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. r Raymond A.Sachs,MD;JenniferSmith. RonaldLouie,MD. r esidential Commission and Health Care Refo esidential CommissionandHealthCare endy Hube W manente Promise. r evention andExposu . Parsons,MD. r east ofPe Y M. JeanGilbert,PhD. ears Ago. r , M D . r manente intheNews. Seymour Grossman,MD. r e Cont r oviding GeneticServices Toupees byAl;p.53 r ol. Select-a-Nose; 14 D r . Ga r r field; 29 m. Mission... The Permanente Health Systems Management Journal is published and 42 Systems Challenge for Primary Care and the Specialties: Relationships and Access. written by the clinicians A roundtable discussion with panelists Patricia Behlmer, MD; Tony Bianchi, MD; of the Permanente Andrew Golden, MD; William Caplan, MD; Steve Lieberman, MD; and Walid Sidani, MD. Medical Groups and KFHP to assist them in 48 Achieving Clinician Use and Acceptance of the Electronic Medical Record. delivering superior Michael A. Krall, MD. health care to our 54 The Coming Tidal Wave: Genetic Testing. Al Weiland, MD. members and our communities.

Permanente Abstracts EpicCare; 48 58 ◆ Heritability of Longitudinal Changes in Coronary Heart Disease Risk Factors in Women Twins ◆ Epidemiology and Outcome of Patients Hospitalized with Acute Lower Gastrointesti- nal Hemorrhage: A Population-Based Study ◆ Specialty Differences in the Management of Asthma. A Cross-Sectional Assessment of Allergists’ Patients and Generalists’ Patients in a Large HMO ◆ Extending Health Maintenance Organization Insurance to the Uninsured. A Controlled Measure of Health Care Utilization ◆ Efficacy and Cost-Effectiveness of Multihole Fine-Needle Aspiration of Head and Neck Masses ◆ Heritability of Factors of the Insulin Resistance Syndrome in Women Twins ◆ Stanford-Kaiser Permanente G1 study for Clinical Stage I to IIA Where to find The Hodgkin’s Disease: Subtotal Lymphoid Irradiation Versus Vinblastine, Methotrexate, and Permanente Journal... Bleomcycin Chemotherapy and Regional Irradiation ◆ Marijuana Use and Mortality A full-text version is available at our Web site (www.kpnw.org/ A Moment In Time ~permjournal/ 61 Anesthetic Agents of the Forties and Fifties. Carl Fisher, MD. permjournal.html). In addition, copies of the Journal are available in Book Review Kaiser Permanente 63 “Color Atlas of Regional Dermatology.” Gary M. White, MD. Vincent J. Felitti, MD. libraries Programwide. Letters To The Editor 64 Your letters will link quarterly issues and create more dynamic exchange on the Internet. Announcements 65 ◆ Eighth Interdivisional Conference on Primary Care, Occupational Health, and Musculoskel- etal Medicine ◆ Health Plan Institute’s Core Program ◆ Second Interdivisional Educational Symposium for Nurse Practitioners, Physician Assistants, Certified Nurse Midwives, and Certified Registered Nurse Anesthetists ◆ Managed Care in Occupational Health ◆ Interdivi- How to Contact The sional Occupational Health Meeting ◆ KP Clinical Practice Exchange ◆ Editing Help with Your Permanente Journal… Manuscripts ◆ 1998 Nike World Masters Games ◆ Kaiser Permanente Clinical Best Practices in E-mail us at Otolaryngology Symposium [email protected]

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The Permanente Journal / Winter 1998/Volume 2 No. 1 1 Editors’ Comments

Drawing Out the Modern Mind Visual Explanations Tom Janisse, MD, Editor-in-Chief To approach visualizing ideas from a different perspective, as an In this third issue of The Permanente Journal, I would editors’ comments editor I work to enhance the environment in which words appear. like to continue my comments on communication from For example, I encourage authors to include tables, graphs, and the second issue, but broaden the scope and context. We diagrams with their articles. Further enhancements include: plac- know how important communication is and how it often ing these articles in a more visually pleasing and diverse environ- could have been done better. We hear how we can’t communicate ment populated with drawings, photographs, icons, and borders; enough, how we communicate more by our actions than our words, the graphic use of white space; and attention to the format and and how we remember visuals better than words after a lecture. In type style of text. Through these methods pages don’t appear so the last couple of years I have been actively trying to draw “pictures dense with words. I believe that these efforts enhance communi- of ideas” to aid in explanation. These pictures are visual representa- cation. It gives the author and the reader the greatest opportunity tions of a concept or a process I am discussing with someone. (Box to connect with each other. Each is more highly stimulated by the 1: Pictures: desktop computer, mouse-generated drawing symbols. content and the context. Box 2: Pictures: palmtop, stylus-generated sketches.) Other pictures Because as editor of The Permanente Journal I oversee all aspects I use routinely are metaphors and stories. of each issue, I spend time with the production staff looking at the Physicians, patients, and other healthcare workers have responded layout, selecting the cover art and the visuals inside, as well as well. They seem to understand me better or feel a picture or dia- attending to the balance, tone, and order of articles—the “feel” of gram has clarified our discussion. This response has encouraged The Permanente Journal. To improve my graphic sensibility I have me to seek new ways to picture ideas to improve my communica- begun to read magazines like, Critique: The Magazine of Graphic tion skill and effectiveness. Because we increasingly understand Design Thinking, and books like Edward Tufte’s series, The Visual the value of innovation in health care delivery, tools to enable and Display of Quantitative Information, Envisioning Information, and diffuse innovations can benefit us. The Permanente Medical Groups Visual Explanations. It was an article in Critique that stimulated this will better define, clarify, and implement Permanente Practice in- editorial. It is called, “Drawing Out the Modern Mind.” The follow- novations if clinicians communicate more effectively with each ing comment introduces the article: “Contrary to old beliefs, the other. Drawing can complement other communication tools we human mind is not a computer: instead of working in a predictable, use—electronic, audio, video, oral, and written. logical, sequential way, our minds work in a flexible, perceptual,

External and Circular views internal relations Feedback loops

Direction and interacting levels Transition state

A cloudy step

ABCS XNZ ------

Three ways there Aligned communication

Multiple off-shoots Box 1. Pictures: desktop computer, mouse-generated drawings

2 The Permanente Journal /Winter 1998/Volume 2 No. 1 “Contrary to old beliefs, the human mind is not a computer: editors’ comments instead of working in a predictable, logical, sequential way, our minds work in a flexible, perceptual, all-at-once way.”

all-at-once way. The modern mind achieves power by combining can, and do, create pictures in the form of metaphors or sto- logic and intuition. And you can sharpen the perceptual skills that ries—two of the four tools of intuitive thinking along with im- underlie intuition by strengthening your drawing skills.” ages and symbols. These tools help to bring the elusive com- plexity of medical science to a common place for people—a What’s The Difference? description of the dilemma or the concept in everyday language You may be asking yourself at this point, how does this make or events. I hesitate using the following dark-side example; how- any difference to me? In the Health Systems Management section ever, I practice clinically as an anesthesiologist, and when people of this issue a roundtable discussion appears on “Primary Care come to surgery they are most afraid of not waking up, of dying and the Specialties: Relationships and Access.” When you read it under anesthesia. They come to the operating room on terms you will engage in a conversation with 6 physicians from across with the surgical procedure, but not with the loss of control of the country who discuss what they have learned from innovative unconsciousness. People often ask, “What are the odds?” Cur- practices they have implemented. You will hear and understand rently, death occurs from anesthesia in about 1 of 200,000 en- more about access to specialists than is present in the words on counters. That doesn’t mean much to those who aren’t statisti- the page. You will import something from the conversational con- cians. So some of us say, “You have a greater chance of dying text in which the words are embedded, the relationships between when you walk across the busy four-lane street out in front of the different practices, and the matrix created as the ideas and the hospital.” They relate to that. It places their impending sur- practices intertwine. You will connect these ideas to your own gery and anesthesia in a common context. experience and so enliven them. You will come away with a pic- Adults have different learning styles. Not all learn through cog- ture greater than the words on the page. nitive means. Some people learn much better by experience, by Well, how else can this matter to me? Most physicians struggle actually trying something out, by doing it. Some learn through a little with how to improve their interaction with patients; with conversation, and some learn through reflection. Some patients how to improve their communication. I was struck by a recent want the numbers and the facts; some want your best hunch. comment I read where a patient said they wished the doctor And some just want to know that you’re giving it your best ef- would have explained it better; they wished he would have drawn fort. Some people just want to know that you care, and then they a picture. Not many of us are artists or can even draw. But we feel safe and reassured.

Box 2: Pictures: palmtop, stylus-generated sketches

The Permanente Journal /Winter 1998/Volume 2 No. 1 3 Draw Me a Picture practice. We can see “shadows” as barriers, the unknown, the Drawing a picture on paper or speaking in visual terms may be feared, constraints, the downside or oppositional view. Both lights a way to expand the effectiveness of our communication. In the and shadows are essential components in achieving perspective editors’ comments article I mentioned, “Drawing Out the Modern Mind,” (Critique, and a balanced approach to understanding. Autumn 1997) the author describes “the seeing strategies that The “gestalt” is the whole, the system, the big picture, the con- underlie the global skill of drawing, without regard to medium text. We speak more about holism in healthcare now: taking into or subject: account the whole person—the emotional, behavioral, and spiri- ✻ The perception of edges tual along with the physical—in arriving at diagnoses, etiologies, ✻ The perception of spaces and best treatments or outcomes. ✻ The perception of relationships ✻ The perception of lights and shadows What’s The Point ✻ The perception of the whole, or the gestalt.” While we can use “seeing strategies” to draw, we can also Giving these “seeing strategies” a medical context will dem- perceive a current problem from a new perspective by using a onstrate their value as perceptual tools, in addition to being different frame of reference or by looking at it in a different drawing tools. Each of these has application for me in the prac- light. I often remind myself of how we look at the heart electri- tice of medicine. cally from 12 leads across the chest, from 12 positions or views. “Edges” can refer to the boundaries of primary care and spe- Most of our clinical practice exists, and can be viewed, in ever- cialty care scope of practice and to the points of interaction be- larger contexts. The Permanente Journal is designed in a lay- tween the two disciplines. As physicians have noted there is some ered context. We look at “Clinical Contributions”—the core prac- overlap in practice, and this is a fertile area for exploring enhance- tice of Permanente medicine—and at “Health Systems Manage- ments in service and patient care. The concept of edges also has ment”—the systems or processes in which we practice—and at meaning in the realm of physicians and affiliated clinicians as they “External Affairs”—those environmental, legislative, media and begin to work in teams and in some cases redefine their real value market forces that impact our practice and systems. Physicians as practitioners. Kaiser Permanente has pioneered the delivery of may benefit by evaluating their practice in a larger context and medical care through the use of nurse practitioners, physician as- from an external view: that of a colleague, another department sistants, and nurse anesthetists, to name three. or discipline, as a customer, from a competitor view, or over “Spaces” can relate to the environment in which we practice: the the long term. space of the exam room or “the room to move” we have in order- Try drawing a picture, though if you don’t take up drawing, or ing tests or prescribing medications, or the time to see patients, even doodling, or create pictures of ideas, you may want to en- pauses in conversation, or our “personal space.” How we per- courage or engage your intuitive mind more actively to see or ceive and use these spaces is critical to our effectiveness. speak more clearly. Use 1 of the other 3 tools for intuitive think- The perception of “relationships” often determines our interaction ing: a metaphor, a symbol, or a story. In addition, “staring into with clinicians in other departments, and with patients. A positive space” and “looking at nothing” are two human activities that relationship with a patient may result in better care. As a medical tend to close down the analytical side of your brain and open up group, we are more aware of a local community and a national the intuitive side. This is an example of applying one of the five market; how we perceive each guides our healthcare strategy. “seeing strategies”: the perception of space. The outcome I would “Lights” are our resources, positive attitudes and influences, ex- hope for is to heighten understanding and enhance communica- panded perspective, enlightened solutions, regard and construc- tion between us for the benefit of the Permanente Medical Groups, tive feedback, innovation and wisdom. These are tools for a better our Health Plan partners, and our members. ❖

4 The Permanente Journal /Winter 1998/Volume 2 No. 1 editors’ comments

External Affairs “Ambulatory Open Shoulder Surgery” by Dr. Sachs and Ms. Smith Scott Rasgon, MD, Editor provides a fully documented clinical series about innovative man- The External Affairs section in this issue of The Per- agement of an important common problem, with sufficient detail manente Journal will be exploring such topics as cul- so that other facilities can—if they wish—adopt the procedures. tural diversity, brand strategy, and new ways of getting Finally, this issue includes a reprint of “The Management of Pneu- medical news to physicians in a computer-based sys- monia (A Review of 517 Cases)” by Dr. Morris Collen, originally tem. We will also be taking a look at what’s happening with the published in July, 1943 in the Permanente Foundation Medical President’s Commission on Managed Care. Bulletin. This is a beautiful article, of high academic caliber, which Jean Gilbert PhD, from the Southern California Permanente Medi- provides a glimpse of Kaiser Permanente practice more than 50 cal Group introduces the importance of cultural diversity in both years ago, and still includes much clinically relevant material. This medical practice and marketing health care. The marketing con- article is placed into perspective by Dr. Elizabeth Andersen, MD, cept of brand strategy and branding Kaiser Permanente is dis- an infectious disease specialist in Oakland, who knows Dr. Collen. cussed by Kathy Swenson and Vaughan Acton . This issue provides a variety of findings, reviews, analyses, and In the information age more medicine and health related articles practice programs of interest and importance. Some, hopefully, are available every day than anyone can possibly keep up with. will stimulate controversy. Civilized comment, critique, dissent, Tom Debley from the California Division reviews a system using and objection are welcome; a lively Letters to the Editors section computers to get important media related information out the health would add spice to the Journal. ❖ care providers. Don Parsons, MD, our Washington lobbyist looks at the activities Health Systems Management of the president’s commission on managed care reform. Lee Jacobs, MD, Editor I am sure the issues discussed are dealt with on a daily basis. I hope In this issue of The Permanente Journal, a panel of you enjoy these articles and find them interesting and relevant. ❖ six Permanente physicians from six different medical groups discuss their views on the primary care pro- Clinical Contributions vider and specialist relationship, especially as it relates Arthur Klatsky, MD, Editor to referrals. As I listened to the panel discussions, I was im- The Clinical Contributions in this issue include a variety pressed with the quality of the Permanente people working on of topics which present a highly gratifying image of Kai- this issue. I believe that you also will be impressed as you read ser Permanente medicine. The review entitled “Managed about the innovations and approaches discussed by the panel- Genetic Care in the Largest HMO: The Challenge of Pro- ists, representing frontline physicians on both sides of the pri- viding Genetic Services to 2.5 Million Members” by Drs. Bachman mary care-specialist fence. However, what I found especially and Schoen presents a view of an area in which the authors and impressive was how the solutions that the discussants presented Kaiser Permanente are on the cutting edge of services offered in a continuously had the patient in the forefront. Such a mindset is field of rapidly increasing interest and practical importance. crucial as we design our future systems in this extremely com- The review entitled “A New Era in Colorectal Cancer Screening petitive world. and Surveillance” by Dr. Grossman is a forthright authoritative It is the hope of those of us at The Permanente Journal that opinion statement by a distinguished recently retired Kaiser Per- this round table discussion will create a dialogue across the Per- manente physician; he and other clinicians and researchers in our manente Groups so that other views and approaches to this ma- organization have played a major role in this area of preventive jor systems challenge can be heard. Let us know your opinion! practices to reduce morbidity and mortality from one of the com- This is the role of The Permanente Journal—to provide a forum monest cancers in both sexes. for such discussions. How well our Permanente Groups get the “Natural Rubber Latex Protein Allergy Prevention and Exposure important issues on the table; how well we capture the delibera- Control” by Drs. Macy, Ms. Eck, and Dr. Huber reviews a common tions through articles and reports; and how well we as Permanente and vexing clinical problem and supplies much information about Medical Groups leverage the knowledge gained, will in the fu- how this is handled in one of our largest Regions. ture define our competitive advantage. ❖

The Permanente Journal /Winter 1998/Volume 2 No. 1 5 By Raymond A. Sachs, MD Jennifer H. Smith, BS Ambulatory Open Shoulder Surgery

Introduction: During 1995, a coordi- During 1994, in a joint effort with the anesthesia nated orthopedic/anesthesia protocol was department, we attempted to create a protocol that used on 100 consecutive patients having am- would decrease all of the above side effects and al- bulatory open shoulder surgery. These pa- low us to perform open shoulder surgery on an out- clinical contributions tients had either Bankart repair, open patient basis. We identified the long half-life of so- acromioplasty, or rotator cuff repair. Ages dium pentothal and the sedative effects of opiate ranged from 15 to 92 years. Anesthesia tech- drugs as the possible culprits for our patients’ lack of nique included induction with propofol alertness. We also recognized the known side effects “Prior to 1994, all (Diprivan), and minimization of intraopera- of opiate drugs as the probable cause of the nausea, open shoulder tive narcotics. Patients were injected with 60 vomiting, and urinary retention. surgery at this mg ketorolac tromethamine (Toradol) 15 to institution was 30 minutes before the conclusion of surgery, Materials and Methods performed on an and wound edges were injected with 10 to 20 Rotator cuff repair, Bankart reconstruction, and inpatient basis.” ml of 1% Marcaine with epinephrine at clo- open acromioplasty are the three most common sure. Strong oral pain medication, usually in- open shoulder procedures performed at our institu- cluding Percocet, was provided to each patient tion. In 1995, 100 consecutive patients had one of on discharge. Data were collected during the these three procedures performed on an ambula- recovery room stay, and a nurse called each tory basis. These patients were not selected, nor patient 3-12 months postoperatively. were they eliminated on the basis of age, social Results: Ninety-seven percent of pa- issues, or medical condition. The ages of our pa- tients were satisfied with care from admission tients ranged from 15 to 92 years. The mean age to discharge. Ninety-seven percent were sat- was 50 years. isfied with pain management during the hos- All surgical procedures were performed using a pital stay. Eighty-four percent were satisfied combined orthopedic/anesthesia protocol with the with pain medication for home use. Only 3% following features: called their physician or the emergency de- • All patients had a general anesthetic partment during the first 48 hours after sur- delivered by endotracheal tube. Induction gery, but in no case was readmission neces- was with propofol (Diprivan) instead of sary. Seventy-nine percent of patients would Pentothal to facilitate quicker recovery “do it this way again.” from anesthesia. Propofol has a half-life of Conclusion: Ambulatory open shoul- only 10 to 15 minutes compared with 8 “Ambulatory der surgery can be performed successfully hours for Pentothal. surgery which can and with high patient satisfaction, regardless • The anesthesiologist minimized the only be accom- of patient age and type of surgery. Currently, intraoperative use of fentanyl and other plished by the with the exception of arthroplasty, we per- narcotics. All patients were injected with extensive use of form all elective open shoulder surgery on an 60 mg of ketorolac tromethamine home care or outpatient basis. (Toradol) 15 to 30 minutes before the rehabilitative conclusion of surgery, and all wound facilities is often Introduction edges were injected with 10 to 20 ml of not a triumph and Before 1994, all open shoulder surgery at this in- Marcaine with epinephrine. merely results in stitution was performed on an inpatient basis. At • All patients were discharged with a sling. cost shifting.” that time, typical anesthesia consisted of sodium However, patients who had pentothal for induction, Forane for maintenance of acromioplasty, with or without rotator cuff anesthesia, and fentanyl for pain control through- repair, were instructed to perform pulley out the procedure. Morphine, Dilaudid, or Demerol exercises for 1 minute every hour to were used in the early postoperative period for pain prevent stiffness. control. We noted that patients often took a long No patient went home with a Foley catheter, and time to regain alertness and that they often com- no home services or rehabilitation facilities were used. plained of severe pain. A retrospective study of our Ambulatory surgery which can only be accomplished own rotator cuff repairs showed that the average by extensive use of home care or rehabilitative facili- hospital stay was 2 days and that 76% of patients ties is often not a triumph and merely results in cost suffered postoperative nausea, while 36% had uri- shifting. An effective outpatient protocol should not nary retention. necessitate such manipulation.

RAYMOND A. SACHS, MD, has been a staff orthopedic surgeon for the Southern California Permanente Medical Group for 15 years. He is an Assistant Clinical Professor of Orthopedics at UCSD as well as shoulder mentor for the San Diego Sports Medicine Fellowship. not pictured JENNIFER H. SMITH, BS, a graduate of UCLA, is now in her third year of medical school at Washington University in St. Louis. She has a strong interest in orthopedic surgery, and will begin her residency in July, 1999.

6 The Permanente Journal /Winter 1998/Volume 2 No. 1 clinical contributions

80% nations). Ninety-two percent were satisfied with their Nausea care from admission to discharge, and given the Urinary Retention choice of inpatient or outpatient procedure, 85% said 70% they would “do it this way again.” Of the four pa- tients who said that they would not have the surgery done again on an ambulatory basis, only one ex- 60% pressed any displeasure with their management. The other three preferred an overnight stay for social rea- sons such as the inconvenience of a long drive home 50% or living alone.

Open Acromioplasty 40% Eleven patients had open acromioplasty. Their ages ranged from 30 to 69 years with a mean age of 49 years. Twenty-seven percent of patients experienced 30% nausea. None had urinary retention. One patient called the hospital because of a high level of pain. No patients were seen in the emergency department 20% or admitted to the hospital. Ninety-one percent of patients were satisfied with the management of their pain in the recovery area, and 91% were satisfied 10% with their pain medicine for home use. Ninety-one percent were satisfied with their care from admis- sion to discharge, and 73% said they would do it this 0% way again. Of the three who said they would not do Pre 1995 Post 1995 the procedure again on an ambulatory basis, only Figure 1. Incidence of postoperative nausea and one had any complaints with the protocol. Two pre- urinary retention in patients undergoing open rotator ferred to stay the night for social reasons. cuff repairs. Rotator Cuff Repair Data were collected on these patients during the Sixty-three patients had rotator cuff repair. Their recovery room stay, and further follow-up data were ages ranged from 42 to 92 years with a mean age collected by one nurse who called the patients 3 to of 61 years. Thirteen percent experienced nausea, 12 months postoperatively. Patients were questioned and one had urinary retention which required a about nausea, vomiting, catheterization, and any call and a visit to the emergency department for other problems which warranted a trip to the emer- catheterization. No patients in this group were ad- gency department or a phone call to their physi- mitted to the hospital. All patients were satisfied cian. They were asked to evaluate the quality and with their pain management in the recovery pe- effectiveness of their pain control regimen. Finally, riod. Eighty-seven percent were satisfied with the they were asked to rate their degree of satisfaction with all aspects of care. Table 1. Incidence of postoperative problems in patients Results undergoing ambulatory open shoulder surgeries Open Bankart Repair Twenty-six patients had Bankart repair. Their ages Bankart Acromioplasty Rotator Cuff Total ranged from 15 to 50 years with a mean age of 24 years. Thirty-six percent of patients experienced nau- Nausea 36% 27% 13% 21% sea. None had urinary retention. One patient called the hospital from home. This patient was seen in the Urinary Retention 0% 0% 0% 1% emergency department and admitted with a wound infection. Ninety-two percent of patients were satis- Called for Help 4% 9% 2% 3% fied with the management of their pain while in the recovery area, and 96% were satisfied with the pain Went to the E.R. 4% 0% 2% 2% medication prescribed for home use (typically ac- Admitted 4% 0% 0% 1% etaminophen and codeine/synthetic codeine combi-

The Permanente Journal /Winter 1998/Volume 2 No. 1 7 pain medicine prescribed for home usage. (Percocet bined orthopedic/anesthesia protocol allowed us to was commonly used during the first 48 hours, fol- sharply diminish the incidence of these common side lowed by acetaminophen/codeine combinations.) effects (Fig 1). We recognize that it is impossible to Ninety-five percent were satisfied with their care separate our protocol into its component parts for clinical contributions from admission to discharge. Seventy-eight percent purpose of analysis. We present this protocol as one said that they would do it this way again. Nine of unified approach that has worked for us, acknowl- “Total time from the 14 who preferred an overnight stay had social edging that there may be other protocols that could admission to reasons only for this preference. work as well or better. discharge averaged Overall, in our group of 100 patients, only 21% 8 hours. There were Age experienced nausea, and only one patient had uri- no significant There were no significant differences in complica- nary retention. Only 3% of patients had problems of differences between tions or in any measure of satisfaction when patients a magnitude that required a call to their doctor, a types of surgical were grouped according to age. nurse, or to the emergency department. Only 2% vis- procedures.” ited the emergency department, and only 1% required Type of Surgical Procedure There were no significant differences in complica- admission (Table 1). As a whole, 97% were satisfied with the management of their pain while in the re- tions or in any measure of satisfaction when patients covery area, and 90% were satisfied with their medi- were grouped according to pathology or type of sur- gical procedure. cation for home use. Ninety-three percent were sat- isfied with their care from admission to discharge, Time of Hospitalization and 79% said that they would have their procedure Total time from admission to discharge averaged done again in the same way (Table 2). Two thirds of 8 hours. There were no significant differences be- patients who preferred an inpatient procedure did tween types of surgical procedures. so for social reasons only. Discussion Conclusions Open shoulder surgery is typically performed in The combined orthopedic/anesthesia protocol was an inpatient setting due to the perceived need to successful in sharply reducing postoperative prob- control postoperative pain with parental narcotics lems with pain, nausea, and urinary retention. as well as to manage significant levels of postop- The low incidence of postoperative problems en- erative nausea and urinary retention. We postu- abled us to perform open shoulder surgery on an lated that nausea and urinary retention were due ambulatory basis with a high level of safety and to the administration of intraoperative narcotics and without the necessity of shifting cost to expensive “The low incidence that the need for both intraoperative and postop- home care. of postoperative erative parenteral narcotics could be minimized by The low incidence of postoperative problems and problems enabled use of intraoperative Toradol and wound injection the high degree of patient satisfaction were not af- us to perform open with a long-acting local anesthetic such as Marcaine fected by the type of open shoulder procedure nor shoulder surgery with epinephrine. by patient age. ❖ on an ambulatory Our own experience prior to 1994 in rotator cuff basis with a high surgery had shown high levels of nausea and urinary References level of safety and retention and significant pain requiring 24 to 48 hours 1. Burns JW, Aitken HA, Bullingham RE, et al. Double-blind without the of parenteral narcotics. Simple adjustments in a com- comparison of the morphine sparing effect of continuous and necessity of cost shifting to expen- Table 2. Incidence of overall satisfaction in patients undergoing ambulatory open sive home care.” shoulder surgeries

Bankart Acromioplasty Rotator Cuff Total

Postoperative pain control 92% 91% 100% 97%

Home pain medications 96% 91% 87% 90%

Total care in hospital 92% 91% 95% 93%

Would do it the same way 85% 73% 78% 79%

8 The Permanente Journal /Winter 1998/Volume 2 No. 1 clinical contributions

intermittent i.m. administration of ketorolac. Br J. Anaesth. the speed of onset of analgesia following intramuscular 1991;67:235-238 administration of ketorolac tromethamine in comparison to 2. Kenny GN, McArdle CS, Aitken HH. Parenteral ketorolac: intramuscular morphine and placebo. Anaesthesia opiate-sparing effect and lack of cardiorespiratory depression in 1991;46:541-544. the perioperative patient. Pharmacotherapy 1990;10:127S-131S. 7. Smith I, Shively RA, White PF. Effects of ketorolac and 3. Liu J, Ding Y, White PF, et al. Effects of ketorolac on postopera- bupivacaine on recovery after outpatient arthroscopy. Anesth. tive analgesia and ventilatory function after laparoscopic Analg. 1992;75:208-212. cholecystectomy. Anesth. Analg. 1993;76:1061-1066. 8. Stanski DR, Cherry C, Bradley R, et al. Efficacy and safety of 4. O’Hara DA, Fragen RJ, Kinzer M. Ketorolac tromethamine as single doses of intramuscular ketorolac tromethamine compared compared with morphine sulfate for treatment of postoperative with meperidine for postoperative pain. Pharmacotherapy pain. Clin. Pharmacol. Ther. 1987;41:556-561. 1990;10:40S-44S. 5. Peirce RJ, Fragen RJ, Pemberton DM. Intravenous ketorolac 9. Wong HY, Carpenter RL, Kopacz DJ, et al. A randomized, tromethamine versus morphine sulfate in the treatment of double-blind evaluation of ketorolac tromethamine for immediate postoperative pain. Pharmacotherapy postoperative analgesia in ambulatory surgery patients. 1990;10:111S-115S. Anesthesiology 1993;78:6-14. 6. Rice AS, Lloyd J, Miller CG, et al. A double-blind study of

Stages to Truth “Every truth passes through three stages before it is recognized. In the first, it is ridiculed, in the second it is opposed, in the third it is regarded as self-evident.” Arthur Schopenhauer

The Permanente Journal /Winter 1998/Volume 2 No. 1 9 By Ronald P. Bachman, MD Managed Genetic Care in the Largest HMO: Edgar J. Schoen, MD The Challenge of Providing Genetic Services To 2.7 Million Members

Comprehensive clinical genetic services are offered to (MSs or equivalent), and 10 genetic 2.7 million members in Northern California by the Kaiser Per- nurses or metabolic nutritionists manente Medical Care Program (KP), a not-for-profit HMO. Four (MSs). genetics centers are staffed by clinical geneticists, genetic coun- Services are coordinated through clinical contributions selors, nurses, and laboratory technologists, who together pro- meetings with geneticists who pro- vide patient and physician education, genetic screening, and pre- vide similar services in other ar- natal, infant, and adult evaluation. These centers provide genetic eas in which KP operates (the care for 19 KP medical centers and 16 satellite clinics. Besides Northwest and Southern Califor- offering lectures and teleconferences, the geneticists publish a nia). In the 3 areas, KP serves newsletter for up to 1200 pediatricians, obstetricians, and other about 5.8 million members, a relevant specialists on how to use genetic services. Clinical ser- population similar to that of sev- “Geneticists are vices offered to members include individual, group, and tele- eral small European countries (eg, rapidly acquiring phone consultations, and easy access to geneticists is provided Norway, Denmark). new abilities for primary care providers who have questions about genetic Divisional genetic policy is es- because of care. In-house laboratory services include blood and tissue cy- tablished through periodic meet- technologic togenetic analysis, DNA testing, and testing of prenatal blood ings of the geneticists in charge advances which and amniotic fluid; specialized testing for inborn errors of me- of the 4 genetic centers with rep- have largely tabolism is centralized at KP Northern California Divisional resentation from the genetic coun- resulted from the Laboratory. An Interdivisional genetics data system is being es- selors and laboratory personnel. Human Genome tablished to link Northern and Southern California and the A single divisional genetics bud- Project.” Northwest (Portland and Hawaii). Under the newly established get is shared by the 4 centers. national KP Care Management Institute (CMI), we propose to Budgetary decisions are arrived at offer selective genetic services to KP facilities across the coun- by consensus based on current try using computer linkages and new technologies such as and future genetic advances rela- telemedicine consultation. tive to estimated costs. Comprehensive services include Introduction Bay area but extends over 200 patient education, provider edu- Genetics is a unique specialty: miles, including 19 hospitals with cation, genetic screening, prena- provision of genetic services en- outpatient departments as well as tal, neonatal, child, and adult compasses all medical fields and 16 freestanding outpatient facili- evaluation, multispecialty clinic age groups. Geneticists are rapidly ties. Genetic services are pro- services, laboratory services, resi- acquiring new abilities because of vided subregionally at 4 cen- dent education, and research. technologic advances which have ters—San Francisco, Oakland, “The goal is to largely resulted from the Human San Jose, and Sacramento. Each Patient and Provider Education offer appropriate, Genome Project. genetics center is staffed by clini- Providers, physicians, and other up-to-date, The Kaiser Permanente Medical cal geneticists and genetic coun- professionals must know what ser- comprehensive, Care Program (KP), a not-for- selors and may also have nurses vices are available and how to use high-quality profit HMO, offers comprehensive and laboratory technologists. the system best. The genetics pro- genetic services clinical genetic services to 2.7 Some genetic centers are re- gram functions most efficiently which are also million health plan members in sponsible for doing specific tasks with appropriate referrals and re- cost-effective.” Northern California; Southern for the entire area. For instance, quests for genetic laboratory tests. California has a similar member- only 2 cytogenetic laboratories and We found that a useful way to ship. These services are coordi- 1 molecular genetics laboratory educate providers to properly use nated by a group of clinical ge- exist. All genetic perinatal screen- genetic services was through a pe- neticists who provide current ge- ing programs are administered riodic, short newsletter titled The netic care and plan for future ser- from a single location (Oakland). Screen, which is directed to appro- vices. The goal is to offer appro- The 4 genetics departments are priate specialists, usually pediatri- priate, up-to-date, comprehen- staffed by 9 clinical geneticists cians and obstetricians. The mail- sive, high-quality genetic services (MDs), 35 genetic counselors ing list of up to 1200 providers is which are also cost-effective. (MSs), 4 laboratory directors (PhDs tailored to the topic (eg, prenatal In Northern California, KP is in cytogenetics and molecular ge- and neonatal hemoglobinopathy concentrated in the San Francisco netics), 20 laboratory technologists screening, triple-marker screening).

left RONALD P. BACHMAN, MD, is chief of the genetics department and has been practicing pediatrics and genetics with TPMG for over 28 years. right EDGAR J. SCHOEN, MD, is senior consultant in pediatrics and director of regional perinatal screening in the genetics department for TPMG. He joined Permanente in 1954.

10 The Permanente Journal /Winter 1998/Volume 2 No. 1 clinical contributions

We have begun providing The Screen to other KP communication occurs between primary and second- divisions and have uploaded it to the bulletin board ary providers. section of our e-mail network, which has made it At these clinics, psychosocial as well as medical even more accessible. Other modes of communicat- and genetic counseling needs of patients are re- ing with our providers include lectures, minicourses, viewed. These multidisciplinary specialty clinics have teleconferences, and personal interaction. been well received by patients and primary care pro- Health plan members are informed about genetic viders. National consultations using telemedicine services through health education centers as well as could be provided to patients at distant sites by us- through a quarterly newsletter, Planning for Health. ing our established team of experts. The health education centers are located in each of the larger facilities and consist of a patient library Perinatal Screening and Genetic Services with exhibits and cubicles for viewing videotapes; The main mission of both HMOs and geneticists is educational material is available for distribution, loan, disease prevention. Instituting preventive measures “In 1994, at the 4 or purchase. before conception is ideal, but often the family does genetics centers, We try to target genetics education to those patient not become concerned until conception has occurred. 5464 phone groups for whom it is most relevant. For example, The following genetics programs are offered dur- consultations with pregnant patients are informed of our services at pre- ing pregnancy: 1) genetic questionnaire; 2) hemo- patients and natal classes. globinopathy screening (for S, C, and E hemoglo- primary care bins); 3) thalassemia screening (for α- and β-thalas- providers and 8515 Role of the Primary Care Physician semia); 4) maternal serum alphafetoprotein (MSAFP) genetic care office Primary care physicians (mainly obstetricians and screening (for neural tube defects, Down syndrome, visits were pediatricians), as well as other providers, are kept and other abnormalities); 5) Tay-Sachs disease (in provided.” informed of genetic services through a variety of Ashkenazi Jewish and French Canadian persons); 6) interfacility communications such as in-service edu- fetal ultrasonography; 7) amniocentesis/chorionic cation at prenatal clinics and labor and delivery ar- villus sampling; and 8) “triple-marker” screening (an eas. Genetic counselors, nutritionists, and nurse co- extension of MSAFP screening, mainly for Down syn- ordinators provide outreach services at the smaller drome, which has been offered through a state pro- clinics through regularly scheduled meetings and in gram since mid-1995). response to quality and utilization surveys and local In addition to prenatal testing, the genetics pro- requests. Geneticists and genetic counselors are avail- gram manages mandated neonatal testing, including able for informal telephone consultations. Patients screening for phenylketonuria, galactosemia, he- as well as providers can call genetic counselors di- moglobinopathy, and hypothyroidism. Tracking and rectly for answers to questions on such issues as ter- follow-up of neonatal screening programs is imple- atogens, or family history of genetic disorders and mented through a special contract with the Califor- “At these clinics, can request a formal consultation. nia State Genetic Disease Branch. psychosocial as In 1994, at the 4 genetics centers, 5464 phone con- Because of our ability to track and monitor prenatal well as medical sultations with patients and primary care providers and neonatal patients with computer programs, we have and genetic and 8515 genetic care office visits were provided. All added infectious disease monitoring to our genetics counseling needs office consultations are followed by a medical report program, including monitoring of prenatal and neona- of patients are to the primary care provider and an explanatory let- tal patients for syphilis, hepatitis B, and human immu- reviewed.” ter to the patient. nodeficiency virus (HIV). We are currently developing At multidisciplinary clinics (metabolic, lipid, spina computer linkage between Northern and Southern Cali- bifida, skeletal dysplasia, neurogenetics, and cranio- fornia to track all prenatal hepatitis B and syphilis cases facial) run by the Oakland genetics department, highly from the 60,000 KP newborn infants born annually in specialized care (eg, metabolic diets, plastic surgery) the state. The potential exists for national expansion of is coordinated in a periodic, centralized, one-stop such programs. We are also evaluating how to deter- way. At these multidisciplinary clinics, we are fol- mine the best way to prevent group B streptococcus lowing up about 150 cases of inborn metabolic er- infection in newborn infants and are developing a sys- rors (eg, phenylketonuria, galactosemia), 160 cases tem for tracking mammography results as part of a breast of spina bifida, 250 cases (including some in adults) cancer management program. of craniofacial anomalies, and 70 cases of children from families with hereditary lipid disorders. The lo- Clinical Genetic Services cal primary care provider cares for the ongoing, daily Aside from the screening programs, referred neo- medical needs of the patient close to home, and close nates, infants, and older children (as well as some

The Permanente Journal /Winter 1998/Volume 2 No. 1 11 adults) are evaluated for birth defects or genetic syn- Southern California, a laboratory was developed dromes by teams of genetic counselors and clinical which specializes in metabolic testing for genetic dis- geneticists (MDs). Pre-evaluation information (records orders (eg, amino and organic acid disorders); prac- and tests) is accumulated by the genetic counselor, titioners in KP Northern California send the KP South- clinical contributions who establishes a relationship with the family and ern California laboratory specimens for metabolic “Our large constructs a genetic pedigree. testing and use the consulting services of their meta- population of This information is reviewed by the clinical geneti- bolic specialists. Similar cooperative use of the KP members, cist before seeing the patient and family. After the Northern California molecular laboratory is planned. including about patient is seen by the geneticist and counselor, the 30,000 deliveries genetic counselor is responsible for follow-up evalu- Clinical Research annually, has ation and for helping the patient to receive the rec- Although providing clinical service is the primary permitted us to ommended testing and treatment. The genetic coun- role of an HMO, a unique opportunity exists to en- develop our own selor also sends a written summary to the family of gage in relevant clinical research such as outcome genetics labora- the affected person. analysis and studies of the cost-effectiveness of ge- tories.” Presymptomatic or predictive testing, an outgrowth netic services. of new technologic advances, is also available An interregional genetic data base has been estab- through the genetic departments. Huntington’s dis- lished and has stored enough data for selected clini- ease, which can be diagnosed before onset of symp- cal research. The data base is housed and supported toms, is an example of a disorder for which by the Center for Health Research, the research arm presymptomatic counseling and testing are avail- of the KP Northwest Division in Portland, Oregon. able for patients at risk. The size and organization of our genetic and peri- If a patient is seen at >1 facility or has laboratory natal screening services has permitted interested cli- “Currently we have work done at different centers, all medical data are nicians to engage in clinical research, and scientific an active program available through a computer medical record stored presentations and publications have resulted.1-6 for breast cancer in a genetics data base. risk counseling as Outcome Measures well as an intramu- Genetic Laboratories The perinatal screening and interdivisional genetic ral innovation Our large population of members, including about data bases provide information which allows the out- research grant for 30,000 deliveries annually, has permitted us to de- come of selected genetic and metabolic disorders to tracking breast velop our own genetics laboratories. We believe that be measured. As an example, we studied outcomes cancer patients.” internal provision of services allows for improved for more than 160 patients with congenital hypothy- quality as well as cost control. roidism whose cases were followed up since 1979, In 1994, our genetic laboratories analyzed 3770 as well as for a group of children with the D/G het- amniocentesis and 148 chorionic villus samples as erozygotic form of galactosemia. We have completed well as 17 percutaneous umbilical vein blood speci- an evaluation of prenatal congenital toxoplasmosis mens. Cytogenetic testing was done on 1082 blood screening6 and are beginning a cost-effectiveness and 265 cancer samples. Our DNA laboratory began analysis of prenatal human immunodeficiency virus operation in mid-1994 and is currently analyzing about (HIV) testing. Periodic patient surveys indicate a high “Although providing 25 specimens weekly; work includes testing for Fragile level of satisfaction with the genetic services offered clinical service is X syndrome, Huntington’s disease, Prader-Willi syn- to members. drome, cystic fibrosis, and sickling disorders as well the primary role of Care Management Institute (CMI) an HMO, a unique as doing Y-probes. We plan to improve cost-effec- opportunity exists tiveness by offering to do molecular studies for other The CMI was recently established jointly by the to engage in KP divisions. Permanente Federation and the Kaiser Foundation relevant clinical Most cytogenetic studies use amniocentesis speci- Health Plan (KFHP) to improve the quality and ef- research such as mens, but peripheral blood, bone marrow, chorionic fectiveness of care delivered to KP members nation- outcome analysis villus sampling, and fluorescent in situ hybridization ally and to discover and share new knowledge with and studies of the (FISH) comprise about 25% of the studies. In addi- the health care community. The aims of the KP North- cost-effectiveness of tion, we are doing an increasing number of bone ern California Genetics Program to collaborate with genetic services.” marrow studies for oncologists. other divisions in a number of pilot projects are rel- Currently we have an active program for breast can- evant to these goals. Current programs which could cer risk counseling as well as an intramural innova- serve as models for transportability under CMI in- tion research grant for tracking breast cancer patients. clude 1) prevention of perinatal hepatitis B and syphi- To avoid duplication and to improve efficiency, lis transmission with tracking of cases; 2) voluntary highly technical functions have been divided. In prenatal HIV testing; 3) consultation for newborn

12 The Permanente Journal /Winter 1998/Volume 2 No. 1 clinical contributions

screening tests; 4) special genetic laboratory stud- work collaboratively with the larger areas such as KP ies; 5) metabolic nutrition services and consul- Northern California to provide current, cost-effective tation for inborn metabolic errors; 6) a system for genetic services to these members. ❖ tracking breast cancer; and 7) genetic and multispecialty clinic consultations through Acknowledgment: The Medical Editing Department, Kaiser Foun- telemedicine. dation Research Institute, provided editorial assistance. Centralized management could implement these “Comprehensive, programs through computer linkage, on-site consul- This article was extracted with permission from related publica- effective, and tation, and staff training to provide standardized, cost- tion: Bachman RP, Schoen EJ: Managed genetic care in a large highly technical effective in-house KP genetic services. HMO. HMO Pract 1996 Jun;10(2):54-8. genetic services can be developed Summary and conclusion References in a managed care Comprehensive, effective, and highly technical ge- 1. Bachman RP, Schoen EJ, Backstrom MV, et al. Phenylalanine system.” netic services can be developed in a managed care embryopathy in three siblings. Am J Dis Child 1993;147:22-23. system. Providing preventive care—the primary mis- 2. Bachman RP, Schoen EJ, Stembridge A, et al. Compliance with childhood cholesterol screening. Am J Dis Child sion of an HMO—coincides with providing genetic 1993;147:382-385. services. Coordination and divisional-interdivisional 3. Witt DR, Blumberg B, Schaefer C, et al. Cystic fibrosis carrier cooperation are the keys to comprehensive, cost-ef- screening in a prenatal population [abstract]. Am J Hum Genet fective genetic care. 1992;51(4 Suppl):A16. 4. Schoen EJ, Marks SM, Clemons MM, Bachman RP. Comparing The extensive national KP membership (currently prenatal and neonatal diagnosis for hemoglobinopathies. 8.8 million members) permits us to develop a pro- Pediatrics 1993;92:354-357. gram to export certain genetic services. Although 5. Schoen EJ, Weber PM. Proposed classification of congenital smaller divisions might not be able to develop these primary hypothyroidism. Clin Pediatr (Phila) 1990;29:731-732. highly specialized programs, they could use computer 6. Schoen EJ, Black S, Cohen D. Screening for neonatal toxoplasmosis [letter]. N Engl J Med 1994;331:1458. linkage and new technologies such as telemedicine to

A Dollar Song “They’re only puttin’ in a nickel, but they want a dollar song.” Song Title

The Permanente Journal /Winter 1998/Volume 2 No. 1 13 soul of the healer

“Select-a-Nose” by Evany Zirul, DO, MFA

EVANY ZIRUL, DO, MFA, is an Ear, Nose, Throat and Facial Plastic Surgeon for the Permanente Medical Group of Mid- America, PA in Kansas City, Missouri. Another piece of her work can be seen on page 53.

14 The Permanente Journal /Winter 1998/Volume 2 No. 1 By Enid K. Eck, RN, MPH

Eric Macy, MD clinical contributions Natural Rubber Latex Protein Allergy Prevention Wendy Huber, MD and Exposure Control

The recently documented increasing incidence of natural rubber latex (Hevea Glossary of Terms brasiliensis protein allergy (HBPA) in health care workers and the general population has HBPA: Hevea brasiliensis protein allergy. led several national organizations and govern- mental agencies to recommend that health care Latex allergy management: Refers to all mea- organizations: modify use of latex products, sures used to mitigate the effect of HBPA. particularly gloves; implement mechanisms to identify persons with HBPA; and initiate strate- Latex-safe environment: Refers to an envi- gies to mitigate HBPA development. ronment in which products containing latex To respond to this emerging challenge protein or binding agents (eg, glove pow- to patients and health care workers, the Kai- der) have been eliminated and/or exposure ser Permanente California Division and North- to such products has been minimized in or- west Division developed the Western Divisions’ der to decrease the risk of latex protein al- “Latex Protein Allergy Prevention and Expo- lergy development or hypersensitivity reac- sure Control Plan.” This collaboratively devel- tions in persons who have HBPA. oped plan builds on the Hawaii Division’s pre- vious work and provides information regard- Natural rubber latex protein allergy: hy- ing 1) identification of patients and health care persensitivity to the protein derived from the workers with HBPA; 2) recommendations for Hevea brasiliensis plant. creation of a health care environment that is “The fraction of a safe for patients and health care workers with population that Non-latex gloves: gloves manufactured using may develop HBPA; and 3) to minimize the risk of develop- synthetic or non-latex-containing materials. ing HPBA (latex-safe strategies). Implementa- serologic evidence tion of this plan should facilitate system-wide for allergic consistency in the evaluation, management, and antibody to latex care coordination of health plan members and able from the authors or from the Western Divisions’ rubber proteins can health care workers with HBPA. Latex Allergy Management Committee. be 2 to 10 times As future health care issues require The incidence of HBPA has dramatically increased higher than the greater collaboration between physicians and with the widespread use of natural rubber latex fraction that non-physician support personnel, this collabo- gloves needed to enact the universal precautions actually has clinical 5 rative effort could serve as a model for devel- necessitated by the HIV epidemic. In a summary symptoms. ” opment of similar comprehensive clinical man- produced in 1993, the United States Food and Drug agement and operational guidelines. Administration (FDA) reported over 1100 adverse events and 15 deaths associated with HBPA.2 All Introduction deaths reported to date have been from parenteral The purpose of this article is to expand awareness exposure such as from barium enema cuffs. The of the problems associated with natural rubber latex most severe symptoms from routine occupational (Hevea brasiliensis ) protein allergy (HBPA) and to exposures reported to date are urticaria, asthma, put the risks of inaction into context. This paper in- and, very rarely, anaphylaxis. cludes a review of the mechanism of HBPA, who is Although only a small (<5 %) fraction of a population at risk, and how to diagnose significant HBPA. Fi- such as health care workers become significantly sensi- nally, it documents what our organization is doing to tized to natural latex rubber proteins and have clinical create a safer work and patient care environment symptoms ranging from sneezing, itching, or hives to through the development and implementation of the asthma and/or anaphylaxis when exposed to natural Kaiser Permanente Western Divisions’ “Latex Protein rubber latex proteins,3,4 the costs associated with caring Allergy and Exposure Control Plan,1” which is avail- for such persons can be substantial. The fraction of a

top ENID K. ECK, RN, MPH, is the HIV and Infectious Disease Nurse Coordinator for Kaiser Permanente’s California Division, Walnut Center.

bottom right ERIC MACY, MD, works in the Department of Allergy in the San Diego Medical Center, as well being a Partner Physician with the Southern California Permanente Medical Group, and an Assistant Clinical Professor of Medicine at the University of California, San Diego.

bottom left WENDY HUBER, MD, works in the Department of Allergy at the South Sacramento Medical Center.

The Permanente Journal /Winter 1998/Volume 2 No. 1 15 population that may develop serologic evidence for Routes of Exposure allergic antibody to latex rubber proteins can be 2 to 10 Latex protein exposure can occur by parenteral, times higher than the fraction that actually has clinical mucosal, inhalation, and cutaneous routes. Anaphy- symptoms.5 Antibody-positive individuals are only po- laxis, a systemic allergic reaction, is more likely to clinical contributions tentially allergic to latex but can account for, by CDC occur the higher the level of antigen exposure is in estimates, up to 10% of the health care worker popula- the circulation and the faster the dose is delivered.3 tion. One measure of the difference between potential Thus, in equivalently HBPA persons, latex protein allergy and significant allergy is the lack of anaphylaxis exposure through contact from gloves on internal seen during surgery. Fewer than 1 in 5000 unscreened organs during surgery or with a latex-cuffed barium individuals has unexplained, possibly latex-protein-in- enema catheter will cause greater problems than la- “Immediate duced anaphylaxis during surgery, yet a much higher tex protein on intact skin. The inhalation of latex hypersensitivity fraction are antibody-positive.6 The fraction of the gen- proteins adherent to the inert powders from gloves reactions have eral patient population that has HBPA is lower than can dissolve on the mucus membrane surfaces of been elicited by health care workers because of lower levels of expo- the upper airway and cause significant allergic reac- latex protein sure to natural rubber latex proteins and is probably tions such as allergic rhinitis and asthma.3 Most envi- exposure dissolved <3%.7 The health care environment has historically been ronmental exposure to latex proteins causes reac- from rubber a significant source of latex protein sensitization for the tions no more severe than cat protein exposure causes gloves, condoms, general population. in a person allergic to cats. barium enema catheters, bladder Natural Rubber Latex Protein Diagnosis of HBPA catheters, balloons, Natural rubber (cis-1,4-polyisoprene) is a pro- The key point in the diagnosis of potentially life- cofferdams, toys, cessed plant product of the commercial rubber tree threatening HBPA is the clinical history. Those who dental prophylactic Hevea brasiliensis. It contains variable amounts of report itching, rhinitis, swelling, hives, or asthma upon cups and sports water-soluble proteins that can be recognized as latex rubber exposure or who have had unexplained equipment.7” allergens by the human immune system. With re- anaphylaxis after medical or surgical procedures, current exposure, a certain fraction of the popula- should be screened for IgE antibodies to latex with tion can become sensitized. Synthetic latex and an ELISA test. Within Southern California Kaiser Per- some rubber products lack these potentially aller- manente, the latex ELISA test, manufactured by gic proteins, though individuals may still have prob- Upjohn-Pharmacia, is conducted by the Immunol- lems with contact sensitization from chemical ad- ogy Laboratory at the Los Angeles Medical Center ditives in processed rubber.8 Natural rubber prod- under the direction of Bruce Goldberg, MD, PhD. ucts from other sources, such as guayule Within the Kaiser Permanente system, the predictive (Parthenium argentatum) contain other potential value of the ELISA has been between 92% and 95%. but less well-studied, allergenic proteins.9 Inquiring for a latex allergy history and sending the confirmatory test if the history is positive should be- Mechanism of Latex Allergy come a routine part of obtaining the drug intoler- Natural rubber latex protein allergy (HBPA) is de- ance history. fined as an IgE-mediated (Type I hypersensitivity) re- If the Latex ELISA is ≥ Class 3, consider the history- action against water-soluble proteins contained in natu- positive subject to truly have HBPA. As with any test, ral rubber products made from the sap of Hevea false-negative latex ELISA tests can occur, but given “The key point in brasiliensis. Exposure to latex proteins in allergic per- the lack of a gold standard, the actual level is difficult the diagnosis of sons causes the immediate onset of mast cell media- to determine short of a diagnostic clinical challenge potentially life tor release. Histamine and other preformed mast cell test. Those at risk of anaphylaxis often have very high threatening mediators cause acutely increased vascular permeabil- levels of anti-latex IgE antibodies and have Latex ELISA ≥ 10 ≤ HBPA is the ity and tissue edema. Mast cells also contain media- of Class 4. If a person has a negative ELISA ( clinical history.” tors that cause delayed inflammatory effects. Immedi- Class 2) test, yet has a compelling clinical history of ate hypersensitivity reactions have been elicited by latex allergy, skin testing can be performed.11 latex protein exposure dissolved from rubber gloves, There is currently no FDA-approved skin test re- condoms, barium enema catheters, bladder catheters, agent for diagnosis of latex allergy. To circumvent balloons, cofferdams, toys, dental prophylactic cups, this problem, a quantitated latex protein solution has and sports equipment.7 The clinical manifestations of been produced by Eric Macy, MD, in the Allergy these reactions include itching, systemic urticaria, rhini- Department at the Claremont Mesa facility in San Di- tis, conjunctivitis, laryngeal edema, bronchospasm, ego for use within the Kaiser Permanente Health Care hypotension, asthma, feeling of impending doom, System. The protein content of a saline extract of anaphylaxis, and, if untreated, death. raw ammoniated latex was measured and diluted to

16 The Permanente Journal /Winter 1998/Volume 2 No. 1 clinical contributions

0.01 mg/ml and 0.1 mg/ml for sequential puncture macy, Medical Center Administration, Safety, Ad- tests. If both were negative a single intradermal test mitting, Risk Management, physicians, and selected using 0.001 mg/ml was used. This reagent has been health care workers. safely used in more than 50 people and will identify This multidisciplinary committee first met in late a fraction of those who have latex ELISA ≤ 2 as pro- 1995 to assess the impact of latex protein allergy ducing some allergic antibody to latex proteins. Those within the Kaiser Permanente Western Divisions, and who have low-level ELISA and positive skin test re- initial investigations have demonstrated a prevalence sults should avoid natural rubber latex proteins, comparable with the CDC estimates noted earlier. To though they are extremely rare. address this situation, throughout 1996, the Commit- tee developed a Latex Protein Allergy Prevention and Populations at Increased Risk for Latex Exposure Control Plan that ultimately incorporated Hypersensitivity all the essential components of the AAAAI recom- Persons who have high levels of latex protein mendations. The plan is designed to 1) create a la- “Individuals, such exposure are at increased risk for latex hypersen- tex-safe environment across the continuum of care as health care sitivity even if they have had no clinical symp- for latex-sensitive person; 2) reduce latex exposure workers, who have toms. Patients with a history of spina bifida and in health care workers; and 3) improve our mem- frequent exposure genitourinary tract anomalies, who have needed bers’ health and satisfaction. to latex proteins multiple surgical procedures and catheterizations, The Exposure Control Plan was formally approved are more likely to are at particularly higher risk of developing latex by senior management and physician leadership of become sensitized protein hypersensitivity, and 18% to 68% of such the participating Divisions in late 1996; to facilitate than average individuals, in the United States, reported to have implementation of the plan, a symposium on latex individuals in the some evidence for latex allergy. In contrast spina allergy for physicians was held in December 1996. population.7” bifida patients from Venezuela who were not ex- Additional staff and patient educational materials posed to latex protein did not have evidence of have been produced and distributed within the elevated levels of HBPA.12 Western Divisions. Persons such as health care workers, who have Additionally, a comprehensive non-latex and pow- frequent exposure to latex proteins, are more likely der-free latex glove evaluation and recommendation to become sensitized than most in the population.7 has been completed, and Purchasing and Materials Because the rate of clinically significant reactions is Management staff have been educated to consider much less than the rate of positive diagnostic tests, potential latex protein exposures when making prod- random or universal screening is not recommended.6 uct selections. Management of HBPA Within Kaiser Permanente Latex Allergy Prevention and The formal diagnosis of latex allergy requires both Exposure Control Guidelines clinical symptoms upon exposure and positive con- The Exposure Control Guidelines address the entire firmatory test results.7 The 1996 American Academy continuum of care, including inpatient, outpatient, and of Allergy, Asthma and Immunology (AAAAI) and home health. Key points in the guidelines include 1) the 1997 National Institute for Occupational Safety mechanisms to assure that patients in high-risk groups and Health (NIOSH) recommendations for latex are provided a latex-safe environment as a part of their avoidance and care management are based on avoid- medical care and that all neonates are provided a latex- ance of latex products as the only measure that can safe environment; 2) mechanisms to promote preven- prevent serious allergic reactions to latex.13,14 tion of latex sensitivity by assuring that powder-free, In response to published reports documenting an low-allergen (as defined by FDA standards), and non- apparent increase in latex protein allergy among latex gloves are provided to reduce aeroallergen levels HCWs and patients and prior to publication of the and to decrease the sensitization of HCWs and patients; AAAAI and NIOSH recommendations, a Latex Al- 3) mechanisms to assure that patients in high-risk groups lergy Prevention and Exposure Management Com- are identified and tested; 4) inclusion by health care mittee was formed consisting of Kaiser Foundation providers of latex-related allergy questions in establish- Hospitals, Health Plan, and Permanente Medical ing, monitoring, and recording the patient’s medical Group representatives from the Northwest, and history; 5) recommendations for patient education; 6) Northern and Southern California Divisions. The dis- strategies to assure that non-latex devices and latex- ciplines involved in the Committee included: safe areas are available for patients and health care Perioperative Services, Departments of Allergy and workers allergic to latex; 7) establishing policies that Dermatology, Nursing, Materials Management, Em- ban all latex products from Kaiser Permanente gift stores ployee Health, Product Utilization, Laboratory, Phar- (ie, ornamental balloons).

The Permanente Journal /Winter 1998/Volume 2 No. 1 17 To facilitate implementation of the Latex Protein and to the health, safety, strategic development, and Allergy Prevention and Exposure Control Plan each retention of a quality health care team. Latex has medical center has convened a local “Latex Allergy been identified as a potentially harmful, and some- Management Committee,” modeled after the Interdi- times lethal, antigen to allergic patients, employ- clinical contributions visional committee. In each area of the health care ees, and physicians. setting, the basic procedures of room selection and From our experience to date, through implementa- preparation, communication strategies, special pre- tion of a comprehensive latex allergy prevention and cautions and considerations for external and internal exposure control plan and a quality improvement product use, management of intravenous therapy and program that includes latex allergy-related indicators, “Although every medication administration, management of emergen- improved patient care, and a reduction in incidence area of the care cies, and educational needs are reviewed by the lo- of latex-related incidents can be realized. ❖ environment may cal committee and revised appropriately to minimize require modifica- latex protein exposure. Substantial progress has been References tion to effectively made in implementation of the Latex Exposure Con- 1. Western Divisions Latex Protein Allergy and Exposure Control manage latex trol Plan within the participating Divisions, and Plan, 1996. 2. Dillard SF, MacCollum MA. Reports to the FDA: Allergic allergy, special completion is on target for the first quarter of 1998. reactions to latex containing medical devices. 1993. FDA, Center consideration Although every area of the care environment may for Devices and Radiological Health, 1390 Piccard Drive, should be given to require modification to effectively manage latex al- Rockville, Maryland, USA 20850. Perioperative lergy, special consideration should be given to 3. Vandenplas O, Delwiche JP, Evrard G, Aimont P, van der services because of Perioperative Services because of the potential for Brempt X, Jamart J, Delaunois L. Prevalence of occupational asthma due to latex among hospital personnel. Am J Respir Crit the potential for intraoperative anaphylaxis. In contrast to most aller- Care Med 1995;151:54-60. intraoperative gic reactions evoked by intravenous drugs, which 4. Turjanmaa K, Alenius H, Makinen-Kiljunen S, Reunala T, anaphylaxis.” occur in 3 minutes, latex reactions usually occur 20 Palosuo T. Natural rubber latex allergy. Allergy 1996;51:593-602. to 60 minutes after induction, when sufficient anti- 5. Ownby DR, Ownby HE, McCullough J, Shafer AW. The prevalence of anti-latex IgE antibodies in 1000 volunteer blood gen has been absorbed transmucosally. Sometimes donors. J Allergy Clin Immunol 1996;97:1188-1192. these reactions may not manifest with all the cardi- 6. Porri F, Lemiere C, Birnbaum J, Guilloux L, Lanteaume A, nal features of anaphylaxis and may be misdiagnosed Didelot R, Vervloet D, Charpin D. Prevalence of latex as pulmonary embolisms, acute myocardial infarc- sensitization in subjects attending health screening: implications tion, aspiration, or vasovagal reaction.6 To assure for a perioperative screening. Clin Exp Allergy 1997;27:413-417. 7. Sussman GL, Beezhold DH. Allergy to latex rubber. Ann proper diagnosis, a high index of suspicion regard- Intern Med 1995;122:43-46. ing latex protein allergy must be maintained. 8. Wilkinson SM, Beck MH. Allergic contact dermatitis from latex rubber. Dermatol 1996;134:910-914. Quality Improvement 9. Siler DJ, Cornish K, Hamilton RG. Absence of cross-reactivity of IgE antibodies from subjects allergic to Hevea brasiliensis Because of the potential workers’ compensation latex with a new source of natural rubber latex from guayule and disability reimbursement costs and the (Parthenium argentatum). J Allergy Clin Immunol 1996;98:895- organization’s liability associated with latex allergy, 902. establishing a quality improvement program that in- 10. Michael T, Niggemann B, Moers A, Seidel U, Wahn U, “To assure proper cludes latex-related indicators is essential. Suggested Scheffner D. Risk factors for latex allergy in patients with spina diagnosis a high bifida. Clin Exp Allergy 1996;26:934-939. indicators or areas for possible investigation include: 11. Hamilton RG, Adkinson NF Jr. Natural rubber latex skin index of suspicion workers compensation claims, union grievances, sick testing reagents: Safety and diagnostic accuracy of regarding latex leave, malpractice claims, adverse anesthesia events, nonammoniated latex, ammoniated latex, and latex rubber protein allergy must and unexplained anaphylaxis events. Additionally, glove extracts. J Allergy Clin Immunol 1996;98:872-883. be maintained.” 12. Capriles-Hulett A, Sanchez-Borges M, Von-Scanzoni C, monitoring of any adverse clinical events occurring Medina JR. Very low frequency of latex and fruit allergy in despite the latex avoidance procedures in place of patients with spina bifida from Venezuela: influence of any error in latex avoidance and the selected glove socioeconomic factors. Ann Allergy Asthma Immunol program should be ongoing to identify any unfore- 1995;75:62-64. seen problems (ie, contact dermatitis, decreased bar- 13. American Academy of Allergy, Asthma and Immunology Latex Guidelines, 1996. rier protection, etc.). 14. National Institute for Occupational Safety and Health. Preventing Allergic Reactions to Natural Rubber Latex in the Conclusion Workplace. DHHS (NIOSH) Pub. No. 97-135. Washington, Kaiser Permanente strives to maintain an environ- CD:NIOSH; 1997. ment that is conducive to, high-quality patient care

18 The Permanente Journal /Winter 1998/Volume 2 No. 1 By Seymour Grossman, MD A New Era in Colorectal Cancer clinical contributions Screening and Surveillance

The following is a distillation of my beliefs, primarily et al showed that after removal of about endoscopic screening and surveillance of average-risk their small rectal TAs and no fur- subjects, as formulated from my clinical experience, research, ther procedures, patients were at and knowledge of the literature. One of several general view- less-than-expected risk for even- points, but one I hold quite strongly, it contains statements and tual development of colorectal can- recommendations that can be considered controversial, although cer.8 On the other hand, all of these to a lessening extent, it appears, as further studies are reported. studies showed clearly that when “ ... virtually all The list of references also is highly selective, limited to the land- the index lesions are advanced ad- colorectal mark and review papers that, for the most part, form the basis enomas, patients are at increased cancers develop for my views. risk of having advanced neoplasms from adenomas, proximally and should therefore usually large and In the United States during the that 1) all adenomas must be have colonoscopy. The large, on- villous, and the 1940s through the 1970s, cancer considered premalignant; 2) the going Kaiser Permanente sigmoi- process occurs 9 clinics in urban areas offered rigid presence of a single adenoma of doscopic screening program has very slowly, over sigmoidoscopy to persons who any size or type puts the patient not yet reported its data, which 5 to 35 years ...” wanted screening for rectal can- at high risk for malignancy; and show that even subjects found on cer. These were probably very ef- 3) new polyps arise quickly and screening to have large TAs in the fective in reducing rectal cancer must be removed, lest they left colon do not have increased deaths as demonstrated by progress to fatal malignancies. prevalence of advanced neoplasms Gilbertsen and Nelms.1 In the in the right colon when compared 1970s, the St. Mark’s Hospital The Flaw in the Guidelines with control subjects. Nor is the group showed that virtually all Understanding what was wrong presence of several small TAs at colorectal cancers develop from with those concepts comes from screening sigmoidoscopy an indi- adenomas, usually large and vil- reexamination and comprehension cation for colonoscopy. lous, and that the process occurs of the true role of the small tubu- Periodic follow-up colonoscopy very slowly, over 5 to 35 years;2 lar adenoma (TA), defined as a TA after initial clearing of the colon advances in fiber-optics and en- < 1 cm in diameter. (Another defi- has been reported in large surveil- gineering led to development of nition: advanced adenoma = TA >1 lance studies to show “unimpor- “In a 1992 case the colonoscope; and its imple- cm in diameter or containing vil- tant pathology.” Of the adenomas control study from mentation was accelerated by the lous elements or severe dysplasia.) found at such surveillance Kaiser Permanente, introduction and widespread use It has been known for almost colonoscopies, 84% to 90% are Selby et al showed of standardized fecal occult two decades that small TAs only small (<1 cm) and mainly tubular; convincingly that blood testing. In the 1980s, the occasionally develop villous ele- they are evenly distributed and subjects who had flexible sigmoidoscope replaced ments and rarely contain severe rarely have high-grade dyspla- 1 10,11 rigid proctoscopic the rigid proctoscope and af- dysplasia or carcinoma and that sia. Careful analysis of costs and clearing of 5 forded the ability to find the they grow very slowly, if at all. benefits of frequent colonoscopic colorectal mucosa majority of colorectal cancers and Several studies have demonstrated surveillance after clearing a were 70% less 3 advanced adenomas. that a small TA in the distal bowel patient’s colon shows it is usually likely to die from 12 The subsequent profusion of does not serve as a marker for not appropriate —the most impor- cancer of the published studies, few of which proximal precancerous or malig- tant exception being the univer- 6-9 rectum or distal were prospective or controlled, nant neoplasms. In a 1989 Kai- sally accepted need for aggressive sigmoid colon, and led the American Cancer Soci- ser Permanente study, Grossman surveillance after removal of a that they were ety and the gastroenterologic et al showed that only 3% of sub- sessile villous polyp. protected for at 4 societies to publish guidelines, jects who had only a single small In recent years, there has been least 10 years.13” which included, starting at age tubular adenoma removed at proc- partial acceptance of these concepts 50 years, lifelong annual stool toscopy were found to have a of less aggressive colonoscopy with Hemoccult testing, sigmoidos- proximal advanced adenoma on the allowance that perhaps the find- copy every 3 years, colonoscopic total colonoscopy: the same find- ing of a 5 mm tubular adenoma at follow-up of any adenoma ings that would be expected in the screening sigmoidoscopy does not found, then lifelong surveillance general population.6 A similar mandate a colonoscopy and that colonoscopies. These guidelines study in 1994 verified those re- routine sigmoidoscopy can be done were based largely on the fear sults.7 At St. Mark’s Hospital, Atkin as infrequently as every 5 years.

SEYMOUR GROSSMAN, MD, retired in 1995 after 30 years with The Permanente Medical Group, Oakland, where he was Chief of Gastroenterology for the last 25 years. He continues as Clinical Director of the Colorectal Cancer Prevention (CoCaP) Program for TPMG, and as Clinical Professor of Medicine at the University of California San Francisco School of Medicine.

The Permanente Journal /Fall 1997/Volume 1 No. 2 19 Sigmoidoscopic Screening dated to undergo an intensive, multifaceted follow-up The 1978 Gilbertsen report was uncontrolled and protocol. The protocol includes frequent interviews had poor documentation of data but suggested that and examinations, blood tests, chest films, and screening proctoscopy could protect against rectal colonoscopies for the rest of the patient’s life. This clinical contributions cancer. In a 1992 case control study from Kaiser Per- aggressive surveillance regimen was based on several manente, Selby et al showed convincingly that sub- questionable premises: first, that every patient with jects who had rigid proctoscopic clearing of colorectal colorectal cancer is at high risk for development of mucosa were 70% less likely to die from cancer of another colorectal cancer; and second, that discovery the rectum or distal sigmoid colon, and that they and treatment of recurrences can save enough lives to were protected for at least 10 years.13 make worthwhile both the immense cost and the life- “Analysis of CEA Flexible sigmoidoscopy reaches 50% to 75% of ad- long ordeal of following that protocol. monitoring shows vanced neoplasms (advanced adenomas plus adeno- Everyone agrees that perioperative (preferably pre- it is expensive, carcinomas).3 Additional advanced neoplasms will be operative) colonoscopy should be performed in all inefficient, and found in the right colon when sigmoidoscopic dis- colorectal cancer patients to establish the presence potentially covery of advanced neoplasms leads to colonoscopy. or absence of synchronous neoplasms, and to re- harmful, because For a sigmoidoscopic screening program to be logis- move any lesions found. However, the rest of the of the many tically feasible, total colonoscopy as a follow-up for mandate has little evidence to support it. The risk for unsuccessful sigmoidoscopic findings must be limited to patients subsequent development of a second colorectal can- operations, who have had more than a small TA in their left cer is quoted variably from 2% to 6%, which is less particularly in colon. Subsequent surveillance must also be limited than the risk of developing a first colorectal cancer elderly, poor-risk as described. in the general population. This risk holds for some- candidates.19” The role of family history in making decisions one whose cancer is an isolated neoplasm. How- about screening and surveillance remains ill-defined. ever, the cancer patient who is young (in 40s or If a subject has a first-degree relative who had younger) or has, in addition to the cancer, synchro- colorectal cancer at age 55 years or younger, or two nous advanced neoplasms, is at high risk for devel- first-degree relatives who had the disease at any opment of a second cancer and should be in a sur- age, we perform early screening colonoscopy, in veillance protocol. As for curing patients with recur- conformity with the recommendations of the Ameri- rences, studies using aggressive systematic follow- can Cancer Society. up protocols have usually proved futile. Suture line recurrences generally occur in patients who already Hemoccult Screening have disseminated disease, so that survival rates are Hemoccult II, the most studied fecal occult blood improved by < 0.5% by the occasional successful re- test (FOBT), is usually positive in 1% to 4% of sub- section of these recurrences. Analysis of CEA moni- jects and has sensitivity for cancer as low as 25% to toring shows it is expensive, inefficient, and poten- 50%.14-15 Cancer is found in about 10% of patients tially harmful because of the many unsuccessful op- testing positive. In the highly publicized Minnesota erations, particularly in elderly, poor-risk candidates.19 “Screening study, slides were rehydrated, increasing sensitivity sigmoidoscopy at great cost (in both dollars and complications). Ten Main Concepts performed on most percent of subjects had positive tests, and cancer was 1. Screening sigmoidoscopy performed on most people every ten found in only 2% of the resulting colonoscopies.16 people every 10 years starting in their sixth decade years starting in Subsequent analysis of this study suggested that much of life would result in a significant reduction in their sixth decade of the reduction in cancer deaths was due to chance colorectal cancer mortality. of life would result colonoscopy, not to FOBT.17 In 1996, Allison et al 2. The small (<1 cm) colorectal TA is a common in a significant showed that by using a combination of two fecal age-related finding. It rarely grows to become a ma- reduction in occult blood tests, one highly sensitive and the sec- lignancy—nor is it a marker for synchronous ad- colorectal cancer ond highly specific, as much as 65% of cancers could vanced neoplasms. Larger TAs now appear to share mortality.” be found.18 Thus, one could add such fecal occult this non-marker quality. Conversely, adenomas con- blood testing to a sigmoidoscopic screening program taining villous or highly dysplastic architecture are and succeed in diagnosing 85% of colon cancers and the main participants in the adenoma-carcinoma se- nearly that percentage of villous adenomas. quence and are markers for synchronous and metachronous advanced neoplasms. Surveillance After Colon Cancer Resection 3. As fecal occult blood tests evolve and improve, In the 1989 AGA/ASGE position paper,4 all patients stool testing will become a more effective part of having curative surgery for colorectal cancer were man- screening programs.

20 The Permanente Journal /Winter 1998/Volume 2 No. 1 clinical contributions

4. The development of cancer from a colonic adenoma and surveillance of colorectal cancer. JAMA 1989;261:580-585. is a very slow process, taking from 5 years to 25 years. 5. Knoernschild H. Growth rate and malignant potential of colonic polyps: Early results. Surg Forum 1963;14:137-138. 5. After a colon cancer is resected, searching for 6. Grossman S, Milos ML, Tekawa IS, Jewell NP. Colonoscopic and treating recurrent cancer is usually futile. If the screening of persons with suspected risk factors for colon primary cancer was not accompanied by other ad- cancer: II. Past history of colorectal neoplasms. Gastroenterol- vanced neoplasms, the likelihood of a second colon ogy 1989;96:299-306. cancer developing is similar to the chance an aver- 7. Zarchy TM, Ershoff D. Do characteristics of adenomas on flexible sigmoidoscopy predict advanced lesions on baseline age-risk person has of developing a first colon can- colonoscopy? Gastroenterology 1994;106:1501-1504. cer (about 5%). 8. Atkin WS, Morson BC, Cuzick J. Long-term risk of colorectal cancer after excision of rectosigmoid adenomas. N Engl J Med Recommendations 1992;326:658-662. 1. Start colorectal cancer screening at about age 55 9. Palitz AM, Selby JV, Grossman S, Finkler LJ et al. The colon “Remove small cancer prevention program (CoCaP): rationale, implementation, polyps at sigmoido- years with a flexible sigmoidoscopy. If results are and preliminary results. HMO Practice 1997;11:5-12. negative (90%), tell the patient to return in 10 years 10. Lance P, Grossman S, Marshall JR. Screening for colorectal scopy or measure for another sigmoidoscopy. cancer. Semin Gastrointest Dis 1992;3:22-32. and biopsy each 2. Remove small polyps at sigmoidoscopy, or 11. Williams CB, Bedenne L. Management of colorectal polyps: small polyp. If the Is all the effort worthwhile? J Gastroenterol Hepatol 1990(suppl measure and biopsy each small polyp. If the polyp polyp is a TA and 1);1:144-165. fully removed, is a TA and fully removed, repeat sigmoidoscopy 12. Ransohoff DF, Lang CA, Kuo HS. Colonoscopic surveillance in 5 years. after polypectomy: considerations of cost effectiveness. Ann repeat sigmoidos- 3. When sigmoidoscopy reveals a large polyp or Intern Med 1991;114:177-182. copy in five years.” 13. Selby JV, Friedman GD, Quesenberry CP, Weiss NS. A case- biopsy shows a polyp to contain villous elements or control study of screening sigmoidoscopy and mortality from high-grade dysplasia, total colonoscopy is indicated. colorectal cancer. N Engl J Med 1992;326:653-657. 4. If colonoscopy shows no other lesions, or only a 14. Allison JE, Feldman R, Tekawa IS. Hemoccult screening in few tiny TAs in addition to the completely removed detecting colorectal neoplasm: sensitivity, specificity, and index lesion, do sigmoidoscopic follow-up in 5 years. predictive value. Long-term follow-up in a large group practice setting. Ann Intern Med 1990;112:328-33. 5. If a patient undergoing cancer resection is shown 15. Alquist DA, Wieand HS, Moertel CG. Accuracy of fecal to have no other advanced neoplasms by occult blood screening for colorectal neoplasia: a prospective perioperative colonoscopy, surveillance sigmoidos- study using Hemoccult and Hemoquant tests. JAMA copy or colonoscopy in 5 years is appropriate fol- 1993;269:1262-67. 16. Mandel JS, Bond JH, Church TR, et al. Reducing mortality low-up. If a cancer patient is unusually young or has from colorectal cancer by screening for fecal occult blood. other advanced lesions removed at perioperative Minnesota Colon Cancer Control Study. N Engl J Med colonoscopy, the first surveillance colonoscopy 1993;328:1365-71. [Published erratum appears in N Engl J Med should be done in 3 years. ❖ 1993 Aug 26;329(9):672] 17. Lang CA, Ransohoff DF. Fecal occult blood screening for colorectal cancer. Is mortality reduced by chance selection for References screening colonoscopy? JAMA 1994; 271: 1011-13. 1. Gilbertsen VA, Nelms JM. The prevention of invasive cancer 18. Allison JA, Tekawa IS, Ransom MS, Adrain AL. A comparison of the rectum. Cancer 1978;41:1137-1139. of fecal occult-blood tests for colorectal-cancer screening. N 2. Muto T, Bussey HJR, Morson BC. The evolution of cancer of Engl J Med 1996;334:155-59. the colon and rectum. Cancer 1975;36:2251-2270. 19. Ballantyne GH, Modlin IM. Postoperative follow-up for 3. Matek W, Hermanek P, Demling L. Is the adenoma-carcinoma colorectal cancer: Who are we kidding? J Clin Gastroenterol sequence contradicted by the differing location of colorectal 1988;10:359-364 (editorial). adenomas and carcinomas? Endoscopy 1986;18:17-19. 4. Fleischer DE, Goldberg SB, Browning TH, et al. Detection

Living Life “We make a living by what we get, but we make a life by what we give.” Norman MacEwan

The Permanente Journal /Winter 1998/Volume 2 No. 1 21 By Morris Collen, MD Elizabeth Anderson, MD Perspective—Kaiser Permanente Medicine 50 Years Ago

This is the second in this series of reprints from a favorably with the report by Bortz1 of 11.7 percent mortality on over quarterly publication, the Permanente Foundation Medical 9000 patients with pneumococcal pneumonia. Of the 121 cases of Bulletin, which Dr. Morris Collen edited from 1943 to 1953. “undetermined” etiology, the majority were probably pneumococ- This entry (from Vol. 1, No. 1; July, 1943) is one of Dr. Collen’s cal in origin, but the organisms were not isolated due to unsatisfac- clinical contributions numerous splendid contributions to the Bulletin. The article tory sputum samples. is accompanied by a perceptive analysis written by Dr. Eliza- beth Anderson, an Infectious Disease subspecialist who Table 1. ETIOLOGICAL CLASSIFICATION OF 517 CASES OF PNEUMONIA knows Dr. Collen. Cases Deaths % Mortality - Arthur Klatsky, MD, Section Editor Pneumococcal ...... 338 39 11.5 Staphylococcal ...... 12 1 8.3 Streptococcal ...... 15 0 0.0 The Management of Pneumonia (A Review of 517 Cases) Virus ...... 31 0 0.0 Morris F. Collen, MD and Gerhardt L. Dybdahl, MD Undetermined ...... 121 2 1.6 In the eight month period from September 1942 to May 1943, ------517 patients with pneumonia were treated at this hospital. The Totals ...... 517 42 8.1 diagnosis of pneumonia was substantiated in every case by a posi- tive roentgenogram of the chest. No questionable cases of “mini- Thirty-one patients were classified as having pneumonia of virus mal pneumonia,” “pneumonitis,” or similar indefinite diagnosis were etiology, or “atypical” pneumonia, because of the characteristic roent- included in this series. Patients with pneumonia as a contributory genogram showing a pneumonic infiltration of the central or lower diagnosis to another illness were excluded. left lung fields, associated with a low leukocyte count, slow pulse, scanty sputum and failure to respond to sulfadiazine therapy. Etiological Classification Table 1 indicates that in the great majority, the pneumonia was Complicating Conditions due to the pneumococcus. Type VII pneumococcus was the most Since sulfadiazine has been used in the treatment of pneumonia, the frequent specific type encountered and was also associated with incidence of complicating conditions has markedly decreased. In this the highest mortality. The gross mortality for the 338 patients with series of 517 patients, sterile pleural effusions were the most frequent pneumococcal pneumonia was 11.5 percent. This figure compared complication and occurred in eleven patients (2%). All of these effusions

Morris F. Collen, MD One of the pioneering physicians of the Kaiser Permanente Medical Care Program, Dr. Collen has played a major role in our organization for 55 years and in the world of medical informatics for much of this time. In the KPMCP, he has been Chief of Medicine at Oakland from 1942-52, Medical Director at Oakland from 1952-4, Chairman of the Executive Committee from 1949-1973, Physician-In-Chief in San Francisco, and Medical Director of the West Bay from 1953-1961, Director of Medical Methods Research from 1961-1979, Director of Division of Technology Assessment from 1979-1983, and a Consultant at the Division of Research from 1983 to the present. Also, of course, he edited the Permanente Foundation Medical Bulletin from 1943-1953. He has had a distinguished parallel career in the area of computer applications to medicine and has published 180 articles and seven books, including a book History of Medical Informatics published in 1995. A partial list of his honors includes election to the Institute of Medicine of the National Academy of Sciences in 1971 and selection as a Distinguished Practitioner of Medicine of the National Academies of Practice in 1983, the 1992 Computers in Healthcare Pioneer Award and the International Health Evaluation Lifetime Achievement Award, and the 1993 American College of Medical Informatics Morris F. Collen Medal. He has been a member of many governmental advisory and study groups and currently has an appointment as scholar-in-residence at the National Library of Medicine. A graduate of the University of Minnesota (under- graduate and medical school), he did internship at Michael Reese Hospital in Chicago and residency at Los Angeles County Hospital, and is a Fellow of the American College of Physicians and of the American College of Medical Informatics.

Elizabeth Anderson, MD Dr. Anderson was educated at Harvard University (BS & MD) and did her residency at Duke and at UCLA. She practiced in Internal Medicine and Infectious Diseases at the Southern California Permanente Medical Group from 1974-1978, and then at The Permanente Medical Group, Oakland, from 1978 to the present. She was Chief of Medicine at Oakland from 1986-1991; Director of Medical Education from 1991-1994; and currently is in charge of hospital-based medicine. She is a Clinical Professor of Medicine at UCSF School of Medicine.

22 The Permanente Journal /Winter 1998/Volume 2 No. 1 clinical contributions

remained uninfected and cleared under the management as outlined below. Empyema did not occur in a single patient in this series. Asthmatic bronchitis was a common associated complicating condition, which tended to exhaust the patient, and make the treatment more difficult. Acute glomerulonephritis, non-purulent arthritis, and erythema nodosum each occurred twice. Septic arthritis, acute bacterial en- docarditis, meningitis, pulmonary embolism (on first ambulatory day), pelvic thrombophlebitis, and spontaneous pneumothorax, each occurred once.

Severity of Cases In this series, 145 patients (28%) had pneumonic involvement of more than one lobe. The gross mortality of the entire group of 517 patients with pneu- monia was 8.1 percent, which is comparable to that of other large series, however, although gross mortality statistics are interesting, they are not significant, because of the multiplicity of factors which influence the mortality in pneumonia (age, number of lobes in- volved, complicating conditions, associated disease, etiological organisms, etc). Graph 1 also indicates the average curve (dot-dash line) ob- Chemotherapy tained by plotting blood sulfadiazine determinations at one-quar- Chemotherapy is the most important single agent in the treat- ter, one, four, eight, twelve and twenty-four hours after an intrave- ment of pneumonia. Before sulfadiazine was administered, speci- nous dose of five grams of sodium sulfadiazine. Within fifteen mens were routinely obtained for blood culture, sputum typing, minutes after the injection, a concentration of over sixteen milli- complete blood count, and urinalysis. grams per one hundred cubic centimeters was uniformly obtained. Sulfadiazine is becoming universally accepted as the drug of The blood level of sulfadiazine then fell gradually over the next choice for pneumonia, because (1) it is the drug most effective twelve hours, so that between twelve to twenty-four hours the against the pneumococcus, streptococcus, staphylococcus, and the curves with oral and intravenous sulfadiazine were about the same. Friedlander’s bacillus, (2) it is most effective as evidenced by com- By combining various initial oral and intravenous doses of sulfa- parative mortality statistics in large numbers of cases,1 and (3) it is diazine, it was finally determined that an initial dose on admission the least toxic of the sulfonamide group.3 of five grams of sodium sulfadiazine intravenously and two grams Throughout the four month period from September to Decem- orally, followed by two grams orally every six hours thereafter ber, all patients with pneumonia received an average initial dose was optimal. This dosage produced an immediate rise in the blood of five grams of sulfadiazine orally, then one gram orally every sulfadiazine concentration to between sixteen to twenty milligrams four hours thereafter, Graph 1 indicates the average curve (dot- per one hundred cubic centimeters (graph 1, solid line), then de- ted line) obtained by plotting blood sulfadiazine determinations creased within four hours to about ten to fifteen milligrams, where found at one, four, eight, twelve and twenty-four hours after an it remained fairly constant as long as the drug was continued. initial oral dose of five grams of sulfadiazine. The maximum con- During the four month period from December to May, all pa- centration of the drug in the blood was reached between four tients with pneumonia, received immediately on admission to this and eight hours after this dose was given, the average level at hospital, five grams of sodium sulfadiazine intravenously and two this time being six to seven milligrams per one hundred cubic grams of sulfadiazine orally, followed by two grams orally every centimeters. Graph 1 emphasizes that (1) sulfadiazine is slowly six hours thereafter. Table 2 indicates the mortality statistics of absorbed from the gastrointestinal tract, forcing a delay of four these two groups of patients, both treated identically in all ways to eight hours before therapeutic concentrations of the drug are by the same staff, except for the difference in dosages and route obtained, (2) the initial oral dose which is usually administered, of sulfadiazine as indicated. is entirely insufficient to obtain the full therapeutic blood con- centrations necessary for optimum curative effect, (3) it is not Table 2. RELATIONSHIP BETWEEN SULFADIAZINE ADMINISTRATION necessary to administer sulfadiazine orally every four hours, since AND MORTALITY a proportionately higher dose every six to eight hours is just as Initial Dose Cases Deaths % Mortality effective. A few patients were given five grams each of sodium 1. Oral ...... 108 10 9.3 bicarbonate and sulfadiazine orally, but no changes in blood 2. Intravenous ...... 409 32 7.7 sulfadiazine concentrations, and no increase in absorption of sul------fadiazine was evident. Total ...... 517 42 8.1

The Permanente Journal /Winter 1998/Volume 2 No. 1 23 It should also be noted that the second and larger series in- discontinued for the next two doses, and the blood non-protein cluded the majority of the winter group of patients with pneumo- nitrogen or urea nitrogen was immediately checked. (Impaired nia, which it was felt, were on the whole more virulent in nature renal function was the usual cause for excessively high blood than the fall group. The average mortality for the group treated sulfadiazine levels.) Fluids were forced in this latter group, and clinical contributions with five grams of sulfadiazine orally and one gram every four the blood sulfadiazine level was again determined in twelve hours; hours thereafter was 9.3 percent. The average mortality for the further dosage of the drug was governed accordingly. The blood group treated with five grams of sodium sulfadiazine intravenously sulfadiazine level was maintained between ten to fifteen milli- and two grams of sulfadiazine orally, then two grams orally every grams per hundred cubic centimeters as closely as possible. six hours thereafter, was 7.7 percent. Sulfadiazine was maintained in full dosage until the temperature No greater incidence in sulfadiazine toxic reactions was noted in was normal for two to three days, then the drug was discontinued. the higher dosage group than in the lower dosage group. Dowling10 The pulse, respirations, white blood count, and percent neutro- has shown that the incidence of relapse, spread of pneumonia to phils should all be normal at this time, and the urine should show another lobe, and slow resolution was less than half as frequent in no albumin or casts (the latter were a valuable index to the toxic- a group treated with small doses. ity of the pneumonia, since very toxic patients constantly showed Since the length of time that elapses before treatment is insti- marked albuminuria and many granular and hyaline casts.) Taper- tuted is a very important factor influencing mortality in pneumo- ing of the dosage of the drug before stopping it is unnecessary; nia, it is essential that full therapeutic blood concentrations of Bullowa has shown that this actually may be harmful.5 sulfadiazine be obtained as soon as possible. Treating the patient by an initial oral dose of sulfadiazine implies that the patient lies Table 3. INCIDENCE OF SULFADIAZINE TOXIC REACTIONS in the hospital up to one-third of a day before the treatment be- (Finland) comes effective. Certainly where delay in a fraction of a day in- Manifestations Cases Percent Percent creases the mortality, it is not desirable to permit a patient with Crystalluria 40 7.7 7.4 pneumonia to wait four to eight hours in the hospital for the sul- Hematuria 7 1.4 5.2 fadiazine to be absorbed from the gastrointestinal tract, when within Skin eruptions 5 1.0 1.5 fifteen minutes an effective blood concentration may so easily be Leukipenia 4 0.8 0.7 obtained by an initial intravenous injection. Psychosis 3 0.6 0.4 All patients having pneumonia are now routinely treated imme- Fever 2 0.4 0.2 diately on admission with five grams of sodium sulfadiazine intra- venously and two grams of sulfadiazine orally (blood and sputum Sulfadiazine toxicity was encountered in twelve percent of the specimens for the laboratory being obtained first), and then two patients in this series. Table 3 lists the frequency with which grams of sulfadiazine orally every six hours thereafter. Patients each of the various toxic manifestations were encountered. The who cannot take any oral medications are maintained on five grams table also presents the frequency of toxic reactions as reported of sodium sulfadiazine intravenously every twelve hours until oral by Finland4 in a series of 460 patients treated with sulfadiazine. It therapy can be instituted. is apparent that no remarkable differences in frequency of drug Sulfadiazine blood concentrations were routinely determined toxicity occurred in the two series. It has been shown6 that toxic between twelve to eighteen hours after admission. This was found reactions are no more numerous in patients treated with large to be imperative, since even doses of sulfadiazine than in those though the majority of patients treated with small doses. showed a blood level of ten to fif- “All patients having pneumonia are now routinely treated Only patients who were re- teen milligrams per hundred cen- immediately on admission with five grams of sodium ported by the laboratory as show- timeters, in the individual case the sulfadiazine intravenously and two grams of sulfadiazine ing “many sulfa crystals” or actual blood concentration was un- orally (blood and sputum specimens for the laboratory “loaded with sulfa crystals” were predictable due to variations in hy- being obtained first), and then two grams of sulfadiazine included as sulfadiazine toxic re- dration and renal function. If the orally every six hours thereafter.” actions. The presence of only a blood concentration of sulfadiaz- few crystals in the urine was not ine was found to be between seven alarming, and indicated only that to ten milligrams per hundred cubic centimeters, 2.5 grams of the fluid intake of the patient should be increased, and that a sodium sulfadiazine were immediately given intravenously, and daily urinalysis should be performed. The development of sul- the blood sulfadiazine level was again determined in twelve hours. fadiazine crystalluria with or without hematuria indicated the If the blood sulfadiazine concentration was found to be less than need to (1) force fluids to 4000 to 5000 cubic centimeters daily, seven milligrams, the full dose of five grams of sodium sulfadiaz- (2) observe output very carefully for oliguria, (3) perform daily ine was gain repeated intravenously, and further blood sulfadi- urinalyses for pH and crystals, (4) give 500 to 1000 cubic centi- azine concentrations were subsequently determined. If the blood meters of one-sixth molar sodium lactate solution intravenously. level was found to be over twenty milligrams, sulfadiazine was The pH of the urine is much more important in the solubility of

24 The Permanente Journal /Winter 1998/Volume 2 No. 1 clinical contributions

sulfadiazine crystals than the quantity of urine.2 The use of so- (1) patients with pneumococcal pneumonia who were sulfadi- dium lactate solution was found to be very satisfactory; within azine “sensitive” or sulfadiazine “fast,” or for other reasons did not eight to twelve hours after administering 1000 cubic centime- satisfactorily respond to chemotherapy, were given serum therapy; ters of the solution, the pH of the urine rose and the sulfadiaz- (2) patients with pneumococcal pneumonia, who had not shown ine crystals disappeared in 90 percent of patients. The use of marked improvement by the time a positive blood culture was oral sodium bicarbonate is much less reliable and more vari- reported, received 50,000 units of serum intravenously every four able in results. An occasional patient required daily injections hours until a definite fall in pulse and temperature occurred; of 1000 cubic centimeters of one-sixth molar sodium lactate (3) patients with pneumococcal pneumonia with negative blood solution for a few days to maintain relatively alkaline urine. cultures, who showed no improvement in twelve to eighteen Hematuria without crystalluria was observed in four patients. hours, received 50,000 units of type specific rabbit serum intra- No other explanation for the hematuria was apparent, and upon venously (after proper testing for sensitivity). Every four hours discontinuing the sulfadiazine and administering sodium lactate 50,000 units were injected until a definite fall in pulse and tem- solution intravenously, the hematuria promptly cleared. perature occurred. Pneumococcal type VII pneumonia proved Skin eruptions were manifested in two patients as a morbilli- especially virulent this winter, and required serum more frequently form rash, and in three patients as a than any other type; scarlatiniform rash. Sulfadiazine was (4) all patients with typed pneumo- discontinued whenever a toxic rash coccal pneumonia who were over fifty appeared, since maculopapular erup- “Asthmatic bronchitis was a frequent complica- years of age, or had multiple lobe in- tions have been observed to progress tion in pneumonia and added to the dyspnea and volvement, acute or chronic alcohol- into bullous and exfoliative derma- anoxia of the patient.” ism, (patients admitted with pneumo- toses upon failure to discontinue the nia and delirium tremens had an es- drug promptly. pecially high mortality), severe liver or Leukopenia with a white blood count below 5000 cells per cubic kidney damage, heart disease, diabetes, or pregnancy were care- millimeter, was observed in only four patients. The lowest count fully observed as possible candidates for serum therapy. observed was 3200 white cells per cubic millimeter. The white count Indications varied, of course, with the toxicity of the individual promptly rose in each case after the drug was discontinued and ten case and with all the other factors which influence the mortality cubic centimeters of pentnucleotide was given intramuscularly three of pneumonia. to four times daily. In severely ill patients with staphylococcic pneumonia, staphy- Psychosis, manifesting itself primarily as a toxic delirium, de- lococcus antitoxin was used as an adjunct. In two patients 40,000 veloped in three patients on the fourth to sixth day of chemo- units of antitoxin were administered intramuscularly twice daily therapy. Symptoms cleared within forty-eight hours after discon- up to a total of 240,000 units, with apparent benefit in one case. tinuing the drug and forcing fluids. It has not been definitely Patients with virus or “atypical” pneumonia were treated by shown that this psychosis is directly due to the sulfadiazine; giv- general supportive and symptomatic therapy. Sulfadiazine was ing full doses of the drug within a week after the psychosis cleared usually discontinued when the diagnosis became certain and a did not produce a return of the delirium. coccal pneumonia was ruled out. No therapy which definitely Fever as a toxic manifestation of sulfadiazine was extremely rare. hastened recovery was found. When a previously normal temperature became elevated it was found much safer to assume that there had developed an effusion, Adjuvant Therapy a spread of pneumonia, or some other complication, rather than Fluids were forced to 4000 to 5000 cubic centimeters daily, pref- to discontinue the drug on the basis of possible drug fever. erably by mouth. Water, sweetened fruit juices, and the more nu- trient fortified milk and egg drinks were encouraged. Frequently, Serum Therapy certain fruit juices and milk distressed a toxic patient by aggravat- About one-fourth of the patients required adjuvant therapy, ing tympanites; these were then withheld for a few days. When either in the form of specific serum, oxygen, or treatment for necessary, parenteral fluids were given by venoclysis, or hypoder- various complicating or associated diseases. moclysis in elderly and cardiac patients. During the initial period Forty-six, or nine percent, of this series of patients received of marked toxicity, more than 1000 cubic centimeters of saline type specific rabbit serum in addition to sulfadiazine. Six pa- parenterally was advised against, since patients in impending shock tients received 50,000 units each, twenty-one patients received may be thrown into pulmonary edema by excess salt. All patients’ 100,000 units each, five received 150,000 units each, twelve re- fluid intake and output was carefully measured and recorded. Olig- ceived 200,000 units each, and two patients received 250,000 uria was regarded as a grave sign, and was usually associated with units of serum each. A total of 6,050,000 units of serum was a state of shock superimposed upon the “febrile nephritis” which administered to this series of patients. Reactions to the rabbit is present in all patients with severe pneumonia. serum occurred in only two cases, both of which had mild serum Expectorants of the saline group were freely used to attempt sickness. Indications for serum therapy which were encountered to decrease the tenacious consistency of the muco-purulent in this series were: sputum and permit free expectoration. Ammonium chloride

The Permanente Journal /Winter 1998/Volume 2 No. 1 25 and potassium iodide were used in small doses three to four Lewis8 the mechanism of relief is similar to that of referred pain. times daily. Patients occasionally became nauseated on treat- A tight scultetus binder across the chest was usually also very ment, and these drugs were discontinued first, as they were helpful. Immobilizing the chest with adhesive tape strapping has usually the cause; sulfadiazine was found to be extremely rare been strongly advised against, since complete fixation of the chest clinical contributions in producing nausea. is undesirable, and severe blistering of the skin frequently re- Oxygen was a very important agent in the treatment of these sults. Occasionally these measures do not furnish sufficient relief patients with pneumonia. The majority of the patients tolerated and the use of codeine is necessary. the soft rubber Barach-Eckmann injector mask7 very well, and 95 Patients who coughed considerably frequently complained of percent oxygen was administered if the patient manifested high upper abdominal and lower chest pain. This was apparently due fever, rapid pulse or respirations, cyanosis, marked toxicity, or any to straining the abdominal musculature by paroxysms of cough- evidence of impending shock. When the condition improved, 50 ing, and was usually completely relieved by a tight scultetus binder percent oxygen was continued as long as necessary. Due to the applied over the lower chest and upper abdomen. frequent momentary lifting of the mask to give fluids to the pa- Pleural effusions were subjected to a diagnostic thoracentesis as tient, excessive drying of the pharynx was rarely observed even soon as the presence of fluid was established. From one hundred when using 95 percent oxygen. An occasional patient in toxic to two hundred cubic centimeters of fluid were removed, and fifty delirium was unable to tolerate the mask, and then an oxygen tent to one hundred cubic centimeters of air were usually injected, but was used for the first twenty-four to forty- the advantages of the latter procedure eight hours. were questionable. If the effusion was sterile, sulfadiazine blood concentrations Treatment of Complicating Conditions “In the last eight months, 517 patients with were maintained between ten and fif- Asthmatic bronchitis was a frequent pneumonia were treated in this hospital with a teen milligrams per one hundred cubic complication in pneumonia and added gross mortality of 8.1 per cent. centimeters until the temperature was to the dyspnea and anoxia of the pa- No questionable cases of ‘minimal pneumonia,’ normal for at least ten days and the fluid tient. The bronchiolar obstruction be- ‘pneumonitis,’ or similar indefinite diagnosis was absorbed. Repeated determinations ing on an inflammatory basis, the usual were included in this series.” of concentrations of sulfadiazine in pleu- measures which are successful in com- ral effusions have shown, without ex- batting allergic bronchial asthma were ception, that the concentration of sulfa- not as effective in asthmatic bronchitis. Epinephrine was usually diazine was always higher in the pleural fluid than in the blood. tried first, using small doses so as not to increase an already There was no need for direct injection of sulfadiazine into the excessive heart rate; minims five given hypodermically every fif- pleural cavity. Roentgenogram examinations of the chest for teen minutes for three to four doses was much more effective progress were repeated every five to seven days. Thoracentesis than a larger dose given in one injection. If relief was observed, was performed again only for the relief of dyspnea, or if evidence then one cubic centimeter of epinephrine in oil was given intra- of increasing fever and toxicity developed. muscularly every eight hours until the asthmatic symptoms sub- Shock and pulmonary edema were usually associated as the most sided. If epinephrine was not effective, aminophylline (theophyl- common immediate cause of death in uncomplicated pneumonia. line with ethylenediamine) was used in doses of one-fourth to Shock in pneumonia must be treated as vigorously as shock in one-half gram intravenously; if relief was obtained, then one- any other condition. One must recognize, however, the increased half gram of aminophylline intramuscularly was given every eight tendency for patients with pneumonia to develop pulmonary hours until the symptoms of asthma subsided. Potassium iodide edema. The recognition of developing shock indicated immediate and ammonium chloride were helpful adjuvants in decreasing treatment; 250 or 500 cubic centimeters of plasma were given in- the tenacity of the mucoid sputum, permitting free expectora- travenously and repeated as necessary. Patients with anemia were tion. given whole blood transfusions. Ninety-five percent oxygen was Tympanites was infrequently seen, but it occasionally became a administered by mask continuously. Parenteral crystalloid fluids serious problem in very toxic patients. The individual or combined were used restrictedly since they often precipitate pulmonary use of continuous 100 percent oxygen, pitressin or prostigmine in edema in a patient in a state of shock. If pulmonary edema was doses of one cubic centimeter hypodermically, an indwelling rectal already apparent, one-half gram of aminophylline (20 cc.), fifty tube, and/or enemas usually produced rapid decompression. All cubic centimeters of fifty percent sucrose, and 250 to 500 cubic cathartics were routinely prohibited in patients with pneumonia; centimeters of plasma intravenously were found to be most ef- low tap water enemas every second or third day were effective in fective. Each of these having a definite purpose and value, the combating constipation and produced less abdominal distention. three agents were usually used together for full effect, and often Pleuritic pain was often a most distressing and disabling symp- dramatic clearing of the lungs resulted in an apparently terminal tom. Intradermal injection of one percent procaine in a linear case. Patients were digitalized only if there was definite evidence series of confluent wheals, perpendicularly to the course of the of congestive heart failure or if auricular fibrillation developed. intercostal nerves, across the area of maximum pain, relieved In these patients, eight cubic centimeters of cedilanid (lanatoside about 60 percent of these patients. As indicated by the work of C) were administered intravenously.

26 The Permanente Journal /Winter 1998/Volume 2 No. 1 clinical contributions

Summary and Conclusions Bibliography 1. In the last eight months, 517 patients with pneumonia were 1. Bortz, E. L.: Therapeutics of Pneumonia on a Statewide Ba- treated in this hospital with a gross mortality of 8.1 percent. sis. J.A.M.A. 121:107 January 9, 1943. 2. Sulfadiazine was advocated in the treatment of pneumonia 2. Jensen, O. L., and Fox, C. L.: Hyrdrogen Ion Concentration in the following dosages: five grams of sodium sulfadiazine in- and the Solubility of Sulfonamides in Urine. J. Urol. ‘49:334, Feb- travenously and two grams of sulfadiazine orally immediately on ruary 1943. admission, then two grams of sulfadiazine orally every six hours 3. Dowling, H.F., and Lepper, M.H.: Toxic Reactions Following thereafter. The advantages of this regime were: (a) the initial Therapy with Sulfapyradine, Sulfathiazole, and Sulfadiazine. intravenous dose of sulfadiazine produced optimum therapeutic J.A.M.A. 121:1190, April 10, 1943. blood sulfadiazine concentrations within fifteen minutes; (b) there 4. Finland, M., Peterson, O.L., Goodman, R.H.: Sulfadiazine; was a resulting lower gross mortality, lower incidence of relapse Further Clinical Studies of its Efficacy and Toxic Effects. Ann. Int. and complications, and better maintenance of optimum thera- Med. 17:920, December 1942. peutic blood sulfadiazine concentrations as compared to those 5. Bullowa, J.G.M., Schackman, N.H., Stals, D.: Chemotherapy of patients treated by lower doses. of Pneumonias and Immunity Reactions. Ann. Int. Med. 16:57, 3. No greater incidence of sulfadiazine toxicity occurred in this Jan. 1942. series as compared to others. Sulfadiazine crystalluria occurred 6. Dowling, H.F., Hartman, C.R., Feldman, H.A., and Jenkins, in 7.7 percent of patients. Intravenous one-sixth molar sodium F.A.: Comparative Value of High and Low Doses of Sulfadiazine lactate solution was the most effective therapeutic agent in com- in the Treatment of Pneumococcic Pneumonia. Am. J. Med. Sc. bating crystalluria. 205:197, February 1943. 4. Sterile pleural effusions developed in two percent of the 7. Cecil, R.L., et al.: Standards of Effective Administration of patients. Empyema did not occur in a single patient. Inhalational Therapy. J.A.M.A. 121:755, March 6, 1943. 5. Specific serum therapy, in addition to chemotherapy, was 8. Lewis, Sir Thomas: Pain. Macmillan Co., New York, 1942. used in nine percent of the patients. 6. Other adjuvant therapeutic measures for associated or com- plicating conditions were used as outlined. ❖

Commentary by Elizabeth Anderson, MD, Infectious Disease Subspecialist at Oakland I was fascinated and challenged upon reviewing this article by in the 1940s; for example, the comparison of mortality with oral Dr. Collen and Dr. Dybdahl in the 1943 Permanente Foundation therapy (10/108 = 9.3%) compared with intravenous therapy Medical Bulletin. Caring for 517 pneumonia patients in an eight- (32/409 = 7.7%) were reported with no p value. To the author’s month period was a major accomplishment. The article demon- credit, no claim of importance of this mortality difference was strates that our founding physicians had the energy and intellec- made; in fact, one of his major concerns was that toxicity was tual curiosity not only to care for a large number of patients, but not greater with intravenous therapy. also: (1) to confirm a specific bacterial diagnosis in 70% by identi- In evaluating a patient with pneumonia, clinicians today must fying and typing the bacteria, (2) to administer a new antibiotic, to struggle more to identify a pathogen. Published series from sulfadiazine, (3) to perform pharmacokinetic studies of sulfadiaz- academic centers indicate a specific diagnosis in only ~ 50% of ine to determine optimal doses, (4) to record clinical complica- cases, despite far more sophisticated diagnostic tools. The Gram tions of both the disease and the medication in a systematic fash- stain remains, although bacterial typing by the Quellung reac- ion, and, finally, (5) to describe their findings in writing clearly tion is long gone. Just to name a few current techniques sug- and concisely. gests the magnitude of the advances: direct fluorescent anti- An analogous study in our time with a similar volume of data body stains, polymerase chain reaction amplification, viral cul- might well have resulted in four publications: one on the epidemi- ture techniques. Almost surely, a substantial proportion of more ology of pneumonia in a specific population—young men, mostly straightforward cases are not hospitalized and have or need 4F draft rejects, building ships in Richmond in World War II; a little diagnostic testing. Failure to identify a specific diagnosis second on the pharmacokinetics of a new antibiotic; a third on the is probably related in many to partial treatment before hospi- efficacy of oral vs. intravenous sulfadiazine; and a fourth on man- talization, selection of fragile hosts (poor cough or inability to agement of a common disease and its complications, comparing mount a purulent response to infection), and higher preva- outcomes with other reported series of cases. The writing is a fluid lence of fastidious organisms (anaerobes, mycoplasma, chlamy- narrative with interspersed tables, instead of the formalized struc- dia, pneumocystis carinii, legionella, etc). ture of today—abstract, introduction, materials and methods, re- We are now rich in choices of specific treatment, with hun- sults, discussion, and conclusions. Statistical analysis was not usual dreds of antibacterial, antifungal, and antiviral agents. Serum

The Permanente Journal /Winter 1998/Volume 2 No. 1 27 therapy is relegated to a few specific, uncommon situations (eg, we do not often enough meet the intellectual challenge of our gamma globulin for congenital or acquired agammaglobuline- profession to systematically examine and record the details of mia, or IVIG for immunomodulatory therapy with acyclovir for experience, so that we may improve the care we give. cytomegaloviral pneumonia in bone marrow transplant recipi- I remember a conversation with Dr. Collen shortly after I arrived clinical contributions ents). Treatment of pneumonia complications (such as broncho- at Oakland. I complained that it often seemed hard to provide much spasm or heart failure) has improved. Nonetheless, the nonspe- help to patients, and that doctors often couldn’t really do much to cific treatments are the same: hydration, pain relief, oxygen. heal the sick. He gently chided me, reminding me of the great Pneumonia remains a tremendous burden for Kaiser Permanente. advances in medical treatment since the Richmond shipyard days. Today, pneumonia is less often a devastating interruption in the He painted a vivid picture of country boys from the South and life of working individuals and more often an end-of-life event for Midwest, many rejected from the military because of illnesses like the aged, or for persons with multiple organ failure, or an immuno- asthma or rheumatic heart disease. They came to California to build compromised condition. The clinical challenge is the same as that ships; many stepped off the train already exhausted and ill. When faced by our colleagues in the 1940s. One should attempt to make they were hospitalized with pneumonia, often to die, “all we had a specific diagnosis, administer the proper antimicrobial drug, and was oxygen, fluids by clysis, and sulfadiazine.” He added, “be thankful always support the patient’s comfort needs and recovery. Perhaps you are practicing today.” ❖

Interdependency “Interdependency ought to be as sought after as self-sufficiency.” Mohandas Gandhi

28 The Permanente Journal /Winter 1998/Volume 2 No. 1 The Lighter Side of Medicine the lighter side of medicine

Do you have a humorous medical joke, anecdote or cartoon? Refer to the Table of By Joe Oleniacz, MD, a Pediatrician for The Carolina Permanente Medical Group, PA. Contents pages to find out how to submit it to us.

By Stephen Bachhuber, MD, an anesthesiologist for Northwest Permanente, PC.

○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○

How to Use Humor to Stay Healthy Babies start to laugh when they are 10 weeks old; six weeks later they are laughing about once every hour. Four-year-olds laugh once every four minutes. The average grown-up is said to laugh only about 15 times per day. Sadly, our culture tends to inhibit humor. We learn to associate growing up with “getting serious,” and being “serious” is somehow equated with being solemn and humorless. We are ordered to “wipe that smile off your face” and told that things are “no laughing matter.” Sometimes we repress our good humor, because we’re afraid that others will think we’re frivolous or foolish. Our funny bone gets broken. Fortu- nately, a laugh prescription is not a bitter pill to swallow. Here are some suggestions for repairing your sense of humor and regaining healthy laughter: • Expose yourself to humor • Keep a humor journal • Tell a joke • Laugh at yourself • Look for the funny side • Exaggerate • Try a retake • Try humor instead of anger • Use humor to handle anxiety • Make up a comedy routine • Hang out with happy people • Put on a happy face Adapted and reprinted with permission from “The Healthy Mind, Healthy Body Handbook” by David Sobel, MD and Robert Ornstein, PhD (Los Altos, CA: DRx, 1996) and “The Mind/Body Health Newsletter.” For further information about the book or for newsletter subscriptions, contact the Center for Health Sciences at 1-800-222-4745.

The Permanente Journal /Winter 1998/Volume 2 No. 1 29 By M. Jean Gilbert, PhD Cultural Competence in Health Care: Another Aspect of Kaiser Permanente’s Commitment to Quality

During 1997, the first handbook on de- with members from specific cultural backgrounds. external affairs livering culturally competent care to a distinct The books also provide epidemiological data that set of ethnic populations, Latinos, was published will aid persons who are planning service delivery under the sponsorship of the National Diver- strategies and systems. sity Council. This is the first of a series of hand- Familiarity with Mexican family roles and caretak- books that summarizes epidemiologic data, ing behavior would enable Carlos’ physician to man- “Cultural compe- health beliefs, and cultural characteristics that age the impasse with the parents more persuasively. tence in health have implications for service delivery to spe- The medical director will understand that the mem- care is defined as cial populations. bers consist primarily of two very different popula- ‘the demonstrated tions with very high prevalence of NIDDM. This un- awareness and Carlos, an 11-year-old Mexican American, has derstanding may lead to assessment of language needs integration of three been newly diagnosed with acute myelogenous leu- and availability of educational and outreach materi- population-specific kemia. His physician feels it is important to include als in Spanish. Spanish-language classes and Span- issues: health- the boy in discussions about his disease, its treat- ish-speaking nurses may also facilitate patient un- related beliefs and ment and its prognosis. The parents, Jesus (who derstanding and compliance. Approaches to both cultural values, speaks English well) and Elena (whose English is populations, including recommended dietary and disease incidence limited), are horrified at this suggestion and ada- lifestyle changes, may be more effective if they are and prevalence, mantly refuse to allow this discussion. given in a culturally relevant context. In the long and treatment A medical director of a large Kaiser Permanente run, such a culturally sound approach has the poten- efficacy.’” medical center located in the Southwest is concerned tial for reducing costs related to the expensive se- that the proportion of members with non-insulin- quelae of this disease. dependent diabetes mellitus (NIDDM) is significantly higher in that service area than in other areas in the Background division. This presents a cost-containment challenge, Why the focus on specific groups now? because, according to the National Medical Expendi- The United States is currently experiencing the ture Survey, per-patient annual expenditures for dia- second-largest wave of immigration in its history. betic patients are 3 to 4 times greater than for non- Shaped by changes in immigration regulations, refu- diabetic patients. The sizable proportion of diabetic gee resettlement, amnesty for undocumented im- patients also means that a great deal of effort will be migrants, and global economics and politics, large “Recent newcom- required to meet the Health Employer Data Informa- numbers of persons from non-Western cultures are ers may be from tion Set (HEDIS)-driven clinical goals around retinal making this country their home. The new entrants cultures with a screening and proportion of diabetic members with are immigrants from all levels of educational and history of long- good blood sugar control. Recently, the marketing class background. standing medical director reported studies indicating that African Ameri- America’s earlier immigrants came primarily from traditions, such as cans make up about 20% of local Southwest market Europe, and their cultures, though variant, had much Ayurvedic or members and that Latinos comprise 52%. About 65% in common with each other and with people al- classical Chinese, of the babies born in the hospital are Latino. ready living in the U.S. The major exception to this, of folk medicine, a Although at first glance the problems confronting of course, was the forced immigration of Africans different set of the physician and the medical director appear to have under slavery. popular (read ‘over little in common, more careful consideration reveals Recent newcomers may be from cultures with a the counter’) that they share a common thread: both are related to history of long-standing medical traditions, such practices or, most the unique cultural and medical needs of a specific as Ayurvedic or classical Chinese, of folk medi- likely, a mixture of population. Effectively addressing these needs will cine, a different set of popular (read “over the biomedicine and require skills currently being called “cultural compe- counter”) practices or, most likely, a mixture of several of these.” tence.” In a recent editorial in the Annals of Internal biomedicine and several of these. Their health care Medicine (May 1996), cultural competence in health practices are guided by a wide variety of beliefs care is defined as “the demonstrated awareness and about anatomy, etiology, and symptomatology. integration of three population-specific issues: health- These beliefs have in turn been shaped by mor- related beliefs and cultural values, disease incidence bidity and mortality patterns in their places of ori- and prevalence, and treatment efficacy.” Adopting gin, by diet and food supply, by differing disease this perspective, the National Diversity Council’s hand- vectors, and by variation in health care policies. book series on culturally competent care is designed Cultural orientations around death and dying and to help individual physicians work more effectively around pain and suffering also guide decision-making

M. JEAN GILBERT, PhD, a medical anthropologist, joined Kaiser Permanente’s Organizational Research Department in 1990. Prior to that, she directed cross-cultural epidemiologic research at UCLA and has published widely in the area of alcohol use and alcoholism. She is currently Director of Cultural Competence for the California Division, Pasadena.

30 The Permanente Journal /Winter 1998/Volume 2 No. 1 external affairsexternal

as do varying concepts of gender roles, and sexual Finally, disease patterns are sometimes linked to and reproductive practices. For example, physicians a specific group’s socioeconomic position through who are now seeing an increasing number of female environmental factors and differential access. The patients from African nations find it hard to understand prevalence of lead poisoning among African Ameri- the belief systems that underlie the practice of female can and Latino children living in older buildings in circumcision. However problematic such practices inner cities is a case in point. High levels of asthma seem, they are deeply embedded in their practitioners’ among inner-city dwellers are hypothesized to be social reality and moral system. linked to environments containing exceptionally Different groups also have distinctive beliefs about high levels of pollutants. “Different groups appropriate ways to interact with physicians, nurses, The National Diversity Council’s handbooks on also have distinc- pharmacists, and other health care personnel and culturally competent care highlight these differences tive beliefs about may have expectations about how they should be in epidemiologic patterns across groups and draw appropriate ways treated in the health care setting. As with all groups, implications from them for planning service deliv- to interact with they bring to the medical encounter the “invisible” ery and patient care. Cultural beliefs and orienta- physicians, nurses, culture of norms, values, and behaviors that affect tions that may impact health care utilization and pharmacists, and their acceptance or rejection of treatment, preven- treatment adherence are also discussed. Major other health care tion strategies, and their judgment of health care groups within the glosses “Latino,” “African Ameri- personnel and may systems and personnel. can” and “Asian” are distinguished. have expectations The Race/Ethnic Variable in Epidemiology Special Treatment or Quality Care? about how they should be treated Along with age and gender, race and ethnicity are Many health care professionals are concerned about in the health care variables which are critical in defining risk factors and focusing on ethnic differences among patients, say- setting.” epidemiology patterns across groups. National stud- ing that patients want to be treated the same regard- ies of disease incidence and prevalence show statisti- less of background. They are rightfully fearful of ste- cally significant differences in the occurrence of many reotyping. A very small minority of physicians see a major diseases along race and ethnic lines. The rea- disease process as being the same in all patients, sons for this systematic variation are complex. whatever the factors that have provoked its onset or Some disorders have a hereditary basis, such as sickle mediate its course and treatment. cell disease in African Americans, Tay Sachs disease in Patients from specific groups often do state that Ashkenaz Jews, alpha- and beta-thalassemia in many they want “the same treatment as others.” Questioned, Asian and Pacific Islander populations, neural tube de- they mean the same good treatment, treatment of fects in Southeast Asians, and NIDDM in some Ameri- equal quality to that which others receive. What they can Indian groups and in groups of American Indian do not mean is that their beliefs and life circumstances mixture. On the other hand, some diseases hypoth- should be ignored or that a one-size-fits-all approach “They bring to the esized to be genetically linked, such as nasopharyngeal should be taken. medical encounter cancer among Chinese persons, may also involve cul- The paradox is that in order to provide the high- the “invisible” tural (especially dietary) factors in their etiology. est quality of care to persons from all groups in culture of norms, Social epidemiology—the study of how culture af- Kaiser Permanente’s membership, knowledge of values, and fects the onset, course, treatment, and outcome of epidemiological, cultural and linguistic factors that behaviors that disease—demonstrates that a cultural group’s beliefs, may affect their health status, that is, group differ- affect their behavioral norms, and practices greatly affect its ences, is important. acceptance or health status. Sexual norms prescribing who may have The handbooks sponsored by the National Diver- rejection of relations with whom, when, and how affect the trans- sity Council present information on different groups treatment, mission of STDs. For example, bisexuality and ho- as statistical probabilities and as generalizations based prevention mosexuality are defined and understood differently on research studies. Also presented are factors that strategies, and across cultures, and norms governing heterosexual effect important intragroup variation. their judgment of and same-sex intercourse vary widely. Dietary be- health care systems liefs and customs affect the prevalence of hyperten- Changes in the Regulatory/Legal Environment and personnel.” sion, heart disease, and diabetes. Differing values re- The importance of physiological and cultural varia- lated to beauty and body size affect acceptance of tion as it impacts health care status has attracted the obesity. Adhering to or rejecting treatment may turn attention of regulatory and accrediting agencies. Many on how well the regimen is integrated with cultural states which send Medicaid recipients into managed understandings and social customs that are not well care programs (such as California, New York, New Jer- understood outside a patient’s culture. sey, Illinois, Massachusetts, Rhode Island, and Wash-

The Permanente Journal /Winter1998/Volume 2 No. 1 31 ington) have written cultural and linguistic requirements make clear our organization’s social purpose. It will external affairs into their contracts, usually to be triggered by defined also enhance our attractiveness to segmented mar- concentrations of specific groups within service areas. kets of health care consumers. Foremost among these stipulations is the cultural train- Perhaps as important, a heightened awareness of ing of health care providers who care for these pa- the cultural aspects of health care enriches the prac- tients. The Health Care Financing Administration is tice of medicine. In the words of one physician upon currently studying these issues in relation to Medicare reviewing a handbook manuscript, “This is fascinat- risk eligibles. As more of the nation’s medically ing stuff. Throughout human history health and heal- underserved children (and their parents) come into ers have been central to all civilizations. I have learned Kaiser Permanente medical offices through the new so much from my patients from different cultures, federal and state programs as well as through our own not just about medicine, although that is important, “The Wall Street Kaiser Cares for Kids program, the diversity of our pa- but about how people adapt to different circum- Journal reported in tient population will grow. stances, how they can learn and change. How people September 1997 The National Committee for Quality Assurance, in see their bodies and their functioning tells us a lot that some medical its first HEDIS for Medicaid-capitated beneficiaries, about how they see life.” malpractice includes the assessment of cultural-group concentra- The provider’s handbooks on culturally compe- insurers were tions and tracking of language needs. The Joint Com- tent care are an integral part of the National Diver- offering 2% to 5% mission for the Accreditation of Healthcare Organi- sity Council’s Strategic Action Plan for Diversity. The premium discounts zations recommends cultural training for health care Council views the diversification of the United States to doctors who professionals. And, finally, The Wall Street Journal population as an opportunity to focus on quality attended a reported in September 1997 that some medical mal- health care for specific markets and members. Driven workshop on practice insurers were offering 2% to 5% premium by data that verify the large number of cultural cultural differences discounts to doctors who attended a workshop on groups among Kaiser Permanente’s current and po- in medicine!” cultural differences in medicine! tential membership, the handbooks offer practical In response to these needs, medical schools such information in highly readable format. Funded and as Stanford University School of Medicine and the administered by the diversity department at Program Robert Wood Johnson School of Medicine are in- Offices, each handbook is well researched, exten- corporating cross-cultural medicine in their cur- sively reviewed, and accompanied by a reference ricula, and the family practice educators have de- list of the best publications available. The review veloped a detailed training curriculum in this area. panel for each handbook consists of a physician Kaiser Permanente’s Handbook on Culturally Com- champion and physician reviewers, all particularly petent Care, Latino Population has drawn high familiar with the groups being considered. The ma- praise from Professor Ronald Garcia, MD, of terial is researched and prepared by doctoral-level Stanford and Professor Robert Like, MD, of Robert students, overseen by the series editor (this author), Wood Johnson. and submitted to the review panel for suggested revisions. The final draft goes through the same ex- Market-Leading Performance haustive peer review process. Publication of the Af- Attention to the needs of specific groups that make rican American handbook is projected for February up the Kaiser Permanente membership is another 1998, and the Asian American handbook will be way to demonstrate market-leading performance and available in early spring 1998. ❖

32 The Permanente Journal /Winter 1998/Volume 2 No. 1 By Donald W. Parsons, MD The Presidential Commission and Health Care Reform affairsexternal

In monarchies, when the king dies, the people say ser Permanente Principles for Consumer Protection, “The king is dead; long live the king” because there announced in September with our partners Group is always another monarch in the line of succession Health Cooperative of Puget Sound, HIP Health In- ready to accept the crown at the moment of the king’s surance Plans, Inc., AARP, and Families USA. It sur- death. So it is with health care reform. prises none of us to see these principles defined in In 1993, the Health Security Act (HSA), that mam- the Commission’s report. What the Commission has moth 4-pound, 1342-page Clinton/Magaziner blue- not recommended is how to implement these con- print for a better health care world, the very one cepts. Powerful and opposing forces from the busi- that Harry and Louise debated and decried in every ness and health plan and insurance communities on living room in America, sank to the bottom from its the one hand, and from consumer advocates on the “The principles, own weight. There were some who said that health other have paralyzed the Commission and torpedoed unless they care reform was dead in our lifetime, and even jokes any hope once entertained that we would know what become legally appeared: Hillary Clinton asks God if we will ever to do with the principles, once articulated. For that enforceable see health care reform. God replies: “Yes. But not reason, do they deserve the lofty title “Bill of Rights,” national standards, in my lifetime.” as guaranteed by the highest of our laws? The prin- will have moral Four years later, after some modest interim changes ciples, unless they become legally enforceable na- standing only.” in federal health policy such as improved guaran- tional standards, will have moral standing only. Con- tees for insurability (established by the Health In- gress will wrestle with the implementation issue for surance Portability and Accountability Act of 1996 the next year and will probably fail to resolve the (HIPAA)) and some tinkering with mental health par- conflicts of federal versus state regulation or of pri- ity and hospital maternity length of stay, we are at it vate accreditation versus governmental mandates. again. The Balanced Budget Act “BUBBA,” signed In an election year, don’t place your bets too early. into law on August 5, 1997, lays the groundwork Senator Jim Jeffords, Chair of the Senate Labor and for conversion of the Medicare program into a “man- Human Resources Committee, has circulated sev- aged competition” model, not unlike the essential eral drafts of a proposal that would establish broad organizing principle of Clinton’s HSA. Quickly standards by law and would set up a Health Qual- emerging on the scene is the report from the ity Council to fill in the details and to monitor com- President’s Commission on Consumer Protection and pliance. Warm-up hearings on the House side this Quality in the Health Care Industry. The Commis- fall have considered Rep. Charlie Norwood’s bill “Some believe sion will first enunciate a Patient Bill of Rights this (HR 1457), which carries some of the same notions there is no fall, followed next spring by a more technical docu- forward in a much more punitive and heavy-handed problem so ment describing various approaches to quality in fashion. Several other copycat bills are already complicated that a health care and allocating responsibility to the vari- crowding into the inside-the-beltway marketplace simple legislative ous parties: purchasers, providers, consumers, and of ideas. Do not be astonished at the large number solution will not government. This Commission’s report is intended of cosponsors claimed by some of the principal fix it.” to create a framework for new legislation, the fore- sponsors of these proposals. Every House seat and bears of which are already in the Congressional hop- a third of the Senate seats open for the constituents’ per. Next year, with elections blowing in the El Niño pleasure just a year from now. What is better grist winds, members of Congress and their campaign for the campaign stump speeches than a claim to opponents will want to impress the electorate with protect all consumers from the ravages of managed their concerns for all the problems caused by man- care? Many politicians will want to carry that mes- aged care. Look forward to a major debate on con- sage home. Rhetoric, however, does not guarantee sumer protection standards in health care and to passage of legislation. possible legislation during 1998. If something does pass next year, will that ap- The President’s Commission Bill of Rights product, pease the angry health policy gods once and for delivered before Thanksgiving 1997, is familiar to all? If pigs could fly ... unfortunately, the process many of us in Kaiser Permanente. Access to emer- does not end until we regain a steady state in the gency care and to specialists, choice and continuity health care sector. With the burgeoning size of the of care, information disclosure, and appeals of health aging population and the specter of both a crum- plan determinations, participation in treatment deci- bling Medicare system and increasing numbers of sions, confidentiality of medical information, quality uninsured persons in the years to come, turbulence improvement, and nondiscrimination among health will continue, perhaps for the professional lifetimes plan members are essential elements also of the Kai- of all who read this. Many have written off a new

DONALD W. PARSONS, MD, is the Associate Medical Director for Government Relations for The Permanente Federa- tion. He represents Permanente physicians to federal policymakers and to other external audiences.

The Permanente Journal /Winter1998/Volume 2 No. 1 37 “baby boomer” Presidential Commission already or- believe there is no problem so complicated that a external affairs ganizing to consider long-term solutions to the simple legislative solution will not fix it. Unfortunately, “More powerful Medicare problem. The prospect of renewed infla- unintended consequences of the most well-meaning than the logic of tion and steep premium increases in the private and well-crafted laws are likely, especially in a field as reasoned policy, medical markets has everyone worried about the complex as health care. More powerful than the logic however, is the implications for our country’s miraculous sustained of reasoned policy, however, is the political pressure political pressure economic growth of the economy during recent to demonstrate fulfillment of campaign promises. Next to demonstrate years. A steady-state equilibrium seems far away. year will be hairy for all involved in the health policy fulfillment Look forward to many years of legislative interest arena. Now is the time for all committed health care of campaign in health care reform. professionals to learn the issues and to voice their promises.” The old saw, “To a hammer, the world looks like a views about the nature of the problems and about the nail” accurately describes the legislative process. Some desirable choices for solutions to these enigmas. ❖

Life is a Juggling Act “The death knell in juggling is to watch any individual object. Our instinct is to look at each ball or task separately, because we want to have control. It’s a very insecure feeling; you influence something, and then you can’t influence it, and then you’re expected to catch it. But if you’re tied to each little specific, you’ll lose sight of the big picture. Concentrate on seeing all the patterns. If you look at things in many different ways, you’ll develop a depth perception that allows you to unscramble several patterns and see them all at once.” Michael Moschen, Fast Company October:November 1997

38 The Permanente Journal /Winter 1998/Volume 2 No. 1 soul of the healer

“Punchbowl Falls, Oregon” by Stu Levy, MD. Dr. Levy’s photography is also featured on the cover.

The Permanente Journal /Winter 1998/Volume 2 No. 1 39 By Tom Debley Keeping Abreast of Permanente in the News

Who at Kaiser Permanente has not been cornered more. Since Walnut Creek’s hometown newspaper external affairs and pummeled with questions about health care at a has been purchased by the Knight-Ridder chain, that family gathering, community meeting, or dinner party same story is now instantly available to editors at in the last few years? I suspect that the number is three dozen Knight-Ridder newspapers across the U.S. small, given the ongoing national debate. The sheer Nine are in communities served by Kaiser Per- amount of news coverage which managed care re- manente, including newspapers in divisions serving ceives illustrates the point. A computer scan of a Colorado, Kansas, North Carolina, Ohio, and Texas national news database for the term “managed care” in addition to California. Likewise, stories about Kai- for the first 11 months of 1997, for example, turned ser Permanente in any one of those newspapers can up 28,801 references—on average, 86 stories printed be “shipped out” instantly over the Knight-Ridder “A computer scan or broadcast per day across the United States. newswire to all those papers. Compound this by the of a national news As a result, Permanente physicians may be caught fact that more than 80% of newspapers are now database for the off guard. Many face being asked questions for which owned by chains. Add that to the instantaneous abil- term ‘managed they do not have answers simply because they were ity of television and radio to move information via care’ for the first not even aware something had become a public is- satellite and fiber-optics. The effect is obvious: We at 11 months of 1997 sue. Frequently, questions are generated by stories Kaiser Permanente must face the fact we live in a turned up 28,801 published in newspapers or aired on newscasts which public relations fishbowl. references.” we neither read nor saw. Topics range from criticism Today, this means everyone at Kaiser Permanente leveled by a politician against Kaiser Permanente to is in the public relations business. How well each a problem in a medical office across town or across one of us can tell the Kaiser Permanente story—be it the country. a media relations representative at a news confer- Media relations staffs are responding by develop- ence or a physician at a community meeting—de- ing prototypical systems for keeping physicians bet- pends on how well we keep ourselves informed. We ter informed about the news via e-mail and perhaps need to know not only who and what we are as an someday by an Intranet system, so they can be bet- organization, but also to understand how we are ter prepared to tell Kaiser Permanente’s story. This is viewed by the media and by the people who read precisely the reason that the media relations staff in newspapers, watch television, listen to the radio, or the California Division has been experimenting with track information on the World Wide Web. an electronic news clipping service that allows Kai- To date, the help we have provided in this en- “Permanente ser Permanente leaders and physicians to keep up deavor in California included a daily news clipping with news headlines and with full texts of news ar- service which resulted from the recent merger of physicians face ticles via e-mail on a daily basis. two services in the former Northern and Southern being asked questions for The idea stems from old paper-based news clip- California Regions. Using a combination of com- pings that media relations staffs have used for years. puter databases, Internet sites, and e-mail services, which they do not These services would photocopy key news articles the California Division News Bureau, (a Public Af- have answers simply because about the organizations they serve and distribute them fairs division) electronically scanned as many daily to key leaders, usually from a few to perhaps 30 or newspapers in California as possible and collected they were not even 40 people. In late 1995, we realized just how difficult transcripts of key radio and television newscasts to aware something had become a it was becoming in the computer age for anyone to assemble a daily electronic packet of news. The fo- keep up with the sheer volume of news in the world. cus is on stories in which Kaiser Permanente is spe- public issue.” We saw, too, how many more people need to have cifically mentioned as well as on articles and news- information—and need it quickly. We began to de- casts about key health care trends. California Divi- velop an electronic news clipping service, and to sion Daily News Clippings are distributed daily via look for ways to give wider distribution to news about e-mail to hundreds of people in leadership roles, Kaiser Permanente. and are made available on one e-mail system for One illustration of how the world of information tracking by any physician. has changed, and how it affects Permanente physi- The format includes a headline summary, because cians, is how chain ownership of newspapers once no one has time to read everything. This strategy owned locally now makes virtually all local news allows the recipient to quickly scan the headlines national. Two years ago, for example, a story in the and names of news organizations. The reader can daily newspaper in Walnut Creek, Calif., about Kai- then make a judgment about the need to know ser Permanente’s medical center in that city wouldn’t more and can skip directly to the article he or she have mattered much to someone in Ohio. Not any- wants to read. The clippings can also be stored for

TOM DEBLEY is Director of Media Relations for the California Division. He has been with Kaiser Permanente since 1995. Prior to that he was with the University of California as Assistant Director of the Berkeley campus news office, Public Affairs Director for Hastings College of Law, and Chief of News Services for the UC Office of the President

40 The Permanente Journal /Winter 1998/Volume 2 No. 1 external affairsexternal

In California, the California Division Daily News Clippings are increasingly being supplemented with more widespread internal distribution via e- mail of news releases prepared for distribution to the media, with postings on Kaiser Permanente’s World Wide Web site, and dissemination through various Web locations, including America Online. Well over 100 news releases were distributed this “We at Kaiser way in 1997 alone. Permanente must As these systems are developed, the goal is to face the fact we give Permanente physicians and others access to live in a public up to-the-minute information so they can be bet- relations fishbowl.” ter communicators. In the meantime, any physi- cian who uses the World Wide Web can set up his or her own interim system to capture news about Kaiser Permanente. Following are two ex- amples. At America Online, you can go to the “News” section on the “Channels” page that is part of your opening screen. Click on “Search & Explore,” then click on “Search.” Once you are on the search page, bookmark it so you can come back to it easily. Fill in the search box with “Kai- “The goal is to give Sample news clipping ser Permanente” and run your search. You should Permanente come up with 25, 50, or more recent articles or physicians and later retrieval. Likewise, a physician leader who news releases. The second system is the Excite! others access to up knows he or she will going to a community meet- “News Tracker.” For this free service, you need to-the-minute ing in the evening can read that day’s news in which only go to the page at http://nt.excite.com/. Look information so Kaiser Permanente has been mentioned. That phy- for the “News Tracker” box and follow the in- they can be better sician can then contact the local public affairs or structions from there to set up a search for Kaiser communicators.” community and government relations staff for ad- Permanente. Once you have saved (bookmarked) ditional information that may be useful for answer- this site, you can come back anytime. Just click ing questions. on the name you have given your search, ie, “Kai- While California has been experimenting with these ser” or “Permanente,” and up will come any cur- new techniques made possible through information rent stories from the database’s News Tracker technology, the Program Office also has begun work searches. And just remember, the next time you in this area and is currently exploring the feasibility think you will be in a setting in which you will of a Program-wide approach to a uniform system be pummeled with questions, arm yourself with that can serve all divisions. Program Office already a quick scan of recent news. After all, when people has in place a news-clipping prototype from which a ask you a question it is because you are their full national service can grow. expert source at that moment. ❖

The Permanente Journal /Winter1998/Volume 2 No. 1 41 Systems Challenge for Primary Care and the Specialties: Relationships and Access Roundtable Discussion

Introduction The request for manuscripts by The Permanente Panelists: Journal generated tremendous response from the Patricia Behlmer, MD—Co-chairperson of the Permanente community. Interestingly, most articles Internal Referrals Committee (TSPMG) submitted to the Health Systems Management sec- Tony Bianchi, MD—Director of Utilization tion of the Journal dealt with issues concerning re- Management (CPMG) ferral-system challenges, specifically the difficulty of Andrew Golden, MD—Chief, Department of health systems management creating systems that result in acceptable access to Family Practice (SCPMG) specialists. Clearly this is an issue that all Permanente William Caplan, MD—Director of Operations Development (TPMG) “Specialty access Medical Groups are dealing with. Steve Lieberman, MD—Chief, Department of in Ohio has been a For this edition of The Permanente Journal, six Urology (NWP,PC) major problem for physicians from six different Permanente groups re- Walid Sidani, MD—Associate Medical Director several years. We cently discussed what their groups are doing to ad- for Medical Operations (OPMG) had an operational dress this Systems Challenge. By sharing their experi- gap between the ences, these physicians will help us all take the first Moderator: Lee Jacobs, MD, Editor, Health Systems specialists and the steps toward a Program-wide solution. Management section of The Permanente Journal primary care - Lee Jacobs, MD, Editor providers as well as a gap in Dr. Lee Jacobs: I would like to start the dis- relationships.” cussion by first asking panel members to give Dr. Patricia Behlmer: In Georgia, we -Walid Sidani, MD our readers their perspectives on the relation- are slightly different from the California ship between the primary care practitioner and Northwest Regions in that we are and the specialists, especially as it impacts the probably more primary care-focused and specialty referrals. What has been the experi- probably have a greater number of specialists who ence of your groups? have had significant private practice experience. Dr. Andrew Golden: In San Diego, At least initially, these specialists tend to be a little the problem of access to specialists has less questioning as to the appropriateness of re- been essentially resolved by programs ferrals because of their past experiences in which implemented over the past few years. fee-for-service referrals were encouraged. With However, at times there is definitely tension be- that said, we also experience a level of tension, tween the primary care physicians and the spe- not so much with the non-discretionary referrals— cialists. This problem gets to be more significant that is, referral of the cancer patients, or patients when there is an imbalance in the workload of one with acute appendicitis—but rather with the dis- or the other, either as a perception or by objective cretionary situations. measures, especially during times of rapid mem- Dr. Tony Bianchi: In Colorado, one ma- bership growth. jor contribution to this tension is the man- Dr. William Caplan: I would agree. Cer- ner of allocating FTEs in primary care and tainly there has been a tension within North- specialty care. Primary care is given re- ern California. Primary care practitioners sources as membership grows, whereas speciality care have felt they were being asked to manage more often than not remains the same. The intent is the health needs for these large populations, and be- to have more of the patient’s care provided by a cause our Medical Groups have been organized primary care provider, implying that the scope of around specialty care, there have been feelings by practice of the primary care physicians must con- primary care of not being adequately supported. tinue to expand in the future as they are given the Dr. Steve Lieberman: I think that there time and resources. The optimum scope of practice is built-in tension between specialists and is obviously a source of controversy between spe- primary care physicians. It goes back to cialists and primary care physicians. our training, when the specialists had to Dr. Walid Sidani: Specialty access in do more years of training, had to be on call more, Ohio has been a major problem for sev- and when we finally went out in practice, the spe- eral years. We had an operational gap be- cialists got paid more, worked different hours, and tween the specialists and the primary care had different lifestyles. providers as well as a gap in relationships. At times,

42 The Permanente Journal /Winter 1998/Volume 2 No. 1 health systems management

written referrals just seemed to be lost. We have with what’s been said. Our experience has been that taken measures to close this gap, primarily by get- this type of primary care specialty communication ting specialists and primary care providers to solve has greatly resolved our access problem and has problems together. enhanced collegiality in our group. Primary care prac- Dr. Jacobs: Tell our readers about some of the titioners in Ohio have been extremely pleased that programs your Regions have instituted to deal they now have someone to talk to. with this challenge. Dr. Jacobs: Sounds like what you all are de- Dr. Lieberman: Several years ago in the North- scribing is the integrated group practice in ac- west group, we initiated the “Urophone” program, tion. Andy, as a primary care physician, what in which one of our six urologists would be avail- is your response to this consultant phone or able by cellular phone for the primary care physi- pager system? cians. We have strongly encouraged, but it is not Dr. Golden: I guess I have a mixed reaction to mandatory, that primary care physicians call on any this system. I’m a little skeptical that the phone or referral during office hours. If a referral is inappro- pages would actually get answered in a timeframe priate, we have the opportunity for one-on-one edu- that would meet my needs. If I am reassured that it “We surveyed the cation and resolve the issue. If a referral is to be does, then I would be more accepting. I like the primary care scheduled, we can recommend the most appropri- aspect of having the patient prepared for the con- physicians, and ate lab tests and x-ray films before the visits, many sult. I’m also fairly realistic in realizing that if you 85% were times eliminating extra unnecessary follow-up visits have to call rather than write out a consult, you overwhelmingly with us. might think more before requesting a consult. So I satisfied.” Dr. Jacobs: What kind of response have you can see how it would work if it is convenient for - Steve received from primary care providers? the primary care physician to make that call. I would Lieberman, MD Dr. Lieberman: Pediatricians like it a lot. Busy be interested to hear what percentage of calls would primary care providers resent having to pick up the actually result in an appointment rather than tele- phone and call us. My contention is that it is easier to phone advice. That may be hard to sort out be- pick up the phone and call us than it is to initiate a cause sometimes I just call up the urologist to ask referral in another way. questions without the intent to refer. Dr. Caplan: Northern California has been experi- Dr. Lieberman: In terms of the prompt response, menting with this Northwest Region cellular phone the only limiting factor is cellular phone technology, approach in orthopedics and urology, and in a vari- as Walid mentioned. When we are in certain parts of ety of different departments. Our model is basically the hospital, the basement, or in x-ray, the phones the same. One of the real, nice aspects of this is just won’t ring or we get cut off during a conversa- that if the specialists are nearby, they can go to the tion; it’s extremely frustrating to the physicians. In exam room of the primary care physician and es- terms of appointments, we actually studied this. A sentially perform a co-visit at that time, basically a third of the calls would be seen that day, a third consultation on site. This model accomplishes many would be given routine appointments, and a third things, one being an educational component in the would not need to be seen. In addition, we surveyed transfer of knowledge one on one, especially help- the primary care physicians, and 85% were over- ful in orthopedics, where you can demonstrate a whelmingly satisfied. We probably need to repeat procedure or technique in the office setting. Most this survey again, because use of the Urophone has important, members have really liked this. Overall, decreased recently, probably secondary to the influx it has worked out quite well. of new physicians. Dr. Lieberman: We do a lot of that also. It is amaz- Dr. Bianchi: In Colorado, we have a mandatory tele- ing how much the members like that kind of service. phone consultation process for the gastroenterology, For example, I can come from across the street to neurology, and cardiology departments, and are plan- quickly assess a scrotal mass of a patient in the exam ning processes for the urology and head and neck de- room of the primary care provider. Members are in- partments. We have good, objective data to measure pri- credibly satisfied with this kind of service. mary care acceptance. In gastroenterology, for example, Dr. Sidani: In Ohio, we have adopted the North- 80% of primary care physicians were extremely satisfied. west model but had to switch to a pager system be- Primary care physicians must know what to ask special- cause the cellular phone did not work in many of ists. Also, they must know their patients well to supply our buildings. Now we have nine specialty depart- specialists with the requested information. We need to ments available daily on a “consult pager.” I do agree measure and value this type of telephone work. Special-

The Permanente Journal /Winter 1998/Volume 2 No. 1 43 ists need to be good teachers, have good telephone man- decrease what they feel are inappropriate refer- ners, and to see this as a valuable service. rals. Have your groups tried any strategies to fa- Dr. Jacobs: What other strategies have your cilitate constructive and timely feedback from Regions undertaken? specialists to the referring physician? Dr. Golden: In San Diego, we developed a solu- Dr. Behlmer: In Georgia, hoping to increase the tion for the long wait times for specialty appoint- quality of feedback to the referring physician, we ments. We established an absolute standard of 80% added a section to the bottom of our referral form

health systems management of referrals being seen within 2 weeks of the date of for the specialist to comment if guidelines were fol- referral, and developed a monthly monitor that re- lowed or not. It didn’t really work. Specialists were “Rather than a ported that access. If a specialty did not meet that reluctant to relay true feelings, even though the fo- punitive approach standard in two consecutive reporting periods, the cus was on helping the primary care provider and to inappropriate department would have to work two extra unpaid not on judging them. Shareholder voting and peer referrals, it was a hours per week. If the standard was still not met input during our appraisal process reinforced this positive educa- after another month, the required extra work in- hesitancy to give feedback. We probably need to fo- tional approach.” creased to 4 hours. As a result of making these con- cus on those providers that send high-quality, ap- - Andrew sequences clear, most departments rearranged their propriate referrals. Specialists know who these phy- Golden, MD priorities and made enough appointment slots avail- sicians are who acquire new skills and knowledge. able for consults, sometimes at the expense of re- They need to be recognized and in some way pre- turns and even of OR time. Implementation of such sented as role models. a program raises the issue of resource needs. Our Dr. Sidani: We also tried several attempts to re- program developed a basis to allocate resources, solve the problem with this kind of feedback, but we when available. If a department was unable to meet were only partially or temporarily successful. the 2 week access standard despite working the 4 Dr. Golden: We have also tried many different hours of extra unpaid work each week, they would approaches in San Diego, and none of them have be in a priority position to receive additional re- been very successful. We have tried having the spe- sources. This model set up a format for departments cialist put a sticker on the consult copy returned to to prove that they need increased staffing. the referring physician when the referral did not meet Dr. Lieberman: The Northwest also adopted this guidelines. These stickers were preprinted with a San Diego approach. What’s interesting is that this specific guideline on each. The enthusiasm for do- gave specialty departments the incentive to fix their ing this quickly waned. For a period of time, the system problems in order to be more efficient. orthopedic department tried to call for “clarification” Dr. Jacobs: I would think that as an educator, of referrals that they found lacking and to suggest the specialist is in a good position to use refer- further care prior to referral. We also tried a “Referral rals to teach the referring physician and maybe Assessment Form” to be completed by the consult- ant and sent to the referring physician with opportu- Panel discussion summary nities to improve identified. It was seldom used. Dr. Jacobs: Andy, why do you think these ini- Interventions Panelists' Value Rating tiatives were not successful? Dr. Golden: I think everyone is busy enough, and Cellular phone/pager systems High understanding and tolerant enough, that on a day- Mandatory two-week minimum waiting by-day basis individuals don’t feel it is worth taking High the time. They would rather just direct their energies time for specialty appointments to taking care of patients scheduled and the other Specialty feedback to PCP after referral Low demands of the day. Dr. Jacobs: Have any of you undertaken an Specialty educating PCPs after study of initiative that attempts to decrease referral de- High inappropriate referrals mand through primary care provider CME-re- lated education? Referral guidelines Low-moderate Dr. Golden: We have a model for doing so that I wish was used more often. Our gastroenterology "Open Access" to specialties department did a study of referrals, identified those New Member High they felt were inappropriate, and placed them in cat- Others Low-moderate egories. They found that the highest number of in- appropriate referrals was based on the inaccurate di- Direct booking by PCP High agnosis of iron deficiency anemia, leading to refer-

44 The Permanente Journal /Winter 1998/Volume 2 No. 1 health systems management

rals for endoscopy. So they took it upon themselves but not to the level that we had thought when we to perform an education program for the primary initially designed them. care providers about the diagnosis of iron deficiency Dr. Caplan: I would probably say the same. There and continue to do that on an ongoing basis with is possibly some benefit. It’s something we probably reminder memos each year. They found this worked haven’t measured extensively, but with the increas- to decrease the inappropriate referrals. Rather than a ing pace of work and the demands on primary care punitive approach to inappropriate referrals, it was a providers, getting people to refer to the guidelines is positive educational approach. not simple. Dr. Lieberman: We also have a set of guidelines Dr. Behlmer: The real strength for us has been in written form; we call it the “Urophone Yellow having the specialists and primary care physicians Pages.” These guidelines address the 10 most com- equally involved in designing the guidelines. This mon reasons people are referred to urology, deter- process has helped diminish some of the tension, mined by my review of over 1000 patients referred while establishing some specific expectations. We also to urology. We then went to various clinics to edu- haven’t seen significant changes in referrals, in part cate providers and to discuss use of the Urophone, because they have not been fully utilized in the pro- emphasizing what information should be obtained cess of patient care. “We’re doing this before the phone call. Dr. Lieberman: I don’t think that the primary by developing a set Dr. Behlmer: An integral component of our rede- care providers have the time to consult the guide- of specialty sign efforts in Georgia has been to assist primary care lines. I do a lot of “guidelining” over the Urophone. interface agree- health care teams in expanding their capabilities, with We can get a lot more done quickly without ex- ments between an initial focus on teaching dermatology and orthope- pecting them to have to look up the guideline. each of the dic skills. Although the programs have been extremely Although we wrote the guidelines, they don’t com- specialty services well received by primary care providers, we have not monly get used. and primary care” yet documented a change in practice habits among Dr. Jacobs: Are your guidelines online in the - William the teams. We realize that we will have to adjust sched- Northwest? Caplan, MD uling processes, both to get patients to the primary Dr. Lieberman: Yes, they are online and very eas- care team for problems previously dealt with by spe- ily accessed, but they are still not commonly used. I cialists, and change visit types so primary care practi- can only speak for my department, and I don’t think tioners have time to apply their new learning.” the guidelines have impacted the number or quality Dr. Bianchi: Since we have computer tracking of of our referrals. referrals by physician, we can identify primary care Dr. Jacobs: Any other strategies that you have physicians who refer at a significantly higher rate than been working on to improve working relation- their peers. If subsequent chart audits suggest a need ships and referral procedures? in this area, the primary care physician is encouraged Dr. Caplan: In Northern California we’re imple- to use CME time in this specialty area. With this strat- menting a large redesign of primary care and part of egy, we have actually seen an improvement in that has been the recognition that we have to find a individual’s referral rates. By the way, these decisions more effective way of offering specialty service to were made by primary care peers along guidelines. this primary care population. There has to be a much Dr. Caplan: We have defined the scope of prac- more collaborative and integrated approach than in tice for primary care practitioners, which is basically the past. We’re doing this by developing a set of a list of skills and competencies which they can be specialty interface agreements between each of the expected to possess, and which are established in specialty services and primary care, with the intent collaboration with primary and specialty chiefs. For being to support the primary care teams that will be the first time, we have spelled this out in detail. Simi- caring for these defined populations of members. larly to what Patricia mentioned as one of Georgia’s These agreements really help define and clarify the strategies, these lists have been developed as part of referral and relationship issues. To develop these, the redesign across Northern California. each specialty group meets with its primary care col- Dr. Jacobs: Do you think that your Region’s ex- leagues using a template which outlines the basic set perience in referral guidelines or in disease of agreements to be reached, and describes expecta- management programs improved the quality of tions for both sides and how access will be offered. referrals or decreased the number of referrals? I believe that these agreements will be extremely Dr. Sidani: Over the years, we have created sets helpful. We’re doing this based on the recognition of referral manuals. They are rarely used. that traditionally, we have not worked particularly Dr. Golden: I think that they have helped a little, well together.

The Permanente Journal /Winter 1998/Volume 2 No. 1 45 Dr. Lieberman: We address this problem in our tor that using the STAR survey. So I would say, no, chiefs’ meetings, where the expectations of one de- we haven’t felt the pressure to develop an open ac- partment to another have been developed. We would cess system for speciality care. take two or three departments at each chief’s meet- Dr . Lieberman: We also have not done anything ing and ask a specialty department if they have met in open access, and there really isn’t any pressure in the expectations of the primary care department and the market to do so. how they could do better. In turn, the specialty de- Dr. Bianchi: With regard to open access to spe-

health systems management partment would describe what they would expect cialists, I believe we have to be very careful that in from primary care physicians, such as assisting in giving the patients what they want, instead of what managing hospitalized patients. they need, we are not compromising their overall Dr. Bianchi: In Colorado, we have had specialists care. The specific focus of specialists may not be as work in the primary care department so they could valuable overall as the broad approach of primary teach while providing hands-on patient care. This care physicians. We are also a complex organiza- has worked well. We would like to see primary care tion, and for the system to work well, we need the physicians work in specialty departments and then primary care physician or team to help patients get “So while I agree become the primary care experts in this area. through the system. So while I agree that we need that we need well- Dr. Jacobs: Let’s focus for a few minutes on ac- well-functioning referral processes, direct access to functioning referral cess. I would like to hear how our panelists re- the specialists may result in inferior care. It doesn’t processes, direct act to the phrase “open access to specialists.” serve us or the patients well. access to the Dr. Caplan: I think this is something that is very Dr. Caplan: We don’t feel that direct access is pre- specialists may active in the California marketplace. However, when cluded by the relationship of primary care and spe- result in inferior our competitors market open access, frequently they cialists. In fact, in certain situations, a patient prob- care.” are selling open access with a price tag. They might ably should have direct access to specialists, such as - Tony Bianchi, MD charge increased copayments or have a different when multiple visits are required for a condition, or premium structure or a more limited list of provid- for a specific type of clinical problem. Criteria would ers. So it is something that people are using in North- be worked out in service agreements between spe- ern California to try to get a competitive advantage. cialty and primary care departments. We have not felt as yet the need to develop open Dr. Jacobs: So advice nurses might be able to access models. send a patient directly to specialty care, depend- Dr. Golden: I’d say the same thing for San Diego. ing on protocols created from these agreements? Recently our membership has grown dramatically. Dr. Caplan: Yes, based on the presenting complaint. We cannot say that lack of direct access to specialists Dr. Golden: We also have a special intake pro- is having a marketing impact. We still promote ease cess that we promote for new members. Any new in getting to a specialist when needed, and we moni- member who has been actively seeing a specialist

PATRICIA BEHLMER, MD, has spent 14 years with Permanente. She is Co-chairperson of the Internal Referrals Committee, as well as a neurologist and Physician-in-Chief at the Glenlake facility for The Southeast Permanente Medical Group.

TONY BIANCHI, MD, has been with the Colorado Permanente Medical Group, PC for the past 25 years. He is an internist, and has been Director of Utilization Management for the past 5 years.

ANDREW GOLDEN, MD, is Chief of the Department of Family Practice, San Diego, and serves as the Regional Coordinating Chief of Family Practice for the Southern California Permanente Medical Group. He is a member of the San Diego Area Task Force, and has been with Permanente for 19 years.

WILLIAM KAPLAN, MD, is the Director of Operations Development for The Permanente Medical Group. He is a Board Certified endocrinologist at the Martinez medical center.

STEVE LIEBERMAN, MD, has been with Northwest Permanente, PC since 1982, and has been Chief since 1987. He completed his urology residency at Oregon Health Sciences University, and obtained his medical degree from the University of Southern California.

WALID SIDANI, MD, is the Associate Medical Director for Medical Operations in the Ohio Permanente Medical Group. He is in charge of the Access initiative, patient satisfaction, quality and resource manage- ment, and the internal referral process. He has been with OPMG for 20 years.

46 The Permanente Journal /Winter 1998/Volume 2 No. 1 health systems management

before joining Kaiser Permanente can have their care pointment with the specialist before they leave the transferred and appointments arranged with our spe- office of the referring physician. We all have work to cialist without going through primary care to be re- do in this area. ferred. These patients are then referred back to pri- Dr. Jacobs: Any final comments? mary care as appropriate. It is not really a very high Dr. Lieberman: Refining our referral process is volume of referrals. very important to the overall success of the delivery Dr. Lieberman: We do the same thing. systems. If our changes are always in the best inter- Dr. Jacobs: Any other related initiatives? est of patients, and provide them with the right care, Dr. Golden: As a result of the 2-week appointment then I think it will be done in the right way. It can be “I believe that this standard being monitored, the concept of directly book- our advantage over any of the captitated systems. is the most ing referrals when patients are in the primary care Dr. Behlmer: I believe that this is the most impor- important issue office was initiated. In the past, we wrote referrals tant issue facing our Medical Groups. Our patients facing our Medical and told patients that the specialty department would expect that they are being cared for by a collaborat- Groups.” call them. However, as it became important for the ing group of physicians with a unified mission, and - Patricia specialty department to get the patient into their of- do not expect to fall between the cracks. The quality Behlmer, MD fice, specialists became more supportive of schedul- of the specialty-primary care interface should be the ing taking place while the patient is still in the office. strength of a well-integrated group model. Now, 30% of our patients leave the office with an Dr. Caplan: I believe that if we can do this right and appointment already booked with the specialist. have a rational plan for providing specialty care, it is a Dr. Caplan: We are doing the same. The direct book- very powerful advertisement for Kaiser Permanente. ing guidelines get reviewed by the specialists. Cer- Dr. Jacobs: I do want to thank our panelists. I tainly it is extremely well received by the members. believe that you have successfully defined the Dr. Lieberman: If the patient needs an appoint- challenge, offered some solutions to the Per- ment and is still in the office when we talk to the manente community, and I am sure that your primary care physician, we have our appointment comments will stimulate a dialogue—a very nec- clerk call the primary care office and give the pa- essary dialogue—across the country. As the Ad- tient an appointment. The member really appreci- visory Board Company states: “the successful ates this service. In the past they were never certain medical groups in the future will be those groups when they left their primary care provider’s office if which resolve the service issues around specialty and when they would hear from the specialist. access.”1 Thanks again for participating. ❖ Dr. Sidani: In Ohio, the step from the pager sys- References tem to direct patient booking has been a tough one 1. To the Greater Good—Recovering the American Physician for us. By opening up specialists’ schedules to pri- Enterprise. The Governance Committee of the Advisory Board mary care, pre-referral pager calls have markedly Company; Washington, DC, 1995. decreased. Our goal is to give our patients an ap-

To our readers: I invite your response to this roundtable discussion. I’m sure much more can be said and that many other innovations are in place in other Kaiser Permanente divisions. Please send your comments to Merry Parker, Managing Editor, via fax at (503) 813-2348 or, mail to 500 NE Multnomah Street, Suite 100, Portland, Oregon, 97232. We will publish a representative sampling of responses in future editions of The Permanente Journal as the dialogue on this key systems challenge continues. - Lee Jacobs, MD, Section Editor, Health Systems Management

The Permanente Journal /Winter 1998/Volume 2 No. 1 47 By Michael A. Krall, MD Achieving Clinician Use and Acceptance of the Electronic Medical Record

Introduction to believe that there is a truly compelling reason to This article addresses the important role clinician make the change. In organizations such as ours, acceptance plays in successful implementation of an this must start with unequivocal and visible support Electronic Medical Record (EMR) system. It discusses from upper management and leadership.5,6 This will various barriers and challenges as well as strategies be absolutely necessary at both the overall Program for overcoming them. and local levels. These individuals must provide the The Kaiser Permanente Medical Care Program has context, the vision, and the strategic rationale, and

health systems management embarked on a national information technology strat- they must communicate it in terms that are mean- egy. The Program intends to invest considerable re- ingful to the people who will be making the change. sources in the next few years to develop and imple- Aligning the values of the various constituencies in ment a Clinical Information System across the coun- an organization is crucial for successful introduc- try. The expected benefits to members, clinicians, tion of major change. “Like other and to the health plan are substantial. These ben- “The institution must communicate clearly the individuals, efits include improved quality of care, improved in- strategic importance of Physician Order Entry and clinicians want to formation management, increased efficiency of prac- work with physicians and other care providers to feel invested in tice, decreased practice variability, and improved develop an approach that they see as helping them projects that cost structure. Installing an EMR system in a large as individuals. If this communication is not put in require them to organization is a great undertaking with a variety of place early, distrust and fear will build into pow- change and exert hurdles to overcome.1 Perhaps chief among the bar- erful barriers to implementation.”5 It is definitely substantial effort.” riers is achieving user acceptance and successful worth spending the effort prospectively to develop use. Unless achieved, the system may otherwise be a detailed and comprehensive communication plan. very acceptable while the project remains a failure.2 This involves identifying the various stakeholders How does one ensure user acceptance? and determining for each the preferred content, The Northwest Division is now the second largest means and frequency of communications. Clini- of seven divisions of the Kaiser Permanente Program. cians must have numerous and varied opportuni- Through its constituent members (Kaiser Permanente ties for input. Individuals will prefer different meth- Northwest, Group Health Cooperative, and Group ods and may not become aware of some opportu- Health Northwest) it serves over one million mem- nities. Options will include surveys, focus groups, bers in three local markets in Oregon, Washington, department meetings, interest groups, and written and Idaho. In 1994, Kaiser Permanente Northwest, and electronic communications. Further, the com- serving Northwest Oregon and Southwest Washing- munication must be bi-directional. Regular ton, began implementation of a comprehensive EMR feedback, progress reports, and updates on project system, EpicCare (Epic Systems, Madison, Wiscon- status to clinicians are essential. Clinicians who sin).3,4 Today, our system is in daily use by more choose not to make use of the opportunities to than 800 physician and allied health clinicians, more provide input must still be aware that such oppor- than 1300 other clinical staff users, directly serving tunities exist. Otherwise, “resisters” will be quick 418,000 plan members in our local market. To our to point out that “No one asked my opinion.” knowledge, we have the largest installation of a com- Making this a reality is difficult. Despite consider- prehensive outpatient medical record system in the able effort, we were unable to meet all the goals set country. The members of our project team are often out in our communication document. Clinicians were asked, “How did you do it? Did you meet any resis- often too busy to attend the “user” sessions; predict- tance along the way? What can you share with oth- ably, users most in need of the sessions were often ers who are about to embark on a similar journey?” least able to attend them. Newsletters and user tips This article will address the issue of clinician “buy- were also more sporadic than intended or optimal in.” It will discuss the types of resistance we met. It and were not of consistent quality. This should be will draw upon our experience and the literature. someone’s clear and important accountability. “We’re in this together?” “It’s not MY system” Like other individuals, clinicians want to feel in- Clinician “buy-in” will require that their involve- vested in projects that require them to change and ment is substantial and real. The project team must exert substantial effort. They need to feel benefit have strong clinician representation from the outset for their effort. If direct personal rewards seem small and throughout the project, including the planning, while requirements seem great, they need at least implementation, and post-implementation phases.5,6

MICHAEL A. KRALL, MD, is a Family Practice Physician who has worked for Northwest Permanente, PC since 1983. He is a former Chief of Primary Care of the Salem, Oregon medical offices and has worked on clinical information projects in the Northwest Division since 1991. Dr. Krall is currently enrolled part-time in the Masters in Medical Informatics program at the Oregon Health Sciences University.

48 The Permanente Journal /Winter 1998/Volume 2 No. 1 health systems management

Clinicians need to believe that the decisions they make matter. This group should include “regular” practi- tioners and formal and informal leaders and opinion makers. It should include computer neophytes as well as more computer- or technology-oriented clinicians. Individuals who resist this technology are quick to criticize an implementation or planning team that has largely non-practicing or reputed “computer nerd” clinicians. Representing a variety of specialties, level of practitioner, and geographic settings will also prove important in most instances. Each department and facility will perceive that they have unique needs. Unless they have ample opportunity for input, they may become disgruntled. Even the best efforts in this regard will fall short at times. Although our ten-mem- ber project team included an internist, a family phy- sician, and an obstetrician/gynecologist, all of whom were in clinical practice at least 50% of the time, we heard from primary care clinicians that they did not feel represented. The team also included a clinical pathologist. Later, we added an oncologist. Implementers must understand the needs and ex- Sample screen from EpicCare pectations of their customers. They also should have a good understanding of their state of readi- We achieved clinician “buy-in” in several ways. First, ness for this innovation, and for change generally. our physician board of directors created the role of Counte reported in 1987 that individuals who re- Assistant Regional Medical Director for Clinical Infor- port the greatest difficulty adapting to medical in- mation Systems to partner with Kaiser Foundation formation systems have a more negative orienta- Health Plan. A national search led to the hiring of an tion toward change in general.7 In our surveys of individual with sound credentials and experience. This users before and after implementing EpicCare in process underlined the importance that the medical two medical offices, we found the factor most group placed on the project and on physician leader- highly correlated with a negative opinion of the ship in its direction. It created a focal point for physi- computer system was disagreement with the state- cian input and communication. Second, physicians ment “At work I like new challenges.”3 Gender, were represented on the project team from the outset. “Implementers age, and attitudes toward or experience with com- These physicians represented both primary and spe- must understand puters did not correlate. cialty care and they were in active clinical practice. the needs and The user community should have a clear understand- The project team regularly solicited input from “ordi- expectations of ing of what the system can and cannot do. Customers nary” physicians and from physician leadership. This their customers.” who are accepting of the technology may have unre- was done through both formal and informal contacts, alistic or inflated expectations about what it will ac- including updates to the Northwest Permanente Board. complish, especially in early phases. They may not In the Northwest, clinicians were gradually intro- appreciate that it is a tool which requires substantial duced to electronic systems. Overall, this helped to configuration with local business rules and with data achieve acceptance. Most clinicians used applica- before realizing much of its promise. They must achieve tions such as office automation or e-mail, a results- a sense of “ownership” of these decisions and of this reporting system, an appointment system, and work. This process can be quite difficult and time con- Internet access prior to our introduction of EpicCare. suming and must begin early. In achieving the local This culture helped prepare, acclimate, and “hook” understandings and agreements, users begin to feel it clinicians on the power and benefits of clinical com- is their system, provided their involvement in the pro- puting. But whereas these applications are easy to cess is substantial and real. Users should understand use and have high benefit for clinicians, the addi- that the product is dynamic and that it is undergoing tional demands placed on clinicians by the com- constant improvement. Communications regarding prehensive EMR system do not always seem to yield changes under development should be frequent. Us- corresponding benefit. ers should see results as rapidly as possible so they By the time the clinician actually begins training, feel they are being heard and supported. attitudes and expectations should be at least “open” if

The Permanente Journal /Winter 1998/Volume 2 No. 1 49 not enthusiastic. Training allows opportunity to rein- tient care, professional autonomy, relationship be- force the rationale and organizational imperative for tween physician and patient, and the art and sci- the EMR system and to hear and address the concerns ence of medicine.”9 of users. To be effective, this requires that representa- The issue of authority and autonomy will affect ac- tives of the project team and clinicians are active in ceptance. Important questions arise: “Will the new sys- training. For effective use and acceptance of an EMR tem enable administrators to monitor or control phy- system, training cannot be overemphasized. Special sician practice behavior and decrease departmental attention must be paid to the unique requirements independence or professional decision making? Is there health systems management and learning styles of adult learners, and there must a shift in the balance of power between clinical per- be ample opportunity for practice and for achieve- sonnel and managers, between departments, and be- ment of mastery. We found advanced training after 6 tween the institution and attending physicians?”10 Such to 12 weeks of use very helpful. We tailor training to changes should occur only when carefully considered individuals based on their identified needs, with the and intended, when clearly justified, or when unavoid- “Our constant primary aim being increased efficiency. able. Even then, they must be honestly acknowledged refrains are ‘make and thoughtfully communicated. the system so easy ”What’s in it for ME?” For every system, implementers should ask, “Whom they want to use it’ The best preparation aside, when users actually does it benefit, and who incurs its cost?” If the ben- and ‘make it easy start to work with the EMR in a real setting, accep- efit accrues to someone other than the individual to do the right tance hinges on usability of the software. What do doing the work or experiencing the inconvenience, thing.’” clinicians want most? Speed and performance. At the result will likely be dissatisfaction. With clinicians the very least, they insist, “Don’t slow me down!” it is preferable whenever possible to use the “car- The system must be fast and easy to use, and the rot,” not the “stick” approach to motivation. We try user interface must behave consistently.5 Users will to add value for clinicians so that they prefer using generally expect sub-second performance for most the system. Our constant refrains are “make the sys- operations and will become increasingly impatient tem so easy they want to use it” and “make it easy to if response time exceeds 2 to 3 seconds. This win- do the right thing.” Unfortunately, we are not always dow may be extended when benefit or time saved successful. Experience has shown how important is perceived to be greater than provided using pre- these principles are to user acceptance. vious methods. When clinicians perceive the time That there are costs and barriers associated with is completely nonproductive, even short waits will using an EMR system must be clearly acknowledged be intolerable. Reduced performance with new ver- to users and potential users (Table 1). Learning and sions or features will be especially poorly accepted. training time, and lost productivity during learning The system must also make sense in the context or training may be particularly difficult in small de- of the clinician’s practice and workflow. Users must partments or in settings where it will be difficult to perceive that the system supports instead of inter- “back fill.” Systems that depend on clinicians enter- feres with the performance of their jobs as they ing clinic notes and orders inevitably impart some define them.8 “Users are supportive of systems which significant cost to them. Expecting this aspect of the support their work patterns, their professional sta- system to be time neutral or better is very optimistic. tus, and professional values such as impact on pa- While some notes and orders may be done more

Table 1. Costs and barriers for clinicians associated with using an electronic medical record

Costs Barriers • Learning and training time • Energy required to overcome the inertia of • Lost productivity during learning the status-quo • Time for order entry and electronic charting • Perception that entry is clerical work • Time and changed workflow required by • Perception that current system is adequate alerts and reminders • Lack of agreement on benefits • Dislike or disagreement with guidance offered by the system • Perceived lack of flexibility of system in interpretation and enforcement of rules

50 The Permanente Journal /Winter 1998/Volume 2 No. 1 health systems management

quickly, especially those which use panels or tem- plates, others may be slower. Our experience is that Table 2. Benefits to clinicians associated with using an a more realistic goal is to achieve sufficient time sav- electronic medical record ings in some tasks such that the total impact on a • Legible charts clinicians’ day is favorable. New tasks associated with the EMR system and alerts and reminders to do more • Ready access to prior notes and other data for each patient, carry time costs. Clinicians some- • Remote and simultaneous access to the medical record times disagree with or feel constrained by the ad- • Ability to easily sort and trend past data vice, and this may be a barrier. • Reduced need for reentering data There are additional potential barriers to clinician • Alerts, reminders, decision support with improved quality acceptance. There is an “energy” cost to overcome and efficiency the inertia of the status quo. Clinicians may have “work-arounds” or local solutions that allow them to ing filing. When appropriate and not overly intru- function, even though these solutions create ineffi- sive, alerts, reminders, and decision support may ciencies elsewhere in the system. Multiple isolated improve both the quality and efficiency of clinicians. records or filing systems may be an example of this. Horak described the relation between user pro- Changing from these systems to the EMR system re- ductivity and time which results after introduction quires a degree of effort and disruption. The percep- of an information system.11 He developed a model tion that the current system is adequate and the new based on experiences implementing 5 integrated system is inflexible and of uncertain benefit also can hospital information systems. After switching to the be hurdles. information system there is a predictable decrement Fortunately, the potential “rewards” or benefits of in productivity as the new technology and workflows such systems are also substantial (Table 2). Commu- are adopted and learned. Later, productivity gradu- “Users want to be nicating the potential rewards genuinely is impor- ally returns. Our experience suggests a similar im- heard, understood, tant. “Over marketing” them then failing to realize pact on user satisfaction during this period.3 In our taken seriously, the benefits can yield dissatisfaction and mistrust. pilot study, satisfaction had dramatically improved acknowledged, Clinicians clearly understand the importance of leg- 4 to 6 months after implementation (Figure 1). An- empathized with, ible charts and ready access to prior notes and other ticipating this effect allows better planning and more and responded to data. The paper record is often unavailable or un- successful management of expectations. Strategies quickly.” readable or the information may be misfiled or await- can minimize the depth and breadth of the decline. The efforts of trainers, support personnel, and imple- 90 mentation teams are crucial. System modifications 2 Months made in response to user requests may also con- 80 4-6 Months tribute substantially. 70 “What have you done for me LATELY?” 60 Credibility and support from the user community must be earned every day during and following imple- 50 mentation. First, the system must perform reliably. 40 In addition, there must be opportunity for ongoing user input. Users want to be heard, understood, taken 30 seriously, acknowledged, empathized with, and re- sponded to quickly. Like other users, clinicians tend 20 to have short memories about the good, long memo- 10 ries about the bad, a seemingly infinite capacity for wanting changes to the software, and a lack of pa- 0 tience for what it takes to change it and maintain it. Agree Neut ral Disagre e Well beyond the initial rollout, ongoing user in- Fig 1. “EpicCare is worth the time and effort to use it.” put is necessary. Formats may differ somewhat from Results of user survey 2 and 4-6 months after “go- the early phases, but opportunities must be con- live” in the Kaiser Permanente Northwest pilot stant. These include phone, e-mail, onsite support implementation.2 At 2 months, 52% agreed, and 39% personnel, and personal contact with members of disagreed (n=33). At 4-6 months, 85% agreed, and the implementation team. User meetings are ex- 6% disagreed (n=34). tremely helpful. They may take place at lunch time

The Permanente Journal /Winter 1998/Volume 2 No. 1 51 (“brown bag” or “hosted”) or before or after work der entry and prescribing, and more prevention re- hours. These provide an opportunity for new fea- minders. With all the initiatives combined, clinicians ture announcements and introductions. More im- find they are expected to do more in less time. portant, users will learn from each other, and this Introduction of computer systems in health care can be especially effective. Informal discussions (at organizations result in changes on several levels. department or work group meetings), and more These include changes for individuals and their formal presentations address different needs. User jobs, departments as a whole, and for performance surveys and evaluations as well as visits from the of the department’s work. It also may affect the health systems management vendor can also be useful ways to gather feedback. structure and functioning of the entire organiza- tion, as well as the quality of both service and ”Where were you when I NEEDED you?” medical care which patients receive.12 Techniques Continuous and immediately available user sup- for overcoming resistance to change include gath- port is absolutely necessary. When clinicians are in ering benchmark data (establishing the imperative the midst of seeing patients, they are frequently run- for change), and analyzing benefits (providing the ning behind, over-scheduled, and under a variety justification). These techniques include assessing of pressures. Even momentary unavailability of the the general organizational climate (understanding “The site specialist system or delayed ability to perform some task is and acknowledging the context for the change), is a trained, onsite troubleshooter unacceptable. If they need an answer about a hard- and finding physician champions (overcoming in- ware problem or how to perform a task such as ertia and resistance). They will also involve devel- with a clinical and/ generating an uncommon order or coding an un- oping general ownership (“buy-in”), and establish- or Information Systems back- usual diagnosis, they want help immediately. Five ing realistic expectations (engaging peer leader- minutes later is frequently too long because before ship and support). Timely training (adequate and ground.” then they need to be on to the next task. Providing thorough preparation), extensive support (readily this kind of support may be difficult and expensive. available help), and system stability (an absolute We hired and trained a group of professionals known requirement) will also be important. Successful as “site specialists.” During rollout, we assigned one implementers will also find ways to protect physi- to each clinic. After rollout, there is about one site cian egos (keeping them “on board”), and to plan specialist for every two clinics, but they are avail- end-stage fun (rewards).6 able by beeper at all times. The site specialist is a Achieving user acceptance and mastery of new trained, onsite troubleshooter with a clinical and/or technologies is far from a new problem. Doctor Information Systems background. These individu- Henry Plummer experienced it in 1907, when he als not only provide timely user support but coordi- introduced the system of central medical records nate trouble reports, user tips, and updates. at the Mayo Clinic. “It was not easy for all the doc- tors to make the change. To some of them the “Oh, brother. One MORE new thing.” new way seemed more cumbersome than the old, It is a cliché as well as a truism that change is a just a lot of unnecessary red tape. It seemed much constant today. Our division and local market, like simpler to jot down a few notes in a ledger lying others, are undergoing major restructuring. This in- open on the desk than to fill in all the blanks on a cludes closing a hospital and entering into new alli- form sheet, much easier to pull out one’s own vol- ances, more than doubling the hospitals we cover. In ume and look up what old record was there than addition, there is major reorganization of primary care to call for an envelope and wait till it was brought services, major member access improvement initia- from the file. At first some [doctors] just forgot about tives, major changes in physician compensation, ma- the record blanks and used their ledgers when they jor geographic expansion, and more. In such an envi- were very busy, but in time they all saw the worth ronment, implementing an EMR system is even more of the new system, and it became a routine fol- challenging as people may be unable to absorb new lowed without question and with tremendous ben- content and behaviors, even if these promise benefit. efit.”13 Those who introduce EMR systems in the Furthermore, along with the EMR system come new late 1990s can hope for as much success. ❖ tasks. Although many of these are not requirements of the EMR itself, the perception may be that they are. Acknowledgments: The author wishes to thank and acknowledge Various constituencies in the organization see the ad- the other members of the Kaiser Permanente Northwest Clinical vent of the EMR as a means to introduce or enforce Information System Project Team: Dan Azevedo, Homer Chin, Larry policies designed to accomplish a variety of goals. Dworkin, Dawn Hayami, Brad Hochhalter, Gary Huscher, Peggy McClure, Nan Robertson, Nick Socotch, Paul Wallace, Richard New tasks for our clinicians include diagnostic cod- Wong, and Jackie Zehner. ing, evaluation and management coding, clinician or-

52 The Permanente Journal /Winter 1998/Volume 2 No. 1 health systems management

References 7. Counte MA, Kjerulff KH, Salloway JC, Campbell BC. Adapting 1. McDonald CJ. The barriers to electronic medical record to the implementation of a medical information system: A systems and how to overcome them. J Am Med Inform Assoc comparison of short versus long-term findings. J Med Syst 1997;4:213-221. 1987;11:11-20. 2. Fischer PJ, et al. User Reaction to PROMIS: Issues related to 8. Kaplan B, Duchon D. Combining qualitative and quantitative acceptability of medical innovations. In O’Neill JT (ed), methods in information systems research: a case study. MIS Proceedings of the Fourth Annual Symposium on Computer Quarterly 1988;12:571-586. Applications in Medical Care. Washington, D.C.: IEEE, 9. Kaplan B. Reducing barriers to physician data entry for computer- 1980;1722-1730. based patient records. Top Health Inf Manage 1994;15:24-34. 3. Krall MA. Acceptance and performance by clinicians using an 10. Kaplan B. National Health Services reforms: Opportunities ambulatory electronic medical record in an HMO. Proc Annu for medical informatics research. In: K.C. Lun et al (Eds.) Symp Comput Appl Med Care 1995; 708-11. MedInfo 92: Proceedings of the 7th World Congress on Medical 4. Chin HL, Krall M. Implementation of a comprehensive Informatics. Amsterdam: Elsevier: 1992:116-117. computer-based patient record system in Kaiser Permanente’s 11. Horak, B. Implementation-time productivity. Organizational Northwest Region. MD Comput 1997;14:41-45. Issues in Medical Informatics 1993;October:1-2. 5. Sittig DF, Stead WW. Computer-based physician order entry: 12. Anderson, JG, Aydin CE, Jay SJ. Evaluating Health Care the state of the art. J Am Med Inform Assoc 1994;1:108-123. Information Systems: Methods and Applications. Thousand 6. Lorenzi NM, Riley RT. Organizational Aspects of Health Oaks, CA: Sage Publications, Inc.:1994:7-8. Informatics: Managing Technological Change. New York: 13. Clapesattle H. The Doctors Mayo, Minneapolis, MN: Univ Springer-Verlag: 1995. Minnesota Press:1941: 524.

“Toupees by Al” by Evany Zirul, DO, MFA. Another piece of her work can be seen on page 14.

The Permanente Journal /Winter 1998/Volume 2 No. 1 53 By Al Weiland, MD The Coming Tidal Wave: Genetic Testing

A number of new technologies now exist that are Illinois, Indiana, Tennessee, and Texas). Most of these likely to have a major impact on the practice of laws ban the release of genetic test results without medicine over the next several years. Telemedicine informed consent of the individual tested; and six is in its infancy, with teleradiology probably the ban insurers from refusing to issue or renew policies most advanced. to individuals or creating differential premiums on The area that should have the greatest impact on the basis of genetic information. Some exceptions to society is the advances in genetics and genetic test- absolute confidentiality have been recognized, such ing. The Human Genome Project has been under- as use of the testing information for research, as long health systems management way for about 6 years, and will finish identification as it is anonymous and cannot be traced. of the structure of human DNA over the next several As both a very large insurer and a provider, Kai- years. Around 4000 single-gene disorders exist, and ser Permanente will have to wrestle with all the this project will characterize the specific location of ethical, legal, moral, and social issues of widespread “Kaiser Per- these defects. That knowledge will provide greatly genetic testing. I can’t think of any medical tech- manente will have enhanced ability to provide prenatal or population nology that could affect the lives of our children to wrestle with all screening and specific genetic therapies. and grandchildren more. the ethical, legal, In addition to the single-gene disorders, a lot of When the Genome Project is finished, some 50,000 moral, and social work is going on to characterize the interaction of to 100,000 genes, and later their specific products, issues of wide- many chronic and degenerative disorders that have will be identified and catalogued. Tests will be avail- spread genetic a genetic predisposition as well as the environmen- able to pinpoint defects in single genes, and the pres- testing.” tal and behavioral factors that may enhance their ex- ence, absence, or partial expression of the gene prod- pression. Many cancers, heart disease, diabetes, ar- uct. Rapidly, new generations of therapies will be- thritides, and a number of mental and neurodegenerative come available designed to replace defective gene disorders are in this category. Over the next 20 years products, modify their function, or stop production or so, it will be possible to prenatally test for the of unwanted proteins. potential to develop a wide range of illnesses during Consider the impact on the practice of medicine of a lifetime. having this body of knowledge available. We have a Let’s think about the implications of this on society glimpse of this future with the identification of the if there is large-scale prenatal screening and case and BRCA1 and BRCA2 genes for breast/ovarian cancer carrier finding. Who will have a stake in knowing susceptibility. Jake Reiss, MD, from NWP,PC led a the genetic status of individuals besides the family national effort to develop a guideline for determin- and caregivers? How about governments attempting ing who should be tested in the population, and for to prioritize budgets? Employers who want healthy, interpreting of the results. This guideline began as a productive employees? Insurers who will write life huge probability spreadsheet, covering six or seven and health insurance? Social agencies and the educa- pages of analysis and interaction of risk factors, de- tional systems to plan their roles? What will happen veloped in order to guide the discussion with the to the confidentiality of this information? Despite laws patient of why or why not be tested, and what a to protect the confidentiality of HIV test information, positive or negative result means. Due to its com- it is now a required test to obtain most life insur- plexity the guideline was later modified to a set of ance, and numerous examples of job, employment, recommendations to primary care providers about and housing discrimination operate against people who should be referred for counseling and possible with HIV. testing. Jake believes that lengthy discussions by The implications of the work of the Human Ge- trained genetic personnel will be required to review nome Project are just being appreciated. A Working the benefits and harms of such testing. At least 4000 Group on Ethical, Legal, and Social Implications, has single-gene disorders and many chronic medical prob- formed a Task Force on Genetic Information and lems have a genetic component. According to John Insurance. This Task Force has recommended vigor- Thompson, MD, the NWP,PC chief of pathology, there ous protection of genetic privacy, while still acknowl- are currently 140 “misspellings” of the gene for cys- edging that insurance companies and others will prob- tic fibrosis, each with a slightly different expression. ably gain access to this information. The major implication I glean from this is that the Recently the President has proposed federal legis- reliance on computer databases to support medical lation to limit use of genetic testing information. Last decision making will become mandatory. Large sys- year, nine states enacted genetic testing legislation tems that can aggregate population information and (Alabama, Arizona, Arkansas, Connecticut, Florida, make the investments to make this information readily

AL WEILAND, MD, joined Northwest Permanente, PC in 1977 as an obstetrics-gynecology physician prior to becoming President and Regional Medical Director in 1993. In addition to being a member of the Permanente Federation Executive Committee, he is also on The Foundation for Medical Excellence Board of Directors, and is Co-chair for Oregon Safe Kids.

54 The Permanente Journal /Winter 1998/Volume 2 No. 1 health systems management

available to clinicians will attract the best and bright- have similar resources in that state. I suspect all the est clinicians to the practice of medicine, not to men- Permanente Groups will have to pool resources and tion create enormous value for members. link them electronically to provide a consistent level There are clearly major cost implications. I suspect of service around the country and to make sure that only a few laboratories will have the resources to we are getting the best information possible to our run all the very specific genetic tests, and they will members. There simply aren’t enough training pro- be expensive. The therapies, if the few current gene- grams in the world to meet the potential needs. specific agents are an indication, will also be very The last area of impact I want to mention is confi- “I suspect all the expensive. Which agents are experimental, which are dentiality. Despite the current legislation in a num- Permanente Groups not; and who will be a candidate for therapy at what ber of states, I think there will be enormous pressure will have to pool level of probable risk will keep new technologies to have genetic profile information available. The line resources and link committees busy for decades. between general medical information and genetic them electronically My fear is that the potential explosion in the cost information will become hopelessly blurred. Does to provide a of medical care, given our society’s value of “I want your child have recurrent ear infections? Is it a result consistent level of everything possible available,” will make health in- of a gene defect controlling immunologic response service around the surance less and less affordable, even further widen- and therefore a pre-existing condition that will con- country ... ” ing the gap between those who have access to ev- tribute to other disorders later in life? This may be a erything, and the rest. little farfetched but not very. I have no answer to the The third area of impact on us will be the availabil- issue of confidentiality; I suspect it will be played ity of personnel trained to deal with all the genetic out in the courts and the legislatures. information and to counsel patients on its interpreta- These issues are all a little way off in the future. tion. Right now, NWP,PC is one of only four Per- They may not seem important now as you struggle manente Groups with an in-house genetic service. through the day, or with EpicCare, our clinical infor- In fact, we support our geneticist, Jake Reiss, MD, in mation system—but they will be, and probably sooner consulting with the State of Idaho because they don’t rather than later. ❖

Inside Microsoft’s Brain “Research is a little like conducting a dinner party. You don’t interrupt the conversations and tell people what they should be saying and thinking. If you pick the right people to convene, more and better things happen than you could have planned.” Nathan Myhrvold, Chief Technology Officer (“Chief Propeller Head”) Fortune, December 8, 1997

The Permanente Journal /Winter 1998/Volume 2 No. 1 55 By Bob Randolph

Gracie in My Heart

Well, Gracie, So Gracie, here we are. you’re in there. Inseparable for the rest of my life

soul of the healer You made it, and for the rest of the life of your aortic heart valve. but- We two, we are one. It’s not quite like the oneness of marriage. but, I don’t think You see, it wasn’t a minister that knit us together. this is what you had in mind. It was a surgeon, Sure, you were hand-picked a surgeon of the heart, when you were a baby or a cub a skilled compassionate heart surgeon, or a piglet a female like you, or whatever newborn pigs are called. and your name is Gracie, and hers is Nora, And you were raised in special sanitary surroundings Nora Burgess to tell the whole story. a “pure porcine environment,” they called it. I’m sure glad the three of us met. So, now you are in my heart, Gracie, Are you also glad, Gracie? or at least part of you is. I hope I can do continuing honor Your perfect aortic valve has replaced to that most precious part of yourself my disfigured one, that was given to me. and though you will not know any more of your own life, Know that yours part of you has joined and is prolonging the life is a place of honor in my heart, of a poetic sort of creature, a human creature. a place of gratitude

I think, Gracie, and honor. ❖ I want to think, Gracie, that when you were whole and had your own integrity as a creature that you once or twice hesitated, lingered, to look a moment at a sunset, or cocked your round head, to listen to a bird call, or heard and wondered about the laughter of children, the cries of newborn baby pigs younger than you.

BOB RANDOLPH, a Kaiser Permanente member, is very active in the world of poetry. He has published 6 books of poetry, hosts two radio programs regularly, and is a guest on several others where he discusses and recites his poetry. He wrote Gracie in my Heart in August 1994, after having an operation to replace his aortic valve with a porcine valve—given to him by a pig he named “Gracie.”

56 The Permanente Journal /Winter 1998/Volume 2 No. 1 Couplets to a Pre-Existing Condition Retirement soul of the healer By Ronald R. Louie, MD By Gopal Nemana, MD

- For H.J.R. Whither your journey, Oh lonely man? In this forest of health care O Solomon! what wisdom is needed for the physician Prowling as a hungry wolf who deals with a child and a “pre-existing condition”: Realizing nobody will care. of all known miseries, the one that presupposes It’s time to play your game of golf a definable beginning, and presumptively imposes and be joyful that you are again a man. a linear relationship of time to illness, with no respect for the sublime When you are through with that turns lugubrious, ending with antecedents circular, unsalvageable code blues and predicated upon a bureaucratic vernacular; Realize you should start singing Which for the peripatetic pediatrician your own life’s blues. presents a peculiar imprecision: Lately, I have been kept awake when caring for very sick children or infants, by the rumor of a golden handshake. with cystic fibrosis or leukemia, for instance, whose spirits hold hostage parental emotions; In reality it’s a kick from a golden boot Are these children just some post-conceived notions, It hurts more than one from a leather boot begging their epistemic question, with exons existential, It doesn’t matter, no one will pay a hoot full of knowing and pre-knowing, (the code confidential)? It is a horn you can no more toot. Can we now really judge origins, without pre-maturity, or assess a person’s, or a population’s risk-pool purity, Pay attention to that call from yonder and not mock the politics of self-determination? Go on the trail, be lonely and ponder Yet Media-tricians trumpet the research’s implication Appreciate nature’s beauty and wonder for these progenitor cell products in our age of new genetics, At God’s creation and all its splendor. ❖ these innocently assorted alleles, (admittedly, at times, pathogenic), whose critical pre-existing condition is birth, with no consideration of bottom-line net worth? ❖

RONALD R. LOUIE, MD, works in the Pediatric Oncology/Hematol- GOPAL NEMANA, MD, is a cardiologist with The ogy Department for Group Health Cooperative in Redmond, WA. Permanente Medical Group, Sacramento.

The Permanente Journal /Winter 1998/Volume 2 No. 1 57 Permanente Abstracts

Heritability of Longitudinal Changes in used to identify adults hospitalized with ALGIH from Coronary Heart Disease Risk Factors in 1990 to 1993. Data were collected by record review Women Twins and telephone calls. Friedlander Y, Austin MA, Newman B, Edwards K, Results: Two hundred nineteen patients had 235 permanente abstracts Mayer-Davis EI, King MC. Am J Hum Genet 1997 hospitalizations, yielding an estimated annual inci- Jun;60(6):1502-12. dence rate of 20.5 patients/100,000 (24.2 in males Numerous studies have demonstrated genetic in- versus 17.2 in females, p < .001). The rate increased fluences on levels of coronary heart disease (CHD) >200-fold from the third to the ninth decades of life. risk factors, but there also may be genetic effects on Diagnoses were: colonic diverticulosis, 91 (41.6%); “Based on longitu- the intraindividual variation in these risk factors over colorectoral malignancy, 20 (9.1%); ischemic colitis, dinal twin data in time. Changes in risk factors are likely to reflect ge- 19 (8.7%); miscellaneous, 63 (28.8%); and unknown, women, this study netic-environmental interactions and may have im- 26 (11.9%). Eight (3.6%) patients died in the hospital demonstrates a portant implications for understanding CHD risk. The (5 of 206 (2.4%) with hemorrhage before admission genetic influence present study examines the heritability of changes in versus 3 of 13 (23.1%) with hemorrhage after admis- on changes in both CHD risk factors, using data from the two examina- sion, p < .001). Follow-up of 210 of 211 (99.5%) sur- lipoprotein risk tions by the Kaiser Permanente Women Twins Study, vivors was 34.0 +/- 1.1 months. In the 83 diverticulo- factors and systolic performed a decade apart. The sample consisted of sis patients without definitive therapy, the hemor- blood pressure 348 pairs of women twins who participated in both rhage recurrence rate (Kaplan-Meier method) was over a decade.” examinations, including 203 MZ pairs and 145 DZ 9% at 1 year, 10% at 2 years, 19% at 3 years, and 25% pairs. Average ages at the two examinations were 41 at 4 years. In the 89 diverticulosis patients who sur- and 51 years, respectively. By means of three differ- vived hospitalization, all-cause mortality rates (none ent statistical analytic approaches, moderate herita- from hemorrhage) were 11% at 1 year, 15% at 2 years, bility estimates were demonstrated for changes in 18% at 3 years, and 20% at 4 years. LDL cholesterol (h2 = .25-.36) and in HDL choles- Conclusions: Hospitalization with ALGIH is related terol (h2 = .23-.58), some of which were statistically to age and male gender. After hemorrhage from co- significant. Although small to moderate heritability lonic diverticulosis, the leading cause, rates of ALGIH estimates were found for systolic blood pressure (.18- recurrence and unrelated death are similar during .37; p < .05 for some estimates), no genetic influence the next 4 years. on changes in diastolic blood pressure was detected. Based on longitudinal twin data in women, this study Specialty Differences in the Management of demonstrates a genetic influence on changes in both Asthma. A Cross-Sectional Assessment of lipoprotein risk factors and systolic blood pressure Allergists’ Patients and Generalists Patients in over a decade. In addition to environmental factors, a Large HMO. which clearly are operating, the effect of various “vari- Vollmer WM, O’Hollaren M, Ettinger KM, Stibolt T, ability genes” may be acting independently of the Wilkins J, Buist AS, Linton KL, Osborne ML. Arch Intern “Hospitalization genetic influences on the absolute levels of these Med 1997 Jun 9;157(11):1201-8. with ALGIH is risk factors. Both mapping the gene(s) underlying Objective: To examine the differences in medi- related to age and intraindividual variations in these CHD risk factors cal management and quality of life between pa- male gender.” and understanding their function(s) could lead to tients with asthma who receive their primary asthma targeted intervention strategies to reduce CHD risk care from allergists and those who receive their among genetically susceptible individuals. care from generalists in a large health maintenance organization (HMO). Epidemiology and Outcome of Patients Methods: We conducted a cross-sectional study of Hospitalized with Acute Lower Gastrointesti- patients with asthma in a large HMO (Kaiser Per- nal Hemorrhage: a Population-Based Study manente, Northwest Region, Portland, Ore). Partici- Longstreth GF. Am J Gastroenterol 1997 Mar;92(3):419-24. pants were 392 individuals aged 15 through 55 years Objectives: Population-based data on the epidemi- with physician-diagnosed asthma, taking anti-asthma ology and outcome of patients hospitalized with acute medications, reporting current asthma symptoms, and lower gastrointestinal hemorrhage (ALGIH) are lack- receiving asthma care from an allergist or from a ing. This survey of the incidence, etiology, therapy, generalist. Primary outcomes included characteristics and long-term outcome of patients with ALGIH was of asthma, health care utilization, and quality of life. conducted in a defined population. Results: Patients cared for by allergists tended to Methods: In a large health maintenance organiza- have more severe asthma than those cared for by tion, discharge data and colonoscopy records were generalists (p < .01). The allergists’ patients tended

58 The Permanente Journal /Winter 1998/Volume 2 No. 1 permanente abstracts

to be older (38.6 +/- 9.6 years vs 35.7 +/- 12.6 years, status of the study group. While both groups uti- p < .01), more atopic (91% vs 78%, p < .01), and lized more services in the early phase of their en- more likely to report perennial (rather than seasonal) rollment, the intensity of this start-up was similar asthma (26% vs 36%, p < .04) than the generalists’ for both groups. patients. Patients receiving their primary asthma care Conclusions: Compared with a commercial from an allergist were considerably more likely than group of the same age and sex, the patterns of generalists’ patients to report using inhaled anti-in- utilization were similar and the financial costs of flammatory agents (p < .01), oral steroids (p < .01), care were only moderately more for a previously and regular (daily) breathing medications to control uninsured group provided with comprehensive “ ... allergists’ their asthma (p < .01). Allergists’ patients were more HMO insurance. With the growth of managed care, patients conformed likely to have asthma exacerbations treated in a clinic these data should be beneficial in the develop- more closely to setting rather than an emergency department (p < ment of health care programs for the growing national asthma .01). Furthermore, allergists’ patients reported signifi- number of uninsured Americans. management cantly improved quality of life as measured by sev- guidelines and eral dimensions of the SF-36 scale (physical func- Efficacy and Cost-Effectiveness of Multihole Fine- Needle Aspiration of Head and Neck Masses reported better tioning, role emotional, bodily pain, and general quality of life than health: p < .05). Mui S, Li T, Rasgon BM, Hilsinger RL Jr, Rumore G, did the generalists’ Conclusions: These findings suggest that specialist Puligandla B, Sawicki J. Laryngoscope 1997;107:759-64. patients.” care of asthma is of benefit for patients with asthma To determine whether the specimen from fine- in a large HMO. Specifically, the allergists’ patients needle aspiration (FNA) biopsy of head and neck conformed more closely to national asthma manage- masses has greater diagnostic accuracy when using ment guidelines and reported better quality of life multihole needles than when using conventional, than did the generalists’ patients. single-hole needles, we did a prospective, random- ized, single-blinded study comparing diagnoses ob- Extending Health Maintenance Organization tained using both types of needles in FNA biopsies Insurance to the Uninsured. A Controlled of head and neck masses. Eighty-eight patients served Measure of Health Care Utilization as their own controls and had 91 FNA biopsies with Bograd H, Ritzwoller DP, Calonge N, Shields K, both multihole and single-hole, 22-gauge needles. Hanrahan M. JAMA 1997;277:1067-72. Order of biopsy was randomized and was unknown Objective: To investigate the utilization of health to the cytopathologist. No statistically significant dif- care services of previously uninsured low-income ferences were noted in quantity of specimen mate- patients after becoming insured by a health mainte- rial obtained, quality of fixation, or diagnostic value nance organization (HMO). between the multihole and conventional needle. We “No statistically Design: Retrospective study of utilization in a pre- found no advantage in using the more costly multihole significant differ- viously uninsured study group compared with an age- needle in FNA biopsy of head and neck masses. ences were noted and sex-matched randomly selected control group in quantity of of commercial HMO enrollees. Heritability of Factors of the Insulin Resis- tance Syndrome in Women Twins specimen material Setting: Group model HMO obtained, quality Patients: A study group of 346 previously uninsured Edwards KL, Newman B, Mayer E, Selby JV, Krauss RM, of fixation, or low-income patients and 382 controls. Austin MA. Genet Epidemiol 1997;14(3):241-53. diagnostic value Measures: Outpatient visits of primary and spe- The insulin resistance syndrome (IRS) is character- between the cialty care, outpatient pharmacy, laboratory, and ized by a combination of interrelated coronary heart multihole and radiology use, and inpatient admissions and hospi- disease (CHD) risk factors, including low high-den- conventional tal days over a 2-year period. Self-reported health sity lipoprotein cholesterol (HDL-C) levels, obesity needle.” status measures were obtained to control for differ- and increases in triglyceride (TG), blood pressure, ences in health status. small low-density lipoprotein particles (LDL), and both Principal Findings: There were no differences be- fasting and postload plasma insulin and glucose. Using tween the study and control groups in hospital ad- factor analysis, we previously identified 3 uncorrelated missions, hospital days, and measures of outpatient factors that explained 66% of the variance among laboratory, pharmacy, and radiology use. The odds these variables, based on data from women partici- of having an outpatient visit per patient per month pating in examination 2 of the Kaiser Permanente was 30% higher for the study group. Approximately Women Twins Study in Oakland, CA during 1989- half the increase in the odds ratio for outpatient 1990. The factors were interpreted as: 1) body mass/ visits were related to the worse self-perceived health fat distribution, 2) insulin/glucose, and 3) lipids: TG,

The Permanente Journal /Winter 1998/Volume 2 No. 1 59 HDL-C, LDL peak particle diameter. In this analysis, the rate of freedom from progressive HD was 92% heritability of each of the factors was estimated based (95% confidence interval [CI], 88% to 96%) for pa- on data from 140 monozygotic and 96 dizygotic pairs tients treated with STLI and 87% (95% CI, 81% to of non-diabetic women twins. Heritability estimates 93%) for patients treated with VBM and regional ra- permanente abstracts were calculated using the classical approach, the diotherapy. Six of seven patients who relapsed are analysis of variance (ANOVA) approach, and the alive and in remission following successful second- maximum likelihood approach. For the body mass/ line therapy. fat distribution factor heritability estimates suggest Conclusion: Given the caveat of a small number of “ ... both genetic moderate genetic influences; 0.61 (p < 0.001), 0.14 patients, the results of extended-field radiotherapy and and environmental (p > 0.05), and 0.71 (p < 0.001), respectively. The VBM and regional radiotherapy are comparable with effects are involved insulin/glucose factor appeared to be highly heri- a median follow-up period of 4 years. VBM serves as in the clustering of table, with estimates of 0.87, 0.92, and 0.57 (all p < a paradigm to reduce late effects in favorable early- IRS risk factors.” 0.001), respectively. The heritability estimates for the stage HD. We do not advocate its routine use in clini- lipid factor were moderate and consistent across meth- cal practice, but instead encourage participation in clini- ods: 0.25 (p < 0.10), 0.32 (p < 0.05), and 0.30 (p < cal trials with the objective of maintaining efficacy while 0.05), respectively. These results are consistent with reducing toxicity in CS I and II HD. genetic influences on each of the 3 “factors,” and suggest that both genetic and environmental effects Marijuana Use and Mortality are involved in the clustering of IRS risk factors. Sidney S, Beck JE, Tekawa IS, Quesenberry CP, Friedman GD. Am J Public Health, 1997 Apr;87(4):585-90. Stanford-Kaiser Permanente G1 study for Objectives: The purpose of this study was to ex- Clinical Stage I to IIA Hodgkin’s Disease: amine the relationship of marijuana use to mortality. Subtotal Lymphoid Irradiation Versus Vinblas- Methods: The study population comprised 65171 tine, Methotrexate, and Bleomcycin Chemo- Kaiser Permanente Medical Care Program enrollees, therapy and Regional Irradiation aged 15 through 49 years, who completed question- “VBM serves as a Horning SJ, Hoppe RT, Mason J, Brown BW, Hancock SL, naires about smoking habits, including marijuana use, paradigm to Baer D, Rosenberg SA. J Clin Oncol 1997 May;15(5):1736-44. between 1979 and 1985. Mortality follow-up was reduce late effects Purpose: We have demonstrated that a relatively conducted through 1991. in favorable early- mild chemotherapy regimen, vinblastine, methotrex- Results: Compared with nonuse or experimenta- stage HD. We do ate, and bleomycin (VBM), and involved-field radio- tion (lifetime use six or fewer times), current mari- not advocate its therapy (IFRT) could substitute for extended-field juana use was not associated with a significantly in- routine use in radiotherapy in patients with favorable Hodgkin’s creased risk of non-acquired immunodeficiency syn- clinical practice, disease (HD) who have been laparotomy-staged. The drome (AIDS) mortality in men (relative risk [RR] = but instead purpose of this study is to determine if VBM and 1.12, 95% confidence interval [CI] = 0.89, 1.39) or of encourage regional radiotherapy can substitute for extended- total mortality in women (RR = 1.09, 95% CI = 0.80, participation in field radiotherapy in favorable clinical stage (CS) I 1.48). Current marijuana use was associated with in- clinical trials with and II HD. creased risk of AIDS mortality in men (RR = 1.90, the objective of Patients and Methods: Seventy-eight patients with 95% CI = 1.33, 2.73), an association that probably maintaining favorable CS I and II HD were randomly assigned to was not casual but most likely represented uncon- efficacy while subtotal lymphoid irradiation (STLI) or VBM chemo- trolled confounding by male homosexual behavior. reducing toxicity in therapy and regional radiotherapy. Randomization This interpretation was supported by the lack of as- CS I and II HD.” was stratified on the basis of age, sex, number of sociation of marijuana use with AIDS mortality in Ann Arbor sites, histology, and institution. Patients men from a Kaiser Permanente AIDS database. Rela- were evaluated for freedom from progressive HD, tive risks for ever use of marijuana were similar. survival, and toxicity. Results were compared with Conclusions: Marijuana use in a prepaid health care- the predecessor trial in pathologically staged patients. based study cohort had little effect on non-AIDS Results: With a median follow-up period of 4 years, mortality in men and on total mortality in women.

60 The Permanente Journal /Winter 1998/Volume 2 No. 1 By Carl Fisher, MD Anesthetic Agents of the Forties and Fifties a moment in time

Some of us remember with trepidation horrendous now, but I have to believe that we did the experience of anesthesia with ether drip in no damage. We always kept a finger on the tempo- the 1930s—without pre-medication and admin- ral pulse, a fingernail in direct view, constantly istered by a non-anesthesiologist. Dr. Fisher tells watching the color of the blood in the operative us about the quantum leap of anesthesia in the field, and frequently took blood pressure readings. forties and fifties. For my gallbladder surgery The most significant observation was that whether in the 1990s, Dr. Bhawar Singh told me he used surgery lasted 1 hour or 8 hours, the patient would midazolam IV preop for sedation and wake up within 5 minutes after the nitrous oxide anxiolysis, induction with IV propofol and main- was turned off and would usually be able to an- tenance with Levoflurane and at times succinyl- swer questions. Perhaps one reason patients did so choline, a short-acting curarelike drug . Perfect well was that there were not a lot of different drugs nirvana, no nausea, and no more fear. mixed in. If anesthesia was lightening, we would - Ek Ursin, Editor give another dose of morphine intramuscularly (so it would act smoothly without depressing respira- Ether, nitrous oxide, cyclopropane, and pentothal tion significantly). were used in 95% of general anesthetics in the 1940s Cyclopropane was used extensively because it al- and 1950s. Other agents used occasionally were lowed a more pleasant and rapid induction than chloroform, Avertin (tribromethanol), used rectally ether. It depressed respiration, so to produce full with nitrous oxide, chiefly for craniotomies. Induc- relaxation we had to pump it in with a bag manu- tion was quiet and lasted a long time. Also in use ally. It took about 30 to 40 minutes to saturate the was Vinethene (divinyl ether), developed by patient enough to do a cholecystectomy comfort- Chauncy Leake, our professor of pharmacology. ably. A fast surgeon would often complain when he Ether was the most commonly used agent because would get there first. The molecule with three double it was the safest in random hands. (I have a friend bonds was highly flammable and explosive. A fel- who had a hysterectomy in a hospital in Aspen where low resident and I tested it at the beach. We set off the janitor gave the anesthetics.) Ether was capable a balloon filled with cyclopropane plus oxygen. A of producing deep relaxation but was slow being 2-inch plank which we put on top of it was blown absorbed, which gave more time to react to abnor- 50 feet in the air. Standing about 50 feet in front of mal situations. Inductions could be a battle. It was a it felt like the concussion of a six-inch gun. Although matter of pride to be skillful enough to do a smooth surgeons increasingly depended on electrocautery, induction with considerable vocal suggestion. About there were strict rules about when and how an in- 40% of patients had nausea post anesthesia, and be- flammable agent could be used, including control cause the anesthesia was flammable, that meant dan- of static. I never heard of more than 4 or 5 explo- ger when electrocautery came into widespread use. sions in the whole country. Nitrous oxide was used for operations where re- When I was an intern just before WWII, any drug laxation was not necessary such as radical mastec- used for anesthesia was expected to do the whole tomy, thyroidectomies, and most orthopedic proce- job by itself. That is the way that pentothal was used dures. We used heavy premedication with barbitu- when it was first available. It never occurred to us to rates and narcotics. Typical might be 200 mg of pen- mix agents or to put a mask on the patient’s face. We tobarbital at 6:00 a.m. and 15 mg of morphine at taped a bit of cotton on the nose to watch the breath- 7:00 a.m. for an 8:00 a.m. induction. At 7:30 a.m., ing while we were out on the arm holding a syringe we would look at the patient. We wanted patients and needle in place. Laparotomies were attempted to be rousable but asleep if left alone. We gave an- in this manner with no great success. The surgeon other dose of morphine if they were not that sleepy. would often ask for some local anesthetic to infil- Induction was quiet, and within 5 minutes they were trate the abdominal wall. This manner of using pen- into first plane with loss of wink reflex. A flow of 2 tothal was the reason for the many anesthesia-re- liters of oxygen and 6 liters of nitrous oxide was lated deaths at Pearl Harbor. However, the word got used for induction and through the denitrogenation around that pentothal induction was pleasant and period. In later years it was reduced to 1 and 4 they all asked for “pentothal anesthesia” and told liters for all patients. The theory was that patients everyone that they had a “pentothal anesthetic” al- who could breathe adequately on room air would though they probably had only a few milliliters for be all right with a 20% oxygen mixture. This sounds induction only.

CARL FISHER, MD, was hired in July 1949 as the first anesthesiologist of any Permanente medical group. This article is taken from “Potpourri of Memories,” which was written by Dr. Fisher about anesthesia in the Northern California Region.

The Permanente Journal /Winter1998/Volume 2 No. 1 61 After the war, trained anesthesiologists began to This approach also spread to the army. We called be available in significant numbers. They were di- it “Slug ‘em, tube em’ and bag em’. Followers of

a moment in time vided into two schools with quite different ap- this approach were highly skilled in the techniques proaches. One was based on the teachings of Ralph of anesthesia and did everything rapidly. It was Waters at the University of Wisconsin. Followers fascinating to watch them. They used pentothal of this approach tended to be purists, using single for all inductions, no matter what the main agent agents mostly and taking all the time necessary to might be. Later teachers added different agents, do a careful job. They considered anesthesia the and different schools developed greater diversity; practice of pharmacology and physiology. The oth- therefore one cannot trace the ideological heritage ers were followers of Lundy at the Mayo Clinic. of present trainees. ❖

WANTED Writers and storytellers for our historical column, “A Moment in Time.” You can be quite serious in your style, or you may mix in an appropriate amount of levity and laughter to describe crises and their resolutions. Subject matter could discuss such topics as how your region came into being, how the main players went about it, or, in the distant past, how your work was organized in your specialty and how it compares with the guideline strategies of today. Please send us an outline of your ideas and we will write or call you to discuss how it will fit into our plans, and approximately when we will be using your work in The Permanente Journal. The suggested total length of approximately 1000 words is somewhat negotiable.

A Slip Away “A ship in port is safe, but that’s not what ships are built for.” Grace Murray Hopper

62 The Permanente Journal /Winter 1998/Volume 2 No. 1 By Vincent J. Felitti, MD “Color Atlas of Regional Dermatology,” by Gary M. White, MD book review A Book Review

Most primary care physicians suffer a common Additional Books Received for Review: problem: our patients keep coming in with skin The Well-Informed Patient’s Guide to Prostate Prob- problems that we cannot identify. This scenario is lems, Charles E. Shapiro, MD and Kathleen Doheny. frustrating to patients, personally embarrassing, and Dell Books 1993, ISBN 0-440-21258-8, Paperback, out costly to the medical group. Dermatology referrals of print. Dr. Shapiro is Chief of Urology at SCPMG often ensue for what turn out to be minor prob- Los Angeles. lems. Rarely, serious problems are overlooked. Anyone Can Intubate, Christine E. Whitten, MD. Though one might attempt to learn dermatology KW Publications, San Diego 1997 (4th edition). Pa- from the well-organized, erudite, and well-written perback, $19.95. ISBN 0-929894-18-9. Dr. Whitten is texts that have been put forth for years by Walter Chief of Anesthesiology at SCPMG San Diego. Shelley or from the fine new text and color illustra- Physician Assistants in American Medicine, Roderick tions of Habif, in fact those books are not satisfac- S. Hooker, PA, and James F. Cawley, PA. Churchill- tory for non-dermatologists when a patient is im- Livingstone 1997. ISBN 0-443-05731-1. Paperback, mediately at hand because they are not designed $29.95. Mr. Hooker is a PA with NWP,PC in Portland. for rapid use. Gary White, the new chief of derma- Stories of Adoption: Loss and Reunion, Eric Blau, tology in San Diego, has filled a need with his inge- MD. NewSage Press, 1993; ISBN 0-93916517-1. Pa- nious idea for a color atlas based on characteristic perback, $16.95. Dr. Blau is an internist with SCPMG location rather than etiology. That, of course, is the San Diego. way patients come in: with a rash on the ankle, or blistering on the inner forearm. The Atlas is divided into sections, including the scalp, forehead, nose, anterior neck, nape, buttocks, On a pilot basis during the next year, a book gluteal cleft, perianal area, and more. All lesions are review column will be published in each is- well photographed in color. Each of the more than sue; reader response will determine its useful- one thousand photos is accompanied by a brief text, ness. Preferential review will be given to Per- advice on treatment, and references to the litera- manente authors of recent medical works. ture. The book is well indexed; inside each cover is Authors should request their publisher to send a rapid guide to pages of the various body loca- a review copy to the Journal; in the case of tions that are used. multiple authorship, please specify who is the The Color Atlas of Regional Dermatology by Dr. Permanente author. While not all submitted White is cleverly suited to be immediately useful to texts can be reviewed, all will be acknowl- primary care practitioners; definitively so in most edged in print, with their authors. instances. I usually find it helpful a few times each week; occasionally it is a jumping off place to some- thing I otherwise never would have learned about. For the practitioner who wants practical assistance in identifying skin lesions, this easy-to-use book is a valuable workaday tool. ❖ Mosby-Wolfe, 1994, $99 for hardback, $39.95 for paperback. ISBN 0-7234-2027-0.

The Permanente Journal /Winter 1998/Volume 2 No. 1 63 Letters to the Editor

To the Editor.-I just received my first copy of The Per- To the Editor.-I have received both copies of The manente Journal (Volume 1, No. 2). I am very impressed Permanente Journal and am quite impressed with with the professional quality of the Journal. the quality of production. You have a much bigger letters to the editor Susan Yee staff than our first two journals and it shows. Morrie Laboratory Administrator Collen did most of The Permanente Foundation Medi- California Division, Berkeley cal Bulletin by himself. Ruth Straus and I did most of The Kaiser Foundation Medical Bulletin. I have no To the Editor.-I have been meaning to tell you that significant criticisms. At my age I would prefer a larger I really do appreciate—and like—the Journal. I used font, but if I had to choose between a larger font some of it for inspiration (and quotes) for the recent with less content I would choose the present way. rating agency presentations. I hope that there will I can’t help but be quite interested in the begin- continue to be such articles as those written by Oliver, nings of your project. Dave, and Merv, as well as the clinical contributions. Carl Fisher, MD By the way, I remember when I joined in 1989, in Anesthesiologist, retired my interview time with Paul Lairson, just being in- The Permanente Medical Group credulous that there was not such a compendium of clinical research articles by Permanente physicians To the Editor.-I just read the latest Permanente ... so eureka! And good job! Journal and it is terrific. You and your team should Janice Murphy feel enormous pride in the quality and scope of this Vice President & Treasurer wonderful publication. My sincere congratulations Kaiser Foundation Hospitals/Health Plan to all involved. Peter Hohl To the Editor.-Very excellent format and content. Director, Alliance/Acquisition Services Bruce Locke, MD Program Offices Administration/Surgery The Permanente Medical Group, Walnut Creek

To the Editor.-I want to congratulate you on The Per- manente Journal I just received (Volume 1, No. 2). It is very professional in appearance (equal to what one sees in a bookstore) and well written. While I am not medically trained, I did find some of the articles inter- esting and within my “span of understanding.” You deserve to feel good about it. Keep up the good work. Ed Denton Director, Design and Construction Consulting Services Program Offices

Flypaper Meeting: “A spontaneous gathering that takes place after two people begin talking in the hallway or an office cubicle, then draw passersby into their conversation.” Gareth Branwyn, Wired, August 1997

64 The Permanente Journal /Winter 1998/Volume 2 No. 1 announcements Announcements

8th Interregional Conference on Primary Managed Care in Occupational Health Care, Occupational Health, and Musculoskel- Practical Approaches to Managing Today’s Job- etal Medicine Related Injuries and Illnesses Conference will be held April 4-11, 1998, at the The American College of Occupational and Envi- Aston Wailea Conference Hotel in Wailea, Maui, Ha- ronmental Medicine (ACOEM) offers a new in-depth, waii. For information or a brochure contact Ferdy 2-day course for physicians and other occupational Massimino, MD at (510) 987-4856, or via e-mail at health care professionals. It is conducted by a na- [email protected]. tionally recognized team of occupational health ex- perts who are proficient in all facets and models of Health Plan Institute’s Core Program managed occupational medicine. An intensive ori- This 3.5-day program will provide the participant entation, the course exposes licensed physicians and with an overview of the rapidly changing contempo- other health care specialists to a variety of managed rary health care marketplace and Kaiser Permanente’s care models. ACOEM has customized the course to place in it. It can assist in helping understand the meet varying levels of expertise and interest. Special context of one’s work, and what KP is doing to meet breakout sessions on day 1 are designed exclusively their customers’ evolving requirements. for physicians and allied health professionals includ- The program will be held July 12 – 15, 1998 at the ing nurses, health care administrators, and others Claremont Hotel in Oakland, California. For addi- involved in health care. tional information, contact David Marton, Health Plan The course, which is being held April 25-26, 1998 in Institute, at (510) 987-2375. Boston, and October 16-17, 1998 in Phoenix, offers two opportunities for CME credits. ACOEM is accred- Second Interregional Educational Symposium ited by the Accreditation Council for Continuing Medi- for Nurse Practitioners, Physician Assistants, cal Education (ACCME) to sponsor continuing medi- Certified Nurse Midwives, and Certified cal education for physicians. ACOEM designates this Registered Nurse Anesthetists continuing medical education activity for 15 credit This conference will be held August 20-22 at the hours in Category 1 of the Physician’s Recognition Hyatt Newporter in Newport Beach, California. Bro- Award of the American Medical Association. ACOEM chures will be mailed this spring. also designated 15 hours of prescribed hours from the For more information, contact Wendy Friedman at American Academy of Family Physicians. (626) 564-3075. For more information, call toll free 1-888-634-7465. Editing Help with Your Manuscripts Interdivisional Occupational Health Meeting Even before you submit your manuscript to The Interdivisional Occupational Health Kaiser-on- The Permanente Journal for publication consideration, the-Job meeting is planned for April 24, 1998. All you can obtain help with its preparation. The Medical interested physicians and managers are encouraged Editing Department, which is part of the Oakland-based to attend this informative program. The intent is to Kaiser Foundation Research Institute, is a resource avail- share program development and best practices: a able to many researchers throughout the Program. The collaborative effort in workers’ compensation busi- department’s professional editors can help you orga- ness and occupational health services. The meeting nize your paper, edit your text, verify references, and will be held in Boston to support those attending the prepare tables and graphics for publication. Call Medi- ACOEM/Kaiser Works, Inc. pre-conference program cal Editing at (510) 987-3573 for information relating to or the ACOEM annual meeting. the cost of editorial services for your manuscript. For more information, call toll free 1-888-634-7465.

KP Clinical Practice Exchange http://www.kpexchange.org KP Clinical Practice Exchange is a secure Internet-based environment for health care professional access to clinical resources, communications, and information within Kaiser Permanente. Search for the latest findings from colleagues, discuss research efforts and share common interests, locate col- leagues around the corner or across the state, and contribute to the diversity and value of the Exchange with your documents. Contact [email protected] for further information.

The Permanente Journal /Winter1998/Volume 2 No. 1 65 Kaiser Permanente Clinical Best Practices in 1998 Nike World Masters Games announcements Otolaryngology Symposium The 1998 NIKE World Masters Games will be held In conjunction with the Pacific Coast Oto- in Portland, Oregon from August 9 to 22. 25,000 ath- Opthalmological Society (PCOOS), Kaiser Per- letes and 100,000 people are expected. Kaiser Per- manente is sponsoring a Clinical Best Practices in manente is the only medical sponsor for the games, Otolaryngology Symposium. This symposium will though shares sponsorship with 15 other national be held on June 24, 1998, the final day of the 82nd and international companies. There are many op- Annual Meeting of PCOOS, at the Kauai Marriott portunities to volunteer to participate in field response Resort and Beach Club in Lihue, Hawaii, June 20- and organization for the medical services. 24, 1998. For meeting information, contact Mireya While KP will not be supplying all of the many Jones, Society Manager, at (626) 564-8114 or fax volunteers needed for medical support and organi- (626) 564-9722. zation, we want as many KP people involved as pos- The purpose of the Best Practices in Otolaryngol- sible. Please send us a letter, e-mail or fax if you are ogy Symposium is to provide the audience with infor- interested. We will send you more details about the mation which will help them evaluate and manage location and exact days of each of the thirty sports. their patients in the most efficient, cost-effective man- KP will also sponsor a Sports Medicine Symposium ner with the best possible outcomes. Presentations slated for August 7-8, preceding the Games. Let us should demonstrate creative, innovative, successful know if you have an interest and sports medicine ways to evaluate and/or manage patients who present expertise to join the national and international speak- with either common or complex otolaryngologic/head ers we already have commitments from. and neck surgery problems. This will be the largest sports event in the world in For Best Practices Symposium information, contact: 1998 and we want our national organization to dem- Raymond L. Hilsinger, Jr., MD onstrate a strong presence. Thank you for your inter- Department of Head and Neck Surgery est and we look forward to your participation. Kaiser Permanente Medical Center For additional information, please e-mail Reed 280 W. MacArthur Blvd. Paulson at [email protected], Tom Janisse at Oakland, CA 94611-5693 [email protected], or The Permanente Journal at Fax (510) 596-1526 [email protected]. Additionally, you may re- E-mail: [email protected] quest information via fax at (503)813-3883.

Send Us Your Announcements The Permanente Journal is interested in your announcements. Topics may include upcoming multidivisional or Programwide meetings, conferences, or other events of interest to Permanente physicians. These events typically should be sponsored by the Permanente Medical Groups or Kaiser Permanente. The Journal is also interested in publishing details of new services available to PMG physicians in more than one medical group (a new Web Page for Permanente pediatricians, for example) and major achievements by Permanente physicians or Permanente Medical Groups. These may include national awards, major grants, leadership appointments, NCQA accreditation, and other significant accomplishments. Deadline for inclusion of your announcements in our next issue, which will be published in May, 1998, is March 16. Items should be short and include a phone number for the key contact. The staff of The Permanente Journal reserves the right to determine which announcements will be published. Send your announcements to Merry Parker, Managing Editor, 500 NE Multnomah St, Ste 100, Port- land, OR 97232.

66 The Permanente Journal /Winter 1998/Volume 2 No. 1 ? Instructions for Authors instructions for authors

Send all manuscripts to: • Health Systems Management Merry Parker, Managing Editor Articles from a “systems” perspective, recogniz- The Permanente Journal ing that medicine is practiced in the larger con- 500 NE Multnomah St, Suite 100 text of health care, including ambulatory care Portland, OR 97232 delivery, hospital strategy, program expansion (503) 813-2659 and network development and is supported by information technology and the Internet. Growth Editorial Policies in this system occurs through the leadership, Manuscripts are received with the understanding education, and development of clinicians. that they have not been published or submitted for (word count range is 725-3000) publication in whole or in part elsewhere, except for • External Affairs a scientific abstract, unless otherwise specified. Manu- Nonclinical articles on external issues related scripts will be reviewed by the Editor, Associate Edi- to the practice and perception of Permanente tors, members of the Review Board, and appropriate medicine. These may include articles by cus- specialists internally and externally as deemed nec- tomers and consumer groups, as well as inter- essary. Acceptance of a paper for publication is based nally generated articles on health policy, the on the relevance, quality of work described, clarity media, the marketplace, and our social mission. of the presentation, and especially applicability to (word count range is 725-3000) daily clinical practice. If the article is accepted for • Medical Legal Update publication, editorial revision may be made to aid Articles educating clinicians about medical le- clarity and understanding without altering the mean- gal issues, including risk management, claims ing. (See Proofreading.) review, loss prevention, and ethical issues. Im- Articles, editorials, letters to the editor, and other proved clinician communication with patients, text material in the Journal represent the opinion of families, and the health care team is the goal. the authors and do not necessarily reflect the opin- (word count range is 725-1400) ion of Kaiser Permanente. • Soul of the Healer Authors submitting a manuscript do so with the Poetry, stories, musings, and nonfiction articles understanding that if it is accepted for publication, written by Permanente clinicians as an expres- copyright of the article, including the right to repro- sion of the soul of the healer. This is a forum to duce the article in all forms and media, shall be as- appreciate each other personally through cre- signed exclusively to the publisher. The publisher ativity in the humanities. will grant any reasonable request by the author for (word count range is 725-2200) permission to reproduce any of his/her contribution • A Moment in Time to the Journal. A look back at milestones in the history of the Permanente Medical Groups. Types of Papers (word count range is 700-740) There is no length requirement, although concise, • Abstracts readable, and practical articles are preferred. Empha- Abstracts from articles published in other jour- size information that clinicians can use in their prac- nals, preferentially featuring the works of Per- tice, that gives them regional and national perspec- manente physicians. tive, and that integrates “Permanente Medicine” into • Announcements the largest scope of health care delivery. Significant achievements related to the prac- tice or management of medicine by Permanente Notes About Specific Sections physicians or Permanente Medical Groups. Also • Clinical Contributions posted will be upcoming courses, meetings, and Clinical articles on the practice of medicine conferences sponsored by the Permanente within The Permanente Medical Groups and Medical Groups or Kaiser Permanente. their affiliates. Article topics may include re- • The Lighter Side of Permanente Medicine views of “successful” practices, programs and Jokes, stories, and humorous encounters tied policies, and analyses of new technologies. to the practice of Permanente medicine, man- (word count range is 725-5000) aged care, or health care in general. • Original Research Articles on Kaiser Permanente’s research con- Manuscript Preparation and Processing tributions through original, empirically-based A 3 1/2” disk containing the article and one com- research in areas of great clinical importance. plete paper copy of the manuscript must be submit- This includes outcomes research, studies that ted, along with a photograph of the author(s) la- use Kaiser Permanente databases, and rigor- beled with name and a 2-3 sentence author profile. ous evaluations of best practices and innova- (Please, no photos smaller than 2x3 or larger than tions in clinical care. 5x7.) If more than four authors, submit the authors’ (word count range is 725-5000) profiles only—no photographs.

The Permanente Journal /Winter1998/Volume 2 No. 1 67 ?

Manuscripts must be typewritten in a word-processing program must also be in numeric order (do not list references in alphabetical (identify program and platform used), double-spaced, with mar- order). The list should be double-spaced, under the heading REF- gins of at least 1 inch. All parts of the manuscript must be included ERENCES. Abbreviations for title of medical periodicals should con- in a single file on the disk, and the disk file must match the print- form to those used in the latest edition of Index Medicus. out. Tables and illustrations are typeset from hard copy and need not be included on the disk. The 3 1/2” disk must be labeled with Examples. instructions for authors the first author’s name, an abbreviated article title, the file name, Journal article, one to four authors the disk format (e.g. Mac), and the word-processing software used 1. Beutler E. The effect of methemoglobin formation on sickle (e.g. Microsoft Word 6.0). cell disease. J Clin Invest 1961;40:1856-1858. The first page of the manuscript should contain the following 2. Karpatkin S, Smith K, Charmatz A. Heterogeneity of human information: 1) title of paper; 2) authors’ names; 3) name(s) of platelets. III. Glycogen metabolism in platelets of different Kaiser Permanente Division and medical office in which work sizes. Br J Haematol 1970;19:135-143. was done; 4) name and address of author to whom communica- Journal article, more than four authors tions regarding the manuscript should be directed; 5) telephone 3. Golomb HM, Vardiman J, Sweet DL Jr, et al. Hairy cell leuke- and fax number of the communicating author. mia: Evidence for the existence of a spectrum of functional The second page of a Clinical Article is to contain an Abstract of characteristics. Br J Haematol 1968;38:161-162. 250 words or less with a conclusion. Non-clinical Articles need Journal article in press only include a brief summary preceding the article. Also list key 4. O’Malley JE, Eisenberg L. The hyperkinetic syndrome. Semin words and terms, in alphabetical order, under which you believe Psychiatry (in press) the article should be indexed. (Note: A copy of the manuscript must be included.) Begin the text on a new page. Define all abbreviations except Complete book those that have been approved by the International System of Units 5. Lillie RD. Histopathologic Technique and Practical Histochem- for length, mass, time, electric current, temperature, luminous in- istry (ed 3). New York, NY: Blakiston: 1965:39-41. tensity, and amount of substance. Provide a footnote or box at the Chapter of book beginning of the article to define abbreviations when great num- 6. Moore G, Minowada J. Human hemopoietic cell lines: A bers of abbreviations are used. Do not create new abbreviations for progress report. In: Farnes P. Hemic Cells in Vitro, vol. 4. drugs, procedures, or substrates. Use generic drug names. 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Each table should be typed on a separate sheet and appropri- ___ 3 1/2” disk labeled with author name, article title, file name, ately numbered. Abbreviations used in the table should be de- word count, disk format, and word-processing software used. fined in the legend to the table; legends should be typed on the ___ Cover letter same sheets as the tables. ___ One copy of manuscript Any figure, table, or long portions of text that have been previ- ___ Title page ously published must be accompanied by a letter of permission to ___ Author profile (2-3 sentences) reprint, signed by the publisher, at the time of submittal. It is the responsibility of the author to obtain such permission. ___ Author photo (no smaller than 2x3, no larger than 5x7) Legal and Ethical Considerations ___ Structured Abstract (limit: 250 words): include key words Avoid use of patient’s names, initials, and health record numbers. ___ References (double-spaced on a separate sheet) A patient must not be recognizable in photographs or case descrip- ___ Illustrations, properly labeled (one original set) tions unless written consent of the subject has been obtained. ___ Figure legends (double-spaced) ___ Tables (provide a brief title) References ___ Permission to reproduce previously published material; References must be numbered with Arabic numerals and cited in photographic consent the text in numeric order. The reference list at the end of the article

68 The Permanente Journal /Winter 1998/Volume 2 No. 1 The Permanente Journal

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