HIT Transformation & Analytics – National Quality & Care Delivery ExcellenceCopyright © 2013

HARVESTING VALUE

Terhilda Garrido, VP HIT Transformation and AnalyticsiHT2 Summit

January 2013

Big Data, Little Data: Value and Transformation Stemming from Kaiser Permanente's HIT

Copyright © 2013

Who we are Our HIT investment

Clinical Evidence / Guidelines Organizational metrics Patient population MD Feedback Patient empowerment

The Opportunities and Challenges

Value

About Kaiser Permanente

Data – From Big to “Little”

Heading to Big(ger) Data

Copyright © 2013

About Kaiser Permanente

Integrated health care delivery3 Organizations in one: Health insurer, hospital system, physician partnerships

9 million members

172,997 employees Serving 9 states and DC

16,658 physicians

Nation’s largest nonprofit health plan

37 hospitals 611 medical offices

$47.9 billion annual revenues (2012)

Copyright © 2013

Our investment in technology:Kaiser Permanente HealthConnect

The world’s largest and one of the most advanced civilian deployments of an electronic health record

KP HealthConnect was implemented 2004-2010 specifically to transform care and service delivery

Our greatest benefits are the resulting improvements in quality and effectiveness of patient care

®

Copyright © 2013

Integrating health care across the continuum

Inpatient and outpatient clinical care: documentation, ordering, decision support

Hospital and outpatient practice management: billing, scheduling, registration, ADT (admission, discharge and transfer)

Ancillary systems: pharmacy, labs, radiology, etc.

Online access to personal health record: My Health Manager on kp.org

One data model underlying all EHR components

40 million records 3.7 petabytes of stored information

Copyright © 2013

I LOVE data

For our clinicians For our system

Clinical Evidence / Guidelines Organizational metrics Patient population MD Feedback Patient empowerment

A Goldmine of Data A Hotbed of Innovation The Blue Sky Vision

About Kaiser Permanente

The Miracle of Data

Standardization & The Advent of

Big Data

Copyright © 2013

What do you know?

Not everything that can be measured counts, and not everything that counts can be measured.

A. Einstein

Copyright © 2013

REPORTABLEINFORMATION

GAP

TIME

AM

OU

NT

DATA

CLINICAL UTILITY

KNOWLEDGE

Source: Michael N. Liebman, PhDExecutive Director Windber Research Institute

Data is a necessity in our care model

8

GAP

Copyright © 2013

“Conclusions: Our findings indicate no consistent association between Electronic Health Records and

Clinical Decision Support and better quality.”

Archives Internal Medicine

January 24, 2011

Copyright © 2013

Kaiser Permanente compared to U.S. market

29 total top rankings – 13 Medicare & 16 commercial – the most No. 1 rankings for health plans in the country

563 applied for Star ratings11 plans across the country received 5 stars6 of those were Kaiser Permanente plans:California, Hawaii, Northwest, Colorado, Mid-Atlantic States, Ohio

17 Top Hospitals33 Hospitals among safest in the nation

Mail-order pharmacy programs rated at the highest level of customer satisfaction in the entire country four years in a row

Highest ranking in member satisfaction among health plans in all five of our larger regions

J.D. Power & Associates

Copyright © 2013

Information is power at many levels

Information is power: Power to know what the

problem is Power to know where to act Power to know what to change

Information driving transformation:

Five levels of information work together to drive improvement in the health care system. They are all enabled and dependant on data.

1. Health care knowledge levelresearch / guidelines

2. Organization level – Big Q

3. Patient population level

4. MD level – performance feedback

5. Patient level – empowerment

Copyright © 2013

1. Health care knowledge level

research / guidelines

Copyright © 2013

1. Health Care Knowledge Level: A tale of two studies

Tale of Study 1 – It was the best of times, it was the worst of times for researchers in the city of San Antonio…

ALLHAT* – a classic RCT – randomized control trial 42,418 patients $120 million Conducted over 8 years

Results – Thiazide-type diuretics are most effective at controlling hypertension

Given the low cost of this diuretic class, they postulated $3.1 billion savings over 10 years

ALLHAT* – Antihypertensive , lipid lowering treatment to prevent health attack trial. Sponsored by the national heart, lung and blood instituteBegley, Sharon, "The Best Medicine," Scientific American 305, no. 1 (2011):50-55

Copyright © 2013

1. Health Care Knowledge Level: A tale of two studies

Tale of study 2 – Meanwhile in Denver, David Magid, MD had an idea….ALLHAT – a classic RCT – randomized control trial 42,418 patients $120 million Conducted over 8 years

Results – Thiazide-type diuretics are most effective at controlling hypertension

*Magid, David J.; Shetterly, Susan J.; Margolis, Karen L.; Tavel, Heather M.; O’Connor, Patrick J.; Selby, Joe V.; Ho, P. Michael, “Comparative Effectiveness of Angiotensin-Converting Enzyme Inhibitors Versus β-Blockers as Second-Line Therapy for Hypertension”, Circ Cardiovasc Qual Outcomes, 2010;3:453-458.

Magid* study• 4,000,000 patients• $200,000• Conducted over 1.5 years

• Results – For the 60% of patients that were not under control / complete hypertension control, ACE Inhibitors and beta blockers are effective as 2nd line medications.

Copyright © 2013

1. Health Care Knowledge Level:A tale of two studies

ALLHAT Study Magid Study

Statistical Design

Randomized Control Trial Retrospective observational

- Eliminate Patient Bias -Adjust for patient bias: Matched case control. N.b. needs a large sample

- Limited target group - Cross-sectional population

- Controlled conditions - Real World conditions

Results $120,000,000 over 8 yrs $200,000 over 1.5 yrs

42,418 patients 4 million patients

RCTs are the traditional gold standard for health care research. EHRs and their vast store of data (in depth and breadth) offer an alternative with pros and cons.

Copyright © 2013

2. Organization level – Big Q

Copyright © 2013

2. Organization Level: Big Q

IllustrativeUnlike other industries, where the common denominator is often profit, health care requires a balanced scorecard approach.

Clinical Effectiveness

Safety Patient satisfaction Cost efficiency Equity in care

17

Copyright © 2013

3. Patient population level

Copyright © 2013

3. Taking accountability for patient populations

Clinical Outcomes in Southern California

Metric Improvement Lives Saved Per Decade1

Blood Pressure Control 38.9% 5,341 Lives

Colorectal cancer screening 30.2% 4,788 Lives

Cholesterol Control 21.8% 1,751 Lives

Blood sugar control 11.5% 1.088 Lives

Smoking Cessation 17.0% 955 Lives

Breast Cancer Screening 11.4% 570 Lives

Cervical Cancer Screening 5.9% 59 Lives

Over

14,000 Lives

Saved1

Copyright © 2013

Mary Gonzales Story

Mary Gonzales' Kaiser Permanente story

Copyright © 2013

3. Patient population tools

The Panel Support tools have been shown to be effective in improving patient quality of care and reducing “care gaps” by up to 21%

Copyright © 2013

4. MD level – performance feedback

Copyright © 2013

0

100

200

300

400

500

600

700

800

900

8/09 9/09 10/09 11/09 12/09 1/10

Co

un

t

August 2009 - January 2010

Untouched Abnormal Lab Results InBasket Messages > 14 Days

Count of Untouched Messages by Location / Department / Recipient

       6 Department Message Recipient Count

XYZ MEDICAL OFFICE DEPT FIRSTNAME, LASTNAME MD

3

  DEPT FIRSTNAME, LASTNAME MD

15

    FIRSTNAME, LASTNAME MD

3

    FIRSTNAME, LASTNAME MD

2

XYZ MEDICAL OFFICE DEPT FIRSTNAME, LASTNAME MD

4

  DEPT FIRSTNAME, LASTNAME MD

28

  DEPT FIRSTNAME, LASTNAME MD

9

4. MD Level: Performance Feedback Loops

MD leaders identify info needs

Analysts extract data and craft report to reflect focus

Dept MD Chiefs share with MDs

MD maintains / improves practice. Reports track progress

Monitoring MD inbaskets resulted in a 70-90% decrease in ‘untouched abnormal lab results 14 days+’

Copyright © 2013

Count of Untouched Messages by Location / Department / Recipient       6 Department Message Recipient Count

XYZ MEDICAL OFFICE DEPT FIRSTNAME, LASTNAME MD 3

  DEPT FIRSTNAME, LASTNAME MD 15

    FIRSTNAME, LASTNAME MD 3

    FIRSTNAME, LASTNAME MD 2

XYZ MEDICAL OFFICE DEPT FIRSTNAME, LASTNAME MD 4

  DEPT FIRSTNAME, LASTNAME MD 28

  DEPT FIRSTNAME, LASTNAME MD 9

4. MD Level: Performance Feedback Loops

Analysts extract data and craft report to reflect focus

MD leaders identify info needs

Copyright © 2013

0

100

200

300

400

500

600

700

800

900

8/09 9/09 10/09 11/09 12/09 1/10

Co

un

t

August 2009 - January 2010

Untouched Abnormal Lab Results InBasket Messages > 14 Days

4. MD Level: Performance Feedback Loops

MD maintains / improves practice. Reports track progress

Monitoring MD inbaskets resulted in a 70-90% decrease in ‘untouched abnormal lab results 14 days+’

Dept MD Chiefs share with MDs

Copyright © 2013

5. Patient level – empowerment

Copyright © 2013

I try to learn as much as possible about diabetes. I have been controlling it with diet and exercise for 3 yrs. Dr. says I am doing a good job, thanks to your site.NCal 2010

I feel much more confident, and I also feel closer to my physician that I had before. I don’t feel intimidated anymore.

I feel more in control over my medical condition. I have access to information, access to people I need to consult with, so it puts me back in charge. KP NW Member, 2004 Online survey

I was curious what they had to say. I have a heart condition, and the words they use are so big that I wanted to go back and be able to actually look at what it was. It was a good thing for me to look at it and to get it to stick with me that I need to take better care of myself when I saw it in black and white.

I think it’s empowering. As individuals we need to take care of ourselves, and we have to assume responsibility and it gives us that.

The website has improved my relationship with my doctors. It’s so easy to communicate with them, and they are all willing to respond quickly. I am very impressed with this method and feel it has made taking care of myself easier and more palatable. I feel supported in this way because the computer is available 24/7.

It’s made it better because I feel there is a closer partnership. It’s like instead of not seeing him for six months, we have communicated in between.

I feel more in touch with the sum and substance of my medical condition.

Copyright © 2013

5. Patient Engagement Rewards: Loyalty & Quality of Care

Member RetentionMy Health Manager users were 2.6 times more likely

to choose to remain members than were those who did not use it.1 Following membership tenure and illness burden, MHM use was the third strongest predictor of remaining a member. The newer the member; the stronger the impact of MHM.

Quality of Care Improved! In a matched-control analysis published in Health

Affairs, secure email was associated with a 2.0 to 6.5% improvement in performance on HEDIS measures, such as glycemic (HbA1c), cholesterol, and blood pressure screening and control2

High Patient Satisfaction!85% rated encounters 8 or 9 on a 1-9 scale3

1 Turley, Marianne; Garrido, Terhilda; Lowenthal, Alex; Zhou, Yi Yvonne, “Association Between Personal Health Record Enrollment and Patient Loyalty,” Am J Manag Care. 2012;18(7):e248-e253 (web exclusive)2Zhou, Yi Yvonne; Kanter, Michael H; Wang, Jian J; Garrido, Terhilda, “Improved Quality at Kaiser Permanente Through E-Mail Between Physicians and Patients,” Health Affairs, Vol 29, No 7 (2010); 1370-1375.3 Internal KP study, “Harvesting Value: Early Findings from Kaiser Permanente HealthConnect™” presented to Center for Information Therapy by T Garrido, C Serrato, J Oldenburg (1/15/2008)

Copyright © 2013

Value

For our clinicians For our system

All info; all patients; all the time Redefining Access / Empowering patients Tackling Care Gaps A Backbone for Reliability

The Challenges

Connectivity

The Miracle of Data

Standardization & Heading to Big Data

Copyright © 2013

Everyone, everything, every interaction leaves a vapor trail

Copyright © 2013

Exogenous Data - e.g. SES (socio economic), Credit Card Purchases, Weather

Layers of data

Patient Reported Outcomes, Surveys, Fit Bit…

External Data – Claims, Biomed Device..

KP HealthConnect

Copyright © 2013

Data, data everywhere and not a thought to think

The ‘Big Data’ era will be characterized by:

Variety Volume

Velocity Veracity

Time is passing and expectations are rising

Copyright © 2013

Care Models – Past, Present, Future

Focus Clinical Encounter Care of Cohorts Individual is their own ‘control’

Data ‘Exhaust’ of encounter EHR / Clinical data A cornucopia of

data sources

Bench to Bedside ‘17 years’Offline data

analysis-months-

‘Real-time learning health care system’

$ FFS Value-based care Wellness & Prevention

Theme “Illness Cured” ‘Disease Stratified’ ‘Wellness Quantified’

Patient-CenteredCare

StratifiedCare

Reactive Care

Copyright © 2013

Integration & Leveraging

IT functionality enables us to

leverage scarce or specialized

expensive clinical resources - MDs, RNs

and other clinical staff.

We use data to focus care delivery and create evidence based practices.

Secure and seamless

transitions “Warm Handoffs” The human skill

sets and operational processes to deliver

care and service effectively,

efficiently, and compassionately.

CustomizationOccurs at any level of the members’ journey with Kaiser

Permanente (choosing health plans, cost sharing, individual care pathways, and communication modalities).

Home as the HubThe home, and other settings, will grow significantly as a

locale of choice for some care delivery (diagnostics).

Our Vision for the Future: “Blue Sky”

Brentari, Ruth; Garrido, Terhilda; Mittman, Robert; Liang, Louise; Weiland, Allan; Wiesenthal, Andrew; Cordova, Richard (2003) “Blue Sky Care Delivery 2015, Part I,” The Permanente Journal, Vol 7, No. 4, Fall 2003, pgs 47-50Brentari, Ruth; Garrido, Terhilda; Mittman, Robert; Liang, Louise; Weiland, Allan; Wiesenthal, Andrew; Cordova, Richard (2004) “Blue Sky Part II: The Health Encounter,” The Permanente Journal, Vol. 8, No. 1, Winter 04, pgs 93-97Brentari, Ruth; Garrido, Terhilda; Mittman, Robert; Liang, Louise; Weiland, Allan; Wiesenthal, Andrew; Cordova, Richard (2004) “Blue Sky Part III: The Chronic Care Encounter,” The Permanente Journal, Vol. 8, No. 2, Spring 04, pgs 71-75