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	We have updated our Frontier/Manila server. We have updated our Manila Software. This is good for all weblogs because the Manila server actually hosts the Radio Weblogs Radio Community Server, as well as all of the Manila Weblogs. This is a reposting for todays date. This is only a test of the aggregator emailing all new postings to a mail list. If a person is subscribed to that mail list, the intent is that Radio emails the new posting to the mail list, which then emails the posting to all subscribers. ... Right now there are only two subscribers, Marc and myself. Just a test of my email publication to a mail list. Trust as a Verb and Insecurity as a Good Thing. Building Trust, by Flores and Solomon is a really good book. I rank it with The Wisdom of Insecurity, by Alan Watts as two of the most mind altering books I have read. Watts turned the conventional wisdom of insecurity on it's head, essentially showing that security or fixedness is closer to death and that insecurity or uncertainty is closer to life. When his wisdom sinks in, one comes to appreciate insecurity for what it is--the experience life-giving growth. On can then quit amplifying a certain amount of natural stress, by dropping the judgment that insecurity is bad. Flores and Solomon turn broken trust and betrayal on their heads, as Watts did with insecurity. They allow one to see that trust and betrayal are sides of the same coin (one meaningless without the possibility of the other) and they also allow one to see that creating and rebuilding trust is the key act in creating a better and shared future. Without such acts of trusting and rebuilding of trust from moments of betrayal, no better future is possible. Trust is not a thing to be shattered. Trusting is a competency for all forward looking people to practice and learn--a verb, not a noun. Below is a kind of relationship diagram that captures some of the ideas that filled my head as I read the book. Clear Leadership. A friend of mine, Gervase Bushe, wrote a very useful book: Clear Leadership. The insights and framework are based upon his career as a professor and business consultant Clear Leadership is full of practical and immediately useful mental models and advise. Organizations are beginning to use is as a framework for leadership training at all levels. After reading this book, I created a mnemonic and drawing that help me keep a few of the book's key points in mind and handy for my use. I give them to you with Gervase's permission. SOFTeNeD stories and maps. Sensing--what is my body telling me? Am I poised for a fight, to flee, to hear, to learn, to have fun, etc. Observing--what would others agree happened, what was objective, what data can we agree upon and share? Feeling--awareness of feelings is very useful early on, as feeling color everything else. experience, each person has a different one Need (want)--what do I want to happen, what do I want in the way of agreements. experience, our stories come from our experience, we can share these and ask others to share their's. Experience is subjective and has numerous aspects (SOFTND) Do--what will I do and what will I agree to do? This little graphic represents for me Gervase's four profound senses of self and matching sets of skills: Appreciative self--the halos, understand what you and the other have done that you would like to see more of. It is a kind of "assets based" approach or "appreciative" approach and comes form the appreciative inquiry framework. Aware self--the recursive loop, suggests that we spend time first going over the SOFTeNeD algorithm personally, before trying to tell others or ask others. Descriptive self--the arrow from my mouth to the other's ear, suggests that I must describe my SOFTeNeD stories and maps to the other in an appreciative frame and expressing understanding that it is only my experience, not all facts. Curious self--the arrow from the other's mouth to my ear, suggests that I must have skill in asking and hearing about their experiences and if possible their SOFTeNeD stories and maps. I try to hear in an appreciative frame. It has been about a year since I read this book and I have not reviewed it for this post. I hope you will pick the book up and work with the concepts in it. We can all do our parts to reduce the "interpersonal mush" in our organizations and communities as well as at home. Which side of the bed?.   I have gradually come to realize that I unconsciously make a binary choice each time I think or act. I get out of my bed either on the defensive side or the learning side. I either start my day holding on to... you name it. Or, I start my day open, willing and interested in learning, being vulnerable, wrong, embarrassed, over worked, surprised, delighted...open to a different future than I had yesterday. I think that it is this almost unconscious step that determines what is possible and what happens. This is a short and somewhat personal post. I doubt that it requires more explaination. I am just trying to be more aware of that first step each morning and each moment. A Poem by John Stone. A friend sent me a link to this poem. I pass it on to you. It is good and it rings true. It is by a doctor and more or less for doctors. But all may appreciate the sentiments. A few lines: "For the head will explain       but the final common pathway is the heart       whatever kingdom may come For what matters finally is how the human spirit is spent" Click here.  Healthcare is science, reason and caring. May none be missing. Dawn Gauthier reports on Shared Care Plan award. PatientPowered.org wins award! PatientPowered.org was recently recognized by receiving a silver eHealthcare Leadership Award in the category "Best Care/Disease Management Site". This award was presented by eHealthcare Strategy and Trends at their annual "Leveraging Technology and the Internet" conference ... (click here to read) Narrative in Medicine. My invaluable assistant, Jill Hickok, told me about an NPR presentation on the use of story telling in medicine. We are trying to do something similar in Whatcom County to heighten the awareness and understanding of the relational aspects of medicine, especially chronic conditions. We are coming to believe that among all the change and stresses of medicine the experience is loosing it's meaning for some providers and patients. Focusing on people and their stories is one way to combat the cynicism fostered by a broken or non-existent system of care. Most of us came into the profession because of a love people and a deep interest in people and their stories. Here is a link to the NPR piece: http://www.npr.org/features/feature.php?wfId=1480863   (I hope their RealPlayer download works better for you than it did for me. May be a firewall issue. I will try it at home tonight.) Here is a link to a piece on the physician that is spearheading the effort, Rita Charon, M.D., Ph.D. http://litsite.alaska.edu/uaa/healing/medicine.html Here is a link to a biosketch on Dr. Charon. http://www.medinfo.ufl.edu/other/histmed/charon.html I hope to learn more about this approach.   I have heard Dr. Rachel Remen talk about the power of story telling.  I find stories more transformative than powerpoint and analytical data. Perhaps it is because they contain what we find most interesting and important--other people. Here are links to her work: http://www.rachelremen.com/; http://www.meaninginmedicine.org/about_fmm.html; http://www.almanacnews.com/morgue/2000/2000_04_12.hfa.html. Albert Camus on Community, Hope and Creativity. "Great ideas come into the world as quietly as doves. Perhaps then , if we listen attentively we shall hear, among the uproar of empires and nations, the faint fluttering of wings, the gentle stirrings of life and hope. Some will say this hope lies in a nation; others in a man. I believe rather that it is awakened, revived, nourished by millions of solitary individuals whose deeds and works every day negate frontiers and the crudest implications of history. Each and every one, on the foundations of their own suffering and joy builds for all." --Albert Camus - On June 9th 2001, on another site http://marpie.weblogs.com/2001/06/09 I posted the above quote from Albert Camus. I like it so much I am reposting it. From Programs to Movements. The Bureau of Primary Health Care has successfully jump started the 100% Access 0 Disparity movement in America. Spokane, WA area is implementing a similar approch. There is a summary of the BPHC experience that is very enlightening, if you wish to switch from projects and programs to "movements". I highly recommend reading it if you need to scale up some initiative to include more stakeholders. A remarkable overview of the journy and the liberating concepts is chronicaled by John Scanlon in "Extrordinary Results on National Goals: Networks and Partnerships in the Bureau of Primary Healht Care's 100%/0 Campaign". The PDF file can be downloaded from THIS LINK on IBM Center for The Business of Government site. The site section is "New Ways to Manage". I agree that it is a real revolutionary way to think about how to manage large scale change. Advanced Access--a Key to System Improvement. Several doctors at the WA State Medical Society meeting ask for more information on what Advanced Access is. So I put a web page together with some good references. Just click on "web page". I am skeptical that rapid improvement can occur until most physicians have taken this step. It is a happy circumstance that their profit should increase about 9% and their number of visits should simultaneously decrease about 16%. Presentation to WA State Medical Society House of Delegates. Yesterday I had the privilege of talking about our Pursuing Perfection initiative with the house of delegates for the Washington State Medical Society. Below I have included to content of my 11 slides and my notes. PURSUING PERFECTION in Whatcom County, WA SLIDE 1, TITLE SLIDE: PURSUING PERFECTION WHAT'S IN A NAME? Perfection? ...when things seem pretty bleak. When the pace and complexity of practicing medicine is at this highest yet. When frustration or even cynicism seems ready to overwhelm many. But in a culture that takes the charge "first do no harm" seriously. A culture where each of us carries the desire and burden for faultless care with us each working moment. I suggest that  by admitting to ourselves and to the public that we are all in the pursuit of perfect care may allow each of us to get some help. As the Chasm Report points out, the problem is with the system. The system that should help us do the right thing. The problem is not with the effort of doctors and nurses nor with a lack of desire or to do the right thing. The pursuit of perfect care leads directly into systems thinking. SLIDE 2, OUR JOURNEY 1990 vision Persistence Access for uninsured, level 2 trauma system, seamless care?, Whatcom Integrated Delivery System, Community Health Record, Whatcom Health Information Network, Whatcom Community Health Improvement Consortium, diabetes collaborative, registry system IOM: To Err is Human & Quality Chasm Pursuing Perfection, Robert Wood Johnson Foundation & Institute for Healthcare Improvement, +16 others Like many of your communities, cooperation has a long history in the community. Community wide efforts developed access for under-insured OB patients and others including dental patients. The community developed a common sense, yet bold vision to have seamless care and the best outcomes in the state within 10 years (It will happen but it will take 20 years. Who knew?) A series of large-scale initiatives have occurred in Whatcom County. The most audacious effort may be the current P2 initiative to transform healthcare in our community and in the nation. SLIDE 3, PARTNERS & FRIENDS LOCAL AND REGIONAL This P2 initiative has caught the imagination of lots of folks. 3000 patients with diabetes & congestive heart failure Family Care Network SeaMar Clinic NorthCascade Cardiology SJH Center for Senior Health St. Joseph Hospital/PeaceHealth Group Health Cooperative Regence Blue Shield, Community Health Plans of Washington Olympic/Sterling/Aon SLIDE 4, PARTNERS & FRIENDS NATIONAL & INTERNATIONAL NATIONALLY Cambridge Health Alliance, Cincinnati Children?s Medical Center, Tallahassee Memorial Hospital, Hackensack University Medical Center, HealthPartners, McLeod Medical Center, and Whatcom County coalition INTERNATIONALLY 8 communities in Great Britain, 1 in the Netherlands, 1 in Sweden SLIDE 5, LEARNING Advanced Access Patient input into design We did not have to wait Collaboration among all sectors Leadership by physicians for collaboration So, in this P2 initiative what have we learned to date: a year and a half into it? Doing Advanced Access, in primary care and specialty care, seems to me to be the only thing that can free up people and time to take on the work of redesigning the acute care system into one that provides chronic care. HealthPartners and Jonkoeping County, Sweden point to this conclusion. We have been working with Catherine Tantau, RN. Others have worked with Mark Murray, MD. Patients are of surprising help in redesigning care systems. Their insights are generally lead to simpler and cheaper solutions that we imagine on our own. We could have been doing this 5 years ago. Without working together little will occur. The innovations almost all require cooperation of others beyond your organization. Fortunately the benefits are that diffuse too. Physicians can lead their organizations into cooperation. It will not happen otherwise. SLIDE 6, 80/20 SYSTEMS THINKING Baby boomer demographic bulge Chronic care in acute care system Winners and losers (modeled) Collaborators (relationships between parts on behalf of all stakeholders) There are a lot of things we all consider doing. but which are the most important? The biggest problem and opportunity is heading our way--the aging baby boomers. Chronic care accounts for almost 80% of the healthcare costs and it is going to get higher. If we can effect this dynamic it will have more impact that almost any other change. (Possibly at the same or lower cost for a given population.) We have reviewed the literature on chronic care, we have worked with our patients and our physicians. We have designed a system for patient-centered, community-wide chronic care management. We have modeled the outcomes. We know who the winners and losers are likely to be. Nothing big will happen if the winners don?? help the losers. Medicare, pharmaceutical companies, employers, and taxpayers will need to rethink their roles if the benefits are to be gained and sustained. SLIDE 7, SOLUTION SPACES Care management and managers Navigators and insider advocates for patients Activated informed patients Group visits Shared care plan  (electronic and paper versions) Advanced access Results based advocacy Our approach combines community-based care managers (nurses). Improved access to information for patients with DM and CHF and for the members of their care team. There are group visits, web access to tailored information and to a personal medical record called the shared care plan. I now call our previous medical records business medical records, not patient medical records. The shared care plan may be a step toward a real patient medical record. None of the changes are manageable in physician offices or with physician staff until excess capacity for seeing patients and for improvement work is created. Advanced access has this great side effect. Modeling the effects of the changes and getting those affected to participate in the solution is essential. Otherwise it is not sustainable. Medicare (thus Congress), pharmaceutical companies, local businesses and government, and patients as purchasers and voters. SLIDE 8, INTERESTED PARTIES Robert Wood Johnson Foundation Institute for Healthcare Improvement Medicare (CMS) Healthcare insurance companies Our community as well as other communities and healthcare organizations Other foundations The work and learning going on in Whatcom County has captured the interest of numerous organizations and communities. Many of whom we are working with. There are now 17 communities or healthcare provider organizations. We are hoping to spread this to Ketchikan, AK. beginning this year. We hope to spread to more of the patients and providers in Whatcom County. SLIDE 9, COOPERATION Necessity or preference? System? ...or only parts? How? or YES! Leaders? Somehow we think this is optional, on an organizational level. We do cooperate as individuals. Our organizations must understand the experience of the patients and design and connect our processes so that they work as a system. Peter Block has written a book called The Answer to How? Is Yes! It is a kind of Nike "Just do it!" attitude. On can delay starting assuming the worst and endlessly asking how, rather than experimenting and working our way forward together, with the patients. A new kind of leader is needed--courageous in collaboration, not in war. SLIDE 10, MORE? http://www.patientpowered.org http://www.wwpp.org http://www.Google.com "Marc Pierson" Call Marc 360 756-6805 http://www.ihi.org http://www.qualityhealthcare.org You may find the details and the tools at these websites. Do feel free to contact me. I put some of what I think on my web log, as do many of the people working in this endeavor. SLIDE 11, PARTNERS? Already down this road? Learn together? Tipping points? The Institute for Halthcare Improvement is attempting to spread the learning from Pursuing Perfection communities. We have time for those who want to transform healthcare locally, in their communities. Thank you for your time and attention. Community meets leaders of its EMR venders. When we began the Pursuing Perfection journey with IHI and Robert Wood Johnson foundation, IDX leadership started that journey with us, traveling to Boston and meeting with all the participants. Today we had the good fortune to meet Mark Leavitt, MD, an internist who started Medicalogic company and developed the ambulatory medical record Logician. I must say that the similarity of vision that among Mark, Malcolm Gleser, (founder of Phamis--now IDX LastWord and CareCast), and this community is remarkable. Kindred spirits. In an complex environment of medical information software and mal-aligned economic incentives for connecting and deploying electronic medical records--this alignment of vision and value is cause for hope and continued collaboration. Mike Raymer, head of LastWord division of IDX, joined us for discussions with patients and several of the participants in Pursuing Perfection in Whatcom County, WA. I hope to report on opportunities that arise from our common vision and from a real intention to work together on the behalf of the patients in this community. Let's hope. Health system innovation, ORGANIC or MECHANICAL?. Imagine this. You are asked to create a human body. You choose a hospital in California to create a gastrointestinal system,  a health system in New York to create a heart and blood vessels, a city in Vermont to create a brain, a hospital Iowa to create a peripheral nervous system, a group of hospitals in Illinois to create the lungs, etc., etc. Enough. Some things can't be done separately, some can. Organic things typically cannot. Some complex things can be "componentized" and assembled, some things must interact to even come into existence. Some people at the Robert Wood Johnson Foundation read the Institute of Medicine Report, Crossing the Quality Chasm and ask organizations to make proposals to radically improve American health care. Experienced people in organizations in Whatcom County took the request very seriously. We had the same hopes and desires and we had been working separately and collectively for the same goal for more than ten years. With much thought and discussion and in collaboration with patients we developed a radical plan for a radical change--no individual piece of it was radical, it was the understanding that it all had to be done together that was radical. To extend the analogy started above, we understand the we needed a small GI system, a small cardiovascular system, a small nervous system, etc. for any of it to work. And that with all the essential systems working to support each other they could grow together to a mature effective health system of care--better than anything in existence. We have been at this for just over one year. It no longer seems unattainable. It is clearly attainable. What is difficult is getting all of this done in less than two years so that it is self-sustaining. We are hopeful that some of the agencies and foundations that fund parallel, sequential, or distributed "demonstration" "projects" can see the difference here and fund an organic, systematic approach. Nothing less will create the radical transformation called for by the IOM Chasm Report and needed by the American public. Reductionist approaches can do much. They cannot build an organism, not yet, perhaps never. Supporting the growth of a small, complete, organism (community health system) may be the right approach to radical transformation of US healthcare. We believe it is. Do you? The minimum  essential small "parts" or "organ systems" that we have in Whatcom County, WA are: 1) direct patient involvement in all teams and in governance, 2) using evidence as the basis for care design, 3) starting with two chronic medical conditions[heart failure and congestive heart failure] and then moving to all others over a few years, 4) information systems designed and deployed so that everyone including the patient has the information that the patient wants them to have when and where they need it, 5) clinical office and hospital  work flow reconfituration so that the new work is integrated into the old and the old is made less frustrating and more efficient for everyone, and finally 6) modeling of the health care benefits and the economic impact on all of the stakeholders so that potential winners and losers can cooperate for the good of the patients and the whole community. "...program is so simple, it's brilliant, "Bellingham Herald editorial board. Link to Bellingham Herald Editorial Link to more about program Helping chronically ill manage care improves lives, cuts costs HEALTH CARE: "Pursuing Perfection" program is so simple, it's brilliant. The whole point of "managed care" started out, at least in theory, as an attempt to contain health-care costs through prevention. It's no secret that's not what happened. In fact, navigating the medical maze has become more difficult than ever, it seems. But there is a solid movement afoot to change that and Whatcom County is one of the ground-zero sites for a program called "Pursuing Perfection: Raising the Bar for Healthcare Performance." Its method isn't complicated. It seeks to help people manage their own health care, sometimes by doing something as simple as regular telephone calls to check up on patients and answer their questions. By heading off potential problems, extensive and pricey hospital visits can often be avoided and a patient's health better maintained. It's so simple, it's brilliant. The Whatcom Community Health Improvement Consortium last year was one of seven groups in the nation to win a $20.9 million grant from Robert Wood Johnson Foundation and the Institute for Healthcare Improvement that funds the program. It's not just some kind of feel-good program, either. The foundation wants to document measurable results in improvement of patients' access to care, patients' self-management and satisfaction, and a decrease in medical errors. Caring for chronically ill people consumes as much as 70 percent of the nation's health-care dollars, so it makes sense that helping them manage their own conditions would reduce those costs and help those people lead more productive and less frustrating lives. In Whatcom County, two of the most common chronic illnesses are diabetes and congestive heart failure. In 2000, St. Joseph Hospital had almost 700 admissions related to diabetes and almost 900 related to congestive heart failure. Empowering patients with better information and better access to people who monitor their progress and can quickly answer questions can help keep many from becoming dangerously ill and compromising their health further. Medical advances happen quickly as new drugs are developed, more information is discovered about drug interactions and new technologies help people monitor their blood sugar. Keeping patients active in helping to make their own decisions will result in better outcomes. After all, who better to "manage" the care than the person living with the illness? Local paper covers Pursuing Perfection. The Bellingham Herald, Whatcom County, ran a Sunday front page spread on Pursuing Perfection in Whatcom County, WA--Power to the Patient (the link to this edition lasts only two weeks) Chronically ill patient finds a health-care advocate (Original photo Unavaialbe at this time) NEW OUTLOOK: The new Pursuing Perfection program aims to help chronically ill patients such as Keith Robinson, who suffers from diabetes, a heart condition and sleep disorders. MAME BURNS HERALD PHOTO Mark Porter, The Bellingham Herald Keith Robinson doesn't sugarcoat his cost to America's health care system. The no-nonsense ex-Marine with chronic ailments, including diabetes and a congenital heart defect, remembers seeing a physician bill after his five-month stay at the University of Washington Medical Center four years ago. The tab: $500,000 - and that didn't include the cost of his hospital stay. He's never seen the bill for room and board and shudders to think how much that cost his insurer, which ultimately reaches into John Q. Public's pocketbook through higher premiums. Heart failure Nearly five million Americans suffer from heart failure, a blanket term that means the heart isn't pumping as well as it should. An estimated 2,000 Whatcom County residents have heart failure. Usually, the heart has been weakened over time by an underlying problem, such as clogged arteries, high blood pressure, a defect in the heart walls or valves, or some other medical condition, according to American Heart Association. People with heart failure don't get enough oxygen, so they feel weak, fatigued or short of breath. More than 500,000 new cases are diagnosed each year in the United States, including children and young adults, but most commonly older people. "People with chronic illnesses end up using more quantities of health care than other people," said Robinson, 54, a lifelong county resident. "And there's more than one person in the same fix I'm in." Robinson is one of about 60 chronically ill county residents taking part in a community project aimed at helping people with heart failure and diabetes to improve their health, and ultimately save money for themselves and others. Pursuing Perfection, a $1.9 million grant from the Robert Wood Johnson Foundation, is an attempt to spread the gospel of patient-centered care with a three-pronged focus: [>] Patients get to help make decisions about their own care. [>] Coordinators help patients through the maze-like health-care system. [>] Patients gain greater access to health information sharing through the Internet. Robinson sees himself as a living example of the need for a new approach that could help him stay out of the hospital, lead a longer and healthier life, and avoid overtaxing the health-care system. It's easy to second-guess the current system, but Robinson wonders if he could have avoided the five-month hospital stay if he had been a Pursuing Perfection patient back in 1999. "If you ignore these chronically ill people, one day you have a hospital filled with chronically ill people who need help," he said. "If we follow those people more closely, maybe we can keep them from getting so sick." History of ailments Robinson was born with a heart defect that was discovered during an eighth-grade school physical. As a 12-year-old, doctors repaired his aorta, the artery that feeds blood from the heart to every part of the body except the lungs. His aorta should have been the size of a quarter, but was the size of the head of a safety pin, he said. That didn't stop him from having a life. He wrestled for Bellingham High School, reaching the state tournament. He then spent four years in the U.S. Marine Corps, where doctors discovered a heart problem during an insurance physical, he said. Diabetes Seventeen million Americans - including an estimated 6,713 Whatcom County residents - have diabetes, a shortage of insulin that allows fats to increase in the blood, eventually damaging vital organs. Diabetes kills more than 200,000 Americans a year, and can cause heart disease, stroke, blindness, kidney failure, leg and foot amputations, pregnancy complications and death related to flu and pneumonia. The economic impact of diabetes totals nearly $100 billion a year, according the federal Centers for Disease Control and Prevention. That led him to a cardiologist who decided he was just fine, and he went on to train on flight director radar for aircraft. But looking back, he said, he ignored subtle warning signs, such as shortness of breath. He returned to the Bellingham area after the service and worked several jobs until he became sick in 1979. An infection from an abscessed tooth spread to his previously repaired aortic valve. The result: surgeons gave him an artificial valve. "I felt pretty good for quite a few years," Robinson said. But the area by the valve began leaking blood. He lost energy. Even mowing the lawn became a monumental task. Robinson became sick again in January 1999, spending three days at St. Joseph Hospital, then off to the University of Washington Medical Center for five months, in part, waiting for a new heart. Doctors then decided to replace the valve again, in May 1999, and later implanted a defibrillator to kick-start his heart if it beats irregularly. A postal worker at the time, Robinson retired in June 2000 because of his chronic health condition, which is considered a disability. Along with his heart problems and adult-onset diabetes, he also suffers from restless leg syndrome, which causes an irresistible urge to move the legs. The urge worsens at night, causing sleeplessness. Robinson also suffers from sleep apnea, meaning he repeatedly stops breathing for short periods while asleep. Getting help Before becoming part of Pursuing Perfection, Robinson got help through Family Care Network, a group of family-care physicians. Family Care employee Nancy Stothart, who now works for St. Joseph, helped Robinson negotiate the tangled medical system, and continues to do so now with Pursuing Perfection. Before, Robinson said nobody helped him keep track of his condition and symptoms - such as his blood-sugar level, weight gain and energy level - that might portend problems. Now, Stothart calls him every other week. Just managing his 14 daily medications is a chore. Stothart helps him make sure than none of the medications conflict with another one or with new ones he might need. "If I have concerns, I can just call her up; she can get the doctor's ear faster than I can," Robinson said. "She's pretty easy to work with, and she seems concerned." Like many people battling chronic illness, Robinson gets help from family. In his case it's his wife, Debbie, whom he started going out with 1983 and married in 1990. She spent the entire time he was in Seattle at his bedside, reading and playing gin rummy to battle the boredom and uncertainty. "We call her Nurse Debbie because she watched and learned everything," Robinson said. Robinson still carries a special beeper so he can rush to Seattle if he is called for a heart transplant. He doesn't expect to be high on the list, because he's stable now. That's fine with him. Modern medicine is the reason he's alive, with or without Pursuing Perfection. He works in his yard and around the house. He's refinishing antiques and cabinets. "In five to 10 years I will need a transplant or another valve," he said. "But from how sick I was in '99, then 10 years down the road is quite a life extension." ----------------------- POWER TO THE PATIENT (Photo not available at this time) MAKING PROGRAM WORK: Nancy Stothart (left) and Connie Golas work for the Pursuing Perfection Project in Bellingham. MAME BURNS HERALD PHOTO Local trial program gives sick people more responsibility for their treatment Mark Porter, The Bellingham Herald Ask any average Joe about a Whatcom County effort to make medical care more cost-effective and patient-centered. Odds are, he'll roll his eyes in disbelief. Pursuing perfection? The Pursuing Perfection project is funded by the Robert Wood Johnson Foundation, a philanthropy which works to improve health care. Whatcom County is one of seven areas across the nation that are giving the program a practical test. Health-care providers involved in the local trial are: Family Care Network, Sea Mar Community Health Center, North Cascade Cardiology, and St. Joseph Hospital with the Center for Senior Health, which is part of the hospital. Participating health-care payers are Group Health Cooperative and Regence Blue Shield. The $1.9 million local grant expires in March. Local advocates hope to continue with new grants. After all, America is the land of disjointed health care - with government, doctors, insurance companies and hospitals all fighting for a share of the trillion-dollar health-care industry. That longtime approach is exactly what the Whatcom Community Health Improvement Consortium is trying to change. The community group was one of seven across the nation last year to receive part of a $20.9 million grant from Robert Wood Johnson Foundation and the Institute for Healthcare Improvement. The program is called Pursuing Perfection: Raising the Bar for Health Care Performance. The idea is simple to understand but tough to carry out: Reduce the need for expensive hospital visits by helping people do more to manage their own health care. The result, organizers hope, is a more-efficient and less-expensive approach to health care that will spread throughout the medical world. "Whatcom County is the focus of the nation," said Nancy Stothart, a registered nurse and clinical care coordinator for the local Pursuing Perfection project. "How can we transform health care within a community, and not just an organization?" A Rand Corp. study published Thursday highlights the lack of coordination in the health care system. According to the study in the New England Journal of Medicine, doctors fail to take nearly half of the recommended steps for treating such common illnesses as diabetes and high blood pressure. Further, patients in the study did not receive a third of the standard medicines for heart disease or half of the recommended care for diabetes. Patient's diary Patient's diary The Pursuing Perfection effort includes a high-tech and low-tech version of a "shared-care plan" available on paper and the Internet. It's a booklet that chronically ill patients can share with their doctors. The booklet includes a personal profile, goals, and a list of caregivers, allergies, medications and diagnoses. The goal is to have information on hand so there's no confusion about the patient's condition and medications. "Health care now is very disjointed," said Marc Pierson, a St. Joseph Hospital vice president and a leader of the Pursuing Perfection project in Whatcom County. "Without question, the model of an integrated plan ... is a model that makes sense," he said. "The question is, 'Can we get it to work?'" Giving guidance Leaders at Robert Wood Johnson Foundation, a health-care philanthropy in Princeton, N.J., want to see statistically provable improvement in patients' access to care, patients' self-management and satisfaction, and a decrease in medical errors. Such measurable improvements could have a huge effect if applied nationwide. Caring for chronically ill people consumes up 70 percent of the nation's health-care dollars. Fifteen million of the 77 million baby boomers are expected to develop congestive heart failure in the coming years, and diabetes cases in the United States doubled from six million to 12 million over the past 20 years. In 2000, St. Joseph Hospital had almost 700 admissions related to diabetes and almost 900 related to congestive heart failure. To bring those numbers down, Stothart and Connie Golas are coordinating the care of about 60 chronically ill county residents participating in the Pursuing Perfection project. They're using computers, the Internet and the plain old telephone to track the residents' health and guide them through the medical maze of doctors, hospitals and insurers. "The person who is managing chronic illness is the person with chronic illness," Stothart said. "We've expected them to do it without support or self-management."Before Pursuing Perfection, there was no standard way to get information to and from such patients. With the project, patients are at the center of the equation, and they like it. "They don't feel like they are going to the principal's office," Pierson said. "They feel like they are partners." Golas said she and Stothart are supposed to be interim helpers. The Pursuing Perfection model calls for training workers in medical offices to become more aware of the needs of chronically ill patients. "We don't want to displace the cardiologists or primary-care doctors, but to help the person self-manage," Stothart said. "I do a fair amount of checking in on the phone, more frequently with heart failure, just doing some monitoring. "I can't think of anyone who hasn't said, 'My life has been better since this started,'" she said. "Sometimes I can tell, just by phone and how they are talking, how they are doing. We are having relationships with people." The fact that Stothart and Golas operate independently of insurance companies and health-care providers is a plus, Pierson said, because they can follow the patient even if he or she changes insurers. Calculating benefits Preliminary results from the project are encouraging, said Mary Minniti, a St. Joseph employee and program manager of the project. Diabetes patients in the program have shown marked improvement in their blood-sugar control, she said. While many haven't reached their long-term targets of near-normal levels, they are moving closer to a target that some had thought was out of reach, she said. In an inefficient care system, patients must repeat medical stories and medical information, then wait for helpful treatment or information, she said. That can eat up work time for patients and their employers, she said. To get a handle on the benefit of Pursuing Perfection, the local consortium asked experts to figure the cost and the savings from a proactive approach to caring for diabetes and heart failure patients. Their conclusion: It would cost $9.8 million to run a local Pursuing Perfection program for the next five years, but would save an estimated $26 million in worker disability expenses. Even with such savings, there still must be insurance reforms if Pursuing Perfection is to succeed, said Mark Donaldson, Group Health Cooperative administrator and a member of the local project's leadership board. There aren't any natural rewards for changes in the current payment system, he said. For example: It's known that group visits and e-mail exchanges help patients, but insurers and the government don't currently cover those, he said. "What is attractive to Group Health about this is we aren't talking about a vertical (company) integration," he said. "We are getting separate business entities trying to get together to benefit the entire community." Doctors say that if Pursuing Perfection works, they will have more time to spend with people who need traditional office visits, and people won't have to wait as long for appointments. The foundation grant runs out in November, but groups in the consortium are committed to funding the effort until spring, and hope more grants follow, Pierson said. The automobile industry improved after learning from Toyota's teamwork and flexible approach to manufacturing, said Andrea Kabcenell, deputy director of the Pursuing Perfection program for the Institute for Healthcare Improvement, in Boston. While health care is not a pure product line, "we can learn from those industries," she said. "The average Joe should care because Pursuing Perfection is an attempt to know what one hand is doing with the other," she said. "That doesn't happen very often in care in the U.S. "If it doesn't work," she said, "health care is in a lot more trouble than we thought."Reach Mark Porter at mark.porter@bellinghamherald.com or call 715-2263. Reach Mark Porter at mark.porter@ bellingham herald.com or call 715-2263. Patients & Physicians. Balanced human interactions will make sense of some of the craziness that is US healthcare. I would like you to read the very thoughtful and humane comments that Daniel Shurman makes. After a very difficult year he and his wife Bonnie have insights we should all reflect upon. There is nothing I can say that will add to his message. Dan is responding to my post on Sunday, June 22, '03.   Reductionism vs. Wholism. Where is the patient in all of this?. After reading the though provoking article Chronic Illness, Comorbidities, and the Need for Medical Generalism, by Kevin Grumbach, MD, in the first edition of Annals of Family Medicine. I had these thoughts: The idea of non-reductionist thinking and wholistic planning is so important and so non-western. A reductionist nightmare. Placing the patient at the center begins to make sense of things. I am not yet sure that we aren't trying to put the PCP at the center; even though that may move in the right direction in some cases. With the help of Robert Wood Johnson Foundation, we in Whatcom County, WA are building a system to deliver "patient-centered, community-wide, chronic disease management" based upon Wagner's chronic care model. Even that model may be too physician centric. See my post. Conidering the chaotic non-system and it's misaligned reimbursement, I am not sure that the overburdened PCP can help all the patients navigate. We are using nurse care coordinators Connie Golas and Nancy Stothard to assist, and we also use a patient centered/patient designed Shared Care Plan I will follow your new journal with interest. As you poit out in the article, we should not be too self congratulatory. For even the best approaches in the US are very inadequate from the patient's perspective. See the Commonwealth Fund report (pdf) A chasm exists. Any narrow focus on the parts, even the PCP role, risks a further Balkanization of US healthcare. We must focus on the patient and their family, we must include the patient in all the discussions. So long as the journals exclude patients from the dialogue they will miss an opportunity for truly integrative solutions. Even the PCPs may be a "specialists" compared to patients and their families. Pursuing Perfection Doctor Honored. Bertha Safford has shown the way to improve patient care as long as I have know her. She helped shape the disease registry collaboration between Family Care Network and PeaceHealth.  She can clearly see her way across organizational boundaries in support of patient care. She goes for what is best for patients, not what is convenient for herself. Here is a link to Washington' Doctor of the Year-County family doctor recognized by peers. (I don't know how long the Bellingham Herald keeps this archive links available.) Source: Collected WWPP publications; Updated: 9:47AM PST.