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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
atio
nshi
p
Serv
ice
Rel
iabi
lity
The Operating System
© 2007, Charles Kilo, GreenField Health
Management Systems
Rel
atio
nshi
p
Serv
ice
Rel
iabi
lity
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
erra
l & U
tiliz
atio
n M
anag
emen
t
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?
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