Using technology to enable a health system that supports total health and makes lives better. Kaiser Permanente Center for Total Health / guest lecture at Stanford School of Medicine : Digital Medicine: Designing IT Innovations that Improve Healthcare Stanford University Biomedical Informatics 207 Summer Quarter 2014

1. Health is the new HIT
Digital Medicine: Designing Innovations that Improve Healthcare:
Stanford Biomedical Informatics 207
July 31, 2014
Ted Eytan, MD MS MPH • The Permanente Federation • twitter: @tedeytan
© 2014 The Permanente Federation, LLC | Photograph: Ted Eytan, MD, http://www.flickr.com/photos/22526649@N03/14064117427

2. Health is the new HIT
Digital Medicine: Designing Innovations that Improve Healthcare:
Stanford Biomedical Informatics 207
July 31, 2014
Ted Eytan, MD MS MPH • The Permanente Federation • twitter: @tedeytan
© 2014 The Permanente Federation, LLC | Photograph: Ted Eytan, MD, http://www.flickr.com/photos/22526649@N03/14064117427

3. “The Pulse of Health Care”
Squawk Box with Andrew Sorkin • July 14, 2014

5. Build Your Best Life Total Health Festival, with Capital Pride, Washington, DC • Kaiser Permanente 2014 Gold Sponsor
I’m an ally
(also a family doctor,
a Permanente physician,
a Kaiser Permanente member,
a Washington, DC resident)
Hi. I’m Ted.

6. We’re here from the future
Kaiser Permanente Center for Total Health,Washington, DC • @KPTotalHealth

7. are you?
Kaiser Permanente Interchange API Code-a-Thon, June, 2013, Washington, DC

8. Innovation System: Kaiser Permanente
“social
innovation”

9. In the future, technology enables us to
Lead in Total Health by
– delivering excellent medical care
– eliminating health disparities
In a health system that
– faces the community, not the hospital
– heals by not harming
– listens to the people it serves
and as a result makes lives better Kaiser Permanente La Mesa Medical Offices, La Mesa, California
70% powered by the sun

10. …deliver excellent medical care
KP member
US 90th %
Source: Zhou YY, Kanter MH, Wang JJ, Garrido T. Improved Quality At Kaiser Permanente Through E-Mail Between Physicians And Patients.
Health Affairs. 2010;29(7):1370-1375. Available at: http://content.healthaffairs.org/cgi/content/abstract/29/7/1370 [Accessed July 7, 2010].

11. + email
US 90th %
Significant? How
about p<0.0001
Source: Zhou YY, Kanter MH, Wang JJ, Garrido T. Improved Quality At Kaiser Permanente Through E-Mail Between Physicians And Patients.
Health Affairs. 2010;29(7):1370-1375. Available at: http://content.healthaffairs.org/cgi/content/abstract/29/7/1370 [Accessed July 7, 2010].
…deliver excellent medical care

12. © 2014 The Permanente Federation, LLC
Source: Kaiser Permanente Web Analytics, updated 07/09/2014
4.5 million members connected, via kp.org

13. © 2014 The Permanente Federation, LLC
Source: Kaiser Permanente Web Analytics, updated 07/09/2014
In 2014, per month
1.6 million emails
3.1 million test results reviewed
50% of the shared results
356 thousand appointments
made
35 % signed on 5 or more times
26 % of visits via mobile device
4.5 million members connected, via kp.org

14. © 2014 The Permanente Federation, LLC
Act for Child / Act for Adult
Source: Kaiser Permanente Internet Services Group Web Analytics
Updated 07/09/2014
and, 545,000 caregivers
!
756,000 subjects

15. © 2012 The Permanente Federation, LLC
The most HEDIS #1’s
Effectiveness of Care Measures Kaiser Permanente #1’s
•Comprehensive diabetes
care — LDL control less than
100 mg/dl (Hawaii Region)
•Osteoporosis management
in women who had a fracture
(Northern California Region)
•Breast cancer screening,
age 42–69 (Northwest
Region)
•Pharmacotherapy
Management of chronic
obstructive pulmonary
disease (COPD)
exacerbation —
bronchodilator (Northwest
Region)
•Cholesterol management
(coronary artery disease),
LDL level less than 100 mg/
dl (Colorado Region)
•Follow-up after
hospitalization for mental
illness — 30 days (Colorado
Region)
•Controlling high blood
pressure — cardiovascular
(Hawaii Region)
•Potentially harmful drug-
disease interaction — total
(Hawaii Region)
•Weight assessment for
adults — body mass index
percentile (Georgia Region)
•Weight assessment for
children — body mass
index percentile
•Counseling for nutrition
for children
•Counseling for physical
activity for children
•Chlamydia screening in
women (ages 16–20,
21–24 and total)
•Appropriate testing for
children with pharyngitis
•Appropriate use of
medications for people
with asthma (ages 12–
50, total)
•Comprehensive diabetes
care — LDL control less
than 100 mg/dl
•Comprehensive diabetes
care — medical attention
for nephropathy
•Antidepressant
medication management
(effective acute phase)
•Antidepressant
medication management
(effective continuation
phase)
•Annual monitoring for
patients on persistent
medications —
anticonvulsants
2011

16. © 2012 The Permanente Federation, LLC
The most HEDIS #1’s
Effectiveness of Care Measures Kaiser Permanente #1’s
•Breast cancer screening,
age 42–69 (Southern
California)
•Use of Spirometry Testing in
the Assessment of COPD
(Hawaii Region)
•Pharmacotherapy
Management of COPD
Exacerbation —
Bronchodilator (Southern
California)
•Cholesterol management
(coronary artery disease),
LDL Screening (Hawaii)
•Cholesterol management
(coronary artery disease),
LDL level less than 100 mg/
dl (Colorado)
•Controlling high blood
pressure — cardiovascular
(Ohio)
•Comprehensive diabetes
care — HbA1c Testing
(Hawaii)
•Comprehensive diabetes
care — LDL level less than
100 mg/dl (Northern
California)
•Comprehensive diabetes
care — Medical Attention for
Nephropathy (Colorado)
•Comprehensive diabetes
care — blood pressure
control (<140/80) (Georgia)
•Comprehensive diabetes
care — blood pressure
control (<140/90) (Colorado)
•Osteoporosis management
in women who had a fracture
(Southern California)
•Potentially harmful drug-
disease interaction —
Dementia (Hawaii)
•Breast cancer screening
•Comprehensive diabetes
care — blood pressure
control (<140/80)
•Comprehensive diabetes
care — blood pressure
control (<140/90)
•Comprehensive diabetes
care — medical attention
for nephropathy
•Antidepressant
medication management
(effective acute phase)
•Antidepressant
medication management
(effective continuation
phase)
•Weight assessment for
children — body mass
index percentile
•Counseling for nutrition
for children
•Counseling for physical
activity for children
•Chlamydia screening in
women (ages 16–20,
21–24 and total)
•Appropriate treatment for
children with upper
respiratory infection
•Avoidance of antibiotic
treatment in adults with
acute bronchitis
•Use of spirometry testing
in assessment &
diagnosis of chronic
obstructive pulmonary
disease
•Annual monitoring for
patients on persistent
medications —
anticonvulsants
•Medical assistance with
smoking cessation —
advising smokers to quit
•Medical assistance with
smoking cessation —
discussing strategies
Source: Kaiser Permanente Newe Center, http://xnet.kp.org/
newscenter/pressreleases/nat/
2012/101012_ncqa_care_measures.html ; http://xnet.kp.org/
newscenter/pressreleases/nat/2012/112812-ncqa-medicare-
measures.html
2012

17. The most HEDIS #1’s
Effectiveness of Care Measures Kaiser Permanente #1’s
•Adult BMI Assessment
•Weight Assessment for
Children
•Counseling for
Nutrition for Children
•Counseling for
Physical Activity for
Children
•Breast Cancer
Screening
•Cervical Cancer
Screening
•Chlamydia Screening
in Women (Ages 16-20,
Ages 21-24, and Total)
•Use of Spirometry
Testing in Assessmand
& Diagnosis of COPD
•Controlling High Blood
Pressure
•Comprehensive
Diabetes Care - Eye
Exams
•Comprehensive
Diabetes Care -
Medical Attention for
Nephropathy
•Comprehensive
diabetes care — blood
pressure control
(<140/80)
•Comprehensive
diabetes care — blood
pressure control
(<140/90)
Source: KP Share, http://share.kaiserpermanente.org/article/kaiser-permanente-leads-the-nation-in-13-commercial-health-plan-quality-measures/ ; http://
share.kaiserpermanente.org/article/kaiser-permanente-leads-the-nation-in-16-health-plan-quality-measures/#sthash.ovQAKsbK.dpuf
2013
•Breast cancer screening
(Southern California) Adult
BMI assessment (Northern
California) Use of spirometry
testing in assessment and
diagnosis of chronic
obstructive pulmonary
disease (Southern
California) Pharmacotherapy
management of COPD
exacerbation —
bronchodilator (Southern
California) Cholesterol
management CAD — LDL
screening (Hawaii)
Cholesterol management
CAD — LDL level <100
(Hawaii) Persistence of beta
blocker treatment after heart
attack (Colorado)
Comprehensive diabetes
care — blood pressure
control (<140/80) (Georgia)
Comprehensive diabetes
care — blood pressure
control (<140/90) (Colorado)
Comprehensive diabetes
care — HbA1c testing
(Hawaii) Comprehensive
diabetes care — <100
(Hawaii) Osteoporosis
management in women who
had a fracture (Southern
California) Antidepressant
medication management —
acute phase (Northern
California) Antidepressant
medication management —
continuation phase
(Northern California)
Potentially harmful drug-
disease interaction —
dementia (Southern
California) Use of high risk
medications in the
elderly — one drug
(Northern California)

18. Why Total Health? Why not?
Leonora Brogan - Kaiser Permanente Center for Total Health
http://kp.org/centerfortotalhealth

19. Exercise as Vital Sign
“I would suggest it makes more
sense to stop measuring blood
pressure at every visit than to
ignore our patient’s exercise
habits, because we know that
being sedentary is a bigger risk
factor for mortality than mild to
moderate levels of hypertension”
– Bob Sallis, MD
Smith, John W
Source: Sallis R. Developing healthcare systems to support exercise: exercise as the fifth vital sign.
Br. J. Sports Med. 2011;45(6):473–474. Available at: http://bjsm.bmj.com/content/45/6/473.short.

20. The Obesity Paradox14,345 men , average 7 year follow-up
Source:Lee D, Sui X, Artero EG, et al. Long-term effects of changes in cardiorespiratory fitness and body mass index on all-cause and cardiovascular disease
mortality in men: the Aerobics Center Longitudinal Study. Circulation. 2011;124(23):2483–90. Available at: http://circ.ahajournals.org/content/124/23/2483.abstract
[Accessed October 8, 2013]. Image © American Heart Assocation
men who became fit
or remained fit had
approximately 40–
50% lower risks of
all-cause and CVD
mortality
!
BMI status change
was not significantly
associated with
either all- cause or
CVD mortality

21. If physical activity were a drug...
activated
activated
activated
deactivated
it works bettertm
Source: Hillman CH, Erickson KI, Kramer AF. Be smart, exercise your heart: exercise effects on brain and cognition. Nature Reviews. Neuroscience. 2008;9(1):58–65..
Slide created by Ted Eytan, MD | @tedeytan | December, 2012

22. Powered by

23. With upload to the cloud

24. “Do You Really Want an iWatch?”
Apple Byte with Brian Tong • July 24, 2014

25. #activetransportation
Source: Ted Eytan, MD, Star Magazine,September 23, 2013, Partnership for Active Transportation

26. Source: Bikesharing Trip Visualizer: http://mvjantzen.com/tools/visualizer/

27. Source: Bikesharing Trip Visualizer: http://mvjantzen.com/tools/visualizer/

28. Bird’s Eye View of Bikesharing
Source: A Bird’s Eye View of Bikesharing -http://www.mvjantzen.com/blog/?p=4513

29. © 2012 The Permanente Federation, LLCSource: Community Health Needs Assessment http://chna.org

30. 2013
obesity rate: 19.1%

31. 2013
obesity rate: 12.5%

32. 2013

33. 1992

34. 2013

35. © 2012 The Permanente Federation, LLC

37. © 2012 The Permanente Federation, LLC
2238 Geary Street, San Francisco, July 30, 2014

38. ….face the community
“Bike-friendly Arlington County,
which works closely with the
National Park Service, has placed
the newest sensor, an expensive,
state-of-the-art, French-made
device, on the trail near Reagan
National Airport.”
Part of TMAP - Trail Modeling and
Assessment Platform
http://www.washingtonpost.com/local/counting-commuters-on-a-bucolic-trail/2013/09/02/0da4700a-054e-11e3-9259-
e2aafe5a5f84_story.html ; http://www.railstotrails.org/ourWork/promotingTrailUse/mapping/TMap.html

39. Annual Adult per Capita Cigarette Consumption and
Major Smoking and Health Events – US 1900-1998
Year
Thousands per year
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990
Great Depression
End of WW II
1st Surgeon
General’s report
Broadcast advertising ban
Federal cigarette
tax doubles
Fairness
Doctrine
messages on
TV and radio
Nonsmoker’s
rights
movement
begins
1st smoking
cancer concern
Surgeon
General’s
report on
environmental
Tobacco smoke
Master
settlement
agreement
Nicotine medications
Available over
the counter
1st World Conference
on smoking and health
1998
1st Great
American smokeout
Is this our our generation’s 1968?
Source: http://www.iom.edu/~/media/Files/Activity%20Files/Nutrition/Obesity-Roundtable/1_Dietz.pdf

40. Site Design
– Designed from the start with green strategies in mind.
– Recycled 90+% of building materials from demolition of existing buildings
– Storm Water Handling
– Designed landscape areas and swales to treat storm water flows
– Increased amount of landscaped area compared to previous site
Water
– Increased plantings of drought-resistant landscaping
– Used water-saving plumbing features
– 36% in domestic water savings - result of water efficient fixtures and non-chemical water
treatment for the cooling towers
Energy
– Designed to use 10% less energy than CA title 22 allows
– 50% annual, mechanical energy savings resulting in $65,000,000 in energy savings over a 50
year life for Kaiser Oakland hospital, 620,000 sf. (energy savings were verified by an independent
third party, Energysoft who performed the 3rd party review for PG&E, the local utility).
– 33% reduction in chiller central plant size as a result of our energy saving design strategy.
– Used high-efficiency glass, sunshades, and blinds to allow natural light while minimizing hot
afternoon sunlight
– Used fluorescent lights with low wattage per square foot and occupancy shut off sensors
Building Products
– Chose rubber flooring, which uses no PVCs and reduces need for maintenance chemicals
– Specified high fly ash content in concrete foundations and walls
– Chose carpet with no PVCs
– Used cotton building insulation in walls
Transportation Management
– Employee parking incentives
– Designated carpool parking
– Web site to assist set up of carpools
– Designated, locked bicycle parking and showers
– Free shuttle service from BART
– Guaranteed ride home program for carpooling staff
– PROVIDE SMART CAR FOR WORK USE ON CHECK OUT BASIS
Source: http://kp.org/oakland

41. “Dream Grounds for a Dream Hospital”
Why
Source: http://kasierpermanentehistory.org ; Joe Bialowitz, MS, HEM, Senior Environmental Stewardship Consultant, Kaiser Permanente

42. Why
Source: http://www.businesswire.com/news/home/20130819005270/en/Mazzetti-Congratulates-Kaiser-Permanente-Opening-Westside-
Medical ; http://xnet.kp.org/newscenter/pressreleases/scal/2012/011712sandiegosolar.html
“Showcases of modern, green hospital design”
Follow: @KPThrive

43. Health Affairs, May 2011: “Kaiser
Permanente Study Finds Use of
Electronic Health Records
Reduces Carbon Emissions,
Waste and Water Consumption”
Poten&al
CO2
emissions
reduc&ons
as
much
as
1.7
million
tons
across
the
en&re
U.S.
popula&on
!Source: Turley M, Porter C, Garrido T, et al. Use of electronic health records can improve the health care industry’s environmental
footprint. Health affairs (Project Hope). 2011;30(5):938-46. Available at: http://content.healthaffairs.org/cgi/content/abstract/30/5/938
[Accessed January 3, 2012].

44. © 2013 The Permanente Federation, LLC
To heal, you have to not harm
NHS England
KP
0.8025
MtCO2e 4.07
MtCO2e
(building
energy
use
&
direct
emissions)
9
million
members
178,000
employees
37
hospitals
611
medical
office
buildings
488
other
facili&es
53
million
people
MtCO2e : Metric Tonne (ton) Carbon Dioxide Equivalent, 2012 Reporting Year
Source: http://www.theclimateregistry.org/ ; http://www.sdu.nhs.uk/sd_and_the_nhs/

45. Speaking of roots…
Center for Total Health, Washington, DC, April 1, 2014

46. kp.org | Spanish

48. Source: Electronic medical records and the transgender patient: recommendations from the World Professional Association for
Transgender Health EMR Working Group. J. Am. Med. Informatics Assoc. 2013. Available at: http://jamia.bmj.com/content/early/
2013/04/29/amiajnl-2012-001472.full [Accessed May 1, 2013].

50. Being a Transgender Ally and Unconscious Bias
Kaiser Permanente 2nd Annual LGBTQI Symposium:
Advancing LGBTI Health Equity
May 2, 2014 | Universal City, California, USA
Ted Eytan, MD, MS, MPH • The Permanente Federation, LLC • @tedeytan
with April Soto, MD & Prudence (Kaiser Permanente member)
© 2014 The Permanente Federation, LLC
Desert Center, 1933

51. Washington, 2013

52. 52
Paul de Kruiff, Kaiser wakes the Doctors, 1943

53. We all have a condition called “me.”
Personalizing Leadership: Awareness, Humility, and Courage, Jack Cochran, MD, FACS, Kaiser
Permanente National Diversity & Inclusion: Mastering Difference to Make a Difference, San Francisco,
CA, November 22, 2013, http://diversity.kp.org/news/news-nd-conference-2013.html

54. Make Lives Better… by Listening

55. Why
Gilbert Salinas, BS, MPA
Director of Patient and Community Relations, Rancho Los Amigos National Rehabilitation Center
2013 Kaiser Permanente Safety Net Fellow, Institute for Healthcare Improvement
Permanente Executive Leadership Summit • June 10, 2014

56. © 2012 The Permanente Federation, LLC
Walking Gallery IV, Baltimore, MD, USA #ARTSCAPE2014, July 18, 2014

57. Being There
“Bouncing a Ball Alone: Grokking Failure” -
Henry Ford Health System, Detroit, November, 2012

58. The Walking Gallery
Regina Holliday | @ReginaHolliday
Source: http://vimeo.com/24857924

59. © 2012 The Permanente Federation, LLC
Casa Ruby LGBT Center 2nd Anniversary, Washington, DC 6/3/2014

60. kp.org/thrive