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    Innovation: A Pioneer on Many Fronts

    Formed as something ahead of its time, the Palo Alto Medical Clinic never became complacent in its work. Innovation, change and early adoption of new developments in medicine were the norm. "Medicine has tended to be pretty conservative and pretty much about, we've done it this way, it works, why change? But Russ Lee was always asking questions about whether things might be better if done differently," said Dr. Harry Hartzell.

    Even after Dr. Lee retired, the culture of innovation remained, driven not only by the Executive Board but also by individual physicians on the front lines. Doctors were encouraged to use sabbatical time and Clinic-sponsored trips to learn about new treatments and technologies, and to bring back their ideas to the partnership.

    As long as a good case could be made that a service would benefit patients and be a sound business investment, the decision-makers were willing to listen. The Clinic's list of "firsts" is long and varied, encompassing not only new equipment, but also new ways of doing business across the organization. Some highlights are profiled below.

    Diagnostic and Therapeutic Radiology

      The first computed tomography (CT) scanners on the West Coast.
    The 1895 invention of the X-ray machine gave physicians their first chance to see inside a patient's body without surgery. The machine could show bones and body cavities, and in the decades that followed, it remained the most widely used technology in diagnostic imaging.

    Though X-ray technology underwent minor improvements, the field of radiology had no major leaps forward until 1967, when a British electrical engineer named Godfrey Hounsfield developed the computed tomography (CT) scanner. CT technology combines X-rays with a computer to create images of cross-sectional "slices" of the body, and early machines produced pictures 100 times clearer than a normal X-ray.

    Subsequent modifications improved speed and accuracy, allowing doctors to see not just bones and big cavities, but also small recesses and soft tissues such as organs and muscles.

      Varian Corp CT scanner
    In the 1970s, Palo Alto Medical Clinic neurosurgeon James Golden served as a medical adviser to Varian Corp., a Palo Alto electronics company that had been approached by British manufacturer EMI Ltd. to build and market CT scanners in the United States.

    Varian asked Dr. Golden to travel to England to evaluate the machine. Accompanied by Clinic radiologist Richard Kramer, Dr. Golden made the trip and came away believing that CT was a major breakthrough. Clinic leaders agreed, and placed an order.

    The scanner, installed in 1974, was only the third in the United States, and the first on the West Coast. It was swamped immediately with patients, some coming from as far away as Alaska, Venezuela and Japan.

       Computer simulations help target cancerous tumors
    The first CT scanners were limited to screening the head. In 1978, the Clinic also installed a CT machine that could screen the whole body, becoming the first medical organization on the Peninsula to do so.

    Eight years later, the Clinic was one of the first outpatient organizations in the country to install a magnetic resonance imaging (MRI) machine, which uses large magnets to elicit radiofrequency signals from the body that can then be converted into visible images. The Clinic was also the first on the West Coast to perform mammography, a key to early detection of breast cancer.

    Radiation can also be employed as therapy for cancer, through linear accelerators that energize electrons to kill tumor cells. In 1950, the Clinic became one of the first facilities in the nation to offer radiation oncology in an outpatient setting. In 1977, it opened the Comprehensive Cancer Center, equipped with an 18-million volt linear accelerator that was the only one of its kind in the Bay Area.

    By the 1980s, the Clinic had one of the best-equipped radiology departments in the country. It continued to add advanced technology over the next two decades. In 1999, the Department of Radiation Oncology (now separate from the diagnostic Department of Radiology) became one of the first outpatient sites in the country to provide two advanced radiation therapy techniques known as three-dimensional conformal radiotherapy (3DCRT) and intensity-modulated radiation therapy (IMRT).

    Physicians and technicians use computer simulations to view the cancerous area in three dimensions, then employ two state-of-the-art Varian 23EX linear accelerators to deliver radiation to the tumor far more precisely than was previously possible. By decreasing radiation to surrounding healthy tissues, the technique reduces side effects.

    In 2004, the Clinic installed a specialized cardiac MRI scanner that is one of only a few such machines in the world. The machine provides a more accurate picture of the heart than does a traditional MRI and is expected to reduce the number of patients who require surgery to diagnose coronary artery disease and other heart conditions.

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    ‘Outpatient Everything'

    The Clinic's early embrace of advanced – and expensive – diagnostic and therapeutic radiation technology was in keeping with its growing desire to offer patients "outpatient everything." Providing as many health care services as possible in the outpatient setting is a common goal today, seen as a way to reduce costs and inconvenience for patients. But the outpatient focus was unusual in the 1970s, when most major procedures were still performed in the hospital.

    Admittedly, this mentality took on greater importance for the Clinic after Palo Alto voters in 1970 defeated its proposal to build a community hospital. But whatever the impetus, by the 1980s Clinic physicians firmly believed that helping patients avoid the stress and financial burden of a long hospital stay improved care.

    In 1976, the Clinic contracted with a Phoenix, Arizona-based firm to open one of the nation's first freestanding outpatient surgery centers. Available to both Clinic and community doctors, the Surgecenter quickly became popular; patients appreciated the convenience and comparatively low costs, while doctors found it easier to schedule operating-room time than at Stanford. The Palo Alto Medical Foundation would later purchase the center, which is now located within PAMF's main campus in Palo Alto, although it is still managed by an outside organization.

    By 1981, the Clinic had an average hospital stay per thousand population of around 400 days – one-third the 1,200-day national average at that time. "Almost half the health care dollar now goes to hospitals," Dr. Robert Jamplis said in a 1982 speech to the American Group Practice Association. "When you realize that the total bill will be over $300 billion this year, it means that if medicine were practiced only by multispecialty groups around the country, the savings would be $100 billion yearly." That figure, he added, would at the time have come close to erasing the national debt.

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    Laser Technology

    Clinic physicians also worked with the Palo Alto Medical Research Foundation to take part in clinical trials and develop new therapies. The most famous of these was an argon laser device developed by Clinic ophthalmologist H. Christian Zweng to treat retinal diseases. It was a breakthrough that helped establish the laser as a revolutionary therapeutic tool for a wide variety of human problems, and patients came from all over the world to receive treatment. The argon laser was later adapted by Clinic plastic surgeon Harvey Lash to treat hemangiomas, or "port wine" discolorations of the skin. The laser was used to lighten the skin, and after the treatment was profiled in Newsweek and other publications, it too attracted an international roster of patients, some from as far away as Australia.

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    The Automated Multi-Test Medical Laboratory

    The Clinic tried not to be swept up in enthusiasm for new technology without some cautious investigation into whether it would be a good investment from both a patient care and financial perspective. Periodically, however, it made a mistake. One failed venture was its first big foray into computerized medicine: the Automated Multi-Test Medical Laboratory (AML).

    Installed in 1970, the AML was located in a large circular room. Patients would sit in a chair and the machine would rotate, mechanically examining blood pressure, temperature, respiration, eyesight and more. It could draw blood, take a medical history and a chest film, ultimately completing a comprehensive physical examination in about two hours, compared to four hours for a comparable examination performed by a live person.

    The AML was "not a very economical machine, but it picked up some major things wrong in about 30 percent of patients screened, with the most common being diabetes and hypertension," said Dr. R. Hewlett Lee. Patients who worked in the Bay Area's burgeoning technology sector liked the AML, as did the Clinic's surgeons. Several internists and family practice physicians, however, opposed having to compete with a machine. In the end, patient demand was not high enough to support a venture of such magnitude, and in 1974, the AML "died an untimely death," Dr. Lee said.

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    Electronic Health Records

    Paperwork is the scourge of today's health care professional. New legal regulations and insurance- company red tape have greatly increased the amount of time doctors and staff members spend filling out and tracking down forms – and the likelihood that crucial information about patient care will get misfiled or miscommunicated. At the same time, the growing complexity of medicine has made it harder for physicians and nurses to remember every clinical guideline or potentially dangerous drug combination, putting patient safety at risk.

       Dr. Paul Tang
    As the information technology revolution took off in the 1990s, a small number of medical organizations – PAMF among them – began to develop electronic health record (EHR) systems that could help address these problems. At PAMF, the charge was led by Dr. Paul Tang, who joined the organization in 1998 as an internist and chief medical information officer.

    Trained in both electrical engineering and medicine, Dr. Tang had worked on EHRs since the early 1990s, first at Hewlett-Packard and later at Northwestern Memorial Hospital in Chicago. "It was apparent to me that this was a guy who...had a real passion to change the way health care is delivered," said PAMF President and CEO Dr. David Druker, who recruited Dr. Tang after meeting him at a conference.

    In 1999, PAMF converted all of its paper records to a comprehensive electronic system that allows doctors and clinical staff members to access patient information from any PAMF department or facility. The EHR can also send electronic prescriptions to pharmacies, reducing the risk that hard-to-read handwriting will lead to medical errors; flag potentially harmful drug interactions; provide physicians with "decision support" tools such as clinical guidelines; and generate printed post-visit summaries for patients, among other benefits. It also makes possible My Health Online, a secure Internet site through which patients can access key components of their EHR, request prescription renewals and appointments, view laboratory test results and communicate with physicians.

    Unlike other industries, U.S. health care organizations have been slow to adopt information technology as a means to improve quality and cut costs. Only about 10 percent have a comprehensive EHR in place. Since 2003, Dr. Tang has been working with federal officials to increase that number, using PAMF's pioneering experience with EHR systems as a model. Among the challenges organizations face in implementing EHRs are paying for complex new computer systems, ensuring patient privacy is protected and convincing physicians and clinical staff members to change ingrained practice styles.

    This latter hurdle existed even at innovation-friendly PAMF, although most providers were converted in the end. "I made a commitment when we got the computer that, because I was the oldest staff member in my department, I was going to just embrace it," said long-time nurse Rosemary Maresca. "I wasn't going to be the little old lady that couldn't do it. And now I really like the idea of the EHR."

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    Advanced Access

    Not all of PAMF's efforts to improve its service through innovation have been technological. As its patient base grew, so too did the difficulty of obtaining a timely appointment. In the late 1990s, Dr. Jamplis noted, "On a Monday morning, we get many more calls than the White House, and the waiting time on the telephone as well as for doctor appointments is completely unsatisfactory." For years, the Foundation put Band-Aids on the access problem, implementing telephone advice nurses, shared medical appointments and improved disease management education in an effort to reduce the need for in-person visits. These measures did make for better patient care, but did little to reduce wait times.

    With poor access to doctors the No. 1 patient complaint, administrators decided they needed a more drastic solution. In 2003, they completely overhauled the appointment-scheduling system. Under the new system, known as Advanced Access, patients in primary care departments (family practice, internal medicine and pediatrics) are offered a same-day appointment every time they call, with their own physician whenever possible. The system has the additional benefit of letting physicians see more of their "own" patients, becoming more familiar with each person's medical needs and strengthening the doctor-patient relationship. Surveys have shown a marked improvement in patient satisfaction with access to primary care doctors, and implementation of a similar system in specialty care departments began in 2004.

    Bringing Advanced Access to life required the buy-in of physicians and staff members, not all of whom were initially happy – initially – about the idea of changing their daily schedules so drastically. In primary care, physicians and staff members added hours to their days and days to their weeks to complete existing appointments and create time for daily requests. Working down the backlog of appointments took about four months.

    "There was an amazing amount of fear about it," said family practitioner Jay Schlumpberger. "But I think people were trusting enough that the leadership had made some good calls recently on the EHR and on the move to the new campus [in Palo Alto], and that they could be trusted that this was probably the right thing to do, and ultimately this would help us with quality of care and our own job satisfaction." Though it takes work to keep the backlog from building back up, most physicians now find it nice to "just be right there for patients," he added.

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