Health Information Technology at Kaiser Permanente

1
Health Information Technology at Kaiser
Permanente

• Andrew M. Wiesenthal, MD, SM
• Associate Executive Director, The Permanente
  Federation
• Advanced Health Leadership Forum Visit to Kaiser
  Permanente
• January 11, 2005

2
What is Kaiser Permanente?

• Kaiser Foundation Health Plan and Hospitals
• Single, national, not-for-profit entity with
  operations in 8 regions of the United States
• Performs insurance functions
• Prices, Markets, Enrolls members
• Owns most of the buildings, employs most of the
  staff except physicians (most staff are unionized)

3
What is Kaiser Permanente?

• Eight Permanente Medical Groups
• Self-governing, for-profit, multi-specialty group
  practices
• Range in size from 250 to 5000 physicians of all
  medical specialties and subspecialties
• Bi-directionally exclusive global contracts
  with Kaiser Foundation Health Plan

4
What is Kaiser Permanente?

• 8.2 million members (6.3 million in California)
• 130,000 employees
• 12,000 physicians
• 30 hospitals, 430 medical offices
• Operations in 9 states and D.C.
• Annual budget 27 billion

5
What is Kaiser Permanente?

• Similar, but not identical, operating model
  across operating regions
• Common Aspects
• All care is managed by the PMGs
• Back Office functionsscheduling, phone triage,
  quality management, utilization management,
  service managementare centralized at the
  regional level
• Physicians are surrounded by an enlarging array
  of support systems
• Care management (e.g. coumadin clinics,
  registries for DM)
• Telephone advice and triage
• Divergent Aspects
• 4 regions own and operate hospitals, 4 do not
• 6 PMGs incorporate virtually all specialties, 2
  are more primary care oriented

6
Key Strategic Decisions

• Either Practice Management Tools or Ambulatory
  EHR first
• Collaborate
• Set clear goalspaperless, reliable, response
  times, use of datamanage toward them
• Terminology-driven
• Integrate ancillary environment
• Backfill for lost productivity
• Involve users in workflow, design, configuration
  decisions
• Invest in infrastructure only to serve practical
  purposes

7
KP HealthConnect Business Case

• Givens
• Current internal and external circumstances
• Our view of the future state
• New capacity required to deliver on our goals
• Business case incorporated
• Software and hardware acquisition costs
• Implementation costs
• Training
• Productivity losses
• Process redesign
• Maintenance costs for 10 years
• Targeted goals, by region for
• Quality enhancement
• Service enhancement
• Revenue enhancement
• Cost/management or reduction
• Regional Presidents and Medical Directors signed
  on for these
• Sensitivity analysis done for all and worst case
  presented to KFH/KFHP Board

8
Scope of KP HealthConnect
Web Access Portal
Infrastructure
Health Plan
Ancillaries
Care Delivery Core
Outpatient
Inpatient
Clinicals
Billing
9
Implementation Schedule
2004
2003
2005
2006
2Q 03
3Q 03
4Q 03
1Q 04
2Q 04
3Q 04
4Q 04
1Q 05
2Q 05
3Q 05
4Q 05
2Q 06
1Q 06
4Q 06
3Q 06
Outpatient Scheduling, Outpatient Registration,
Professional Billing
Tapestry Eligibility (TBD)
Outpatient Clinicals
CO
Exempla ADT, Hospital and Professional Billing,
Inpatient Clinicals, IP Order Entry, IP
Documentation, IP Pharmacy, OR Management (End
Date TBD)
Outpatient Scheduling Upgrade
Outpatient Registration Professional Billing
Outpatient Clinicals (Official Date TBD)
GA
Tapestry Eligibility
Inpatient ADT/Registration, IP Pharmacy, and
Hospital Billing
Outpatient Clinicals
IP Order Entry
Outpatient/Inpatient Scheduling
Outpatient Reg, Professional Billing
HI
OR Management, ED
Inpatient Nursing Documentation
Tapestry Eligibility (TBD)
Benefits Engine
Inpatient Physician Documentation
Outpatient Clinicals
Outpatient Registration, Professional Billing,
Check-in Check-out
Tapestry Eligibility, UM/CM
MAS
Outpatient Scheduling
Registration, Billing (Hospital Professional),
Check-in
Outpatient Clinicals (TBD)
Inpatient Pharmacy
NCAL
ADT, ED
CDR Viewer
OR Mgmt Q4/07
Tapestry Eligibility (TBD)
Inpatient Clinicals Q4/07
Outpatient Registration, Professional Billing,
Check-in/Check-out
Outpatient Clinicals Upgrade
(2002/CB Version)
OR Management and ED
Legend KP HealthConnect Initial Go Live
Inpatient Scheduling, ADT, Hospital Billing
Outpatient Clinicals Upgrade (2001)
NW
Tapestry Eligibility (TBD)
Inpatient Clinicals, IP Pharmacy, IP
Documentation, IP Order Entry
Outpatient Scheduling, Outpatient Registration,
Professional Billing
Tapestry Eligibility (TBD)
OH
Outpatient Clinicals
Billing (Hospital and Professional)
Registration and Scheduling (OP IP)
CDR Viewer
SCAL
Outpatient Clinicals
7/08
Inpatient Clinicals
10/08
Inpatient Pharmacy
10/07
Tapestry Eligibility (TBD)
Collaborative Build Sent to Regions
NGP in effect in all regions
10
Regional Milestones KP HealthConnect
As of 3/25/05
2004
2003
2005
2006
2007
2008
2Q 05
1Q 07
2Q 07
4Q 07
3Q 07
1Q 04
2Q 04
3Q 04
4Q 04
1Q 05
3Q 05
4Q 05
1Q 06
2Q 06
4Q 06
3Q 06
Outpatient Scheduling, Outpatient Registration,
Professional Billing, Tapestry Eligibility (7-19)
KP HealthConnect Online, EpicWeb (1Q/06 TBD)
Tapestry UM/CM, EpicLink (4Q/05 TBD)
CO
Outpatient Clinicals(10-11)
Exempla ADT, Hospital and Professional Billing,
Inpatient Clinicals, IP Order Entry, IP
Documentation, IP Pharmacy, OR Management (12-1)
(End Date TBD)
Outpatient Scheduling Upgrade
Join Collaborative Build (1-30)
GA
Outpatient Clinicals (5-31)(End Date TBD)
Outpatient Registration Professional Billing,
Tapestry Eligibility
HIM-Chart Tracking (4-4)
KP HealthConnect Online (2006 TBD)
Inpatient ADT/Registration, IP Pharmacy,
Hospital Billing, HIM (1-23)
Outpatient Clinicals (4-20)
Inpatient Clinicals Documentation, ED (Date TBD)
HI
OP Registration, IP/OP Scheduling, OP Billing,
Benefits Engine, Tapestry Eligibility (10-1)
Inpatient Clinicals Order Entry, OpTime
KP HealthConnect Online (8/05)
Outpatient Clinicals (9-8)
Nurse Triage (Date TBD)
OR Mgmt (Date TBD)
MAS
Tapestry UM/CM (12-15)
KP HealthConnect Online (2Q/06 TBD)
Outpatient Registration, Prof Billing, Check-in
Check-out (11-1) (End Date TBD)
Outpatient Scheduling (End TBD)
Registration, Professional Billing, Check-in
(12-8)
Outpatient Clinicals (2-2)
Q1/08
NCAL
Inpatient Pharmacy, ADT, Hospital Billing, ED Mgr
(6-24)
ED
Q4/08
KP HealthConnect Online (10-26 TBD)
Inpatient Clinicals, HIM
Q4/08
OR Mgmt
Join Collaborative Build (5-7)
Move to Hyperspace
Outpatient Clinicals Upgrade (2001)
ADT, Hospital Billing, HIM, Inpatient Pharmacy,
ED-Tracking (10-8)
Exam Room Computing
NW
PHL (MyChart) Upgrade
KP HealthConnect Online (11/05)
Scheduling (Pilot 6-6)(Big Bang 7-12)
Inpatient Clinicals, Nurse, Doc, CPOE, ED-Doc, OR
Mgmt (4-1)
Outpatient Registration, Professional Billing,
Check-in/Check-out, Tapestry Eligibility (10-25)
Tapestry UM (6-6)
Outpatient Scheduling, Outpatient Registration,
Professional Billing (6-25)
Outpatient Clinicals (11-28)
OH
Tapestry UM/CM (Date TBD)
Tapestry Eligibility
KP HealthConnect Online (2006 TBD)
Billing (Professional 9-1, Hospital 11-14)
KP HealthConnect Online (8-17 TBD)
Registration, Check-In (9-1)
Ends 7/31/07
Outpatient Clinicals (10-7)
CDR Viewer (10-7)
SCAL
(Note Orange County IPRx Implementation in 9/07)
Inpatient Pharmacy (11-14)
Inpatient ADT(8-22) Clinicals (12-1)
Ends 4/11/08
HIM 6-5)
Scheduling/ Chart Pull (6-1)
http//kpnet.kp.org/kphealthconnect/pc/rcoordinati
on.htm
Collaborative Build Sent to Regions
11
Areas of Risk

• Project management
• Insufficient implementation support or ongoing
  support
• Focus on goals
• Implementation
• Benefits realization
• Leadership

12
The Limitations of the Old Way--1987

• Quality Assurance was a necessary afterthought,
  trapped in a Potter Stewart modelI know it when
  I see it.
• There were no acceptable or accepted measures of
  clinical quality
• Outside of KP, claims data were being used to try
  to understand what was going on
• Inside KP, there was not even claims data
• Worst of all, fellow clinicians experience of
  the quality assurance function was as the quarry
  of an erratic policeman

13
The Limitations of the Old Way--2004

• Quality measurement is acceptable and possibly
  even good
• There is some quality data, more related to
  measures of process than of outcomes, but some of
  both
• Within the PMGs, being the physician in charge of
  Quality Management is respectable, even respected
• The Potter Stewart approach is no longer, yet
  many assert that we have the finest health care
  system in the world despite accumulating
  evidence to the contrary

14
The Contrary View

• Lucien Leapes safety study is now a decade old,
  but it remains compelling
• The sound bite The annual total of avoidable
  deaths in U.S. hospitals is the equivalent of a
  full 747 crashing and killing all on board every
  other day, all year long.
• Is there anyone in this room who does not have
  direct experience of a patient or family member
  who was seriously injured or killed due to a flaw
  in a care system?
• There is no evidence that the system is safer
  than it was 1 or 2 decades agoincreasing
  complexity and more diverse potential for
  intervention may have rendered it more dangerous

15
The Contrary View

• The average time between published description of
  a clearly beneficial clinical intervention and
  its widespread adoption is 17 years
• At todays rate of research innovation, that may
  mean that the new recommendation will have
  changed 4 or 5 times before we ever implement it
  in the first place
• On average, the odds of receiving clearly
  recommended care if you are a Medicare
  beneficiary is not much better than the odds of a
  heads or tails if flipping a coin

16
Disturbing facts

• Study of 6712 randomly selected adults in 12
  cities
• Physician performance evaluated on 439 quality
  indicators for 30 medical conditions
• Patients received 55 of recommended care
• In other words, physicians had a 45 rate of
  noncompliance with established practice
  guidelines
• McGlynn et al. N Engl J Med 20033482635

17
The Contrary View

• Aspects of health care delivery may be good, and
  certain data have improved over time, but our
  health care system is not much more capable of
  delivering safe, timely, evidence-based care that
  is consistent with patient preference than it was
  20 years ago.
• A new approach is needed, but which one?

18
An Iconic View of Quality Methodology

• Three perspectives, summarized by three icons
• Robert Pirsig, author of Zen and the Art of
  Motorcycle Maintenance
• A craft-based view train the operators
  extremely well, give them exactly the right tools
  at exactly the right time, foster a cult of pride
  in performance, reward excellence and drive out
  mediocrity (both in the eye of the beholder)
• Spike Lee, auteur of Do the Right Thing
• A values-based view understand clearly what the
  right thing is, articulate it to the operators in
  the system, make it the easiest thing to do
• Brent James, surgeon and health care quality guru
• An industrial quality improvement view make
  care systematic, measure system output, intervene
  and then re-measure system outputI dont care
  if you get it right as long as you get it the
  same.

19
Zen and the Art

• Pro
• Very appealing professionally
• Strong sense of excellence and pride
• Con
• Hard to demonstrate
• Purchasers and individual patients are
  increasingly dubious

20
Do the Right Thing

• Pro
• Based on learning and evidence
• Patients best interest is always central to
  decision-making
• Somewhat easier to measure (HEDIS)
• Con
• You have to know what the right thing is
• You have to be able to implement the right thing
  at the right time
• May not allow for sufficient influence of patient
  values

21
Get it the Same

• Pro
• Start with common agreements
• Build iteratively
• Easiest to measure
• Outcome focused
• Con
• Seems antithetical at times
• May not account for necessary variation
• Possibly depersonalizing for practitioners and
  patients

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Enter KP HealthConnect

• Basic/Passive Decision Support
• Advanced Decision Support
• Population Management Tools
• Health Care Team Communication Tools
• Workflow Management Tools
• Iterative Learning off a Common Platform
• Measurement, Feedback, Innovation, Diffusion,
  Transformation

23
Basic/Passive Decision Support

• Structure of the Navigator
• Documentation tools
• Preference lists

24
Advanced/Active Decision Support

• Best Practice Alerts
• Soft Stop and Hard Stop Alerts and Warnings
• Alternative Rx
• Decision Rules

25
Population Management Tools

• Query-based reports to MyEpic
• Soon-to-be-available Reporting Workbench
• Builds registries from an individual practice and
  allows for simple positive reporting or
  exception-based reporting and action
• PCIS
• KP built population management tools integrated
  with and complementary to Reporting Workbench

26
Team Communication and Workflow Management

• Information movement within the health care team
  allocates the work
• Information triage
• Information flow management and management
  reports
• Nothing between the cracks
• Tickler systems
• Emails
• CCing and virtual consultation

27
Iterative Learning

• Data and workflows will now be very similar if
  not identical across a region and between regions
• Scenario
• A team becomes frustrated by an ineffective
  workflow and implements an innovation
• The outcome of the innovation and frequency of
  use can be readily measured
• Improvement is noted and the workflow is made
  permanent
• The results are published
• Others, because their platforms and measurement
  systems are similar, can see the improvement and
  implement it themselves with a reasonable
  guarantee of similar results

28
The QI Feedback Loop

• Because work is largely automated, the elements
  of the Quality Improvement Cycle Measurement,
  Feedback, Innovation, Re-measurementcan be
  routinized, creating a learning team
• Diffusing what one learning team learns to all
  others creates a learning organization
• Successful adoption after diffusion results in a
  transformed organization

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KP HealthConnect Clinical Content Vision
Benefits/Outcomes of the Vision
Afford-ability
Clinical Outcomes Improved
Enhance-ment of Clinical Practice
Consumer-Centric Care