Embedding Guidance in the Kaiser Permanente EHR. Wiley Chan, MD Kaiser Permanente Care Management Institute Oakland, CA, USA

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1 Embedding Guidance in the Kaiser Permanente EHR Wiley Chan, MD Kaiser Permanente Care Management Institute Oakland, CA, USA

2 Statement of Disclosure Wiley Chan, MD I have no commercial or academic conflicts of interest Employment: Northwest Permanente Medical Group, which works exclusively with the Kaiser Foundation Health Plan in the US Member: US National Heart, Lung and Blood Institute (NHLBI) Expert Panel on Integrated Cardiovascular Risk Reduction Co-Chair: NHLBI Implementation Science Work Group Member: State of Oregon Health Evidence Review Commission (HERC) Chair: HERC Evidence-Based Guidelines Subcommittee

3 About Kaiser Permanente One of the USA s largest nonprofit health plans Integrated health care delivery system Serving 9 states and the District of Columbia 9.1 million members 17,000+ physicians 49,000+ nurses 175,000+ employees 37 hospitals 618 medical offices and outpatient facilities $50.6 billion operating revenue* Scope includes ambulatory care, inpatient care, primary care, specialty care, behavioral health, Ambulatory Surgery Centers, Skilled Nursing Facilities, home health, hospice, pharmacy, imaging, laboratory, optical, dental, and insurance *Source: 2012 Kaiser Permanente Annual Report 3

4 Overview Guidelines must be implemented to impact health outcomes Guidelines must be rigorously, transparently evidence-based and contain actionable recommendations to be implementable Robust tools exist to embed guidance in Electronic Health Records (EHRs) High-quality evidence of effectiveness in improving health care process measures (Lobach. AHRQ April 2012) Tools aimed at patients are rapidly proliferating Effective use of EHR tools requires thoughtful planning, management and full integration into health care delivery system workflows and operational infrastructure

5 EHR Content & Decision Support That Get Used Based on reliable guidance Evidence based Accurately targeted Modal alerts (force user to interact with alerts) Pieces of content that do one thing quickly & well All-encompassing content not generally well accepted More efficient than alternative methods Easy to navigate Streamlines workflow (eg, ordering multiple disparate items) Embedded guidance for Clinician, Staff, Member Do it right the first time

6 EHR Content & Decision Support That Get Used Fully integrated into standard workflows Developed in collaboration with end-users Right place & right time Targeted toward lowest permissible and desirable scope of practice Fully supported by implementation tools and training Actively promoted High-level Leadership support Aligned with organization s priorities Aligned with and supports improvement in performance metrics User training Centralized, coordinated governance Aligned clinical guidance Judicious use of decision support

7 KP National HTN Algorithm

8 Hypertension SmartSet SmartSet: Hypertension Search for SmartSets Triggered by Encounter or Problem List Diagnosis Triggered by Reason for Visit

9 Hypertension SmartSet SmartSet: Hyperlink to Web Hypertension Portal Orders Can be Defaulted Expandable Sections with Embedded Guidance Contains All the Tools Required for Point-of-Care

10 Hypertension SmartRx Hyperlink to Web Portal SmartRx: Alternative Order Type Diagnosis or Condition into Order Field Embedded Guidance Link to SmartSet Alternatives in Preferred Order

11 Best Practice Advisories Best Practice Alert: Aspirin Defaulted Link to SmartSet Highly Utilized, Single-Purpose Best Practice Advisory Programmable Triggering Logic 11

12 Best Practice Advisories Best Practice Alert: Aspirin SmartSet Defaulted Medication Order & Patient Instructions Medication Order Placed 12

13 Best Practice Advisories Best Practice Alert: Aspirin Patient Instructions Patient Instructions Generated

14 Patient Support Tool: Panel View PST Panel View Search Panel for Specific Care Gaps Sort Panel by Various Criteria Gap Score Constructed to Reflect Clinical Importance of Care Gaps Y Denotes Membership in Registry Color Reflects Clinical Importance of Registry-Specific Care Gaps

15 Patient Support Tool: Detail View Registry Membership Care Gap Acuity (Color) & Gap Score PST Detail View Visits, Immunizations, Vitals, & CAD Risk Care Recommendations Active Prescriptions Pertinent Labs

16 Clinical Knowledge Management KPNW Guidelines/EBM EHR Clinical Content Knowledge Synthesis & Maintenance^ Knowledge Representation Knowledge Integration & Alignment* KPHC** Content Maintenance* Governance Metrics Usage Statistics Outcomes ^ Includes Knowledge Discovery, Acquisition and Creation *Primary Focus Areas for KPNW Knowledge Management Team ** Kaiser Permanente HealthConnect and Related Applications

17 Lifecycle of EHR Content Implementation Maintain/Revise Requirements Definition Measure/Evaluate Design Deploy/Champion Develop/Build

18 Lifecycle of EHR Content Implementation Requirements Definition What problem are you trying to solve and what are the explicit objectives? Who are the stakeholders? Who needs to be involved in the design? How? When? What workflow processes are involved? Requirements Definition

19 Determining When/Where/How to Embed Guidance: Clinical Pathway Analysis Member identified: Lipid screen needed Leverage Point Identified Lipid test ordered Member advised to go to lab for lipid test Leverage Point Identified Member goes to lab for lipid test Area of concern Lipid test results in Provider in-basket Member sees lipid test result in KP.org Provider reviews lab results Member notified of lipid results 2 min 2 min 5 min 20 min 10 min 10 min 10 min Immediate or Not at all 0-7 days Immediate or Not at all 6-24 hours Hours-days 0-7 days Green box= touch time Red box= wait time

20 Lifecycle of EHR Content Implementation Measure & Evaluate Does the content reflect explicit goals & metrics? How will you measure its effects? How will you evaluate your results? When and how will you iterate based on data? Measure/Evaluate

21 Effect of Best Practice Advisory Chlamydia Screening Rates (HEDIS)

22 Unblinded Internal Reporting of Performance Metrics

23 Lifecycle of EHR Content Implementation Maintain/Revise Requirements Definition Measure/Evaluate Design Deploy/Champion Develop/Build

24 KP.org: My Health Manager

25 KP.org Personal Action Plan Demographics section Cancer Screening Breast Cancer Screening (Mammogram) Cervical Cancer Screening (Pap Test) Colorectal Cancer Screening Welcome Message Heart Health LDL Cholesterol Blood Pressure Chronic Health Conditions Diabetes (A1c Lab Test) Asthma Preventive Care Body Mass Index (BMI) Tobacco Use General Clinical Guidelines Preventive Care Guidelines Cancer Screening Guidelines Additional Screening Guidelines Recommended Immunizations Schedule Medications Adherent Non Adherent

26 KP.org Personal Action Plan: Medications

27 KP.org Personal Action Plan: Medications

28 Impact of KP.org Use on Quality of Care Selected Measures/Pre-Post Matched-Control Study Zhou YY. Health Affairs 2010;29: Among KP Southern California members with diabetes &/or hypertension, use of KP.org was associated with statistically significant improvement in 9 HEDIS measures evaluated, by % HbA1c Screening HbA1c <9% LDL-C Screening LDL-C <100 mg/dl BP <140/90 BP <130/80 Post: Non-Users Post: Users *Thread = series of connected questions and replies; one patient-physician conversation.

29 Summary: Embedding Guidance Robust tools exist to embed guidance at the point of care Guidance aimed directly at patients can greatly expand the point of care Convenient access to medical record and resources Communication and transactions Enhance patient engagement Tools are necessary, but insufficient to affect health outcomes Every stage of EHR content implementation lifecycle is important Full integration into health care delivery system workflows and operational infrastructure is critical

30 Summary: Embedding Guidance EHR Content & Decision Support That Get Used More efficient than alternative methods Convenience for patients Integrated into standard workflows Offload clinicians Supported by training & implementation tools Developed in collaboration with end-users Improved workflow integration Enhanced acceptance by end-users Associated with reported performance metrics Simple and explicit metrics Focused on performance gaps & potential benefit

31 Summary: Embedding Guidance EHR Content & Decision Support That Get Used Aligned with organizations priorities Actively promoted and supported Centralized, coordinated governance Aligned with other content and with guidelines Carefully deployed, accurate, and rigorously maintained Patient tools that enhance engagement Based on reliable guidance Accurately targeted Evidence-based Guideline Developer s Role Write Evidence-Based, Implementable Recommendations

32 Embedding Guidance in the Kaiser Permanente EHR Wiley Chan, MD 32

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