Redesigning Health Care Delivery Systems

KP as a Disruptive Business Model Disruptive technologies and business models have been the mechanisms that brought affordability, consistent quality, and convenient accessibility to most aspects of our society.... [In health care], capitation actually encourages the development of disruptive business models within these integrated provider organizations. The Innovator s Prescription, Clayton Christensen, Jerome Grossman, MD, and Jason Hwang, MD Copyright 2010 Kaiser Permanente 2

Our Vision for the Future: Blue Sky Home as the Hub The home, and other settings, will grow significantly as a locale of choice for some care delivery An individual s care delivery support system has expanded to explicitly include other community and family resources Integration & Leveraging Medical services are integrated with wellness activities; care delivery processes are integrated with health plan operations IT functionality enables us to leverage scarce or specialized clinical resources - MDs, RNs and other clinical staff. Secure and seamless transitions Warm Handoffs - The human skill sets and operational processes to deliver care and service effectively, efficiently, and compassionately. Customization Occurs at any level of the members journey with KP (choosing health plans, cost sharing, individual care pathways, and communication modalities.) The member drives customization and KP responds. Copyright 2010 Kaiser Permanente 3

Our Strategic Imperatives Achieving our strategic imperatives will allow us to deliver on our strategy and be the model for the future of health care. Community Benefit Making a Measurable Impact on the Health of the Communities We Serve Strategic Imperatives Areas of Focus Transforming Care Delivery Achieving Best Quality and Service Leading Prevention and Total Health Leading Care for Chronic Conditions Best Hospitals Service Excellence Enabling Performance Through People Being the Best Place to Work Great People Workforce Effectiveness Health and Safety of Our People High-Performance Culture Implementing Infrastructure Realizing Value Care Delivery Settings Care Delivery Systems / Tools Health Plan Systems / Tools Business Systems / Tools Improving Cost Structure Bending the Trend Appropriate Utilization Care Delivery Efficiency Administrative Efficiency Growing into Capacity Growing Membership Expanding Access to KP Care Price Point and Sustainable Pricing Strategies Marketing, Products, Sales and Distribution Customer and Member Service, Administration and Retention Facility Enhancement and Geographic Expansion Collaboration & Alignment Working through Partnerships Copyright 2010 Kaiser Permanente 4

Our Investment in Technology: Kaiser Permanente HealthConnect The world s largest private-sector deployment of an electronic health record KP HealthConnect was implemented specifically to transform care and service delivery. Our greatest benefits are the resulting improvements in quality, service, and effectiveness of patient care. Copyright 2010 Kaiser Permanente 5

KP s IT Infrastructure Supports: Direct patient care, documentation, and communication between clinicians Communication with our patients Population management Decision support Performance reporting, management, innovation, and improvement Automated outreach to patients Health information online Copyright 2010 Kaiser Permanente 6

KP Clinical Content Tools and templates that facilitate the delivery of evidencebased medicine Dynamic decision-support tools that enhance quality and patient safety Drug-Drug Interactions Alerts Drug Allergy Alerts Best Practice Alerts Health Maintenance Reminders Alternative Order and Medication Alerts Patient education and tools to support self-care Copyright 2010 Kaiser Permanente 7

Transforming & Streamlining Modalities of Care By Catherine Chen, Terhilda Garrido, Don Chock, Grant Okawa, and Louise Liang, MD. Published in Health Affairs, March 2009. Deployed KP HealthConnect (EHR) and My Health Manager (PHR) in Hawaii Region in 2005. Impact between 2004 and 2007: Annual office visit rate: -26.2% primary care: -25.3% specialty care: -21.5% Total patient contacts: +8.3 % Quality and satisfaction maintained or slightly improved. Copyright 2010 Kaiser Permanente 9

Kaiser Permanente HealthConnect : Improving Patient Safety and Quality In one hospital site using barcode scanning linked to KP HealthConnect, the rate of medication errors declined by 57 %. Results in another region showed that with drug-drug interaction alerts in place, elderly patients on high-risk medications decreased 34 % from 2000 to 2006. Reduction in progression of diabetic nephropathy Improved pharmacologic intervention in coronary disease (aspirinlovastatin-lisinopril=all) Dramatic (75-90%) reductions in post-ami mortality Standardization of care orthopedics, anesthesia, obstetrics, oncology, inpatient nursing care planning Copyright 2010 Kaiser Permanente 10

The Care Management Institute 1997-2005 Mission: Making the right thing easier to do. Identify the right things Evidence-based medicine Measurement Successful practices Make the right things easier Focus on the delivery system Technology to support effective work Networks of individuals and groups Copyright 2010 Kaiser Permanente 11

The Care Management Institute 2005 - present Keeping patients at the center of care Harnessing technology Integrating capabilities across Kaiser Permanente Applying medical evidence Measuring results Spreading successful practices Copyright 2010 Kaiser Permanente 12

CMI s Priority Areas Kaiser Permanente is focusing on four priority areas, with evidencebased guidelines and population care management programs created and spread by our Care Management Institute: Palliative care Transitions in care Complete care for complex conditions Integrated cardiovascular disease care Copyright 2010 Kaiser Permanente 13

Transforming Primary Care: 21 st Century Care Innovation Project National pilot program to develop primary care strategies leveraging health IT Improve clinical outcomes Increase primary care sustainability Increase patient satisfaction Optimize resource utilization Copyright 2010 Kaiser Permanente 14

The Change Package: 21 st 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-toface office visits which can build capacity and give members choice Collaborative care planning with the member Copyright 2010 Kaiser Permanente 15

Distribution of Alternatives 100% 21st Century Care - "Gold" Teams Distribution of Provider Touches 80% 60% 40% 20% 0% O-05 D-05 F-06 A-06 J-06 A-06 O-06 D-06 F-07 A-07 J-07 A-07 O-07 D-07 F-08 Office Visits Telephone Visits Online Encounters Copyright 2010 Kaiser Permanente 16

The Panel Support Tool Every night the Panel Support Tool downloads specific patient data from KP HealthConnect, the claims system, ancillary systems (lab, radiology, pharmacy), and the membership system and displays the information on a dynamic spreadsheet. It automatically sorts members with the highest care gaps to the top of the list of the patient panel. Copyright 2010 Kaiser Permanente 19

kp.org: My Health Manager Integrated Clinical Information Systems Labs Inpatient Outpatient Emergency Pharmacy Imaging Immunization Membership Financial and Benefits KP HealthConnect Secure Web-Based Universal Access Real Time Linked to delivery system Not claims-based kp.org and My Health Manager Copyright 2010 Kaiser Permanente 21 Population Management Tool Disease registries Risk stratification Patient management tools Targeted panel lists Inreach Clinical prompts & reminders Outreach- Letters & calls Continuous process improvement

The Archimedes Model is a mathematical model of human physiology, diseases, interventions, and health care systems: Physiology-based Realistic Rigorously validated Comprehensive Clinically and administratively detailed Enables decision makers to understand likely outcomes of various interventions Copyright 2010 Kaiser Permanente 22... a KAISER PERMANENTE Innovation

The Model Describes Virtual People and Populations Family history Gliburide Insulin treatment Insulin level Unexplained variance in OGT OGT OGTT test Sex Race/ ethnicity Age BMI Type 1 Diabetes feature Type 2 Diabetes feature Age, sex, race/ ethnicity Joint Diabetes feature Metformin Insulin production (Pancreas) Glucose uptake by muscle Insulin efficiency (Muscle) Glucose production Insulin by liver efficiency (Liver) Normal liver glucose production UKPDS data FPG Untreated insulin level Random plasma glucose Random error and variation Care processes Fractional change in Insulin Random plasma glucose test FPG test HbA1c test Urine ketone test Ketoacidosis Diabetes diagnosis To treatment models Height Weight Diet and exercise FPG Hypoglycemia Diabetes blood pressure factor Peripheral resistance HDL cholesterol Mean arterial pressure LDL cholesterol Systolic blood pressure Triglyceride s Coronary artery stenosis Smoking Diabetes cardiac risk factor FPG Propensity to blurred vision Propensity to polyuria Blurred vision Polyuria Patient takes action Memory Perception Cardiac output Arterial compliance Pulse \ pressure Propensity to fatigue Fatigue To the Retinopathy model To the To the Nephropath Neuropathy y model model To the Coronary artery disease model Propensity to thirst Thirst Copyright 2010 Kaiser Permanente 24 24

Family history Sex Race/ ethnicity Age BMI Height Type 1 Diabetes feature Type 2 Diabetes feature Age, sex, race/ ethnicity Weight Diabetes blood pressure factor Peripheral resistance Cardiac output Gliburide Joint Diabetes feature Metformin Diet and exercise HDL cholesterol Mean arterial pressure Arterial compliance Insulin treatment Insulin production (Pancreas) Insulin efficiency (Muscle) Insulin efficiency (Liver) LDL cholesterol Systolic blood pressure Pulse \ pressure To the Retinopathy model Insulin level UKPDS data Glucose uptake by muscle Glucose production by liver Normal liver glucose production Triglyceride s Coronary artery stenosis To the Nephropath y model FPG Untreated insulin level Smoking To the Neuropathy model Unexplained variance in OGT Diabetes cardiac risk factor FPG To the Coronary artery disease model OGT Random plasma glucose Random error and variation Care processes Fractional change in Insulin FPG Propensity to blurred vision Propensity to polyuria Propensity to fatigue Propensity to thirst OGTT test Random plasma glucose test FPG test HbA1c test Urine ketone test Hypoglycemia Ketoacidosis Blurred vision Polyuria Fatigue Thirst Diabetes diagnosis To treatment models Patient takes action Memory Perception Comprehensive Care Delivery Model Behaviors Symptoms Signs Diseases Outcomes Copyright 2010 Kaiser Permanente 25

Currently in the Model Asthma Breast cancer Colon cancer Congestive heart failure Coronary artery disease Diabetes Dyslipidemia Hypertension Lung cancer Metabolic syndrome Obesity Stroke Copyright 2010 Kaiser Permanente 26

Distinguishing Features of the Model Can tailor to specific populations, settings, and costs: Populations Demographics, behaviors, test results, symptoms, past medical histories, current conditions, current treatments All at individual level Protocols and practice patterns Guidelines Performance levels Costs Tests, treatments, visits, hospitalizations, procedures Copyright 2010 Kaiser Permanente 27 27

Integrated Cardiovascular Care: A-L-L (Aspirin, Lisinopril, and Lovastatin) Initiative Launched in 2004 Targeted 400,000 KP members in 8 regions: diabetics > 55, and all CAD (coronary artery disease) patients Three daily medications Health benefits predicted by Archimedes modeling Successful practices used health IT systems and registries to identify eligible members Copyright 2010 Kaiser Permanente 28

A-L-L for Preventing Heart Attack and Stroke Evidence: Statins, ACE inhibitors, and aspirin greatly reduce risk All are vastly underused KP Approach a simplified bundle: Aspirin 81 mg Lovastatin 40 mg Lisinopril 20 mg Results: 1,271 avoided events per year! Copyright 2010 Kaiser Permanente 29

Applying KP Results to the U.S. Conservatively assuming that 20% of the 5.8 million Americans over the age of 65 who are predicted to have diabetes by the year 2010 are exposed to the [ALL] bundle for 1 to 365 days over 24 months, more than 17,000 MIs and strokes would be avoided the following year. - Preventing Myocardial Infarction and Stroke with a Simplified Bundle of Cardioprotective Medications, The American Journal of Managed Care, Volume 15, Number 10, 2009 Copyright 2010 Kaiser Permanente 30

IndiGO Pilot Uses person-specific information from KP HealthConnect Biomarkers (e.g. LDL, SBP, TC, BMI) Demographics (age, gender, ethnicity) Health history (e.g., previous MI, DM diagnosis) Current medications (e.g. statins, BP meds, aspirin) Behaviors (e.g. smoking) to calculate for each person Risk of CVD and diabetes-related events Reduction in risks caused by a range of treatments and combinations of treatments -- a benefit score This information is presented to physicians and patients and used to determine the optimal treatments for each person.... a KAISER PERMANENTE Innovation Copyright 2010 Kaiser Permanente 31

Clinician Shares the PST Member Report A. Click checkbox to change graph based on patient s actual aspirin usage H I A B. Risk of similar healthy individual* C. Risk of patient today D. Risk increase if patient stops meds E. Risk decrease with each intervention E J Arrows = Change in Relative Risk F. Risk with combination of selected options G. Click checkboxes below graph and click New Total to recalculate graph based on intervention(s) selected by patient B C D F H. Document via dropdown I. Click Generate Handout at top to print the Member Report for the patient. Bars = Absolute Risk J. Click Go to PreDM Optimizer Graph to view this patient s Getting Diabetes Report. G Not shown: Patient-Friendly Descriptions at bottom of page Copyright 2010 Kaiser Permanente 32 NOTE: Doses shown are not the starting dose they are the doses modeled in Optimizer and often represent the maximum dose.

Independent Evaluation done by KP Care Management Institute High acceptance All doctors agreed that IndiGO helped them make the best clinical decisions for their patients. Patients exposed to IndiGO were substantially more likely to report that they had been asked to change their medication, diet, and exercise habits. Increased compliance Patients who had a care gap for statins under standard guidelines were 6 times more likely to close the gap after a PCP visit that included IndiGO. For high-risk patients identified by IndiGO, there was a 7 times improvement in prescription dispenses as compared to EHR and panel support tool alone. Improved outcomes A 13% reduction in 5-year CVD more than EHR and panel support tool alone. If used throughout KP, we estimate 4500 heart and strokes would be averted annually. Reduced costs An estimated $128M could be saved annually. Copyright 2010 Kaiser Permanente 33

Use of IndiGO averts almost twice as many events as current guidelines Example of 10,000 people randomly sampled from a health plan By treating the high-risk, low-ldl members (red dots), IndiGO increases the number of potential MIs and strokes averted by 92% 3 2 Fraction Events treated Averted* NNT** CVD Risk 1 Red: IndiGO Blue: ATPIII Purple: ATPIII and IndiGO 1) ATPIII only 10.3% 10 103 2) ATPIII & IndiGO 14.6% 41 36 3) IndiGO Only 18.4% 47 39 **Number needed to treat to avert one event LDL Copyright 2010 Kaiser Permanente 34

IndiGO improves care in other ways Improves identification of at-risk patients Gives physicians and care managers a prioritized list of members needing treatment Promotes collaborative decision-making between the physician and the patient Increases compliance by helping members better understand the risk and the benefits of treatments Improves the efficiency of outreach programs by identifying those who will benefit the most from treatment Copyright 2010 Kaiser Permanente 35

Transforming Care Delivery The cornerstone of our strategy is to leverage our integrated model to shape the future of health care through our quality and service leadership. Transforming Care Delivery Achieving Best Quality and Service Leading Prevention and Total Health Leading Care for Chronic Conditions Best Hospitals Service Excellence Data / Research Evidence-Based Medicine Best Practice Protocols Reliably-Delivered Patient-Centered Care Measured Against Internal Targets and External Benchmarks Leading Prevention and Total Health Early detection Prevention and healthy behaviors Population health Leading Care for Chronic Conditions Proactive coordinated care Member engagement Complete care for complex conditions Continuous process improvement Best Hospitals Highly reliable and efficient Patient safety Seamless transitions in care Service Excellence Leadership and culture Timely and convenient access Patient and family-centered care Leading, Learning, Transparent, Compassionate, Innovative High-functioning teams supported by technology-enabled tools Copyright 2010 Kaiser Permanente 36

Key Messages Broad implementation and use of a combined EHR/PHR is well received by health care professionals and patients due to perceived value. Fundamental redesign of daily work processes in health care delivery are required. Dramatic improvements in quality, safety, and service are possible. It is becoming possible to individualize and prioritize best practices! Copyright 2010 Kaiser Permanente 37