Making the right thing easier…
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Making the Right Thing Easier… Health Plan Initiatives in Quality Enhancement and Error Reducrion The Quality Colloquium August 23, 2004 Paul Wallace MD Care Management Institute Kaiser Permanente Paul.Wallace@kp.org Kaiser Permanente America’s oldest and largest private, nonprofit, integrated health care delivery and financing system — Founded in 1945 Multi-specialty group practice prepayment program — Headquartered in Oakland, CA Operations in 9 states and Washington, D.C. with 29 Medical Centers and 423 Clinics KP Research Centers - $100,000,000 in external funding in 2003 for Health Systems Research 8.3 million members — 6.1 million members in California Over 12,000 physicians representing all specialties and 130,000+ additional employees All employees and their families are KP members 2 The Pursuit of Value: Make the right thing easier... Identify the right thing • Evidence-based medicine • Measurement • Successful practices • Member centered and culturally competent care Make the right thing easier • Focus on the delivery system • Networks of individuals and groups • Technology to support effective work 3 The Pursuit of Defect Free Care Critical Design Considerations • The Clinician – Knowledge management – Information seeking behavior • The Patient – Who are these folks? – What else is likely going on? Co-morbidities – What is the patient’s role in their care? System Support • A Model of Care – The Population View – The Chronic Condition Model • Leverage of Information Technologies – Support for Decision Making – Ongoing Care 4 Knowledge Management…One Approach 5 Common Threats to Safety • • • • • Interruptions Fatigue Poor communication Limited memory capacity Limited ability to multi-task 6 Information-Seeking Activities of Kaiser Permanente Clinicians Holly Jimison, PhD, Mina Monroe, MPH, Mary-Anna Rae, PhD ABD, Aaron Snyder, MD Methodology • Observed clinical day for 20 KP clinicians – – – – – – 4 Regions (CO, NW, NC, SC) 1 Physician consultant in each region 1 expert computer user in each region 1 Physician novice computer user in each region 1 Physician Assistant or Nurse Practitioner in each region 1 Medical specialist in each region • Data – Ethnographic Notes – Pictures – Artifacts 7 Desk Close-Up 8 Stickies were ubiquitous Labels with patient Information and pre-visit summaries are also used as reminders 9 Physicians Forget? 10 Need for Information at the Point of Care Clinicians carry frequently used information resources with them Information systems goal: Empty the lab coat pocket 11 Clinical Information Classification Medical Nonmedical PatientNon-patientspecific specific Patient Medical Medical Record Science Social & Operational Demographic 12 Why Were Questions Unanswered? Features of the environment • Time • Memory (short-term and long-term) • Pervasive irritation with handling information • Risk-aversion (economics of time invested) Barriers • • • • • Design Incomplete Data Incomplete Access difficulties Time issues Communications 13 Permanente Knowledge Connection http://pkc.kp.org More than 30,000 KP clinical knowledge documents Online Access to over 180 journals and over 100 textbooks Comprehensive databases in Mental Health, Alternative Medicine and EBM Partnering to Provide Clinicians with Relevant and Trusted Information at the Point of Care 15 Making the right thing easier… Evidence in the exam room What’s wrong with this picture? 16 The patients we see... All Physician Encounters, 2002, Southern California DESCRIPTION HYPERTENSION NOS ROUTINE MEDICAL EXAM ACUTE URI NOS DMII WO CMP NT ST UNCNTR VIRAL INFECTION NOS BACKACHE NOS ABDMNAL PAIN UNSPCF SITE ACUTE SINUSITIS NOS ACUTE BRONCHITIS URIN TRACT INFECTION NOS FOLLOW-UP SURGERY NOS DERMATITIS NOS HYPERLIPIDEMIA NEC/NOS ALLERGIC RHINITIS NOS ASTHMA W/O STATUS ASTHM CELLULITIS NOS SCREEN MAL NEOP-CERVIX ACTINIC KERATOSIS SPRAIN NOS HEADACHE NONINF GASTROENTERIT NEC OBESITY NOS OSTEOARTHROS NOS-UNSPEC # visits 548152 399709 333785 228718 201255 200177 161436 151216 149490 144969 144540 132286 116853 115779 Total 112796 109130 108894 100671 100389 94300 88132 87859 Total 85860 CHRONIC CONDITIONS 17 KP/CMI Population Based Care Clinical Area Asthma Coronary Artery Disease Depression Diabetes Heart Failure (1 or more of the above Cancer Chronic Pain Elder Care Obesity Self Care & Shared Decision Making Anti-coagulation… KP Members with this Condition 141,000 256,000 411,000 577,000 94,000 (2.1% of members) (3.8%) (6.2%) (8.7%) (1.4%) 1,120,000 or 16.1% of members) 25,000 new cases/yr ~1,000,000 (?) 917,000 ~ 25% of adults 8.2 MM ~100-150,000? 18 Delivering Care… Then… Going Forward… • Process and experience oriented • Outcome and knowledge oriented • Local and tribal • National and global • Access: to Clinicians and Visits • Access: to what you need, whenever you need it • Knowledge Management — Paper and Recall • Knowledge Management — Electrons and Judgment • Clinician treating patients and curing acute conditions • Teams — including members — managing chronic conditions 19 20 Managing Populations… Community Health System Health Care Organization Information systems support Resources and Policies Self Management Delivery System Design Support Informed, Activated Patient Decision support tools Productive Interactions Prepared, Proactive Practice Team Improved Outcomes Source: From Improving Chronic Illness Care, Ed Wagner, Md 21 Associating High Performance with Operational Features- Examples Glycemic Screening x Action Plans 90% 85% 80% 75% 70% 0 2 4 6 8 10 Performance (Adjusted) - Eye Exams Performance (Adjusted) Glycemic Control Eye Exams x AMR 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% Practice Score - Action Plans 0% 0 2 4 6 8 10 Practice Score - Automated Medical Record Performance values shown are adjusted for all other Practices, based on model estimates 22 Associating High Performance with Operational Features Practices most associated with high performance • • • • Practices sometimes associated with performance, but with less strength and/or consistency • • • Financial incentives Provider alerts Guideline distribution & training Practices under further study • • • • 23 Action plans Automated medical record Registry Outreach and follow-up Patient education Self-Mgmt Integrated with care Stratified services Risk stratification • • • • Inreach Care coordination Team-based care Cultural competence 23 Community Health System Health Care Organization lf anagement upport Delivery System Design Information systems support Decision support tools Productive Interactions Prepared, Proactive Practice Team Source: From Improving Chronic Illness Care, Ed Wagner, Md Improved Outcomes 24 Is There Capacity for Delivering Health? Yarnall KSH, Pollack KI, Ostbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health 2003; 93:635-641 25 Best Practice Alerts- Intrusive Decrease reliance on memory. Minimize variation. 26 Drug-Drug Interaction Flag harm. Use constraints. 27 Oncology Breast Care Plan Minimizes variation. Decrease reliance on memory. Use constraints. 28 Care Plan Documentation Minimizes variation. Decrease reliance on memory. Use constraints. 29 Care Plan- Dosage Documentation Minimizes variation. Decrease reliance on memory. Use constraints. 30 Care Plan- Patient Education Minimizes variation. Engage patient as partner . 31 Oncology Dosing Support Minimizes variation. Decrease reliance on memory. Use constraints. 32 Safe, Evidence-based Oncology Care Treatment Plan Management • Oncologists Treatment Administration • Treatment Nurses/Pharmacists Infusion Center Management • Treatment Coordinators Patient View of Treatment Plan • Patients Designed With Safety in Mind 33 Ongoing Health Conditions Engage patient as partner. 34 Understanding Your Condition Engage patient as partner. 35 Lab Results Engage patient as partner. Facilitate follow-up. 36 Contact a Professional Engage patient as partner. Facilitate follow-up. 37 Pharmacist Question Engage patient as partner. Facilitate follow-up. 38 Drug Information and Identification Engage patient as partner. 39 If we can make the right thing easier… …it will likely happen Clinicians + Systems + Patients
