HIT AND HSR FOR ACTIONABLE KNOWLEDGE:
HEALTH SYSTEM SUMMARY
PARTNER: Kaiser Permanente
Organization and IT Infrastructure
Organizational Description and History
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Kaiser Permanente is a not-for-profit, mainly capitated health plan and integrated
delivery system with operations in eight regions: Northern CA, Southern CA,
Northwest (OR, WA), CO, HI, GA, OH, and Mid Atlantic (DC, MD, VA), and
serving a total of 8.6 million members.
The health system comprises 35 hospital medical centers and 431 outpatient
medical offices across the country.
Electronic Health Record (EHR) History
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KP undertook multiple regionally-based, independent HIT initiatives over a 30+
year period.
Beginning in 2003, Kaiser implemented KP HealthConnect®, (KPHC) a
comprehensive Epic system, evolved from a similar system first implemented in
KP’s Northwest region in 1994.
KP HealthConnect® has a national governance structure and employs common
data definitions with some regional localization. However, each region maintains
its own KP HealthConnect® system; as regional roll-out has been concluded in
2010, planning and design for inter-region data exchange is underway.
Research Influence in EHR Design
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The origin of KP’s use of HIT was in research. The organization’s first EHR
system was implemented during the 1970s in Northern CA by researchers as part
of an NIH grant to look at the role of HIT in supporting systematic population
based prevention.
Researchers were not directly at the table in design of most subsequent systems
including KP HealthConnect®, but have maintained indirect influence through the
KP leadership accountable for research.
Data Management
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Because KP HealthConnect® and most KP research is localized at the regional
level, our observations based on the site visit and case study focused on the
Northern CA region (unless otherwise noted in this report).
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NCAL DOR has developed a research database (RDB) on an Oracle platform that
serves as a repository for legacy and KPHC data. It aggregates into a single data
warehouse the hundreds of separate regional data sets that researchers now access
to extract the data elements needed for their research projects.
Part of the RDB is a virtual data warehouse (VDW), It conform both legacy and
KPHC data into standard database structures that is optimized for research queries
and retrieval. It uses a security model that meets all HIPAA, IRB and KP
requirements.
The RDB and VDW databases are used by KP researchers to support a variety of
epidemiological studies, health services research and informatics projects. The
RDB receives daily updates from KPHC’s clinical databases, in addition to other
KP clinical data sources not available through KPHC. Because KP has had some
form of electronic medical record for almost 40 years, those historical records,
which are preserved in legacy databases, are imported into the Research Database.
This provides a unique opportunity for researchers to study secular trends of
disease, as well as following the health and disease status of large cohorts over
time.
The VDW is also, a collection of standardized, haromonized datasets developed
by the HMO Research Network (HMORN) of which KP is a member
(www.hmoresearchnetwork.org). In addition to being used internally at KP, the
VDW allows the health system to participate in research with other health plans
participating in the HMORN.
Technologically, the VDW comprising an Oracle database and SAS-based
datasets are stored and used in a Sun hardware environment.
Analytic datasets for research and quality improvement/measurement purposes
are provided in PC format, Server SAS, or Teradata SQL Assistant (for quality
improvement and dashboard purposes).
Datasets for business intelligence are provided in ad hoc or structured formats to
support users’ direct queries of the data. NCAL DOR has been developing an
“i2b2” tool that will be used to perform this function.
Data Available For Research
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VDW includes data on:
o Plan enrollment
o Demographics
o Oncology
o Outpatient Pharmacy
o Diagnoses
o Procedures
o Utilization (admitting source/discharge disposition for inpatient,
diagnoses, procedures, provider, and facilities)
o Vital signs
o Provider
o Census
o Mortality
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o Laboratory
VDW data elements are harmonized across all HMORN participating
organizations.
IT Support For Research
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In the Northern CA region, Division of Research has its own IT staff that
maintains the RDB and VDW and prepares analytic databases for particular
projects
Data processing resources at DOR consist of a local area network (LAN) with
>600 desktop Windows workstations, and two MacIntosh workstations. The
workstations also have access to four large IBM mainframe computers at the
Kaiser Permanente Data Center in Southern California. The LAN is a shared
100BaseT Ethernet network with file servers running Windows 2000 and 2003
server operating systems. There are six Sun Solaris servers and two Red Hat
Linux servers.
Analysis and database software available on the Sun computers include SAS,
Gauss, Stata, Epicure and Oracle. Languages available for the Suns are C, C++,
Java and Perl. The LAN is connected to the Internet via a T-1 line through a Level
3 firewall.
Ten network workstations are dedicated to data entry and run a commercial keyto-disk program (Textware). An optical scanner and Teleform software are used
to create survey forms that, when filled out, can be scanned optically into a
computer for data entry locally or by fax from outside sites. Mainframe terminal
emulation software (Attachmate Extra) on workstations enables users to either run
a program on a mainframe or upload or download data sets between LAN file
server storage and mainframe disk or tape. X-windows software (Starnet Xwin32) on workstations enable users to connect to any Unix server and run programs
or transfer files. Routers provide wide-area-network connectivity to LANs at
other Kaiser Permanente locations via DS3 data lines.
Other resources at the regional Kaiser Permanente California Data Center
(Corona, CA) available to DOR include four mainframe computers (IBM and
Hitachi). These mainframes have access to multi-terabytes of disk storage,
multiple cartridge tape drives. Software available at the Data Center include data
management programs (DB2, AS, IS, DL/1, CCS, EASYTRIEVE, FOCUS,
MARK IV), data communication programs (RJE, TO, VTAM), statistical analysis
programs (SAS, SPSS, BMDP) and programming languages (PL/I, Fortran,
Cobol, C, C++, PERL).
Research Environment
How Research Is Organized
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All KP regions support research through organized centers that may be a part of
the Kaiser Foundation Health Plan or the local Permanente Medical Group
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About 90 percent of KP research is undertaken regionally, but national efforts
include research concerning health policy and reform and KP’s new national
effort around comparative effectiveness research, the Clinical Effectiveness and
Safety Research (CESR) program.
Types of secondary/research uses of HIT data at KP include clinical, health
services research, public health/health promotion research, health policy, quality
measurement and analysis, and business analysis.
DOR approves and prioritizes projects that will use data from RDB for Northern
CA region.
The National Kaiser Foundation Research Institute provides national support to
regions for research governance, IRBs, and legal matters.
Health Services Research
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First HSR began in Northern CA region’s DOR (originally Department of
Medical Methods Research) in the late 1960s with a U.S. Public Health Services
grant for computer-based medical records with a database to support both patient
care and HSR.
Research is intended to inform internal patient care/value proposition and to
contribute to larger scientific literature.
Of KP’s Research Centers, the largest are the DOR in the Northern CA region and
the Center for Health Research that serves the Northwest (OR, WA), HI, and
Southeast (GA) regions.
The Northern CA DOR includes a Health Policy Team as well as research groups
focused on disparities research and other HSR.
KP’s national Institute for Health Policy (IHP) is a part of the Health Plan’s
Community Benefit, Research, and Health Policy Portfolio. The IHP serves the
KP system as a whole, conducts research and analysis related to delivery system
reforms, HIT, and developing an evidence base to help manage medical
technology use.
Center for Effectiveness and Safety Research (CESR), a national research center
with assets distributed across regions, conducts comparative effectiveness and
related studies.
Research Funding
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KP conducts research totaling $100 million annually collectively across all
regions with funds coming from government, industry, foundations, and internal
funding, including as part of the health plan’s community benefit.
The health system employs more than 1,000 investigators and staff, including
some who also provide non-research-related care to KP members.
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Research Culture
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In addition to some national and cross-regional internal research studies, Kaiser
Permanente collaborates with a variety of outside research organizations and
Universities throughout the country and through the HMORN. These
collaborations include health services as well as other types of research.
KP sponsors the Permanente Journal, a peer-reviewed scholarly journal, in which
KP researchers publish.
In addition, researchers publish in outside peer-reviewed scientific literature.
Investigators at KP for whom research is part of their job descriptions are
expected to publish and participate in other forms of scholarly communication.
Data Stewardship
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All research takes place behind each KP region’s security firewall.
Each KP region has its own IRBs. Northern CA maintains two IRBs, one for
biomedical research and one for health services research and related studies.
Studies that involve patients and data from more than one region require IRB
review and approval in each region.
In addition, the national Kaiser Foundation Research Institute provides legal and
governance support for privacy, IRBs, intellectual property and related issues to
all regions as well as for inter-institutional research.
Organization of Quality-Related Functions at Kaiser Permanente
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The national KP organizations maintain several quality initiatives with additional
quality activities occurring at the regional level.
Kaiser Permanente’s national quality and service department, a division of the
national Kaiser Foundation Health Plan (KFHP), partners with the Permanente
Medical Groups, Kaiser Foundation Hospitals, and regional and national leaders
to oversee Kaiser Permanente’s national quality agenda, with a focus on
measurement for clinical quality improvement including the development and
implementation of the BigQ dashboard for providers.
The Utility for Care Data Analysis is a program office department within the
national KFHP’s Community Benefit, Research, and Health Policy organization,
which draws data from KP HealthConnect® and other enterprise IT interregionally for specific measurement projects or “data marts” including for
research on disparities.
The Customer Analytics and Reporting unit, which is also part of the national
KFHP, provides measurement and reporting to employers, CMS and other
customers.
The Care Management Institute, with shared accountability and oversight by the
Permanente Medical Groups and the national KFHP synthesizes knowledge to
support best clinical practices including management of chronic and complex
conditions, palliative care, and care transitions.
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