Terhilda Garrido, VP HIT Transformation and Analytics Dutch Health Care Leaders Group October 2012 KP HealthConnect & Big Data Value and Transformation HARVESTING VALUE HIT Transformation & Analytics National Quality & Care Delivery Excellence
The Impact of HIT on Health Care at KP Discussion today: 2
KP Strategic Elements for Health Care Value Creation 3
Our Investment in Technology: Kaiser Permanente HealthConnect 4
Integrating Health Care across the Continuum Inpatient and outpatient clinical care: documentation, ordering, decision support Hospital and outpatient practice management: billing, scheduling, registration, ADT (admission, discharge and transfer) Ancillary systems: pharmacy, labs, radiology, etc. Online access to personal health record: My Health Manager on kp.org One data model underlying all EHR components 5
Scope of Kaiser Permanente HealthConnect KP HealthConnect Web Access Portal / kp.org Ancillaries Care Delivery Core Health Plan Finance Outpatient Pharmacy Lab Radiology/ Imaging Others (EKG, dictation) Outpatient Scheduling Registration Clinicals Billing Health Information Management Inpatient Admission, Discharge & Transfer CPOE Clinical documentation Pharmacy Emergency Department Operating Room Billing Referral & Utilization Management Membership/ Benefits Claims Processing Benefits Accumulation Pricing System General Ledger Capital Planning Financial Reporting Data Repository 6
KP HC Implementation Timeline 11/02 NW pilots PHR (MyChart) 6/03 Blue Sky Vision NW Region implements Epic O/P CO Region implements IBM CIS KP/IBM partnership to build EHR KP CIS 9/02 New CEO George Halvorson requests review of vendors 3/03 Board approves Epic for O/P 4/04-08 Outpatient Implementation Inpatient Implementation 533+ clinics 36 hospitals 16,000 MDs 45,000 RNs 200 interfaces 9/03 Board approves Epic I/P Business Case 7
Clinical IT projects are incredibly complex social endeavors in unforgiving environments that happen to involve computers as opposed to IT projects that happen to involve MDs Prof Scott Silverstein, MD 8
The Decision Leadership Alignment A vision and commitment from the top CEO George Halvorson Alignment and commitment from physician leadership Appropriate resourcing The business case An ROI was calculated but Justification to the operations, to our membership, to our organization was based on quality and patient safety Some saw data to improve clinical outcomes Some saw improved MD / staff work processes Some saw a new exciting technology to keep up with the community Some saw the power of information The vendor selection 3 choices: Continue with KP / IBM developed solution Cerner Epic Considerations: An honest assessment of KP s core strengths and gaps Trust in the vendor : Vendors proven record for improvement and customer satisfaction Cultural alignment with vendors; A long-term relationship Products that enabled an integrated system (reflecting KP s integrated program) 9
Implementation Lessons Learned Leadership Alignment A vision and commitment from the top CEO George Halvorson complete in 3 years Alignment and commitment from physician leadership there was no MD that could opt out SVP over KP HealthConnect was also the SVP for Quality of Care and she was an MD under George. Focus and THE priority Shared Vision of Care Delivery Better care; a Blue Sky Vision Strategic and well-resourced investment Tiger Team Protected space within the organization for the KP HC team to develop new ways of working with the regions / operations Essential Partnership / engagement Physicians (and nurses) were in leadership roles at all levels ; not IT Epic was critical Practice Changes Culture Standardization and consistency balanced against need for local modification Parallel Investment Building infrastructure for performance improvement and innovation. Developing tracking, knowledge management and evaluation processes MD / staff training and time to succeed KP has ongoing training for staff lagging in EHR skills 10
Blue Sky Vision In the future, the care delivery model is a consumer-centric paradigm where the consumer presumes choice. Members will characterize KP as providing customized and fully integrated/leveraged services with secure and seamless transitions from person to person with care that can occur in their homes for an affordable cost. Home as the Hub The home, and other settings, will grow significantly as a locale of choice for some care delivery Integration and Leveraging IT functionality enables us to leverage scarce or specialized clinical resources - MDs, RNs and other clinical staff and make our processes more efficient. Secure and seamless transitions Warm Handoffs - The human skill sets and operational processes to deliver care and service effectively, efficiently, and compassionately. Customization Occurs at any level of the members journey with KP 11
The Impact of HIT on Health Care at KP Discussion today: 12
All care information. All patients. All the time. KP HealthConnect Is the Foundation of What We Do 36 million 105 thousand medical records 12 million daily MyChart logons secure emails 8 petabytes of information 99.96% system availability 70 thousand 7 million concurrent users online Rx refills 380 million 21 million weekly views online lab results Patient chart Before KP HC After KP HC available Before KP HC, patient charts At the visit 40-70% 100% In the Emergency Room For a phone call 5% 100% ----- 100% Providing vital information Dr. Kohler, the chief of one of Kaiser Permanente s most called-on ED s, explains how invaluable KP HealthConnect information is when a patient is brought in unconscious and unaccompanied and how KP HealthConnect ensures continuity of care. Providing Vital Information 13
Increased Operational Efficiencies & Cost Savings Going from paper records to electronic records saves: Millions in printing costs, labor and storage space. The savings in costs of printed forms was immediate. One region saw a $1.4 million decrease in printing expenses of annual outpatient forms alone. Chart room FTE savings are significant. 14
A Value Chain of Green No Paper Charts! Health Information Technology KP & patient experience Which means The impact Your Electronic Medical Record EHR KP HealthConnect All Chart info is now electronic! No paper charts! More trees Replacing forms with e-signatures Saved H 2 O No X-ray films! AgNO 3 Less Silver Nitrate, Hydroquinone 15
The Impact of HIT on Health Care at KP Discussion today: 16
Redefining Access Empowering Patients Copyright Kaiser Permanente 17 Doris Taylor, a KP member talks about contacting her Doctor from the convenience of her home. She sends a secure message to her doctor via KP HealthConnect. Dr. Liu receives Doris s question and proceeds to reply almost instantaneously. Transforming Access
My Health Manager Anytime, anywhere 4M users 100M visits 30M test results viewed 12M secure emails sent 10M Rx refills 8M mobile-optimized website visits 214,000 iphone and Android app downloads 2012 YTD through June 18
Transforming Primary Care Encounters Care is not just delivered in face-to-face visits now. It is now done on the phone and through secure emails. In 2003, there were essentially 0% secure emails Now it represents 28% of the primary care patient encounters. In 2010 KP provided care in 83 million patient encounters. KP Program Wide Source: UCDA Core Value Metrics 19
Improved Efficiency and Quality of Care Efficiency /convenience improved! Patients who use secure e-mail: Are 7% to 10% less likely to schedule a routine office visit 1 Make about 14% fewer phone contacts Those who book appointments online are up to 50% more likely to keep them Quality of Care Improved! In a matched-control analysis published in Health Affairs, secure email was associated with a 2.0 to 6.5% improvement in performance on HEDIS measures, such as glycemic (HbA1c), cholesterol, and blood pressure screening and control 2 High Patient Satisfaction! 85% rated encounters 8 or 9 on a 1-9 scale 3 1 Zhou, Yi Yvonne; Garrido, Terhilda; Chin, Homer; Wiesenthal, Andrew; Liang, Louise, Patient access to an electronic health record with secure messaging: impact on primary care utilization, The American Journal of Managed Care, Vol 13:418-424, July 2007. 2 Zhou, Yi Yvonne; Kanter, Michael H; Wang, Jian J; Garrido, Terhilda, Improved Quality at Kaiser Permanente Through E-Mail Between Physicians and Patients, Health Affairs, Vol 29, No 7 (2010); 1370-1375. 3 Internal KP study, Harvesting Value: Early Findings from Kaiser Permanente HealthConnect presented to Center for Information Therapy by T Garrido, C Serrato, J Oldenburg (1/15/2008) 20
A Value Chain of Green Virtual Visits Health Information Technology KP & patient experience Which means The green impact! Latest Labs Info from last visit Latest Rx EHR KP HealthConnect More efficient visits All info for a productive visit is always available Fewer carbon emissions Dear Doc: Some replacement of visits with phone, secure e-mails, and mailed Rx refills Less patient travel to the Clinic! Your doctor will secure e-mail you OIL OIL OIL OIL OIL OIL Fewer barrels of oil used PHR kp.org/myhealthmanager M. Turley, C. Porter, T. Garrido, K. Gerwig, S. Young, L. Radler R. Shaber, Use of Electronic Health Records Can Improve the Health Care Industry s Environmental Footprint, Health Affairs 30, no. 5 May 2011; 938-946 21
KP HealthConnect - Care Delivery Transformation Cost Peak KP HealthConnect Implementation KP Operating Cost Trend Line KP CEO George Halvorsen: Our overall medical cost trend since the medical record system has been installed has been about 20% - 30% lower than the cost trend of anybody else in health care. 22
The Impact of HIT on Health Care at KP Discussion today: 23
Taking accountability for patient populations Clinical Outcomes in Southern California Metric Improvement Lives Saved Per Decade 1 Blood Pressure Control 38.9% 5,341 Lives Colorectal cancer screening 30.2% 4,788 Lives Cholesterol Control 21.8% 1,751 Lives Blood sugar control 11.5% 1.088 Lives Smoking Cessation 17.0% 955 Lives Breast Cancer Screening 11.4% 570 Lives Cervical Cancer Screening 5.9% 59 Lives Over 14,000 Lives Saved 1 1/ Based on NCQA Quality Dividend Calculator 24
Patient Population Tools The Panel Support tools have been shown to be effective in improving patient quality of care and reducing care gaps by up to 21% 25
Early Cancer Detection Member Mary Gonzales talks about her experience with Kaiser Permanente, and how a receptionist using KP HealthConnect prompted and scheduled her for a mammogram. 26
KP Strategic Elements for Health Care Value Creation 27
The Impact of HIT on Health Care at KP Discussion today: 28
Use of Best Oncology Chemotherapy Protocols 29
Quality - Use of National Oncology Protocols Significantly high use of initial protocols as is *, 63% - 84% represents reliability of care and we see this sustained throughout the rollouts. This high % is unprecedented when comparing to other clinical content acceptance rates. The current 2011 use of protocols is 87%. The protocols change with the latest evidence quickly. % of Protocols - Used as is and Modified By Region - Within One Month after Go-live 100% 90% 80% % of Protocols 70% 60% 50% 40% 30% 20% 10% 0% San Jose Vallejo Fresno Richmond Oakland San Rafael Fremont Go-Live Date 11/07 7/08 8/08 10/08 10/08 3/09 4/09 % of National protocols - used as is % of National protocols - modified % of Unique protocols used 30
Oncology Patient Safety - Reduced Adverse Events Adverse Events per 1,000 Medications Ordered 120 100 Implementation Month +2sd 80 60 Post Imp Avg:66.5 Avg 40 Pre Imp Avg:73.2-2sd 20 0 Nov 1st Go LIve 0 5 10 15 20 25 30 Treatment Week Patient Safety - Reduced adverse events and other measures in place Adverse Events per 1000 medications reduced 9% from 73.2 to 66.5. 35 40 45 50 55 The oncology module s required use of dual signatures for all high alert drugs and barcode scanning at the point of drug administration provides new levels of automation supporting higher patient safety. 31
KP Strategic Elements for Health Care Value Creation 32
Supporting the Jump in Quality of Care Although there are many contributing factors, KP HealthConnect and Panel Support Tools enabled higher performance. Note middling performance in years 2003 and 2004 prior to full PST / KP HC implementation. Promotion of Healthy Behaviors Best Care for Chronic Conditions Best Hospitals Leading Prevention and Cancer Screening Transformational 100 th percentile Performance relative to national benchmarks 90 th percentile NOW NOW NOW NOW NOW NOW 2004 NOW NOW NOW NOW NOW 75 th percentile 2007 NOW 2004 At par with competition 2004 2008 2004 2003 2004 2003 2003 2004 25 th percentile 2004 2004 10 th percentile Cancer screening composite Childhood immunizations Pediatric weight assessment Clinical effectiveness composite Diabetes care composite Cardiovascular care composite 33 Hospital clinical effectiveness Hospital mortality Note: Placement of current status and starting points approximate Prevention composite Breast cancer screening Cervical cancer screening Colon cancer screening
The Impact of HIT on Health Care at KP Discussion today: 34
How do you know? Not everything that can be measured counts, and not everything that counts can be measured. A. Einstein 35
Information is power at many levels 3. Patient panel -population health Information is power: Power to know what the problem is Power to know where to act Power to know what to change Information driving reform: 5 levels of information work together to drive improvement in the healthcare system. They are all enabled and dependant on the EHR for data. 1. Healthcare knowledge level research / guidelines 2. Organization level Big Q 3. Patient population level 4. MD level performance feedback 5. Patient level empowerment 36
1. Health care Knowledge Level: A Tale of 2 Studies Tale of Study 1 It was the best of times, it was the worst of times for researchers in the city of San Antonio. ALLHAT* a classic RCT randomized control trial 42,418 patients $120 million Conducted over 8 years Results Thiazide-type diuretics are most effective at controlling hypertension Given the low cost of this diuretic class, they postulated $3.1 billion savings over 10 years ALLHAT* Antihypertensive, lipid lowering treatment to prevent health attack trial. Sponsored by the national heart, lung and blood institute 37
1. Health Care Knowledge Level: A Tale of 2 Studies Tale 2 Meanwhile in Denver, David Magid, MD had an idea. ALLHAT a classic RCT randomized control trial 42,418 patients $120 million Conducted over 8 years Magid* study 4,000,000 patients $200,000 Conducted over 1.5 years Results Thiazide-type diuretics are most effective at controlling hypertension Results For the 60% of patients that were not under control / complete hypertension control, ACE Inhibitors and beta blockers are effective as 2 nd line medications. *Magid, David J.; Shetterly, Susan J.; Margolis, Karen L.; Tavel, Heather M.; O Connor, Patrick J.; Selby, Joe V.; Ho, P. Michael, Comparative Effectiveness of Angiotensin-Converting Enzyme Inhibitors Versus β-blockers as Second-Line Therapy for Hypertension, Circ Cardiovasc Qual Outcomes, 2010;3:453-458. 38
1. Health Care Knowledge Level: A Tale of 2 Studies RCTs are the traditional gold standard for healthcare research. EHRs and their vast store of data (in depth and breadth) offer an alternative with pros and cons. Statistical Design ALLHAT Study Randomized Control Trial Magid Study Retrospective observational - Eliminate Patient Bias -Adjust for patient bias: Matched case control. N.b. needs a large sample - Limited target group - Cross-sectional population - Controlled conditions - Real World conditions Results $120,000,000 over 8 yrs $200,000 over 1.5 yrs 42,418 patients 4 million patients 39
2. Organization- Level: Big Q Unlike other industries, where the common denominator is often $, healthcare requires a balanced scorecard approach. Clinical Effectiveness Safety Patient satisfaction Cost efficiency Equity in care 40
4. MD Level: Performance Feedback Loops MD leaders identify info needs Analysts extract data and craft report to reflect focus Count of Untouched Messages by Location / Department / Recipient Monitoring MD in-baskets resulted in a 70-90% decrease in untouched abnormal lab 900 results 14 days+ Count Untouched Abnormal Lab Results InBasket Messages > 14 Days 800 700 600 500 400 300 200 100 0 8/09 9/09 10/09 11/09 12/09 1/10 August 2009 - January 2010 MD maintains / improves practice. Reports track progress 6 Department Message Recipient Count XYZ MEDICAL OFFICE DEPT FIRSTNAME, LASTNAME MD DEPT FIRSTNAME, LASTNAME MD FIRSTNAME, LASTNAME MD FIRSTNAME, LASTNAME MD XYZ MEDICAL OFFICE DEPT FIRSTNAME, LASTNAME MD DEPT FIRSTNAME, LASTNAME MD DEPT FIRSTNAME, LASTNAME MD Dept MD Chiefs share with MDs 3 15 3 2 4 28 9 41
The Advent of Big Data 3. Patient panel -population health Technology and access to data are allowing organizations to rethink how we use data. In the next decade, billions of data points will surround each individual this will allow predictions about health and disease in each person. We need to build systems capable of resolving this complexity into simple hypothesis about health and wellness. 1. Healthcare knowledge level research / guidelines 2. Organization level Big Q 3. Patient population level 4. MD level performance feedback 5. Patient level empowerment 42
Care Models Past, Present, Future Reactive Care Stratified Care Focus Clinical Encounter Care of Cohorts Participative Care Individual is their own control Data Exhaust of encounter EHR / Clinical data Merge of analytics & decision support Bench to Bedside 17 years Offline data analysis -months- Realtime learning healthcare System $ FFS Value-based care Wellness & Prevention Theme Illness Cured Disease Stratified Wellness Quantified 43
The Impact of HIT on Health Care at KP Discussion today: 44
Looming Innovative Technology and Applications Mobile apps using the SmartPhone Spanish Patient Portal Teledermatology Teleconsultation Social Media Shared Decision Making Patient Reported Outcomes..? 45
Blue Sky Vision In the future, the care delivery model is a consumer-centric paradigm where the consumer presumes choice. Members will characterize KP as providing customized and fully integrated/leveraged services with secure and seamless transitions from person to person with care that can occur in their homes for an affordable cost. Home as the Hub The home, and other settings, will grow significantly as a locale of choice for some care delivery Integration and Leveraging IT functionality enables us to leverage scarce or specialized clinical resources - MDs, RNs and other clinical staff and make our processes more efficient. Secure and seamless transitions Warm Handoffs - The human skill sets and operational processes to deliver care and service effectively, efficiently, and compassionately. Customization Occurs at any level of the members journey with KP 46