Kaiser Permanente HealthConnect Andrew M. Wiesenthal, MD, SM Associate Executive Director, The Permanente Federation

Andrew M. Wiesenthal, MD, SM

Associate Executive Director, The Permanente Federation

About Kaiser Permanente Integrated health care delivery system 32 hospitals and medical centers 430+ medical offices *$35 billion annual revenues 8.5 million members 150,000+ employees 8 regions serving 9 states and D.C. 13,000+ physicians Largest nonprofit health plan in US * 2006 revenues

Integrated health care delivery system

32 hospitals and medical centers

430+ medical offices

*$35 billion annual revenues

8.5 million members

150,000+ employees

8 regions serving 9 states and D.C.

13,000+ physicians

Largest nonprofit health plan in US

About Kaiser Permanente HealthConnect™ We are deploying virtually all major applications in the Epic product suites: Clinicals—inpatient and ambulatory, and inpatient pharmacy Access—scheduling, registration and ADT Revenue Cycle—billing and claims eHealth Enterprise Foundation—synchronization software Managed Care—utilization management and referral management The largest civilian deployment of an electronic health record in the world.

We are deploying virtually all major applications in the Epic product suites:

Clinicals—inpatient and ambulatory, and inpatient pharmacy

Access—scheduling, registration and ADT

Revenue Cycle—billing and claims

eHealth

Enterprise Foundation—synchronization software

Managed Care—utilization management and referral management

The largest civilian deployment of an electronic health record in the world.

Scope of KP HealthConnect Care Delivery Core Outpatient Inpatient Scope of KP HealthConnect Suite Scheduling Registration Clinicals Billing Scheduling Admission, Discharge and Transfer Clinicals Billing Pharmacy Emergency Department Operating Room Health Plan Web Access Portal Ancillaries Referral & Utilization Management Finance Lab Radiology/ Imaging Others (immunizations, EKG, dictation) Outpatient Pharmacy Claims Processing Membership/ Benefits Benefits Accumulation Pricing System Data Warehouse / EDR Enterprise Data Repository Capital Planning General Ledger Financial Reporting

KP HealthConnect Delivers the KP Promise Quality Our Patients Can Trust High Quality We have clinical information available 24/7. Our clinical outcomes are unsurpassed. Our clinicians know in real-time the recommended best practices. We are the national leaders in patient safety. We enhance our research to support evidence-based care. Personal & Convenient Service Personal We have and use up-to-date clinical, social and patient preference information. We provide patients information for shared decision making. We enhance personalized care. Convenient Our patients access information via telephone, Web and email. We actively support our patients’ participation in their own care. We minimize wait times and out-of-pocket costs with efficient access to care. We achieve superior integration and continuity of care. Affordable Health Care Affordable We reduce the cost of care and improve visit experiences. We eliminate waste associated with paper medical records and missing medical records. We eliminate costly in-person services unless medically necessary or desired by the patient. We streamline IT and administrative processes and costs

High Quality

We have clinical information available 24/7.

Our clinical outcomes are unsurpassed.

Our clinicians know in real-time the recommended best practices.

We are the national leaders in patient safety.

We enhance our research to support evidence-based care.

Personal

We have and use up-to-date clinical, social and patient preference information.

We provide patients information for shared decision making.

We enhance personalized care.

Convenient

Our patients access information via telephone, Web and email.

We actively support our patients’ participation in their own care.

We minimize wait times and out-of-pocket costs with efficient access to care.

We achieve superior integration and continuity of care.

Affordable

We reduce the cost of care and improve visit experiences.

We eliminate waste associated with paper medical records and missing medical records.

We eliminate costly in-person services unless medically necessary or desired by the patient.

We streamline IT and administrative processes and costs

Progress to Date More than 8 million members have a partial or complete EpicCare® Ambulatory record All members will have one by mid-2008 On-line functionality for members (MyChart®) is live in all of our 8 regions 2.5 million members are currently registered to access KP HealthConnect through kp.org Seven KP hospitals are now live with EpicCare® Inpatient 27 more hospitals will go live by 2009 (including hospitals currently under construction) Practice Management (Access & Revenue Cycle) deployments are complete

More than 8 million members have a partial or complete EpicCare® Ambulatory record

All members will have one by mid-2008

On-line functionality for members (MyChart®) is live in all of our 8 regions

2.5 million members are currently registered to access KP HealthConnect through kp.org

Seven KP hospitals are now live with EpicCare® Inpatient

27 more hospitals will go live by 2009 (including hospitals currently under construction)

Practice Management (Access & Revenue Cycle) deployments are complete

Conformance to Standards KP HealthConnect is based on an array of existing and emerging national (US) and international standard vocabularies Chief among these standards is SNOMED-CT Others include: LOINC—laboratory DICOM—images RxNORM—pharmaceuticals NIC, NOC, NANDA—nursing assessment vocabularies We have assembled all of these into a logical hierarchy we call CMT, or convergent medical terminology All intersystem messaging is HL-7 compliant

KP HealthConnect is based on an array of existing and emerging national (US) and international standard vocabularies

Chief among these standards is SNOMED-CT

Others include:

LOINC—laboratory

DICOM—images

RxNORM—pharmaceuticals

NIC, NOC, NANDA—nursing assessment vocabularies

We have assembled all of these into a logical hierarchy we call CMT, or convergent medical terminology

All intersystem messaging is HL-7 compliant

Standardized Vocabularies vs. ICD and CPT Richer, more granular expression More familiar to clinicians Hierarchical, group-able, and susceptible to concatenation Ideal qualities for decision support, analysis, and population-based clinical and public health intervention Greater clarity across interfaces

Richer, more granular expression

More familiar to clinicians

Hierarchical, group-able, and susceptible to concatenation

Ideal qualities for decision support, analysis, and population-based clinical and public health intervention

Greater clarity across interfaces

How Does it Work? Epic software is organized around a set of Master Files Visualize spreadsheets of terms Name Unique identifier Aliases/synonyms Maps to other data/classification schemes (ICD, CPT) The key Master Files are: Diagnosis (around 40,000 SNOMED-CT terms) Procedures (around 100,000 terms—includes supplies) Anatomy

Epic software is organized around a set of Master Files

Visualize spreadsheets of terms

Name

Unique identifier

Aliases/synonyms

Maps to other data/classification schemes (ICD, CPT)

The key Master Files are:

Diagnosis (around 40,000 SNOMED-CT terms)

Procedures (around 100,000 terms—includes supplies)

Anatomy

How Does it Work? When a clinician documents care, the software constrains entry technique and choice in certain categories Chief complaint Vital signs Physical findings Assessment/Diagnosis Plan Orders Patient instructions

When a clinician documents care, the software constrains entry technique and choice in certain categories

Chief complaint

Vital signs

Physical findings

Assessment/Diagnosis

Plan

Orders

Patient instructions

How Does it Work? When a clinician uses the chart for longitudinal purposes, entry technique and choices are also constrained Problem list History Medical, Surgical, Family, Social Allergies Immunizations Medication management

When a clinician uses the chart for longitudinal purposes, entry technique and choices are also constrained

Problem list

History

Medical, Surgical, Family, Social

Allergies

Immunizations

Medication management

Why do it This Way? We are implementing an EHR, not a vocabulary We need to enable clinicians to document in a language that sounds right Extraction of data for financial, performance management, and research purposes is a crucial derivative function of the EHR SNOMED-CT and the group of vocabularies in our CMT offer the most robust solution to this problem set

We are implementing an EHR, not a vocabulary

We need to enable clinicians to document in a language that sounds right

Extraction of data for financial, performance management, and research purposes is a crucial derivative function of the EHR

SNOMED-CT and the group of vocabularies in our CMT offer the most robust solution to this problem set

What are the Problems? We are among the first to do this Publicly available SNOMED-CT has had some gaps Certain diagnostic categories Procedures and supplies Mappings to classification schemes of financial importance in the US ICD, CPT SNOMED did not (and the IHTSDO does not) have the internal resources to fill those gaps rapidly Work is ongoing to refine the process of requesting or uploading new terms

We are among the first to do this

Publicly available SNOMED-CT has had some gaps

Certain diagnostic categories

Procedures and supplies

Mappings to classification schemes of financial importance in the US

ICD, CPT

SNOMED did not (and the IHTSDO does not) have the internal resources to fill those gaps rapidly

Work is ongoing to refine the process of requesting or uploading new terms

What Does it Look Like?

Key Chart Elements are Encoded Chief Complaint Vital Signs Allergies Health Risks

Medications are Encoded Prescribed at our pharmacy Patient reported

Patient “Snap Shot”

Documenting Review of Systems with Encoded Elements

Documenting Review of Systems…

Documenting Review of Systems…

Documenting Physical Examination with Encoded Elements

Free Text is also Possible

Encoding Allows for Alerts

Granular Encoding in Medication Ordering

…Also Allows for Alerts by Drug Name…

…Or Drug Class

Orders Can be Associated with Diagnoses

Documentation can be Structured into Historical Flows

In the End… The Holy Grail Physicians Document Nurses Document Data is created Systematic Feedback Occurs Improved Health Outcomes and Operational Efficiencies are Possible DATA

The Holy Grail

Physicians Document

Nurses Document

Data is created

Systematic Feedback Occurs

Improved Health Outcomes and Operational Efficiencies are Possible

What Has this Meant for Kaiser Permanente’s Members? Dramatically lowered cardiac disease mortality Improved use of preferred drugs COX-II inhibitor story Better Syndromic Surveillance Rotavirus Vaccine and Intussusception Data about Clinician Performance Improved Clinical Research Capabilities More to Come Adult oncology standardization and protocol improvement

Dramatically lowered cardiac disease mortality

Improved use of preferred drugs

COX-II inhibitor story

Better Syndromic Surveillance

Rotavirus Vaccine and Intussusception

Data about Clinician Performance

Improved Clinical Research Capabilities

More to Come

Adult oncology standardization and protocol improvement