... a KAISER PERMANENTE Innovation

IndiGO:Tailoring Guidelines to Individuals

David M Eddy MD PhDFounder and Chief Medical Officer Emeritus

ArchimedesSan Francisco, CA

The Problem• Quality and cost of healthcare are largely determined

by guidelines• Current guidelines are clunky

– Designed for groups of people, not individuals– Designed for one risk factor at a time

E.g. blood pressure, cholesterol, glucose, …– Use sharp cut-points

E.g., “Treat if BP>140”– No information about effects on health outcomes– No basis for informed decisions– Implicitly assume all interventions are equally important

Today’s guidelines are too simplisticMrs. Smith and Mr. Jones

Who should be treated for hypertension?

• Age• Height• Weight• Smoker• Diabetes• History of MI or stroke• SBP• DBP• LDL• HDL• FPG• Currently on hypertension meds

Mrs. Smith425’6”244nonono142881166189no

Mr. Jones455’11”345nonono1388017835116no

• Risk of MI or stroke in 5 years• Absolute risk reduction if lower BP

1.2%0.4%

7.1%2.1%

“Individualized Guidelines”IndiGO

• Uses all the important information in a clinically realistic way• Spans multiple conditions, risk factors, treatments in a single

“integrated guideline”• Takes into account more than 30 patient variables• Identifies all potentially beneficial treatments• Calculates and displays patient’s current risks, and effects of

treatments– One-by-one and in combinations

• Made possible by EHRs– Gets patient-specific data from EHR– Presents results through EHR

IndiGO is based on the Archimedes Model

• Archimedes Model – Spans multiple diseases– Is “physiologically and clinically realistic”

Represents physiology pathways Is continuous

– Includes care processes, behaviors, utilization, costs …– Is built from and validated against publicly available data

National datasets (e.g., NHANES, NACS, NHDS) Clinical trials (e.g. NIH diabetes trials) Epidemiological studies (e.g. ARIC)

– Can be customized to particular settings

Some uses of IndiGO

• Individual patient-physician decision making– During a patient visit– Direct patient access

• Prioritize outreach programs• A personal health score• A population-level health score

Independent evaluation by Care Management Institute

• High physician acceptance– “All doctors agreed it helped them make the best

decisions.”

• High patient acceptance– “It was pretty impressive, the tools and the outcomes and

how it could show what is going on in my life. It made an impact.”

– “For me it was more like the doctor wants us to be a participant in our own health you know. I guess without us participating, the results aren’t going be very good.”

Independent evaluation by Care Management Institute

• Increases patient adherence– Candidates for statins showed 6-fold increase in use

• Improves outcomes– A 13% reduction in 5-year CVD risk, compared to EHR and

panel support tool alone– For every 1 million members, 1400 heart attacks and

strokes averted annually• Reduces hospitalizations and costs– Estimated $98 million saved annually

Adoption is good• Kaiser Permanente– Southern California – Colorado– Georgia

• Two ONC Beacon communities– Colorado– Tulsa

• ACO pioneer– Fairview

• Seven others in progress • More than 15 others in active discussion

This afternoon:Uses of IndiGO for ACOs

• Individual patient-physician decision making– During a patient visit– Direct patient access

• Prioritize outreach programs• A personal health score• A population-level health score