When Conventional Wisdom Becomes Outdated: How new perioperative guidelines can save time, pain, and cost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

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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.

I Want To Be The Next Summer Intern!

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This summer, I interned at the Center for Total Health through the Kaiser Permanente Mid-Atlantic Summer Internship Program. I am currently a senior at James Madison University majoring in Health Science and with minor in Health Communications.  After graduation in May 2017, I plan on attending graduate school to obtain a Master’s in Public Health.  My future career goal is to educate disadvantaged populations in the United States about various health topics to help eliminate current health disparities in our country.  The Kaiser Permanente Mid-Atlantic Summer Internship Program has tremendously prepared me for success in the future and in an industry-leading healthcare company.

On July 22, 2016, I provided tours to the youth participants of the 2016 DC Summer Youth Employment Program. [Photo By: O Grant]

On July 22, 2016, I provided tours to the youth participants of the 2016 DC Summer Youth Employment Program.
[Photo By: O Grant]

I was given various projects this summer that have honed my skills and knowledge of health.  One project I was given was to provide informative tours of the Center for Total Health to guests.  The tour consists of content exploring topics including Kaiser Permanente’s history, different aspects of total health, and advancements in telemedicine.  Not only have my presentation skills improved, I am now equipped with conversation starters to engage in meaningful dialogues with professionals in health related fields. Another project I was given, also my personal favorite, was the honor to design a display showcasing African-American history throughout Kaiser Permanente.  It will be displayed at a VIP luncheon hosted for top employers and partners of Kaiser Permanente Foundation Health Plan and Hospitals, held in September.  Kaiser Permanente Foundation Health Plan and Hospitals demonstrates and embraces diversity in the workplace, therefore the company is a proud financial contributor to the new African-American History Smithsonian in Washington, DC.  To complete the project, I researched the content, contacted Kaiser Permanente diversity committees, and wrote a creative brief for the display.  This project allowed me to take the initiative and utilize the leadership skills I have learned throughout college.

As a participant of the Kaiser Permanente Mid-Atlantic Summer Internship Program, I also attended weekly professional development forums organized by current Kaiser Permanente employees. The forums were interactive, informative and a key to my professional growth this summer. We discussed resume writing, networking skills, interview tips, professional dress and much more.  In addition to the professional development forums, we attended a Nationals’ baseball game in July and spent an afternoon volunteering with SOME (So Others Might Eat), a community based organization in DC to help poor and homeless residents.

The ten-week program has placed me a step ahead of my peers entering the workforce after graduation in May.  At the conclusion of the program, I have taken away valuable items to place into a portfolio, strong communication skills, confidence in my work ability and strengthened my soft skills in professional office setting.  I am very thankful for this opportunity and appreciate the Center for Total staff for welcoming me on board this summer.  In the future, I would love to work for Kaiser Permanente after completing my education.

If you are interested in being an undergrad intern through the Kaiser Permanente Mid-Atlantic Summer Internship Program next summer, please visit www.kaiserpermanentejobs.org to learn more!

This Week in Total Health: Sweating the Details

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Another busy week has drawn to a close at the Center for Total Health.

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Brendan O’Grady, WELL AP, explains initial readings to Kathy Gerwig, vice president of Employee Safety, Health and Wellness, and environmental stewardship officer and Carol Corr, AIA, LEED GA, EDAC, Design Program Manager, National Planning and Design, National Facilities Services

On Monday and Tuesday, the center welcomed Delos (@DelosLiving)for the first step of our WELL Building Standard Certification.  Ted Eytan (@tedeytan) wrote an in-depth summary of the experience.

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Kathy Porter

Our team was thrilled to meet Kathy Porter, who is the face of the original Alexandra persona used by our design teams, and Cathryn Burby from the American Cancer Society this week.

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Cathryn Burby, Senior Director, Community Engagement at the American Cancer Society

August brings heat and humidity to our nation’s capital, making it a notoriously quiet month across the city. Our team is taking advantage of this time to get our ducks in a row for a busy fall. If you’d like to come the Center for Total Health for a tour or event, please let us know!

Week in Total Health: All About the Future

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The week of July 18 was a busy one for the Center for Total Health, with six events in five days, including three for 100 people each.

The week started off with the Smart Growth America Local Leaders Summit (@SGALocalLeaders), a gathering of local officials from cities and towns across the country. The day covered a number of strategies for building health into municipalities of all sizes, from small, rural towns to large, urban cities. True to form, the attendees enjoyed a walk through the neighborhood, including a view of our complete street from the bridge above.

SGA Walk

A health organization team retreat and a school nutrition non-profit training kept us on our toes on Wednesday.

The end of the week was filled by young residents of Washington, DC, participating in the city’s Summer Youth Employment Program (@MBSYEP). Over two days, nearly 200 participants came to the CTH to participate in health workshops led by Kaiser Permanente’s  (@KPMidAtlantic) Health Education team on topics ranging from quality ratings to relaxation techniques.

Deputy Mayor for Greater Economic Opportunity Courtney R. Snowden (@DMGEOSnowden) spoke to the students, reminding them that every minute of every day is an opportunity to work toward their goals. It was great to spend two days with the future of this city.

Deputy Mayor for Greater Economic Opportunity Courtney R. Snowden addresses SYEP participants.

Deputy Mayor Snowden addresses SYEP participants

This Week in Total Health: It’s All About Care

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Another busy week wraps up at the Center for Total Health. We welcomed inspiring visitors and conversations ranging from telehealth to heart health, focused both on our own members and the community at large.

On Wednesday, Kaiser Permanente’s Community Benefit team hosted a convening for community practitioners to share our ALL/PHASE protocol, which is a  simple, inexpensive, evidence-based regimen of medications that dramatically reduces the risk of heart attack and stroke among diabetics. The ALL/PHASE program was a winner of the 2010 James A. Vohs Award for Quality and is one of the innovative ways Kaiser Permanente shares information and tools to measure disparities and promote equitable care. The attendees also very literally walked the walk of heart health by joining the CTH team for a 30 minute walk before lunch.

Kaiser Permanente's ALL/PHASE Community Convening

Kaiser Permanente’s ALL/PHASE Community Convening

Michael Adcock, FACHE, Administrator at the University of Mississippi Center for TeleHealth, presents to the Connected Health Coalition.

Michael Adcock, FACHE, Administrator of the University of Mississippi Center for TeleHealth.

On Tuesday, the Connected HealthCoalition hosted an in-person meeting featuring a presentation from the University of Mississippi Medical Center’s Center for Telehealth (@UMMCTelehealth). Michael Adcock, FACHE, the Administrator of the Center for TeleHealth, shared the amazing work going that organization is leading across the state to increase access for all residents to medical care, health education and public health services through telehealth.

 

We were also honored to host an event focused on the transgender community. The “Transgender Health Meet and Greet,”  included physicians, nurses, and health leaders from Kaiser Permanente Mid-Atlantic States, Mid-Atlantic Permanente Medical Group, and The Southeast Permanente Medical Group. Our physicians and clinicians hosted two surgeons, along with representatives from the LGBTQ community from Washington DC, Maryland, and Virginia to talk about surgical care for people who are transgender or gender non-conforming. A full post about that event can be found here.

Interns from the Mid-Atlantic Permanente Medical Group

Interns from the Mid-Atlantic Permanente Medical Group

Another thrill for the week – to meet the Mid-Atlantic Permanente Medical Group’s summer interns. These future health care leaders had great ideas about total health, and enjoyed our newest exhibit – a virtual reality tour of Baltimore.

As always, these are just a few of the pictures from the week. The full set can be found here.

Hepatitis C: It’s Curable, So Let’s Find the People who Need to be Cured

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Dr. Michael Horberg is Executive Director Research, Community Benefit and Medicaid Strategy of the Mid-Atlantic Permanente Medical Group (MAPMG) and the director of the Mid-Atlantic Permanente Research Institute (MAPRI). Carla Rodriguez , PhD, MPH, and Cabell Jonas, PhD also contributed to this post. 

Too often, news coverage of hepatitis C focuses on the cost of new drugs and not the importance of determining which patients have hepatitis C and getting them into effective care.

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The Kaiser Permanente Center for Total Health regularly updates the information in our displays in collaboration with our health systems partners in Kaiser Foundation Health Plan and the Permanente Medical Groups. The Q1 2016 update focuses on Quality & Expert medicine, as led and delivered by the Mid-Atlantic Permanente Medical Group.

An estimated 50 percent to 80 percent of those with hepatitis C are unaware of their infection. Experts believe that is a group of some 800,000 people. Screening them all could prevent 120,000 deaths – not to mention stop the spread of infection to others. Simple blood testing and liver damage assessment, seems like a low price to save 120,000 lives – or thought of differently, preventing a deadly plane crash every day for the next year.

It is well known across medicine who should be screened (everyone born between 1945 and 1965, plus at-risk individuals such as those with HIV or patients on kidney dialysis, men who have sex with men, and people who have used injectable drugs now or in the past). But we at the Mid-Atlantic Permanente Research Institute (MAPRI), the institutional research arm of Kaiser Permanente of the Mid-Atlantic States and the Mid-Atlantic Permanente Medical Group (MAPMG), set out to find a way to actually make it happen. Data suggests only a few percent get screened (0.7-12.7 percent) – and less than half of those end up actually linked to care they need. If others could adopt our innovative program, the impact could be tremendous.

Knowing the problem is half the battle. We found that most doctors have a hard time remembering when to recommend their patient be screened. And, for those doctors who order the screening, patients may still not follow through because they need to complete three discrete steps (an antibody blood test, an RNA blood test, and liver imaging or biopsy). Therefore, our solution carefully addressed each problem. The solution:

  • Automated alert when doctors open charts during visits with patients who match screening criteria
  • The antibody blood test is linked to an order for the confirmatory HCV RNA test (meaning blood is collected at a single visit to the lab rather than asking the patient back for a second blood draw for the HCV RNA test)
  • Provided for a dedicated coordinator who could make sure no one fell through the cracks and helped them get the liver damage testing they may need contingent upon blood test results as well as linkage to ongoing care from their physician or a specialist
  • Offered patients a non-invasive, pain free liver damage assessment rather than a biopsy (when clinically feasible)

New peer-reviewed research shows that the integrated screening approach is working. Screenings are up dramatically, those who start step one of screening are getting a complete diagnosis and linkage to care

While the cost of treating hepatitis C is no doubt an important issue, we also need to pay attention to and champion screening advances that will help us do a better job of diagnosing and stopping the spread of this deadly virus.

Preview: Better Together Health Returns to CTH

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Next week, the Council of Accountable Physician Practices (@accountableDOCS) will host the second in a series of Better Together events at the Center for Total Health. The program will focus on patient expectations accountable physician practices.

The transformation of American health care means more than reducing costs and improving quality scores. Healthcare systems have to focus on closing the gap between what patients actually want and what they are experiencing, especially for those with chronic illness. How can we bring true accountability to the system? The Council of Accountable Physician Practices and the Bipartisan Policy Center invite you to hear patients and doctors tell their stories of what patient-centered care really looks like.

To attend in person or gain access to the live webcast, REGISTER HERE.

The first event, focused on technology-enabled interactions between patients and physicians. Two of the personal patient stories shared at the event – Emma, a baby with severe burns, and Karen, an oncology patient- can be seen here.

If you have questions about this year’s event, please contact Elizabeth Keating via this link.

 

This Week in Total Health: Championing the Future

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As we tend to do, we hosted leaders who look ahead. The Accelerated Leadership Development Program came to the Center to see how the Washington, DC environment impacts their work in health, with an additional special guest Armond Kinsey, who’s the Director of Diversity, Kaiser Permanente Mid-Atlantic States.

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This week was also the American College of Physicians Internal Medicine Meeting 2016, held in Washington, DC, which brought additional champions of the future our way, including Priya Radhakrishnan, MD, from the Practice Innovation Institute, in Phoenix, Arizona. Always here to learn and to teach.

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See all of the photos from this week here.

This Week in Total Health: The End of an Era

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As another busy week comes to a close at the Center for Total Health, our team would like to first take a moment to thank Yen Greene (@YenGreene), who has been with us for almost five years, for all of her hard work and dedication. She’s a remarkable person and colleague, and though she isn’t going far, she will be missed. Our loss is Kaiser Permanente Mid-Atantic’s gain.

On Thursday, the Center for Health Design hosted Health Design Insights, an evening for health care architects and designers. The featured speakers were Jeff Shub, MD, of GapingVoid (@gapingvoid); Patrick Schultz, AIA, EDAC, LEED, AP, of HKS Architects (@HKSArchitects); and Barbara Huelat, FASID, AAID, EDAC, of Huelat Davis (@HuelatDavis). As always, it’s inspiring to witness a group of people dedicating their incredible talents and intelligence to the health of others.

Center for Health Design - Health Design Insights

Center for Health Design – Health Design Insights

As those who have been to the center might know, we installed a pedestrian counter outside along the Metropolitan Branch Trail to track pedestrian traffic as part of a network of counters across Washington, DC. (Learn more about that project here.) This week, the counter got a new battery (thank you, Tracy Hadden Loh!).

New battery for the EcoCounter pedestrian counter

New battery for the EcoCounter pedestrian counter

Find all of this week’s pictures here. And, for posterity, some of our favorite pictures of Yen over the years. Thanks for all the laughs, Yen!