Kaiser Web-based Tool Enhances Patient Care, Part II

Kaiser Permanente in October released the first large studies of its proprietary Panel Support Tool, first rolled out in 2006, which extracts information from Kaiser’s HealthConnect electronic Health Record (EHR) to help physicians improve and manage their patients’ care. The studies are the organization’s first that evaluate the effectiveness of the tool on the large, divergent population in the Pacific Northwest.

The first study, “Effect of a Patient Panel-Support Tool on Care Delivery,” (published in the October issue of The American Journal of Managed Care , followed 204 primary care teams who are using the Panel Support Tool to manage care of 48,344 patients with diabetes and/or heart disease. The second study, “Improving Population Care with an Integrated Electronic Panel Support Tool,” published online in Population Health Management , involved 207 primary-care teams who were using the Panel Support Tool to manage the care of 263,509 adult patients, some of whom were relatively healthy and others who have chronic diseases. Both resulted in significant, quantifiable improvements in patient care, according to the reports.

For this second part of a two-part interview, HCI Managing Editor John DeGaspari asked Robert Unitan, M.D., one of the authors of the first study, and Yvonne Zhou, Ph.D., lead author of the second study, about the Panel Support Tool’s integration with HealthConnect EHR, improvements with patient care and patient outreach, and how the tool is being expanded and refined.

Healthcare Informatics: Kaiser Permanente invested heavily on its Epic-based EMR system and customizing it. Is the Panel Support Tool a supplement to the Epic system?

Robert Unitan, M.D. : Yes. One of things that you have to realize is that not all of the data about our patients is in the electronic record. We have patients that see clinicians, say if they get injured somewhere and they are seen outside of our region while they are on vacation; or intentionally, there may be certain services that we don’t provide inside. So we have to rely on our claims system, to bring that information in. Not all of the prescriptions our patients fill are filled at Kaiser’s pharmacies. We have to have another way to input that data. So it really is all about the data. The fact that the Panel Support Tool is not running off of just the data that is available in HealthConnect, but rather it is running all of the data that is flowing into our data warehouse, makes it much more comprehensive.

And so, we wouldn’t trade what we have for an EMR-based tool that functioned in the same. We had to develop [the Panel Support Tool] outside the EMR. The data that flows into the [data] warehouse from HealthConnect is huge; [most] of that data flowing into that warehouse is probably coming from our Epic EMR. But it is that other [data]that is still very important. Because we had a data warehouse that was already very robust to begin with, the incremental cost of building this Panel Support Tool was nothing like the cost of implementing HealthConnect EMR.

A lot of [data] comes in from our claims system. Our lab, pharmacy, radiology system are integrated with HealthConnect vis-à-vis systems that exchange information, but they are not part of the electronic medical record. We also have our membership system that has demographic information about our patients that may not be in the medical record. So there are lots of sources for the data; and the data warehouse is the repository that makes the Panel Support Tool possible.

HCI: What is biggest advantage of the Panel Support Tool that you have seen?

Yvonne Zhou, Ph.D.: The Panel Support Tool has enabled us to systemize the knowledge of our medical science and provide that information in an integrated way. So it is not just the one condition; it can provide many conditions. It’s not just one care gap, it is many care gaps—mammography screening, gap diabetes A1 screening. It can be many [care gaps] and it is all integrated together. That is really the key distinction between the Panel Support Tool and some other registries or other things. In addition it has data that is very real time, very accurate, and complete. So we have all of this information, and the support of data to our healthcare teams, at the point of care, really allow physicians to provide the best, latest recommended care accurately, 100 percent of the time.

Information technology [alone] is not going to improve healthcare, but if we marry IT with medical signs, and that is built into our clinical system, that is going to enhance our memory, and sometimes to expand our knowledge a little bit, to allow us to more reliably and more effectively accomplish our care goals.

HCI: One of the papers mentions that this is a dynamically updated system that each day reviews what is new and plugs that information into the records. Can you elaborate?

Unitan: That’s correct; and we used to print out similar information. But again, to Yvonne’s point, it would only generally deal with a couple of care gaps, and not 45 or 50. And as soon as that paper report hit the desk of the clinician, it was already out of date and just got more and more out of date. So you could send out [paper reports] quarterly, but they wound up being recycled in weeks often. Part of the freshness of the data is another thing that has gained greater acceptance and appreciation.

HCI: With so much more patient data available to clinicians and a lot more information coming through, this must add to a physician’s workload, right?

Unitan: It’s true, and in one article that we wrote there was a quote from a physician in Hawaii, who said, ‘This does not make my day any easier.’ You are now addressing a much wider range of conditions than you would have been addressing if you were just going after the chief complaint. But the physicians do feel that it makes their day better. They feel that they are not leaving a lot of stuff undone.

Our internal medicine physicians and family physicians are very compulsive people. They want to do the right thing every time they can. So by making it as easy as possible, to do what is extra work, we really are enhancing care. These patients come into our offices, some of them several times a year, the ones who have chronic conditions. But the physicians found out is that, the first time they used a Panel Support Tool on a patient, it was more, it added minutes to a visit, it added minutes to the visit. There were more orders, more things to look at. But the next time the patient came in, because all of that stuff had been dealt with, it made it easier, the time the patient came in the subsequent year. So it’s a double-edged sword. You are going to have to do this work at some point, if you are taking good care of your patients. And we just put it right up front and center.

Zhou: And sometimes an office visit may prevent another office visit; and also, to a certain degree, that helps patients, because it saves the patient time. It is really the next-generation population care; from population care perspective, it is really trying to address all of the care needs for the patients based on their condition. It is not just the illness, the chief complaints, and that’s all you have to do. We are trying to be proactive.

HCI: The Panel Support Tool is tightly integrated with HealthConnect. How important is the tight integration? Is this type of tool doable with any EMR out there?

Unitan: Then integration is really around the workflow for the clinician and the front-line staff. When we first went live, we were less tightly integrated. You essentially had to toggle back and forth between the applications. About two years ago, we were able to actually add a button in the electronic medical record that, with a single click and via single sign-on, because you already used your password, to get into the EMR. We were able to do all of that authentication on the back-end, so that, we can, within a matter of seconds, bring up the panel support tool, within a window, essentially a Web browser window, within the EMR. It’s still a standalone application, but [to] the end-user, it looks like they are right in HealthConnect doing their work. And so, tighter integration means being able to actually click on things in the actual [EMR] tool that would then actually tend the orders themselves. If you click on a care gap for an LDL, it would actually order a lipid lab. It is possible to configure what we call Web services, to be able to enable that. We have not [done that] yet here in the Northwest.

But if you have an incomplete data set, it is not necessarily going to be helpful. The tool will alert to things that the patient had [not] done, but some other system outside the EMR knows they have done. Like the claims system; we have people, for example, in some of our outlying areas, where all of the mammograms are obtained outside of Kaiser. We have to rely on our claims system to be able to essentially satisfy that care gap for that patient. If you just had it as part of the EMR, you would miss things. And that gets annoying for patients as you are reaching out to them, telling them that they need to get things done that they have already had done.

I think that being completely EMR-centric, with respect to the data source, is potentially problematic. Using the data warehouse instead is probably a better solution. And that there are definitely ways that you can use the Web browser windows, etc., in the tools, in the EMR, to make it appear as though the tool is more tightly integrated than it really is.

Zhou: It does have certain requirements for the database, for EMR. I generally expect that a full-blown EMR should have all discrete data elements, like a problem list, like a lab results, values, orders. So all those discrete data elements can be tracked and extracted into data warehouse. Meaningful use has several stages, and some of the stages and requirements are really trying to define or make sure that some of the key data elements are stored in the database at the back end, and therefore can be used for tools like the Panel Support Tool.

[Meaningful use requirements can lead to] better tools or at least tools that will have all of the key data elements needed for support the tool’s functionality.

HCI: Are there health conditions that stand out as difficult to monitor and that the Panel Support Tool is helpful?

Unitan: Certainly for diabetes and cardiovascular disease, there are a lot of both HEDIS and non-HEDIS measures that indicate good care for these patients. But, for example, there is no HEDIS measure for having the feet of a diabetic checked every year, and just having that in there to remind the clinician to do that is an important thing. When you think about all of the potential organs that can be damaged by a disease like that, there is a lot to keep track of. Other diseases that are major contributors to chronic illness include hypertension, chronic kidney disease, congestive heart failure, asthma, and COPD [chronic obstructive pulmonary disease]. As you start to add those up, each with their own individual sets of care recommendations, a tool like this can make much easier to keep track of over time.

Zhou: I think the Panel Support Tool is able to improve preventable care, screening measures, more quickly. Probably this is just the way it is for some of the control measures like diabetes LDL control or diabetes A1C control. In general, it’s much harder to improve these measures because it’s not just one test, it takes a while to [implement] medication or other care management strategies, [and to] to work with the patient to include those measures.

However, the Panel Support Tool is still pretty effective for those measures, because it has a total care gap score. Those gaps will keep referring to the pop up list and help the healthcare teams and clinicians to go out, visit them, outreach to them frequently. So, in general, it’s much quicker to improve preventive measures, screening measures. It will take a little while to improve control measures, but still more effective than other tools.

HCI: You are talking about reaching out to the patients, right?

Zhou: Bring further pressure immediately after the visit. You have to work with the patient.

Unitan: That is an important distinction that Yvonne made. When you look at what the 90th percentile value is for some of these tests, just making sure that everyone with diabetes has had a hemoglobin A1C, the test that assesses their blood sugar over time, and having that checked once a year, that’s a pretty easy thing to tell somebody to do. And we get that right now probably 94 percent to 95 percent of the time. It’s harder to actually make sure that the person has their A1C under control; that they are compliant with their diabetes medication; and their diet and their exercise, and all of the other things that go into that. So, we are doing a good job if we have something close to 78 percent or 79 percent of our patients with diabetes having that A1C level being less than 9 percent, which is one of the HEDIS measures around diabetes control.

So the control measures are always more difficult. Getting that LDL, that lipid level below 100 for a patient with diabetes or a patient with cardiovascular disease is much more difficult than just making sure that they have had the test. The Panel Support Tool, to Yvonne’s point, helps with both.

HCI: How important is having a good EMR system in place for a tool such as the Panel Support Tool to work?

Unitan: It is necessary. It would be very difficult to build this [Panel Support Tool] without the EMR underlying it. The government [is making investing in] an EMR system easier all the time with the funding they are putting out. I’m proud of my organization, which essentially made a big $4 to $5 billion bet that that was the right thing to do for the health of our membership. And we didn’t need the government to tell us that we had to do it or that we would risk losing tens of thousands of dollars per physician if we didn’t go down that road. We also have resources that individual physicians and small group practices don’t have. So definitely we are on a different scale. Far be it from me to be critical of people who are lagging behind. Ultimately everybody is going to have to get there and it will be good for the country when they do.

HCI: Kaiser Permanente was ahead of curve with EMR, and this is the next step?

Unitan: Right. And we are very committed to improving the health for the entire community that we serve. It’s not just about our members. We want to set a good example and want people to think of us as a health organization that is invested in the health of the entire population. By doing this work we can set a good example with other healthcare institutions that resonate with our corporate mission.

HCI: What refinements to the Panel Support Tool are being worked on now?

Unitan: Now what we are doing in the Northwest, and Hawaii as well, is trying to expand its usage into specialty care. So it goes beyond primary care, and we are touching patients with this tool everywhere they access the care. We have a number of specialties to do this work, and staging the work for the primary care physician, to increasing the likelihood that the patient will get these things done.

We are also creating specialty specific content. So we did build in 2008, a pediatric version of the tool focused on pediatric immunization. It also covers pediatric diseases [such as] ADHD. We are now building an Ob-Gyn tool that is going to help [physicians] manage abnormal cervical pathology from the pap smears. So there won’t just be a tool that tells patient that she needs a pap smear every three years. It will actually look at the result of the pap smear, and if it’s abnormal the tool will also be able to keep track of what the woman needs, if she needs to have screening more often.

So that is a future direction. I think that, as we have a few more years, we have the ability to look at health outcomes over time, and to look at also how it has expanded the reach of the primary care clinician, will prove important.