Health IT at Kaiser Permanente:

Health IT at Kaiser Permanente:
Building to Present Success
Largely based on work led by Andy M. Wiesenthal, MD, SM; Associate Executive Director, The Permanente Federation
Paul Wallace, MD
The Permanente Federation, Kaiser Permanente
paul.wallace@kp.org
Agenda
• A Brief History of Health IT in Kaiser
Permanente before KP HealthConnect
• KP HealthConnect Deployment
• How Does It Work?
• Population Management Tools
• Early Benefits
• Lessons Learned
2
Electronic Health Records (EHRs) in Kaiser
Permanente —the First Attempts
• 1970s: Morris Collen, MD in Northern California, pioneers the use of computers in
recording and sorting clinical data in real time at the San Francisco Medical Center.
The focus is on physical examination and laboratory screening.
• 1970-1980s: Individual KP Regions independently automate demographic,
appointments, pharmacy, laboratory, and other ancillary systems.
• Late 1980s: Regions experiment with clinical systems development and
deployment without wide success.
• Early 1990s: Several regions develop operations data stores, notably Northern
California (CIPS), Ohio (MARS), and Mid-Atlantic States (PACE) with various forms
of real-time data views and entry.
• Mid-1990s: Northwest deploys EpicCare to all MDs and RNs; Colorado deploys
CIS (joint development with IBM) to all MDs and RNs. These are the first two
products not internally developed.
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Lesson Learned—the Early Years
• Long-term funding (at least 5 years, preferably 10)
is essential for success.
• Funding commitments cannot be subject to minor to
moderate political pressure or change.
• Funding commitments must transcend annual
budget cycles while remaining aligned with financial
realities.
• A thorough business case reflecting true costs and
likely benefits must be prepared to address the
concerns of those responsible for finances.
4
EHRs in Kaiser Permanente—the National Projects
• 1997: A national clinical information system is established as a
corporate goal of KP.
• 1997-98: Distributed internal development with national integration.
As this project founders, a detailed additional reassessment produces:
• 1999-2002: Joint development with IBM and initial deployment
• 2002: Further reassessment of strategy and shift to Epic Systems
ƒ Key strategic questions:
ƒ Buy versus build? (Decided to buy from vendor)
ƒ Suite versus best of breed? ( suite)
ƒ Single instance of entire program versus multiple instances to be
synchronized? ( multiple instances)
ƒ What are our clinical/operational goals?
• 2003-present: KP HealthConnect, based on EpicCare
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Lessons Learned from the Early National Projects
• It is possible and preferable to buy, not build.
• A well-integrated system suite is preferable to
integration of best of breed.
• Clarity about operational goals must be achieved
before beginning.
• Engineering dogma is sometimes precisely that.
6
Make vs. Buy Decision
• Pre-2002 “build” strategy was risky and expensive.
• Epic offered much broader integrated
applications portfolio including
outpatient, inpatient, and practice
management; web interface for
members and providers; and reporting
capability.
• Ten-year costs were substantially less than a build and
maintain strategy.
• Total involvement converted a push strategy (“you have to
do this”) to a pull strategy (“we want to do this”).
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Why We Chose Epic Systems
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• Epic’s solution ranked highest in our technology review.
• Epic had the best track record for implementation and
partnering, with a very positive earlier experience in 1 KP
region (The Northwest).
• Integration less complex because elements are already in
use in certain regions within the Kaiser Permanente system.
• Epic eliminates redundant entry of information, thus
eliminating more work steps, increasing operational
efficiencies, and improving customer service.
• Epic had the highest industry rankings for relationships and
commitment.
• Epic was most closely aligned with Kaiser Permanente’s
program strategy.
Kaiser Permanente HealthConnect™
• Overall effort renamed “KP HealthConnect” - More
than just an electronic medical record
• The development and deployment of a highlysophisticated information management and delivery
system
• A programwide system that will integrate the
clinical record with appointments, registration, and
billing
• A complete health care business system that will
enhance the quality of patient care
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Kaiser Permanente HealthConnect™ Goals
Quality Our Patients
Can Trust
High Quality
• We have clinical
information available
24/7.
• Our clinical outcomes are
unsurpassed.
• Our clinicians know in
real-time the
recommended best
practices.
• We are the national
leaders in patient safety.
• We enhance our
research to support
evidence-based care.
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Personal & Convenient
Service
Personal
• We have and use up-to-date
clinical, social, and patient
preference information.
• We provide patients information
for shared decision-making.
• We enhance personalized care.
Convenient
• Our patients access information
via telephone, web, and e-mail.
• We actively support our
patients’ participation in their
own care.
• We minimize wait times and
out-of-pocket costs with
efficient access to care.
• We achieve superior integration
and continuity of care.
Affordable
Health Care
Affordable
• We reduce the cost of
care and improve visit
experiences.
• We eliminate waste
associated with paper
medical records and
missing medical records.
• We eliminate costly inperson services unless
medically necessary or
desired by the patient.
• We streamline IT and
administrative processes
and costs.
Scope of Kaiser Permanente HealthConnect™
Web Access Portal
Ancillaries
Care Delivery Core
Health Plan
Finance
Scope of Epic Suite
Outpatient
Pharmacy
Scheduling
Inpatient
Scheduling
Admission, Discharge,
and Transfer
Lab
Registration
Radiology/
Imaging
Pharmacy
Clinicals
Emergency
Department
Operating Room
Others
(immunizations,
EKG, dictation)
Clinicals
Billing
Billing
Data Warehouse / EDR Enterprise Data Repository
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Referral & Utilization Management
Outpatient
Membership/
Benefits
General
Ledger
Claims
Processing
Capital
Planning
Benefits
Accumulation
Financial
Reporting
Pricing
System
Blue Sky Vision Themes 2015: care delivery model is consumer-centric
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Home As the Hub
Self-monitoring with patient-based decision support:
ƒ They are already on their own most of the time.
The care team:
ƒ Notified of patient decisions.
ƒ Receives all data, but attention is only drawn to data requiring a decision
from the team.
The office visit no longer defines the core activity of the primary care
physician; true panel management does.
Systems will:
ƒ Deliver and maintain the decision support tools for patients.
ƒ Sort through and prioritize incoming data.
ƒ Provide horizontal views of an individual patient and aggregate views of
populations and subpopulations.
ƒ Allow for easy intervention at the population level.
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Secure and Seamless Transitions
The patient will not bear the responsibility for system
navigation:
ƒ Some transitions will be automated based on evidence.
Example: A patient drops below an LVEF threshold for the
first time, automatically triggering a cardiology referral, any
indicated further tests before the referral, and an e-mail to
the patient helping them to make the appointment unless the
APC doc chooses to redirect.
The care team will not have to remember the navigation
rules:
ƒ This “business intelligence” will be built into the system.
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Customization
Patients will choose how they want to communicate with the
care team and the system will know that.
Information delivered to patients can be tailored to their
problems and social history and circumstances.
ƒ An Enterprise Data Warehouse will help us craft a Life Care Plan
for every member, based on everything we know (and some things
other organizations know).
ƒ The Life Care Plan will be actionable by the patient as well as the
health care team.
Mass communications to populations can be customized to
each individual within the population.
ƒ Example: “lastlab” within a letter
Pre-visit questionnaires can result in better focus during a visit.
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Integration and Leveraging
Scarcer adult primary care physicians will be
more leveraged:
ƒ More support staff doing more things for physician
review.
ƒ NB: regulatory changes may be crucial here—the
licensing world has to catch up with the capabilities
of the new information world, and we should direct
lobbying efforts toward that end.
ƒ Manage the panel, not results and messages
layered on to a day filled with visits.
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Health Data Standards
KP HealthConnect meets national and
international standards for the transmittal
and storage of health data:
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
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HL7
SNOMED-CT
LOINC
RXNORM
NIC
NOC
NANDA
DICOM, etc.
How Does It Work?
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How Does It Work?
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How Does It Work?
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How Does It Work?
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How Does It Work?
22
Members Can Actively Participate in Care
Expanded Online Access for Members
Access medical record
www.kp.org
Member Web Portal
Care Delivery Core
Scope of KP HealthConnect Suite
Make/change appointments
Send email to doctor
Check lab results
Outpatient
Scheduling
Inpatient
Scheduling
Admission, Discharge,
And Transfer
Registration
Clinicals
Pharmacy
Access health Information
Clinicals
Review eligibility & benefits
Emergency
Department
Operating Room
Billing
Account summary
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Billing
Online Features Launch Status
24
How Does It Work?
25
How Does It Work?
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Patients are in Control
The system will let patients control
the simple transactions:
ƒ Appointment-making (just like
the airlines)
ƒ Lab and imaging results review
ƒ Managing their illness
according to guidelines
ƒ Communicating with the team
asynchronously—a huge
potential time saver and
satisfier for them and for the
clinician
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Challenges
System capability needed to:
ƒ Share data and move information across 18
instances in 8 regions real time.
ƒ Provide a consistent data model to populate a
national data repository to support all reporting
needs .
ƒ Reduce variation and provide evidenced-based
clinical decision support and documentation.
ƒ Share successful work practices across the country
to streamline internal processes and reduce work
variation.
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Challenges
3
3
3
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Formidable
Get Value from
KP HealthConnect
Leadership & Regions’
Responsibility
Demanding: Regions’
Implement
KP HealthConnect
In Medical Offices
and Hospitals
Collaborative
Build of Clinical
And Business
Content
Responsibility with help
from National Project Team
Difficult:
Vendor / Project Team/
Regions Responsibility
Areas of Risk
Project management
Infrastructure capacity
Insufficient implementation support or
ongoing support
Focus on goals—
ƒ Implementation
ƒ Benefits realization
Leadership
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Lessons Learned
• Consistency and local modification need to be
balanced
• Centralized control vs. local autonomy
• IT is the “great magnifier” – it will always show
you the weak points in a plan or system
• Integration into the basic work is critical
• IT system drives massive change
• Operational leadership is essential
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Health IT…Encompassing multiple needs
Population
Care
Management
Medical Office Visit
(aka The EMR)
Personal Health Record
Research
33
¾ Chronic Disease
Management
Systems (CDMS) were more
effective at supporting
Chronic Disease
Management than
Commercial EMRs
¾ On a per-MD basis, CDMS
required less investment of
time, money and effort
¾ CDMSs were significantly
less expensive than EMRs
34
http://www.chcf.org/topics/chronicdisease/index.cfm?itemID=123057
Population Management Tools
Vision
35
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Diversified Access: Time and “Touches”
Physician Time
Use When Care is
More Diversified
Average Daily "Touches"
500
80
RN-HCT contacts
Email contacts
300
Phone contacts
Annual health goals
200
"Fast Track"'s
Group visits
100
Office visits
0
1
Dr G.37Livaudais, Maui Lani Clinic, Hawaii,
“Gerard.F.Livaudais @KP.ORG”
No. of Daily Contacts
US mail contacts
400
Minutes
US mail contacts
70
RN and HCT contacts
60
Email contacts
50
Phone contacts
40
Annual health goals
30
"Fast Track"'s
20
Group visits
10
0
Office visits
1
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Personal Health Record (PHR) Statistics
• Available to all 8.6 million members, including proxy
access
• More than 3 million active users, with >80,000 more
enrolling monthly. This means about 35% of Kaiser
Permanente members are currently using the passwordprotected features of our Web site, "My Health Manager,"
which include e-mailing their doctors, getting lab results
and ordering prescriptions online, seeing much of their
medical record online, etc.
• More than 500,000 secure messages exchanged with
practitioners each month
• My Health Manager users are 65% more likely to stay
with KPwhen they have an option to change Health
Plans.
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Benefits Realized to Date
• Increasingly rational legacy systems environment
ƒ Retirement of multiple legacy systems=$ millions in savings with much
more to come
• 24-7-365 access to health information
ƒ 11% decrease overall in face-to-face visits
• Dramatic satisfaction increases with the use of the After Visit
Summary
• 7-10% primary care visit reduction in members using secure
messaging
• Reduction in ancillary utilization
ƒ Presumed drop in redundant testing and imaging
• Appointments scheduled online reduce call center costs $2.58 per
appointment
• Prescription refills mailed to homes save $4-$13 per script
• Lower no-show rates for appointments booked on My Health
Manager (6-7% no-show versus 12-14% for appointments booked on
phone)
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Benefits Realized to Date (continued)
• Tantalizing:
ƒ Reduction in progression of diabetic nephropathy
ƒ Improved pharmacologic intervention in coronary
disease (aspirin-lovastatin-lisinopril=ALL)
ƒ Standardization of care—orthopedics, anesthesia,
obstetrics, oncology, inpatient nursing care planning
ƒ “Longitudinal care” is increasing
ƒ Reduce phone and letter traffic related to results
notification (15 million laboratory results released on-line
in the first year)
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The Global Context
•
•
•
•
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Europe
ƒ Connecting for Health in the UK
ƒ Smartcards in Germany
ƒ Integration efforts in Finland, Sweden
ƒ Vocabulary work and hospital-based systems in the
Netherlands
The Americas
ƒ VistA in the VA, KP, many multispecialty medical groups, a
few hospitals
ƒ Smartcards in Brazil
Down Under
ƒ NEHTA in Australia
ƒ Systems Integration in New Zealand
Asia
ƒ Hong Kong, Singapore, Taiwan trying to extend local
(hospital) efforts
Questions?
Questions?
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