#HASummit14

Session #22:Integrating Process and Informatics at

CO Kaiser Permanente to Achieve Benchmark Cardiovascular Outcomes

John A. Merenich, MD, FACP, FNLA

Medical Director, Clinical Pharmacy Cardiac Risk Service, KPCO

Medical Director, Clinical Informatics & Decisions Support, KPCO

Associate Clinical Professor of Medicine, University of Colorado

Pre-Session Poll Question

What is the biggest challenge/barrier in your care setting to prevent stroke and heart attacks?

a) Inconsistent misunderstood changing guidelines

b) Lack of timely and accurate metricsc) Dependence on physicians to do all the

interventionsd) Patient resistance and non-compliancee) Time and money

#HASummit14

Poll Question #2eful***?

2

What is the priority of implementing a stroke and heart attack prevention program in your care setting?

a) Top priority – Our current outcomes are known, and they are NOT optimal. Clearly more needs to be done.

b) High priority – Our current outcomes are above average, but we feel there is need for improvement.

c) Moderate priority – We are satisfied that we have done what is needed in this area but don’t plan to do anything different for now.

d) Low priority – We would like to do more, but our outcomes and baseline metrics are unknown and/or our implementation challenges are overwhelming.

e) Unsure or not applicable

#HASummit14

Key Messages• The Kaiser Permanente of Colorado (KPCO)

approach of the past 15 years has resulted in benchmark outcomes

• Technology/Informatics support has been essential, but people and process factors were /are the primary drivers of cardiovascular (CV) outcomes• Docs can’t and SHOULD NOT be solely

responsible for CV outcomes• Cardiovascular GAPS are the bridge

between Process and Technology• Risk stratifying to match resources to

appropriate level of patient need helps identify opportunities and prioritize resources

• Tools to increase individualized, personalized care and Shared Decision Making are critical

#HASummit14

Kaiser Permanente by the numbers

Nation’s largest nonprofit health plan

Integrated health caredelivery system

9.1 million members

17,000+ physicians

49,000+ nurses

175,000+ employees

Serving 9 states and the District of Columbia

37 hospitals

618 medical offices/ outpatient facilities

$50.6 billion operating revenue*

Scope includes ambulatory, inpatient, ASC, behavioral health, SNF, home health, hospice, pharmacy, imaging, laboratory, optical, dental, and insurance

4

#HASummit14

Colorado KP: Population Health Management Priorities in 2015

Get more members self(co)-managing their care• Get personalized ACTIONABLE care gap information

directly to the member• Easy access to educational, coaching, support

materials

Focus on maintaining Health & Wellness• Earlier detection and PREVENTION of chronic diseases• Slowing the progression of chronic diseases

Reduce cost of providing Health Care (Triple Aim)• Reduced ED visits and hospital admissions• Promote more efficient care team collaboration• Transition from Quality to VALUE dashboards

#HASummit14

PATIENT-CENTERED focusIntegrated teamsCoordinated CarePatient as team member

PEOPLE

Guidelines and protocolsDriver diagrams/Process mapsMETRICS/METRICS/METRICS ***GOVERNANCE***

PROCESS

RegistriesElectronic Medical RecordWeb and other resources ACTIONABLE data

TECHNOLOGY

80%

KPCO winning strategy over the years

#HASummit14

• Gap between what we know should be done (evidence base) and what was actually happening for patients with known CAD

• High recidivism even when meds for CAD started

• Focus of resources on high-cost classic rehab

• MDs seldom had time to convey messages, start, and monitor therapy

Flashback to 1996: The first KPCO problem to be solved…

#HASummit14

88% Reduction in all-cause mortality

Technology & Tools• Electronic medical record• Computerized disease registry

Information• Development of protocols to

improve outcomes

• Rehabilitation Program

• Medication Management

• Prompts and reports to support protocols – accessible to all members of care team

Teams• Physician• Nurse• Clinical Pharmacist

8

Collaborative Cardiac Care Service

#HASummit14

The solution

9

In 1996, KPCO developed the Collaborative Cardiac Care Service (CCCS) with the goal of improving the health of patients with CAD.Team consists of a nursing team (the KP Cardiac Rehabilitation program), a pharmacy team (the Clinical Pharmacy Cardiac Risk Service), and Primary Care and Specialty physicians.Collaboration systematically occurs with patients, primary care physicians, cardiologists, and other health care professionals to coordinate proven cardiac risk reduction strategies for patients with CAD.Evidence-Based Intervention includes activities such as lifestyle modification, medication initiation and adjustment, patient education, laboratory monitoring, and management of adverse events. All are all coordinated through CCCS.

#HASummit14

HealthTRAC registry system (separate from EMR) with “slice and dice” stratification and drill-down function

#HASummit14

Data drove next steps: ICVHThe majority of CVD events occur in patients without previous history of ASCVD events**

**Colorado Kaiser Quarter 1 2014 CV event analysis

“First event” patients 65%Age (21-98) Average 66 yrNot on statin 61%Smokers/unknown status 30%DM 17%BP not controlled 22%CV Risk Unknown 21%Low Framingham Risk 10%Moderate Framingham Risk 10%

#HASummit14 12

Integrated Cardiovascular Health (ICVH)

• ICVH team has met quarterly for last 10+ years

• Replaced all the previously “siloed” governing groups• Puts holistic patient back in the middle

where it belongs• Representatives: PATIENTS, MDs (primary

and specialty), Nursing, Pharmacy, Operations, Lab, Informatics, Nutrition, Prevention

• Owns and prioritizes the Regional ICVH Driver Diagram

• Coordinates care across teams• Determines Informatics needs/priorities

#HASummit14

People and Process: You need a driver diagram

“If you don’t know where you are going, you’ll wind up someplace else.” (Yogi Berra)

#HASummit14

LDL screening and CV risk determination

&

Statin for patients with diabetes

Statin, ASA, and BP control for high-risk groups

Exercise as vital sign

Encourage consideration of statin for moderate risk

“Test the Untested”

“Treat the un/under treated”

The “keep it simple” version:Integrated Cardiovascular Health Focus Last 5 Years On Primary Prevention

#HASummit14 15

Initial request:I just need a list of my patients with…

REALLY???(The aspirin example)

• Patients on ASA …takes you only so far!!!• Where is ASA use documented; how often

to determine “current” user• Who is at risk and needs ASA; what dose?• Other antiplatelet/anticoagulation meds?• Age, gender, risk factors, changing

evidence base• Risk/Benefit for individual• On other CV-risk reducing agents?

#HASummit14

FROM List and rules……

Aspirin IndicatedOne or more of the following: · Age 18-80 And ASCVD And Not On Aspirin(ASA) And Not On Anticoagulant Medication And Not

On Antiplatelet Medication · Age 18-80 And CV Risk > 10% And ASCVD Equivalent And Not On Aspirin(ASA) And Not On

Anticoagulant Medication And Not On Antiplatelet Medication · Age 18-80 And CV Risk > 20% And Not ASCVD or ASCVD Equivalent And Not Diabetes And Not

On Aspirin(ASA) And Not On Anticoagulant Medication And Not On Antiplatelet Medication · Age 40 to 80 And Diabetes And CV Risk > 10% And Not ASCVD or ASCVD Equivalent And Not On

Aspirin(ASA) And Not On Anticoagulant Medication And Not On Antiplatelet Medication · Male Age 45-69 And CV Risk 15-19% And Not Diabetes And Not ASCVD or ASCVD Equivalent

And Not On Aspirin(ASA) And Not On Anticoagulant Medication And Not On Antiplatelet Medication

· Female Age 55-69 And CV Risk 15-19% And Not Diabetes And Not ASCVD or ASCVD Equivalent And Not On Aspirin(ASA) And Not On Anticoagulant Medication And Not On Antiplatelet Medication

Does this Patient meet KPCO criteria for ASA today…… YES or NO??

…TO GAPS:

#HASummit14

Lists to Actionable Data

Val

ue

Complexity

List

ActionableData

Elements of a Patient List• A set of patients sharing a

common set of characteristics such as diagnosis or medications.

Elements of a complete registry• Integrated with HealthConnect • Individualized care pathways• Integrated data sources • Flexible design• Automated outreach • Integration of data from multiple

sources• Rule transparency• Actionable care gaps• Legally compliant (HIPAA,

HASP)• Automating elements of clinical

workflow

Clinical Decision Support

Population Management

Cohort

Population Based Rules

Individualized Rules

#HASummit14 18

Go to the “GREEN (bottom) LINE”

#HASummit14

From Lists to ACTIONABLE GAPS:These patients need to do something!

#HASummit14

Constantly update and revise CV GAPS

Individualized for every adult, Yes or No for:

Need to screen for lab or blood pressure or

Statin neededHigh DOSE statin indicatedAspirinBlood Pressure MedAspirin GAP NEWSmoking documentation and counsellingDietitian visit revision

#HASummit14

Getting ALL the GAPS into the workflow….HealthTRAC Landing Page

#HASummit14 22

The “World According to Gap”

GAPS:• Simplified output for complex decisions

• Individualized/personalized• Can be cofigured to accommodate for patient

preference• Easy to aggregate and display across disease state

• Single source of (synchronized) truth for all patient actions

• Truly actionable• What to do and NOT do (e.g. Choosing Wisely

efforts)• “Currency” and lead metric for Informatics tools and

process effectiveness (i.e. how efficiently GAPS are closed)

• Correlate with cost both short- and long-term outcomes

#HASummit14 23

GAP “Solutions”: “Auto” ordering”

Corresponding Lab or procedure to close the GAP automatically ordered in our Epic system

Problem list status Active

MD Consent (Enrollment

in Population Program)

GAP

#HASummit14 24

GAPS in the workflow:Transparency, utility, context, andone-stop shopping

...and real-time decision support

#HASummit14

Dynamic, Individualized

#HASummit14

Decision support for Aspirin Indication: (Age/Gender specific Risk vs Benefit Shown)

#HASummit14 27

GAPS Drive right to the Member level and view:“Personal Action Plan”

Patient with CV GAPS in the EMR:Clicks On Action Plan in KP.org…

#HASummit14

Measure and share unblinded metrics often to stimulate friendly completion and cross sharing of best practice

#HASummit14

Poll Question #3eful***?

29

What would help your organization improve CV care, and where would you focus?

a) EMR process management tools

b) Actionable lists (gaps) based on advanced decision support

c) Direct to consumer/patient portal tools

d) Lead metric outcomes measures (e.g. number of patients on statins, BP control) compared to benchmarks

e) “Slicer dicer” including utilization data for discovery at all business levels

***Recognizing that they are all important and would all be included in an optima solution

#HASummit14 30

Cardiovascular Disease Value Dashboard Prototypes

Quality: Cholesterol Management for Patients with Cardiovascular Conditions (Screening), Cholesterol Management for Patients with Cardiovascular Conditions (Control LDL-C Level<100 mg/dL)Resource Use: Inpatient, E&M, Surgery and Procedures, excludes Pharmacy

Relative Resource Use by Relative Quality, HEDIS 2009Medical Use and Care for Cardiovascular Conditions

NC not reported, no E&M data for Medical Use composite

GHC

SC

CO

GAHI

MANW

OH

0.80

1.00

1.20

0.40 1.00 1.60

Relative Resource Use Indexed Ratio

Rel

ativ

e Q

ual

ity

Ind

ex

HIGHER QUALITY, LOWER RESOURCE USE

LOWER QUALITY, LOWER RESOURCE USE

HIGHER QUALITY, HIGHER RESOURCE USE

LOWER QUALITY, HIGHER RESOURCE USE

#HASummit14

Major Coronary Events in KPCO have decreased by more than 60% the past 10 years(THIS DOES WORK!!!)

#HASummit14

| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

MCE/MCVE costs saved in KPCO

MI:2,375 fewer events per year over the last decade (accounting per population growth)

CVA:165 fewer strokes per year over the last 3 years (accounting per population growth)

#HASummit14

Lessons Learned

33

• Informatics and Decision Support must be developed and structured

by processes and people implementing them• Risk stratify, divide, and conquer!

• Measure, share, adjust…over and over• CV outcomes are the purview of ALL providers—not just Docs

• Indeed, CV care is largely empiric and the purview of teams and non-MDs...including the patient!!

• Allocate tools and resources to based on CV risk• Develop tools to highlight ACTIONABLE PERSONALIZED GAPS

• NOT creation of endless LISTS• GAPS must be accurate, timely, specific to patient, delivered at the

time and place needed• Quality first….Value will follow for the most part

#HASummit14

Analytic Insights

AQuestions &

Answers

34

#HASummit14

Choose one thing…

35

Write down one thing will you do differently after hearing this presentation

#HASummit14

Thank You

36

#HASummit1437

Session Feedback Survey

1. On a scale of 1-5, how satisfied were you overall with this session?

1) Not at all satisfied

2) Somewhat satisfied

3) Moderately satisfied

4) Very satisfied

5) Extremely satisfied

2. What feedback or suggestions do you have?

#HASummit14 38

Upcoming Sessions

Breakout Sessions – Wave 4 (1:15 PM – 2:00 PM)

26) Panel – How Community Hospitals Thrive with AnalyticsJohn Wadsworth, Vice President, Technical Operations, Health Catalyst

27) Quality Improvement in Healthcare: An ACO Palliative Care CaseDr. Robert Sawicki, MD, Senior Vice President, Supportive Care, OSF HealthcareRoopa Foulger, Executive Director, Data Delivery, OSF HealthcareLinda Fehr, RN, Division Director, Supportive Care, OSF Healthcare

28) Clinical Standards Work To Improve Evidence-Based Care Delivery: A How-To WorkshopCharles Macias, MD, MPH, Chief Clinical Systems Integration Officer, Texas Children’s HospitalTerri Brown, MSN, RN, CPN, Assistant Director, Clinical Outcomes & Data Support; Research Specialist, Center for Research and EBP, Texas Children’s Hospital

29) Five Months to Improvement: How Stanford Built an Improvement Program the Gets ResultsSpencer H. Kubo, MD, Associate Professor of Radiology (Pediatric Radiology), Stanford University Medical Center

30) Breaking Down Silos: Resolving Academic, Medical, and Research Interests Once and for AllSamuel L. Volchenboum, MS, MD, PhD, Assistant Professor of Pediatrics, Director, Informatics Program, The University of Chicago Medicine)

Location

Imperial Ballroom B

Imperial Ballroom A

Grand Salon

Murano

Venezia