter Reed National Military Medical Center  (NICOE)
  • ONC Blue Button – Empoweirng patients with their electronic health record information  (SafariBlueButton)
  • OPOWER – leveraging the latest behavior change science to transform energy consumption  
  • Uniformed Services University (USU) Simulation Center (USUSIM)
  • MedStar Health’s Simulation Training & Education Lab (SiTEL)
  • The Bridge to ER One at MedStar Washington Hospital Center
Walter Reed Dedication

Walter Reed Dedication

ILN Attendees with the Surgeon General

ILN Attendees with the Surgeon General

Attendees hurried back to the Center for Total Health for remarks from Rear Admiral (RADM) Boris D. Lushniak, M.D., M.P.H., Acting Surgeon General of the United States, who reminded us that we haven’t failed until we stop trying.

The afternoon included more great speakers and a walking break to the Supreme Court. Tonight, we’re looking forward to a healthy dinner at 1776 with health startups on the cutting edge of technology and innovation.


Innovation Learning Network, In Person: Day 1

By | Center for Total Health, Health Innovation | No Comments

Yesterday, the Center for Total Health was excited to kick off the Spring Innovation Learning Network (ILN) In Person meeting after months of planning. In partnership with Kaiser Permanente, the Military Health System, MedStar Health and other organizations, the ILN convenes health care innovators from around the world to share ideas, problems, solutions, and inspiration.

Newly Titled Innovation Divas  Ted Eytan, MD, Chris McCarthy, Keith Montgomery, Tim Rawson

Newly Titled Innovation Divas
Ted Eytan, MD, Chris McCarthy, Keith Montgomery, Tim Rawson

The three-day conference has the theme of complex system change, and kicked off with tours of the Center for Total Health. Speakers included our own Keith Montgomery, executive director for the Center for Total Health, author Paul Plsek, and MedStar’sEd Tori. Themes included being willing to take risks (and possibly fail before you succeed) and moving to a focus on simple rules built by the users (rather than dictated by the top).

Ed Tori, MedStar

Ed Tori, MedStar

So much more to learn on days 2 & 3! Follow along on twitter via #ILN14 !

Photos of the Week: A Busy Thursday

By | Center for Total Health, Photos | No Comments

Today was a busy day at the Center for Total Health. We were excited to welcome a range of guests from across the total health spectrum. Guests included a  group of nursing students from George Washington University, the Coalition to Transform Advanced Care (C-TAC), and Hal Ruddick, Executive Director of the Coalition of Kaiser Permanente Unions.

Lu Casa, ARNP, welcomes George Washington Nursing students

Lu Casa, ARNP, welcomes George Washington Nursing students

C-TAC's Advanced Care Project Kick-Off Meeting

C-TAC’s Advanced Care Project Kick-Off Meeting

Keith Montgomery, Executive Director of the Center for Total Health, and Hal Ruddick, Executive Director of the Coalition of Kaiser Permanente Unions, wearing two different types of fitness/activity tracking devices

Keith Montgomery, Executive Director of the Center for Total Health, and Hal Ruddick, Executive Director of the Coalition of Kaiser Permanente Unions, wearing two different types of fitness/activity tracking devices

Photo of the Week: German IT Delegation

By | Center for Total Health, Experts, Health IT | No Comments

Today at the Center for Total Health, Kaiser Permanente International hosted a group of German Health IT delegates for an informational session. Joy Lewis, MPH provided an overview of Kaiser Permanente to set the context for the dialogue that followed. The group saw a KP HealthConnect demonstration and heard about being a physician Tom Tesoriero, MD, from the Mid-Atlantic Permanante Medical Group, followed by a discussion with Sandra Stuart, Executive Director of Health IT Standards. Sandra talked with the group about the future of HIT and shared some examples of how Kaiser Permanente is forward-thinking about the use of technology at four different care sites (hospital, clinic, home and virtual).

Dr. Tesoriero

Dr. Tesoriero



Group Discussion


Sandra Stuart speaks to the group about Kaiser Permanente's approach to Health IT

Sandra Stuart speaks to the group about Kaiser Permanente’s approach to Health IT


The Next Total Health Focus at CTH: Connecting Patients & Social Support for Better Health

By | Care Delivery, Center for Total Health, Community Health Initiatives, Experts, Health Innovation, Healthy Communities, Live Chat, Video | No Comments

Bookmark this post in your browser and return January 23 (3 p.m. to 4 p.m. Eastern, noon to 1 p.m. Pacific) to watch the webcast live.


On January 23, the Center for Total Health will host the next Total Health and Technology Focus, this time looking at tools to support the social needs of patients.

Total health is about the mind, body and spirit. but there are other influences on our health — such as the community a person lives in, the environment that surrounds them and all their relationships that influence healthier behaviors.  Unrecognized needs such as support for housing, food/nutrition or other psycho-social stressors also have an impact on health.  Clinicians often feel unable or unprepared to address these needs.

Our January 23 event will feature Healthify and Health Leads, two organizations with innovative models that help people with unmet social needs connect to available community services.  Join us for a discussion on how clinicians can be part of a health system solution.

About the Organizations
Healthify  is:

  • a dynamic screening tool that identifies and quantifies the social and behavioral needs of your patients
  • a matching algorithm that finds, refers, and texts patients about the best resources for their needs
  • a dashboard to allow staff to search for resources and gain insight into their population

Health Leads works with clinics to connect patients to basic resources, improving health outcomes and patient satisfaction while lowering the cost of care. Health Leads enables doctors and other healthcare providers to “prescribe” basic resources like food and heat just as they do medication. The organization recruits and trains college students to “fill” these prescriptions by working side by side with patients to connect them with the basic resources they need to be healthy.


Please note that Kaiser Permanente does not endorse the products featured in these discussions.