L2 Using Information Technology

21st Century Care Innovation Project Transforming Primary Care with KP HealthConnect

Using Information Technology to Redesign Primary Care

Institute for Healthcare Improvement’s 8th Annual International Summit on Redesigning the Clinical Office PracticeNashville, TN, March 25-27, 2007

Charles Kilo, MD, MPHCEO, GreenField Health, Portland, OR Chuck.Kilo@GreenFieldHealth.com

Reginald Wallen, MDPhysician Director, MidAtlantic Permanente Medical Group Reginald.Wallen@kp.org

Objectives

By the end of this session, participants will be able to:• Describe the components of a practice IT system• List considerations for workflow redesign during IT

selection and implementation• Discuss critical aspects of using an IT system to

improve quality of care• Challenge each other to think flexibly about their

practice and their patient’s future

Its not about the IT…

• We will discuss aspects of the technology, but we will focus on what IT enables us to do for our patients

• Care and caring are at the center – the future is about caring for the patient, not about the visit

• EHR implementation is a Trojan horse – it provides the opportunity to question and redesign processes, workflow, roles and how you interact with patients

Leverage the opportunityDon’t pave the cowpaths

• Implementation is an ongoing journey, not a one time event

Chronic Care Model: What are the challenges?

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Improved Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health SystemResources and Policies

Community Health Care Organization

Basic Elements of IT for Primary Care

Foundations• Practice management software for billing and scheduling• EHR with integrated scanning, faxing, e-prescribing (integrated with PM)• Decision-support (patient & practice)• Disease Registry• Clinic / Medical Group intranet

Systems for connecting with patients• Patient facing shared record/personal health record• Secure messaging• Patient e-newsletter

System-basics• High-speed internet connection • Connectivity to other critical IT (e.g., hospital, lab, radiology)• VPN for secure use from home• System Software and Security – OS, antivirus, anti-spam, back-up

• Your primary focus in the design your practice system will determine what your system will look like when you’re done, including your IT.

• Options include, for example:Improving physician efficiency/productivityImproving clinical qualityIntegration with colleaguesMarket differentiationPatient at the center

Organizing Principles

Organizing Principles – GreenField Health

Use our team and our system design to deliver on the promises of:

• Relationships• Service• Clinical Reliability

Continually work to integrate care across boundaries

The GreenField Model TM

Management Systems

Rel

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Serv

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Rel

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The Operating System

© 2007, Charles Kilo, GreenField Health

Management Systems

Rel

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Serv

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Customized Experience

The GreenField Model TM

© 2007, Charles Kilo, GreenField Health

1. GE Centricity EHR2. GE Centricity PM3. Kryptiq’s Care Manager disease registries4. Kryptiq’s DocuTrak scanning5. Kryptiq secure messaging and local RHIO6. Kryptiq web portal with patient access to records7. Kryptiq E-prescribing8. Hospital interface for lab, x-ray, hospital documents9. Brentwood ECG – integrated10. Midmark Spirometer – integrated11. Clinical Content – encounter forms12. GreenField intranet and web site13. Electronic patient newsletter14. Networking hardware & software15. Knowledge sources – Epocrates, UpToDate, PubMed, Google16. Remote access to hospital IS and our own IS17. Network faxing18. Network with backup, antiviral, antispam, and security software19. Telecommunications – phone system, cell phones

GreenField Health’s IT System

RelationshipServiceClinical Reliability

© 2007, Charles Kilo, GreenField Health

Integration using ample supply of duct tape and bailing wire

Basic Elements of Medical Practice IT

FoundationsBilling / Scheduling softwareEHRDecision-support (patient & practice)Disease RegistryClinic / Medical Group intranet

Connecting with PatientsWeb portal/personal health recordPatient e-newsletter Secure messaging

The NetworkVPN for secure use from remote locationsConnectivity to other IT (hospital, lab, radiology)Connectivity network between practices (virtual integration)Internet connectionSecurity including antivirus, anti-spam, back-upTelecommunication systems

Relationship

Service

Clinical Reliability

© 2007, Charles Kilo, GreenField Health

Basic Elements of Medical Practice IT

FoundationsBilling / Scheduling softwareEHRDecision-support (patient & practice)Disease RegistryClinic / Medical Group intranet

Connecting with PatientsWeb portal/personal health recordPatient e-newsletter Secure messaging

The NetworkVPN for secure use from remote locationsConnectivity to other IT (hospital, lab, radiology)Connectivity network between practices (virtual integration)Internet connectionSecurity including antivirus, anti-spam, back-upTelecommunication systems

Relationship

Service

Clinical Reliability

© 2007, Charles Kilo, GreenField Health

Basic Elements of Medical Practice IT

FoundationsBilling / Scheduling softwareEHRDecision-support (patient & practice)Disease RegistryClinic / Medical Group intranet

Connecting with PatientsWeb portal/personal health recordPatient e-newsletter Secure messaging

The NetworkVPN for secure use from remote locationsConnectivity to other IT (hospital, lab, radiology)Connectivity network between practices (virtual integration)Internet connectionSecurity including antivirus, anti-spam, back-upTelecommunication systems

Relationship

Service

Clinical Reliability

© 2007, Charles Kilo, GreenField Health

Hardware and the Network: The Basics

Application softwareEHR, PMS, Outlook®, MS Office ®Decision support

ServersApplication softwareImagesFax and email

User DevicesWired PCsWireless PCs

Scanners

Diagnostic Equipment (ECG, Spirometer)

MessagingInternalExternal

NetworkLocal area network (LAN) withinWide area network (WAN) between

Interfaces between systems

What are the key adoption challenges?

1. Cost2. Intimidation3. Lack of management capability4. Lack of IT experience5. Lack of desire, will, compelling need

Environmental challenges

Where do I start? Where do I get advice? Are others going to pay me to have an HER, or

will others pay for my EHR? What is the role of health systems and their

ability to provide IT to independent medical practices?

What’s the role of QIOs?

21st Century Care Innovation Project Transforming Primary Care with KP HealthConnect

Introduction to KP HealthConnect

What is Kaiser Permanente HealthConnect?

• More than just an electronic medical record• The development and deployment of a highly-

sophisticated information management and delivery system

• A program-wide 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 and support the KP Promise

KP HealthConnect Supports:

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.

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 email.

• 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

• We reduce the cost of care and improve visit experiences.

• We decrease the cost of paper medical records.

• We maximize appropriate revenue capture.

• Our pricing matches our risk.• We administer benefits and

new products both correctly and efficiently.

• We continually improve operations.

Quality OurPatients Can Trust

Personal &Convenient Service

Affordable Health Care

Program Scope

Lab

Radiology/Imaging

Others (immunizations, EKG, dictation)

Outpatient Pharmacy

Health Plan

ClaimsProcessing

Membership/Benefits

Benefits Accumulation

PricingSystem

Web Access Portal

Data Warehouse / EDR Enterprise Data Repository

Ancillaries Finance

Capital Planning

General Ledger

FinancialReporting

Care Delivery Core

Outpatient Inpatient

Scope of KP HealthConnect Suite

Scheduling

Registration

Clinicals

Billing

Admission, Dischargeand Transfer

Health InformationManagement

Clinicals

Billing

Pharmacy

EmergencyDepartment

Operating Room

Health InformationManagement

Ref

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l & U

tiliz

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anag

emen

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Members Can Actively Participate in Care

www.kp.orgMember Web Portal

Make/change appointments

Send messages to doctor

Check lab results

Access health Information

Access medical record

Account summary

Care Delivery Core

Outpatient Inpatient

Scope of KP HealthConnect Suite

Scheduling

Registration

Clinicals

Billing

Scheduling

Admission, DischargeAnd Transfer

Clinicals

Billing

Pharmacy

EmergencyDepartment

Operating RoomReview eligibility & benefits

Member’s View Through members.kp.org

Member’s View Through members.kp.org

Progress to Date

Nearly 5 million members have a partial or complete KP HealthConnect ambulatory record

All members will have one by mid-2008

Access to KP HealthConnect through kp.org is live in 7 of our 8 regions

More than 1.7 million members are currently registered on kp.org

Two KP hospitals are now live with KP HealthConnectA total of 36 hospitals will be live by the end of 2009 (including hospitals currently under construction)

By the end of 2006, the KP HealthConnect practice management deployments will be complete

Percentage of KP Population Coverage by Year/Suite

20042004

2005

2005

2005

2006

2006

2006

2006

2007

2007

20072007

2008

2008

2009

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Practice ManagementBilling & Registration

Outpatient Clinicals andDecision Support

Inpatient Clinicals KP HealthConnect Online

Population coverage based on actual & planned finish dates

“Blue Sky”

In 2015, 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.

Our Blue Sky Vision

Members are Utilizing KP.org Features

Number of kp.org registered users: 1,706,009Lab tests released online: 4,529,426 Test viewed online: 1,437,699Member messages sent: 624,461Average messages sent per member: 2.0 Visits to past office visits: 85,846Visits to Your future appointments: 279,857

As of July 2006

Online Access Is Improving Member Experience

Preliminary research in the Northwest region shows that member usage of online features is resulting in statistically significant:

Reductions in primary care visits Reductions in telephone callsHigh member satisfaction with online alternatives

21st Century Care Innovation Project

Creating a Patient-Centered Focus, where the care team and work flow are organized to meet the needs of the population

Empowering Members to be the “real” primary care provider with the care system providing people and tools to support the member

Supporting Panel Ownership by the primary care provider which enables caring for a person as a total being; earlier intervention in disease progression; and greater oversight of members with chronic disease

Offering Alternatives to 1:1 Face-to-face Office Visits which can build capacity and give members choice

Telephone visits are enabled and enhanced by KP HealthConnect

With KP HealthConnect…All the relevant patient information are easily accessed by the provider during a telephone visit.“Real-time” processing (notes, lab-orders, Rx orders) is possible during a telephone visit. Work is completed during the telephone visit with few or no hand-offs required.

While telephone visits could have been (and were on a small scale) provided previously, Whittier has found that KP HealthConnect enables greater ease, efficiency, and scale.

Case: Telephone Visits @ Whittier

Providers report that telephone visits are a better way to manage patient demand

Whittier Family Medicine Provider Survey, 4/2006(10 Providers, 1: strongly disagree; 5: strongly agree)

4.7 4.6 4.6

1.5

0

1

2

3

4

5

Model makes my day easier

Better way to managepatient demand for

care

Model gives me more control over

my day

I want to go back toold system

Whittier Family Medicine providers report that the phone visits gives them more control and is a better way to manage patient demand.

The Medical Assistants for the physicians doing a higher quantity of phone visits can use that time to assist in Population Care Management duties and outreach for clinical strategic goals (PAP, Mammo, & Pneumonia vaccine reminders)

Case: Telephone Visits @ Whittier

Members are very satisfied with the telephone visits.Members who had a telephone visits are

highly satisfied.87% ranked their satisfaction with the telephone visits a “5” on a scale of 1-5 (low/high).

80% of members surveyed would be willing to “pay” something for a telephone visit.

Whittier is learning that members need to be made aware of their options.

Whittier is working on “educating”members of their options and recently had a test where all calls coming in for a physician was triaged first by an RN. Almost 40% of all calls resulted in a telephone encounter.

Members Satisfaction with Telephone Visits

87%

8%

5%

5 = Highly Satisfied

4 = Satisfied

3 = Neutral

Members' Willingness to Pay for Telephone Visits

0%

5%

10%

15%

20%

25%

$0 $5 $10 >$15 $ - Uncertainhow much

Dollar Amount

Perc

ent R

espo

ndin

g

Note: KP is pursuing detailed surveys with Whittier members in July/August 2006 to get in-depth understanding of member reaction to telephone visits.

Case: Telephone Visits @ Whittier

Whittier is not doing the same work differently but different work.

Old Model New Model (in testing)

1. Most patient-provider interaction occurs face-to-face in the office.

2. Medical Assistants spend the majority of time processing patients, even those coming in for “inappropriate” office visits.

3. RNs triage and book follow-ups for nearly all patients requesting appointment with physician.

1. Patient has option to speak to provider over the phone or email if appropriate.

2. Medical Assistants are able to use their time to help proactively care for patients with chronic conditions, e.g. lab reminders, outreach, etc.

3. RNs triage and offer members on alternative care options and handle appropriate calls themselves.

We believe we are building capacity in our care team.

Camp Springs Touches (Visits & Telephone) / Physician FTE

250

450

650

850

1050

Dec

-05

Jan-

06

Feb-

06

Mar

-06

Apr

-06

May

-06

Jun-

06

Jul-0

6

Aug

-06

Sep

-06

Oct

-06

Nov

-06

Dec

-06

Access: Increasing capacity to touch more of patients on our panel

Source: Clarity Warehouse. Report run by: National Analytical support. Note: Telephone includes TAVs and telephone encounters.

791

292~14 touches/ day/physician

~ 42 touches/ day/physician

From 2006 utilization for Camp Springs membership,

•Office Visit rate = 0.16

•Telephone rate = 0.27

Access: Increasing capacity to touch more of patients on our panel

Comparison of 21st CCI teams Percent of Panel Touched - Office or Phone Encounter

2006Team 1

73%Team 2

69% Team 3 62% Team 4

51%

Camp Springs76% Team 5

56%

0%

20%

40%

60%

80%

100%

Source: Clarity Warehouse. Report run by: National Analytical support. Note: Telephone includes TAVs and telephone encounters.

•76% of CS IM members engaged by office visits and phone encounter during 2006.

0%

5%

10%

15%

20%

25%

Jan-06 Feb-06

Mar-06

Apr-06 May-06

Jun-06 Jul-06 Aug-06

Sep-06

Oct-06Nov-06 Dec-06

Camp Springs IM - % of paneled members with PCP encounter by month

Average daily ‘Touches’before panel management

0

10

20

30

40

50

60

70

80

1

No.

of D

aily

Con

tact

s

Office visits0

10

20

30

40

50

60

70

80

1

No.

of D

aily

Con

tact

s

US mail contacts

RN and HCT contacts

Email contacts

Phone contacts

Annual health goals

"Fast Track"'s

Group visits

Office visits

CEC Presentation 5/2/2005 Gerard F Livaudais MD, MPH Kaiser Permanente Hawaii Region

Average Daily ‘Touches’ with panel management

More Touches -- Less Visits

“Many Hands Make Light Work.”

What can we do?

Demo Site: http://devinternal.or.kp.org/im/demo/login.cfm

GreenField Health

Primary care practiceResearch and development on delivery system designLeadership in local and national performance improvement initiatives (e.g., ACP, AAFP, IHI, AAMC, etc.)

Services:1. GreenField Health – 6 physicians2. Practice management services3. Teaching and consulting in practice performance

improvement

Physician Workspace

Users

User Devices: Wired PCs Telephones

Staff Workspace

Users

User Devices: Wired PCs +

Printers TelephonesDigital Vitals

Devices for Clinical Users

Pen Tablet•Battery•Screen•Stylus for point and click•Wireless Antennae•Virtual Keyboard•Voice files•Handwriting recognition•All Applications on the network•All network devices (printers, fax)

Convertible•Battery•Screen•Stylus for point and click•Wireless Antennae•Physical keyboard like notebook•Voice files•Handwriting recognition•All Applications on the network•All network devices (printers, fax)

Docking Stations•Power•Battery recharges•Node on the network•Nothing without a computer (either above)

LCD Screen (no touch) Physical Keyboard w/Touch Pad

Physical Keyboard (plus mouse)

Options that connect to Docking Station:

Number of Encounters by Type per Patient per Year

Phone Care4.9

Office Visit1.7

E-mail4.8

Beyond the Visit at GreenField Health: Distribution of Patient Encounters

EE--visitsvisits

The Myths are Not True• Patients are very respectful of clinician time• Managing challenging patients• Patient are connecting to us as the trusted source, not

besieging us with garbage from the internet• A great opportunity for managing challenging patients• Doctors will not participate

Visit Prep• Eliminates the need for some visits• Makes visits shorter and more satisfying• Eases documentation

Issues of Reimbursement• Easiest in integrated models• Spreading adoption by insurers• In addition to direct payment, consider:

Impact on overall productivityStickiness – patient allegiance to your practiceThe energy of innovationIt’s the right thing to do

Secure Messaging and E VisitsSecure Messaging and E Visits

Knowledge Management

• Access to the right information at the right time to support the continuous healing relationship

• Understanding the needs of our patients if they are in the office or at home – population management

• Decision support to make the right thing the easiest thing to do

“We Know You”

• Numerous options exist within the EHR to allow providers to better “know” their patients.

SnapshotDemographicsProblem ListsSocial DocumentationHealth Maintenance AlertsFlowsheetsQuestionnaire

Prescribing

Refills

Knowledge Management

Summary

• Redesigning our practices around our patients’ needs is our goal

• IT enables changes that we have always wanted to make

• The EHR is a Trojan horse - Use the great magnifier at the moment of flexibility to improve all of your processes, clarify roles and responsibilities and be more patient centered

Kaiser Permanente

GreenFieldHealth

Thank You!

Questions?