Embedding Guidance in the Kaiser Permanente EHR · 3 About Kaiser Permanente One of the USA’s largest nonprofit health plans Integrated health care delivery system Serving 9 states
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Embedding Guidance in the Kaiser Permanente EHR Wiley Chan, MD Kaiser Permanente Care Management Institute Oakland, CA, USA
Kaiser Permanente Care Management Institute Oakland, CA, USA
Statement of Disclosure Wiley Chan, MD
• I have no commercial or academic conflicts of interest • Employment: Northwest Permanente Medical Group, which works
exclusively with the Kaiser Foundation Health Plan in the US • Member: US National Heart, Lung and Blood Institute (NHLBI)
Expert Panel on Integrated Cardiovascular Risk Reduction • Co-Chair: NHLBI Implementation Science Work Group
• Member: State of Oregon Health Evidence Review Commission (HERC) • Chair: HERC Evidence-Based Guidelines Subcommittee
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About Kaiser Permanente One of the USA’s largest nonprofit health plans
Integrated health care delivery system
Serving 9 states and the District of Columbia
9.1 million members
17,000+ physicians
49,000+ nurses
175,000+ employees
37 hospitals
618 medical offices and outpatient facilities
$50.6 billion operating revenue*
Scope includes ambulatory care, inpatient care, primary care, specialty care, behavioral health, Ambulatory Surgery Centers, Skilled Nursing Facilities, home
health, hospice, pharmacy, imaging, laboratory, optical, dental, and insurance
*Source: 2012 Kaiser Permanente Annual Report
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Integrated health care delivery system: Health Plans, Hospitals (in some Regions), Medical Groups with aligned incentives and shared governance. We own our hospitals in some Regions, but not all. Where we do not own hospitals, “integration” still encompasses health plans and medical groups with shared mission, incentives, and governance. In Regions where we do not own the hospitals, success factors include: close alignment between medical group and contract hospitals members represent a substantial portion of the hospital’s business
Overview Guidelines must be implemented to impact health
outcomes Guidelines must be rigorously, transparently evidence-based and contain
actionable recommendations to be implementable Robust tools exist to embed guidance in Electronic
Health Records (EHRs) High-quality evidence of effectiveness in improving health care process
measures (Lobach. AHRQ April 2012) Tools aimed at patients are rapidly proliferating
Effective use of EHR tools requires thoughtful planning, management and full integration into health care delivery system workflows and operational infrastructure
EHR Content & Decision Support That Get Used
Based on reliable guidance • Evidence based • Accurately targeted
Modal alerts (force user to interact with alerts) Pieces of content that do one thing quickly & well
• All-encompassing content not generally well accepted
More efficient than alternative methods • Easy to navigate • Streamlines workflow (eg, ordering multiple disparate items) • Embedded guidance for Clinician, Staff, Member
Do it right the first time
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Accurate targeting is aided in KPNW by our use of Active Problem List entries to trigger CDS. Primary Care Clinicians “own” the Problem List for their patients. It’s obvious why a particular patient is triggering CDS, and how to fix the problem if it’s not accurate. But it requires active monitoring of the “gap” between data-driven registries and our Problem-List-driven “Action List.” Suspected Diagnosis functionality is built into PST for ACVD, DM, and HTN, as of September 2009.
EHR Content & Decision Support That Get Used
Fully integrated into standard workflows • Developed in collaboration with end-users • Right place & right time • Targeted toward lowest permissible and desirable scope of practice • Fully supported by implementation tools and training
Actively promoted • High-level Leadership support • Aligned with organization’s priorities • Aligned with and supports improvement in performance metrics • User training
Centralized, coordinated governance • Aligned clinical guidance • Judicious use of decision support
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These are all key requirements. However, nothing happens without high-level leadership support, which in turn drives creation of performance metrics, which in turn leads creation of EMR content, CDS, & workflow agreements. The last critical step is to invest in user training.
KP National HTN Algorithm
SmartSet: Hypertension Hypertension SmartSet
Triggered by Encounter or Problem List Diagnosis Triggered by Reason for Visit
Search for SmartSets
SmartSet: Hypertension
Orders Can be Defaulted
Hypertension SmartSet
Expandable Sections with Embedded Guidance
Hyperlink to Web Portal
Contains All the Tools Required for Point-of-Care
SmartRx: Alternative Order Type Diagnosis or Condition
into Order Field
Link to SmartSet
Hypertension SmartRx Hyperlink to Web Portal
Embedded Guidance
Alternatives in Preferred Order
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Best Practice Alert: Aspirin
Highly Utilized, Single-Purpose Best Practice Advisory
Programmable Triggering Logic
Best Practice Advisories
Defaulted Link to SmartSet
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Here’s a BPA and its associated SmartSet that are very tightly focused.
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Best Practice Alert: Aspirin SmartSet
Defaulted Medication Order & Patient Instructions
Best Practice Advisories
Medication Order Placed
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Medication orders and Patient Instructions are defaulted, so clinician has only to Accept/Sign, once s/he launches the SmartSet.
Best Practice Alert: Aspirin Patient Instructions
Patient Instructions Generated
Best Practice Advisories
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These Patient Instructions appear in the AVS by default, but can be over-written.
PST Panel View Patient Support Tool: Panel View
Sort Panel by Various Criteria
“Gap Score” Constructed to Reflect Clinical Importance
of Care Gaps
“Y” Denotes Membership in Registry Color Reflects Clinical Importance of
Registry-Specific Care Gaps
Search Panel for Specific Care Gaps
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The PST fully supports Outreach by a Primary Care Health Care Team, or Module An entire panel can be sorted by Gap Score, specific Care Gaps, birthday (supports “birthday letters”), Date of Last Visit, etc. Gap Score is an expert-opinion system to rank deficiencies in clinical care. NW Primary Care Clinicians use PST routinely & are very focused on reducing their entire panel’s gap scores. A “Y” in a Chronic Disease Column indicates membership in a Registry, which is based on a qualifying active Problem List Diagnosis Code. Thus membership in the Registries remains under the control of the Primary Care Clinician. However, we also maintain “Suspected Diagnosis” functionality, where we place an “S” in a column for people meeting other criteria suspicious for the condition (eg, Encounter Diagnosis Code, lab values, pharmacy dispenses, procedure codes). Color codes indicate the presence of a Care Gap related to that condition, with Red indicating more important Care Gaps and Green indicating no Care Gaps. Detailed panel queries are supported (limit by age, gender, LDL-C, HbA1c, medications, etc).
PST Detail View Patient Support Tool: Detail View
Active Prescriptions
Registry Membership Care Gap Acuity (Color)
& Gap Score
Pertinent Labs
Care Recommendations Visits, Immunizations, Vitals, & CAD Risk
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In the Detail View, all of a members clinical care deficiencies are called out (in red), with relevant information displayed for various chronic diseases. Notice the detailed specifications required to drive PST and guide clinicians to specific actions. ACE and Statin flags, for example, have specific dose requirements, or an “Increase Dose?” flag is triggered. GFR <30 should alter Statin dose recommendations and Cr >2.5 should eliminate an ACE flag. NW PCPs typically print this out as part of the pre-visit summary. Many Health Care Teams have detailed workflows for the MAs to initiate conversations with members & pend relevant orders.
KPHC** Content
Maintenance*
Knowledge Representation
Knowledge Synthesis &
Maintenance^
Knowledge Integration
& Alignment*
EHR Clinical Content Guidelines/EBM
^ Includes Knowledge Discovery, Acquisition and Creation *Primary Focus Areas for KPNW Knowledge Management Team ** Kaiser Permanente HealthConnect and Related Applications
Governance Metrics
Usage Statistics Outcomes
Clinical Knowledge Management KPNW
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Requirements Definition
Design
Develop/Build Deploy/Champion
Measure/Evaluate
Maintain/Revise
Lifecycle of EHR Content Implementation
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During the more than 18 years of experience that KPNW and other KP regions have had implementing electronic medical records we have learned a few lessons. One of these is that when it comes to clinical content, it is not true that “if you build it, they will come”. There are probably thousands of hours of time people have invested in building content that has seldom or never been used. Why is that? Well, no doubt there are a variety of reasons. However, I submit that the overarching reason is due to a lack of attention to the entire spectrum of activities required to be successful. We have characterized that spectrum into what we are calling the “lifecycle of content implementation”. In the next few minutes, let’s introduce the 6 main steps. Then, through the course of the day, we will delve deeper into them.
Lifecycle of EHR Content Implementation Requirements Definition What problem are you trying to
solve and what are the explicit objectives?
Who are the stakeholders?
Who needs to be involved in the design? How? When?
What workflow processes are involved?
Requirements Definition
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I very frequently get calls or emails from people wanting help with creating a particular tool or piece of content. Often the person making the inquiry is already deep into creating or at least imagining a specific solution. Very frequently in that situation, after listening to the question or proposal, I respond by asking, “wait a minute, what problem are you trying to solve?” When I do this I amazed how often the person has real difficulty in answering that question. Very often they do not clearly understand the answer themselves. If they can articulate a response, not infrequently it is a partial response because it is a view from a limited frame of reference. Often they have not taken the time to consider who else might be impacted by the problem or benefited or impacted by the solution. Likewise, often the problem or the solution has been considered in isolation and not in the context of the workflow, care team, or care processes. Content often fails to be adopted or utilized because requirements definition has not been adequately performed.
2 min 5 min 20 min 10 min 10 min 10 min 2 min
Immediate or Not at all 0-7 days Hours-days 6-24 hours Immediate
or Not at all 0-7 days
Member identified:
Lipid screen needed
Member goes
to lab for lipid test
Leverage Point Identified
Member notified of
lipid results
Provider reviews lab
results
Member advised
to go to lab for lipid test
Lipid test ordered
Leverage Point Identified
Member sees lipid test result in KP.org
Lipid test results in Provider in-basket
Area of concern
Determining When/Where/How to Embed Guidance: Clinical Pathway Analysis
Lifecycle of EHR Content Implementation Measure & Evaluate Does the content reflect explicit
goals & metrics?
How will you measure its effects?
How will you evaluate your results?
When and how will you iterate based on data?
Measure/Evaluate
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OK. Well of course there’s more. How do we know if we are successful unless we measure and evaluate what we have done? And furthermore, how do we know what to even measure if we have not been explicit about what the goals are? The use of content is necessary but it sufficient in itself. We are only successful if via use we moves closer to specific desired outcomes. We will spend some time today talking about what we can measure and how, and how we will use this information to revise our content and/or our implementation approaches.
Effect of Best Practice Advisory Chlamydia Screening Rates (HEDIS)
Unblinded Internal Reporting of Performance Metrics
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Active Promotion of recommendations is another key to success. High-Priority Measures are chosen, based on evidence-basis, potential clinical benefit, and performance gaps Performance on these measures affect Incentive Compensation Pay for clinicians and staff KPNW Leadership routinely publicize and actively support efforts to improve performance on these and other important measures. Performance metrics for our High-Priority Measures are posted unblinded on our intranet By individual clinician, Module, Building or Department and Primary Care Service Area Promotes healthy competition to improve performance at all levels Primary Care Modules print and display results in their work area Note that the data can be exported to Excel. Other views allow comparisons between Office Buildings. Two of our core Regional metrics are the % of HEDIS metrics at or above the 90th percentile, and the % of HEDIS metrics at or below 75th percentile. Our goal is to have all HEDIS measures at or above 90th percentile by 2010. We post all of the HEDIS metrics on our intranet, but only at the Regional level. Only the top 8 High-Priority Measures are posted at the Individual, Building or Department, or Module levels. We also post selected HEDIS metrics publicly on the internet for anyone to see, but only at the Medical Office Building level. Important Issues for Metrics Simple & explicit, so users can easily tell why a given patient is a numerator failure & what to do about it. Focused on performance gaps & potential benefits Examples: Aspirin, Statin, ACEI versus LDL <100 and BP <140/90, in Atherosclerotic CVD and DM age >=40 Our first goal is to get people on ALL, then push for target LDL and BP. Simply getting people on ALL will improve LDL & BP control, and the biggest bang for the buck is from getting people on the meds, not from the titration. Aspirin evidence for DM is eroding (POPADAD, JPAD), but recommendation hasn’t changed BP Goal <140/90 versus <130/80 for DM, CAD, CHF, CKD This is partly because of the lack of evidence behind a more stringent goal of <130/80 in these groups, but also partly because of the difficulty in training & maintaining the front-line workflow for different BP goals in different clinical scenarios. LDL Goal <100 versus optional LDL Goal <70
Requirements Definition
Design
Develop/Build Deploy/Champion
Measure/Evaluate
Maintain/Revise
Lifecycle of EHR Content Implementation
KP.org: My Health Manager
Demographics section
Welcome Message
Cancer Screening Breast Cancer Screening (Mammogram)
Cervical Cancer Screening (Pap Test) Colorectal Cancer Screening
Heart Health LDL Cholesterol Blood Pressure
Chronic Health Conditions Diabetes (A1c Lab Test)
Asthma
Preventive Care Body Mass Index (BMI) Tobacco Use
General Clinical Guidelines Preventive Care Guidelines
Cancer Screening Guidelines Additional Screening Guidelines
Recommended Immunizations Schedule
Medications Adherent Non Adherent
KP.org Personal Action Plan
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Unlike other regions, KPSC’s Online PAP will show personalized status (whether due or not) service area-level instructions to close care gaps lots of linkages to our resources
KP.org Personal Action Plan: Medications
KP.org Personal Action Plan: Medications
Impact of KP.org Use on Quality of Care
Selected Measures/Pre-Post Matched-Control Study
*Thread = series of connected questions and replies; one patient-physician “conversation”.
Zhou YY. Health Affairs 2010;29:1370-1375
Among KP Southern California members with diabetes &/or hypertension, use of KP.org was associated with statistically significant improvement in 9 HEDIS measures evaluated, by 2.0-6.5%.
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60
70
80
90
100
HbA1cScreening
HbA1c <9% LDL-CScreening
LDL-C<100 mg/dL
BP <140/90 BP <130/80
Post: Non-Users Post: Users
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Goal: To evaluate the quality impact of secure patient-physician e-mail. Design, Setting, and Participants: Retrospective observational study in SCAL using 2005-2008 data from 35,423 members with diabetes and/or hypertension who used secure e-mail. A pre-post and a matched-control analysis were conducted. Patients who used secure e-mail were matched to patients who did not by baseline status on HEDIS measures, age, sex, primary care provider, and diagnostic cost group score. Outcome measures: For members with diabetes, performance on eight HEDIS measures: HbA1c screening and control, LDL-C screening and control, retinopathy screening, nephropathy screening, and blood pressure control (<140/90 and <130/80). For members with hypertension alone, performance on HEDIS blood pressure control (<140/90). Findings: HEDIS performance differences between members who used secure e-mail and those who did not ranged from 4.0% (BP control) to 11.1% (HbA1c control). In the matched control analysis, performance differences ranged from 2.0% (BP control) to 6.5% (LDL-C control). Two or more secure e-mail threads* were associated with a greater likelihood of better performance than a single thread on HbA1c and LDL-C screening, HbA1c control, and nephropathy screening. During study period, 556,339 secure e-mail threads contained 630,807 messages. The average thread contained 1.13 patient messages and 1.16 provider messages. In a pilot study of physician responses to secure e-mail with patients, one SCAL MD said, “I love this for diabetics. They can print the doses and numbers. They follow my instructions to the letter with e-mail. It’s easy, helpful, and better than playing phone tag.”
Summary: Embedding Guidance Robust tools exist to embed guidance at the point of care Guidance aimed directly at patients can greatly expand the
point of care • Convenient access to medical record and resources • Communication and transactions • Enhance patient engagement
Tools are necessary, but insufficient to affect health outcomes
• Every stage of EHR content implementation lifecycle is important • Full integration into health care delivery system workflows and
operational infrastructure is critical
Summary: Embedding Guidance EHR Content & Decision Support That Get Used
• More efficient than alternative methods Convenience for patients
• Integrated into standard workflows Offload clinicians Supported by training & implementation tools
• Developed in collaboration with end-users Improved workflow integration Enhanced acceptance by end-users
• Associated with reported performance metrics Simple and explicit metrics Focused on performance gaps & potential benefit
Summary: Embedding Guidance EHR Content & Decision Support That Get Used
• Aligned with organizations’ priorities Actively promoted and supported
• Centralized, coordinated governance Aligned with other content and with guidelines Carefully deployed, accurate, and rigorously maintained
• Patient tools that enhance engagement • Based on reliable guidance Accurately targeted Evidence-based
Guideline Developer’s Role • Write Evidence-Based, Implementable Recommendations
