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PHR's : What are they good for (508 COMPLIANT VERSION)
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PHR's : What are they good for (508 COMPLIANT VERSION)

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This is a 508-Compliant version of the "PHR's: What are they good for" presentation I gave at the AHRQ Annual Conference. See http://www.tedeytan.com/tag/ahrq for a full view of these slides.

This is a 508-Compliant version of the "PHR's: What are they good for" presentation I gave at the AHRQ Annual Conference. See http://www.tedeytan.com/tag/ahrq for a full view of these slides.


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  • 1. Personal Health Records - What Are They Good For? Ted Eytan, MD MS MPH ted.a.eytan@kp.org • twitter: tedeytan The Permanente Federation, LLC • Washington, DC USA September 14, 2009 Tuesday, September 15, 2009 1 Images: Wall from Sidney Garfield Center for Health Care Innovation with poster: “Imagine, Weʼll be right there”; Mr. Yogato Yogurt Shop, Dupont Circle with neon “Open” sign; Mobile computer table with kp.org web site visible: “Thrive”
  • 2. In the beginning... Sidney Garfield, MD “ROM is Rationally Organized Medicine” Tuesday, September 15, 2009 2 Images: Portrait, Sidney Garfield, MD; Drawing produced by Sidney Garfield, MD “ROM is Rationally Organized Medicine”
  • 3. ...medical care was already complex Sidney Garfield, MD “History of Total Health” blog: http://www.kaiserpermanentehistory.org/ Tuesday, September 15, 2009 3 Images: Sidney Garfield, MD, in front of contractors general hospital; Diagram of health care process, 1900 and 1935, produced by Sidney Garfield, MD.
  • 4. The original good idea Audio: Kaiser Permanente “Thrive” radio advertisement (2009) Tuesday, September 15, 2009 4 Image: Home page of kp.org
  • 5. My health manager – Enabling Patient-Centered Care Secure view of the Electronic Health Record: ! Linked to KP HealthConnect ! Ambulatory deployment of KP HealthConnect completed April 2008 with 431 medical offices live ! Inpatient deployment of KP HealthConnect complete early 2010, 28 of 35 hospitals live ! All regions live with My health manager November 2007 Tuesday, September 15, 2009 5 Image: Home page of kp.org; Arrow pointing to hyperlink to “Experience my health manager” interactive demonstration
  • 6. My Health Manager – How big? 4,000,000 Registered members Member Activity during Quarter 3,000,000 40% signed on 11 or more times (in 2008) 2,000,000 91% of members satisfied or very satisfied with kp.org (survey in 2Q 2009) 1,000,000 1Q 07 0 3Q 07 1Q 08 3Q 08 1Q 09 Source: Kaiser Permanente Internet Services Group Web quarter *Activity for Analytics Tuesday, September 15, 2009 6 Image: Bar chart, organized by quarter, from first quarter 2007 to first quarter 2009, showing 3.1 million members have registered to use My health manager.
  • 7. My health manager - Who? Users aged 65 and over kp.org users 14.00% 14 % are Medicare beneficiaries 10.50% 41 % of Medicare beneficiaries are registered 7.00% to use My health manager Average age : 47.7 years, 4 3.50% years older than the average KP member 0% 65+ Users of kp.org % Users of the internet % Source: Kaiser Permanente Internet Services Group Web Analytics; Susannah Fox, Pew Internet & American Life Project (pewinternet.org) Tuesday, September 15, 2009 7 Image: Chart showing one bar of % users of kp.org who are aged 65 and over (approx 14%), one bar showing % users of the internet (approx 9 %) Additional data: 53% of KP members are female, 59% of members registered on kp.org are female
  • 8. My health manager - Who? 50.00% Mean sign-ons per 6 months 37.50% Significantly higher among users with High school or less education: 25.00% (21.5 vs 17.2) Significantly higher 12.50% among users with household incomes less than $50,000 : 0% (21.4 vs 14.0) High School or Less Some college College grad Post grad degree Users of kp.org % Users of the internet % Source: Kaiser Permanente 2009 Pharmacy Center Survey; Susannah Fox, Pew Internet & American Life Project (pewinternet.org) Tuesday, September 15, 2009 8 Image: Chart showing % users of kp.org in 4 educational categories - high school or less, some college, college graduate, post graduate degree.
  • 9. My Health Manager – What do they do? Registered members 6,000,000 Lab Results Viewed Member Activity E-mails sent during Quarter After Visit Information Accessed First half of 2009 Prescriptions Refilled Online 4,500,000 10.5 million My Test Results Viewed 4 million E-mail My 3,000,000 Doctor messages sent 3.2 million 1,500,000 prescription refills online 0 1Q 07 3Q 07 1Q 08 3Q 08 1Q 09 Source: Kaiser Permanente Internet Services Group Web quarter *Activity for Analytics Tuesday, September 15, 2009 9 Image: Line chart showing trends in use of services: lab results viewed, e-mails sent, after visit information accessed, and prescriptions refilled online. Additional data: Labs viewed since launch: 41,504,756 Labs viewed in 2008: 16,773,273 Labs viewed in 2009: 10,517,372 (ytd through June) Member messages sent since launch: 16,220,008 Member messages sent in 2008: 6,078,838 Messages initiated by providers in 2008: 849,079 Messages initiated by providers in 2008: 849,079 Messages initiated by providers in 2009: 700,185 (ytd through June)
  • 10. How does it change care delivery? Past Visit Information • What were my vital signs? • What instructions did the doctor give? • Heat or ice? • How long will it take to recover? • What tests were ordered? • What medications were ordered? Tuesday, September 15, 2009 10 Image: Screen capture of “Past Visit Information” from kp.org
  • 11. How does it change care delivery? The After Visit Summary... • Increases member satisfaction with provider interactions • 14 and 9.5 point increases in “% Delighted” for primary care / specialty care • Increases confidence in ability to follow treatment plan • 93% vs. 76% • Is more helpful with provider discussion (of handout) • 89% vs. 32% Source: Kaiser Permanente HealthConnect and kp.org SmartBook for Value Realization and Optimization ; Studies performed in Northwest (2006), Southern California (2007), and Colorado (2006) Regions. Tuesday, September 15, 2009 11 Image: Screen capture of “Past Visit Information” from kp.org
  • 12. After Visit Summary: “A Process, Not a Souvenir” Percent Face to Face Physician Visits with an AVS Printed 100% KP CO Text 75% GA HI MA 50% NW OH SC 25% Mark Snyder, MD 0% 06Q1 06Q3 07Q1 07Q3 08Q1 08Q3 09Q1 Source: Kaiser Permanente Utility for Care Data Analysis Tuesday, September 15, 2009 12 Image: Photograph of Mark Snyder, MD, in front of electronic medical record; Line chart showing percent face to face visits with an after visit summary printed, showing a marked increased trend from 2006 to 2009.
  • 13. Proactive use of the PHR as a clinical tool Usual Care PHR + Pharmacist 60 51% 45 29% 30 15 0 BP Control, 12 months Source: Green BB, Cook AJ, Ralston JD, Fishman PA, Catz SL, Carlson J, et al. Effectiveness of Home Blood Pressure Monitoring, Web Communication, and Pharmacist Care on Hypertension Control: A Randomized Controlled Trial [Internet]. JAMA. 2008 Jun 25;299(24):2857-2867.[cited 2008 Jun 24 ] Available from: http://jama.ama-assn.org/ cgi/content/abstract/299/24/2857 Tuesday, September 15, 2009 13 Image: Bar chart showing the difference between patients who are enrolled in a PHR-assisted blood pressure control, showing markedly improved blood pressure control with the assistance of a personal health record and pharmacist management.
  • 14. Transforming, Streamlining a System Kaiser Permanente, Hawaii: Visits per Member In Person 5 Telephone Member Activity Secure E-mail during Quarter Secure e-mails / member 4 2005: 0.03 “For the majority of 2006: 0.11 (HEDIS Quality) 2007: 0.23 3 measures that were comparable, (p < 0.001) performance 1 remained stable during the study period.” 0 Jan 2006 August 2008 Source: Chen C, Garrido T, Chock D, Okawa G, Liang L. The Kaiser Permanente Electronic Health Record: Transforming And Streamlining Modalities Of Care [Internet]. Health Aff. 2009 Mar 1;28(2):323-333.[cited 2009 Mar 11 ] Available from: http:// content.healthaffairs.org/cgi/content/abstract/28/2/323for quarter *Activity Tuesday, September 15, 2009 14 Image: Line chart showing changes in in person visits, telephone visits, and secure e-mail visits in the Kaiser Permanente Hawaii region, Jan. 2006 - August 2008
  • 15. “I know her that much better” Kaiser Permanente YouTube Channel http://www.youtube.com/kaiserpermanenteorg Tuesday, September 15, 2009 15 Image: Video of member speaking of her My health manager experience ( available at http://www.youtube.com/kaiserpermanenteorg )
  • 16. Next: The Web Presence Platform Consumer Portal Purchaser Portal An initiative to Business Applications migrate kp.org from a legacy platform to User Facing Broker Portal Workforce Portal a new portal-based Web platform. Application Content Content Configuration User Interface Services Publishing Publishing & Admin Shared Development Workflows Workflows Scripts Federated Web Content Web Single Web Components Admin Tool Proxy Single Search Management Sign On Intelligence Sign On Web Presence Platform Physical & Software Shared Zip Code Article Executive & WPP Content Secure Artifact Coverage Archive Operational Central/ Rendering Messaging Lifecycle Portlet Portlet Dashboards Sigma Portlet Enterprise Portlets Operating Portal Application Database Application Virtualization Web Servers Infrastructure Systems Servers Servers Servers Monitoring Physical Environments Physical (e.g. Data Center, Facilities, Server Storage Networks Load Power & Cooling Boxes Balancing 1 Tuesday, September 15, 2009 16 Image: A visual diagram of the new architecture of the Web Presence Platform, for kp.org Current state: Migrating to a new technology platform that will provide significant development, performance and production advantages over the current technology suite. Essentially one single body of code Development and text complexity leads to fewer, more costly releases Difficult to diagnose and correct performance and stability issues Design limits the practical number of developers who can engage in simultaneous work Content management requires a single point of coordination Future state: Shared infrastructure across multiple applications improves user experience Use of standard services and portlets divides the code into self-contained units and improves trouble shooting and performance Releases become much smaller thereby lowering costs and increasing time-to-market The use of standard services and portlets improves troubleshooting and performance Many different groups can develop in parallel Distributed content management delivers content control to various regions and functional areas New applications can be “assembled” from existing components, reducing time to market Applications are mobile-ready Intranet and Internet will leverage may of the same capabilities with common architecture and services
  • 17. Next: The Web Presence Platform Consumer Portal Purchaser Portal Business Applications User Facing Broker Portal Workforce Portal Application Content Content Configuration User Interface Services Publishing Publishing & Admin Shared Development Workflows Workflows Scripts Federated Web Content Web Single Web Components Admin Tool Proxy Single Search Management Sign On Intelligence Sign On Web Presence Platform Physical & Software Shared Zip Code Article Executive & WPP Content Secure Artifact Coverage Archive Operational Central/ Rendering Messaging Lifecycle Portlet Portlet Dashboards Sigma Portlet Enterprise Portlets Operating Portal Application Database Application Virtualization Web Servers Infrastructure Systems Servers Servers Servers Monitoring Physical Environments Physical (e.g. Data Center, Facilities, Server Storage Networks Load Power & Cooling Boxes Balancing 1 Tuesday, September 15, 2009 17 Current state: Migrating to a new technology platform that will provide significant development, performance and production advantages over the current technology suite. Essentially one single body of code Development and text complexity leads to fewer, more costly releases Difficult to diagnose and correct performance and stability issues Design limits the practical number of developers who can engage in simultaneous work Content management requires a single point of coordination Future state: Shared infrastructure across multiple applications improves user experience Use of standard services and portlets divides the code into self-contained units and improves trouble shooting and performance Releases become much smaller thereby lowering costs and increasing time-to-market The use of standard services and portlets improves troubleshooting and performance Many different groups can develop in parallel Distributed content management delivers content control to various regions and functional areas New applications can be “assembled” from existing components, reducing time to market Applications are mobile-ready Intranet and Internet will leverage may of the same capabilities with common architecture and services
  • 18. National Supply and Demand Not Somewhat Interested 100 “Consumers in Medicare and 75 Medicaid, as well as the uninsured, are just as interested in 50 these tools and services as commercial enrollees.” 25 0 E-mail Results, Rx, Sched PHR + Doctor Supply and Demand Consumers Deloitte 2009 Survey of Health Care Tuesday, September 15, 2009 18 Image: Bar chart showing patient interest in E-mail with physicians, access to test results, and access to a personal health record and their doctor online This is the second thing. Patient access is for everyone. Raise your hands if you have secure access to these features in your health care. Now keep them up if you are a member of Kaiser Permanente. What other industry do you know of that has such a mismatched supply and demand profile?
  • 19. Your patients will tell you what this means for them “When we were not allowed to see the medical record at the first hospital I went down to medical records to get a copy. They said it would be a 21 day wait and 73 cents a page.” Regina Holliday’s Medical Advocacy Blog http://reginaholliday.blogspot.com/ Tuesday, September 15, 2009 19 Image: Notebook, on a table, overstuffed with paper
  • 20. “73 Cents” in Washington, DC “I am using paint brushes I have had for 17 years. I am applying acrylic paint (paid for by donations of friends and strangers) on a wall donated by a gas station.” -Regina Holliday Tuesday, September 15, 2009 20 Image: Google map of the location of “73 cents” mural; 73 cents mural, Washington, DC
  • 21. “73 Cents” in Washington, DC Tuesday, September 15, 2009 21 Image: Photograph of “73 cents” mural, Washington, DC Narrative (from Regina Hollidayʼs blog): In August of 2008, My husband's dream came true. He was hired by American University to teach film studies. He was so happy. He was such a great teacher. Now, we could finally afford family insurance. In January 2009 he began going to the doctor because of pain in his chest. In February the pain went to his back. He no longer could carry his books and papers to the classes he taught; so he began using our son's rolling backpack. By March the pain was so severe we demanded an MRI. On March 27 at 11:00 am my husband was diagnosed with Metastatic Kidney Cancer. He was in stage four by the time of diagnoses. My husband was hospitalized at five different medical facilities in a three month period. He suffered through 40 ambulance transports to receive radiation, had repeated and unnecessary tests, routinely had delay in pain treatment due to lack of data access during transfers. After suffering in a health system more concerned about quantity of care over quality of care, Fred died on June 17th at the age of 39.
  • 22. “73 Cents” in Washington, DC Tuesday, September 15, 2009 22 Image: Page from British Medical Journal International Print Edition, showing photograph of the week is the “73 cents” mural, photographed by Ted Eytan. September 12, 2009 issue.
  • 23. Being connected, then... Panorama City Hospital, 1962 Tuesday, September 15, 2009 23 Images: Sidney Garfield, MD, with caption “Dedicated to achieving positive health and prevention of illness”; Panorama City Hospital, opening day, 1962
  • 24. ...and now Kaiser Permanente YouTube Channel http://www.youtube.com/kaiserpermanenteorg Tuesday, September 15, 2009 24 Image: “Connected” Commercial, Kaiser Permanente (available at http://youtube.com/kaiserpermanenteorg)
  • 25. Thank you. Tuesday, September 15, 2009 25 Image: “Thrive” spelled out with sports equipment
  • 26. Appendix: Prioritizing Patient-Time Ambulatory Care Visit (published data) 120 90 Time with provider Exam Room Wait 60 Waiting Room Check in/out 30 Travel to and from 0 Minutes Source: Chen C, Garrido T, Chock D, Okawa G, Liang L. The Kaiser Permanente Electronic Health Record: Transforming And Streamlining Modalities Of Care [Internet]. Health Aff. 2009 Mar 1;28(2):323-333.[cited 2009 Mar 11 ] Available from: http:// content.healthaffairs.org/cgi/content/abstract/28/2/323 Tuesday, September 15, 2009 26 Image: Bar chart showing the cumulative amount of minutes a patient spends to see a physician in person.