#HASummit14 Session #22: Integrating Process and Informatics at CO Kaiser Permanente to Achieve...
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Transcript of #HASummit14 Session #22: Integrating Process and Informatics at CO Kaiser Permanente to Achieve...
#HASummit14
Session #22:Integrating Process and Informatics at
CO Kaiser Permanente to Achieve Benchmark Cardiovascular Outcomes
John A. Merenich, MD, FACP, FNLA
Medical Director, Clinical Pharmacy Cardiac Risk Service, KPCO
Medical Director, Clinical Informatics & Decisions Support, KPCO
Associate Clinical Professor of Medicine, University of Colorado
Pre-Session Poll Question
What is the biggest challenge/barrier in your care setting to prevent stroke and heart attacks?
a) Inconsistent misunderstood changing guidelines
b) Lack of timely and accurate metricsc) Dependence on physicians to do all the
interventionsd) Patient resistance and non-compliancee) Time and money
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Poll Question #2eful***?
2
What is the priority of implementing a stroke and heart attack prevention program in your care setting?
a) Top priority – Our current outcomes are known, and they are NOT optimal. Clearly more needs to be done.
b) High priority – Our current outcomes are above average, but we feel there is need for improvement.
c) Moderate priority – We are satisfied that we have done what is needed in this area but don’t plan to do anything different for now.
d) Low priority – We would like to do more, but our outcomes and baseline metrics are unknown and/or our implementation challenges are overwhelming.
e) Unsure or not applicable
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Key Messages• The Kaiser Permanente of Colorado (KPCO)
approach of the past 15 years has resulted in benchmark outcomes
• Technology/Informatics support has been essential, but people and process factors were /are the primary drivers of cardiovascular (CV) outcomes• Docs can’t and SHOULD NOT be solely
responsible for CV outcomes• Cardiovascular GAPS are the bridge
between Process and Technology• Risk stratifying to match resources to
appropriate level of patient need helps identify opportunities and prioritize resources
• Tools to increase individualized, personalized care and Shared Decision Making are critical
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Kaiser Permanente by the numbers
Nation’s largest nonprofit health plan
Integrated health caredelivery system
9.1 million members
17,000+ physicians
49,000+ nurses
175,000+ employees
Serving 9 states and the District of Columbia
37 hospitals
618 medical offices/ outpatient facilities
$50.6 billion operating revenue*
Scope includes ambulatory, inpatient, ASC, behavioral health, SNF, home health, hospice, pharmacy, imaging, laboratory, optical, dental, and insurance
4
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Colorado KP: Population Health Management Priorities in 2015
Get more members self(co)-managing their care• Get personalized ACTIONABLE care gap information
directly to the member• Easy access to educational, coaching, support
materials
Focus on maintaining Health & Wellness• Earlier detection and PREVENTION of chronic diseases• Slowing the progression of chronic diseases
Reduce cost of providing Health Care (Triple Aim)• Reduced ED visits and hospital admissions• Promote more efficient care team collaboration• Transition from Quality to VALUE dashboards
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PATIENT-CENTERED focusIntegrated teamsCoordinated CarePatient as team member
PEOPLE
Guidelines and protocolsDriver diagrams/Process mapsMETRICS/METRICS/METRICS ***GOVERNANCE***
PROCESS
RegistriesElectronic Medical RecordWeb and other resources ACTIONABLE data
TECHNOLOGY
80%
KPCO winning strategy over the years
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• Gap between what we know should be done (evidence base) and what was actually happening for patients with known CAD
• High recidivism even when meds for CAD started
• Focus of resources on high-cost classic rehab
• MDs seldom had time to convey messages, start, and monitor therapy
Flashback to 1996: The first KPCO problem to be solved…
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88% Reduction in all-cause mortality
Technology & Tools• Electronic medical record• Computerized disease registry
Information• Development of protocols to
improve outcomes
• Rehabilitation Program
• Medication Management
• Prompts and reports to support protocols – accessible to all members of care team
Teams• Physician• Nurse• Clinical Pharmacist
8
Collaborative Cardiac Care Service
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The solution
9
In 1996, KPCO developed the Collaborative Cardiac Care Service (CCCS) with the goal of improving the health of patients with CAD.Team consists of a nursing team (the KP Cardiac Rehabilitation program), a pharmacy team (the Clinical Pharmacy Cardiac Risk Service), and Primary Care and Specialty physicians.Collaboration systematically occurs with patients, primary care physicians, cardiologists, and other health care professionals to coordinate proven cardiac risk reduction strategies for patients with CAD.Evidence-Based Intervention includes activities such as lifestyle modification, medication initiation and adjustment, patient education, laboratory monitoring, and management of adverse events. All are all coordinated through CCCS.
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HealthTRAC registry system (separate from EMR) with “slice and dice” stratification and drill-down function
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Data drove next steps: ICVHThe majority of CVD events occur in patients without previous history of ASCVD events**
**Colorado Kaiser Quarter 1 2014 CV event analysis
“First event” patients 65%Age (21-98) Average 66 yrNot on statin 61%Smokers/unknown status 30%DM 17%BP not controlled 22%CV Risk Unknown 21%Low Framingham Risk 10%Moderate Framingham Risk 10%
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Integrated Cardiovascular Health (ICVH)
• ICVH team has met quarterly for last 10+ years
• Replaced all the previously “siloed” governing groups• Puts holistic patient back in the middle
where it belongs• Representatives: PATIENTS, MDs (primary
and specialty), Nursing, Pharmacy, Operations, Lab, Informatics, Nutrition, Prevention
• Owns and prioritizes the Regional ICVH Driver Diagram
• Coordinates care across teams• Determines Informatics needs/priorities
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People and Process: You need a driver diagram
“If you don’t know where you are going, you’ll wind up someplace else.” (Yogi Berra)
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LDL screening and CV risk determination
&
Statin for patients with diabetes
Statin, ASA, and BP control for high-risk groups
Exercise as vital sign
Encourage consideration of statin for moderate risk
“Test the Untested”
“Treat the un/under treated”
The “keep it simple” version:Integrated Cardiovascular Health Focus Last 5 Years On Primary Prevention
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Initial request:I just need a list of my patients with…
REALLY???(The aspirin example)
• Patients on ASA …takes you only so far!!!• Where is ASA use documented; how often
to determine “current” user• Who is at risk and needs ASA; what dose?• Other antiplatelet/anticoagulation meds?• Age, gender, risk factors, changing
evidence base• Risk/Benefit for individual• On other CV-risk reducing agents?
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FROM List and rules……
Aspirin IndicatedOne or more of the following: · Age 18-80 And ASCVD And Not On Aspirin(ASA) And Not On Anticoagulant Medication And Not
On Antiplatelet Medication · Age 18-80 And CV Risk > 10% And ASCVD Equivalent And Not On Aspirin(ASA) And Not On
Anticoagulant Medication And Not On Antiplatelet Medication · Age 18-80 And CV Risk > 20% And Not ASCVD or ASCVD Equivalent And Not Diabetes And Not
On Aspirin(ASA) And Not On Anticoagulant Medication And Not On Antiplatelet Medication · Age 40 to 80 And Diabetes And CV Risk > 10% And Not ASCVD or ASCVD Equivalent And Not On
Aspirin(ASA) And Not On Anticoagulant Medication And Not On Antiplatelet Medication · Male Age 45-69 And CV Risk 15-19% And Not Diabetes And Not ASCVD or ASCVD Equivalent
And Not On Aspirin(ASA) And Not On Anticoagulant Medication And Not On Antiplatelet Medication
· Female Age 55-69 And CV Risk 15-19% And Not Diabetes And Not ASCVD or ASCVD Equivalent And Not On Aspirin(ASA) And Not On Anticoagulant Medication And Not On Antiplatelet Medication
Does this Patient meet KPCO criteria for ASA today…… YES or NO??
…TO GAPS:
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Lists to Actionable Data
Val
ue
Complexity
List
ActionableData
Elements of a Patient List• A set of patients sharing a
common set of characteristics such as diagnosis or medications.
Elements of a complete registry• Integrated with HealthConnect • Individualized care pathways• Integrated data sources • Flexible design• Automated outreach • Integration of data from multiple
sources• Rule transparency• Actionable care gaps• Legally compliant (HIPAA,
HASP)• Automating elements of clinical
workflow
Clinical Decision Support
Population Management
Cohort
Population Based Rules
Individualized Rules
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Go to the “GREEN (bottom) LINE”
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From Lists to ACTIONABLE GAPS:These patients need to do something!
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Constantly update and revise CV GAPS
Individualized for every adult, Yes or No for:
Need to screen for lab or blood pressure or
Statin neededHigh DOSE statin indicatedAspirinBlood Pressure MedAspirin GAP NEWSmoking documentation and counsellingDietitian visit revision
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Getting ALL the GAPS into the workflow….HealthTRAC Landing Page
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The “World According to Gap”
GAPS:• Simplified output for complex decisions
• Individualized/personalized• Can be cofigured to accommodate for patient
preference• Easy to aggregate and display across disease state
• Single source of (synchronized) truth for all patient actions
• Truly actionable• What to do and NOT do (e.g. Choosing Wisely
efforts)• “Currency” and lead metric for Informatics tools and
process effectiveness (i.e. how efficiently GAPS are closed)
• Correlate with cost both short- and long-term outcomes
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GAP “Solutions”: “Auto” ordering”
Corresponding Lab or procedure to close the GAP automatically ordered in our Epic system
Problem list status Active
MD Consent (Enrollment
in Population Program)
GAP
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GAPS in the workflow:Transparency, utility, context, andone-stop shopping
...and real-time decision support
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Dynamic, Individualized
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Decision support for Aspirin Indication: (Age/Gender specific Risk vs Benefit Shown)
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GAPS Drive right to the Member level and view:“Personal Action Plan”
Patient with CV GAPS in the EMR:Clicks On Action Plan in KP.org…
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Measure and share unblinded metrics often to stimulate friendly completion and cross sharing of best practice
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Poll Question #3eful***?
29
What would help your organization improve CV care, and where would you focus?
a) EMR process management tools
b) Actionable lists (gaps) based on advanced decision support
c) Direct to consumer/patient portal tools
d) Lead metric outcomes measures (e.g. number of patients on statins, BP control) compared to benchmarks
e) “Slicer dicer” including utilization data for discovery at all business levels
***Recognizing that they are all important and would all be included in an optima solution
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Cardiovascular Disease Value Dashboard Prototypes
Quality: Cholesterol Management for Patients with Cardiovascular Conditions (Screening), Cholesterol Management for Patients with Cardiovascular Conditions (Control LDL-C Level<100 mg/dL)Resource Use: Inpatient, E&M, Surgery and Procedures, excludes Pharmacy
Relative Resource Use by Relative Quality, HEDIS 2009Medical Use and Care for Cardiovascular Conditions
NC not reported, no E&M data for Medical Use composite
GHC
SC
CO
GAHI
MANW
OH
0.80
1.00
1.20
0.40 1.00 1.60
Relative Resource Use Indexed Ratio
Rel
ativ
e Q
ual
ity
Ind
ex
HIGHER QUALITY, LOWER RESOURCE USE
LOWER QUALITY, LOWER RESOURCE USE
HIGHER QUALITY, HIGHER RESOURCE USE
LOWER QUALITY, HIGHER RESOURCE USE
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Major Coronary Events in KPCO have decreased by more than 60% the past 10 years(THIS DOES WORK!!!)
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| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
MCE/MCVE costs saved in KPCO
MI:2,375 fewer events per year over the last decade (accounting per population growth)
CVA:165 fewer strokes per year over the last 3 years (accounting per population growth)
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Lessons Learned
33
• Informatics and Decision Support must be developed and structured
by processes and people implementing them• Risk stratify, divide, and conquer!
• Measure, share, adjust…over and over• CV outcomes are the purview of ALL providers—not just Docs
• Indeed, CV care is largely empiric and the purview of teams and non-MDs...including the patient!!
• Allocate tools and resources to based on CV risk• Develop tools to highlight ACTIONABLE PERSONALIZED GAPS
• NOT creation of endless LISTS• GAPS must be accurate, timely, specific to patient, delivered at the
time and place needed• Quality first….Value will follow for the most part
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Analytic Insights
AQuestions &
Answers
34
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Choose one thing…
35
Write down one thing will you do differently after hearing this presentation
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Thank You
36
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Session Feedback Survey
1. On a scale of 1-5, how satisfied were you overall with this session?
1) Not at all satisfied
2) Somewhat satisfied
3) Moderately satisfied
4) Very satisfied
5) Extremely satisfied
2. What feedback or suggestions do you have?
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Upcoming Sessions
Breakout Sessions – Wave 4 (1:15 PM – 2:00 PM)
26) Panel – How Community Hospitals Thrive with AnalyticsJohn Wadsworth, Vice President, Technical Operations, Health Catalyst
27) Quality Improvement in Healthcare: An ACO Palliative Care CaseDr. Robert Sawicki, MD, Senior Vice President, Supportive Care, OSF HealthcareRoopa Foulger, Executive Director, Data Delivery, OSF HealthcareLinda Fehr, RN, Division Director, Supportive Care, OSF Healthcare
28) Clinical Standards Work To Improve Evidence-Based Care Delivery: A How-To WorkshopCharles Macias, MD, MPH, Chief Clinical Systems Integration Officer, Texas Children’s HospitalTerri Brown, MSN, RN, CPN, Assistant Director, Clinical Outcomes & Data Support; Research Specialist, Center for Research and EBP, Texas Children’s Hospital
29) Five Months to Improvement: How Stanford Built an Improvement Program the Gets ResultsSpencer H. Kubo, MD, Associate Professor of Radiology (Pediatric Radiology), Stanford University Medical Center
30) Breaking Down Silos: Resolving Academic, Medical, and Research Interests Once and for AllSamuel L. Volchenboum, MS, MD, PhD, Assistant Professor of Pediatrics, Director, Informatics Program, The University of Chicago Medicine)
Location
Imperial Ballroom B
Imperial Ballroom A
Grand Salon
Murano
Venezia