iht2 health it summit in phoenix 2013 – terhilda garrido, vp, hit tranformation & analytics,...
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Case Study "Big Data, Little Data: Value and Transformation stemming from KP's HIT" Learning Objectives: ∙ Learn about KP's investment in the EHR and its transformative value ∙ Learn how data and access to information has impacted clinical operations, the patient experience and how we approach research ∙ Learn how this data is more patient centric and patient empoweringTRANSCRIPT
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
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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
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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)
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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
®
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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
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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
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What do you know?
Not everything that can be measured counts, and not everything that counts can be measured.
A. Einstein
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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
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GAP
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“Conclusions: Our findings indicate no consistent association between Electronic Health Records and
Clinical Decision Support and better quality.”
Archives Internal Medicine
January 24, 2011
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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
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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
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1. Health care knowledge level
research / guidelines
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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
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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.
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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.
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2. Organization level – Big Q
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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
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3. Patient population level
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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
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Mary Gonzales Story
Mary Gonzales' Kaiser Permanente story
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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%
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4. MD level – performance feedback
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0
100
200
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400
500
600
700
800
900
8/09 9/09 10/09 11/09 12/09 1/10
Co
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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+’
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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
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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
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5. Patient level – empowerment
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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.
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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)
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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
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Everyone, everything, every interaction leaves a vapor trail
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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
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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
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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
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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