As of 2009, only 9 percent of America’s hospitals were using even a basic form of electronic medical records (EHR) and as of 2008 only 13 percent of practicing doctors were doing so. Yet one private health insurer has integrated EHR for hospitals, physicians, outpatient and other services. I am of course talking about Kaiser Permanente.
Today I will review the book Connected for Health, which details how Kaiser implemented EHR in their system. The book is not an objective evaluation in that it is written by the people who participated in Kaiser EHR implementation. The lack of objectivity, however, is more than offset by the “insider” point of view the authors offer. This is not a book for people interested in a fun read or general health policy. However, if you are interested in implementing EHR in your organization, this book will likely prove invaluable.
Kaiser Permanente is an enormous organization. It employs 14,000 physicians, 45,000 nurses, and thousands of other clinicians and staff. It has nine regions: Northern California, Southern California, Colorado (Denver), Colorado (Southern), Georgia, Hawaii, DC/Maryland/Virginia, Ohio, Oregon/Washington.
Kaiser EHR Functionality
Kaiser’s electronic health records system, KP HealthConnect, is based primary on software from Epic Systems of Wisconsin. The KPHealthConect system has the following functionalities:
- A personal health record,
- Outpatient practice management
- Outpatient clinicals (e.g., physician order entry, clinical documentation),
- Inpatient billing,
- Inpatient pharmacy,
- Inpatient administrative systems,
- Inpatient clinicals,
- Non-Epic Systems and Pre-existing applications that integrate with KPHealth Connect.
Of particular interest is the personal health record. Patients can view most parts of their medical record such as lab results, immunizations, past office visits, prescriptions, and more. Patients can send secure messages to providers and view, schedule or cancel appointments. Members can also view information on health risk assessments, drug encyclopedias, and use health insurance management tools.
KPHealthConnect was an enormous undertaking. Creating a single system capable of dealing with the idiosyncrasies across regions was a challenge. In fact, in 1997 Kaiser Permanente made a commitment to create an ambulatory, or outpatient, medical record system for all its regions. Kaiser settled on the Clinical Information System (CIS) developed by its Coloardo Region. However, since CIS only addressed outpaient medical offices and had not kept pace with recent advances in EHR, CEO George Halvorson decided that the CIS was not sufficient and Kaiser needed a system-wide program capable of integrating all operations. Halvorson had experience with quality metrics from his time at the NCQA developing HEDIS. The CIS program was abandoned. Instead, Kaiser settled on using a customized version of the off-the-shelf EHR software produced by Epic Systems. In fact, Kaiser’s Northwest Region already had been using Epic and was one of Epic’s earliest clients.
To implement KPHealthConnect, Halvorson allocated fixed budgets for each region. Without this stipulation, each region would have an incentive to put off the EHR initiative since EHR implementation increases cost and only has a payoff years down the road.
Another key was involving the labor unions in the EHR implementation. In 1997,Kaiser established the Labor Management Partnership (LMP) which was a coalition of Kaiser’s 26 local unions.
The Kaiser team also focused on standardizing KPHealthConnect as much as possible across regions. “Diverging later would be easy, but converging later would be almost impossible.” Standardization included the use of Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT) developed by the College of American Pathologists.
Training also needed to be appropriately tailored. At first, the training was system-centric (i.e., what does this application do, what is the software functionality). Later, Kaiser realized that user-centric training (i.e., separate training for physicians, nurses, administrators, etc) was needed.
To gain support for the EHR implementation, Kaiser targeted 3 types of physicians: operational leaders (i.e., bosses), opinion leaders (i.e., leaders in their field), and technologically adept physicians.
Effect of KPHealthConnect on Care
Overall, there are the types of benefits from implementing EHR:
- Immediate: Patient-level data, legibility, ubiquitous access to medical record, information available across settings
- Leveraging Existing Features: Drug-drug interaction alerts, health maintenance reminders, best practice alerts, dose restrictions, after-visit summary reports
- Accelerating Patient Safety: Closing the loop on lab and test results, barcoding, refining decision support, creating surveillance systems for drug use.
In Hawaii, after KPHealthConnect was implemented, there was a 26% decrease in office visits. Because the EHR system allows patients to email doctors, pharmacists and other clinicians, patient interactions with providers increased, but office visits decreased.
Using the data generated from EHR also allows for sophisticated medical studies. For instance, Kaiser began monitoring the impact of influenza vaccine on influenza, pneumonia (a well-established flu complications), hospitalization, and death.
Not all managerial improvements, however, rely on EHR. For instance, Kaiser implemented Nurse Knowledge Exchange (NKE) to standardize knowledge transfer during shift changes. “Before NKE, patients described the hospital floor during shift change as a ‘ghost town,’ since nurses would exchange information or shift reports behind closed doors of a conference room or staff lounge. Now, the nurses convey this information at the patient’s bedside, and key information such as diet and expected tests are written on the patient whiteboard.
- Louise L. Liang and Donald M. Berwick, Connected for Health: Using Electronic Health Records to Transform Care Delivery, Pfeiffer, 2010, 272 pages.