“Can’t achieve high performance and efficiency with a ruler, excel, stickies, and highlighters” – Day 2 at Kaiser Permanente Southern California #kppopcare

Today’s quote in the title of the post comes from Monique Ferguson, at Kaiser Permanente Southern California’s Family Medicine Prevention Outreach, where a team of staff use the next-generation health information technology systems to support primary care physicians and their teams in making sure their patients preventive services are up to date.

Photos, click any to enlarge:

Current-state HIT is typically engineered for the single-patient-encounter-with-orders-and-documentation. As a result, it has been the norm in most of health care to use the tools described in Monique’s quote to reach out to people to get their mammograms, colon, and cervical cancer screening tests to prevent and treat these diseases.

Here, however, the comprehensive electronic health record, KP HealthConnect is linked to a population care system that oversees and reports gaps in preventive care, which is in turn linked to workflow tools that allow the staff here to know when patients have been contacted, what their needs are, and arrange for tests. This includes scheduling the mammogram, sending out the colon cancer test kit, scheduling the pap smear visit.

Monique told us “We know their birthdays, vacations and weddings,” in reference to the tight bond her team forms with the panels of the physician practices they support.

And actually, this is a challenge of a system this comprehensive – great care is taken to make sure that members are not over-contacted, and the systems are engineered to track and stage outreach so it is not overdone.

At the same time, we hear stories of the cancer that was treated, the early death that was prevented when different members of the practice / outreach team contacted, listened, encouraged patients to receive recommended tests.

I have spoken previously about the importance of leadership, that a high-tech computer system does not by itself result in wellness for a population, and here we shadowed a team huddle (which they graciously postponed until we arrived), and listened in to patient phone calls. As you can see in the photograph above, this is a time for the team to review what’s working, what’s not working, any hurdles, and successes.

What was impressive to me was the precision with which the team carries with it – for each targeted condition, the number of patients down to the person is known, along with the number to reach targets for the year, and, more importantly, what 100% looks like. This is not a 90th percentile operation.

Just look at the example of mammography – the screening rate here is well over 80% for commercial enrollees (aged 42-69) and over 90% for medicare enrollees. The national 90th percentile (not the average, the top 10%) of commercial (non-medicare) health plans is 78 % (HEDIS 2010). For the last three years, the #1 health plan in the United States for mammography screening has been toppled by a Kaiser Permanente region toppling another Kaiser Permanente region (Southern California, Hawaii, Georgia).

Earlier in the day, we visited the Physician Callback program for Kaiser Permanente Orange County, located at KP Irvine Medical Center. Here, physicians and nurses contact patients recently discharged from the hospital to assess their overall well-being, medication use, ensure they have follow-up physician appointments, and assess their care experience.

Because I have always been a Permanente physician, I am used to the level of coordination that comes from integration, so I made sure to ask some of my less-experienced KP colleagues how this was innovative to their eyes. They pointed out two areas:

• The personalized, holistic approach. Physicians contacting patients from this unit have their entire medical record available to them – not just the hospital record or the outpatient record, or the personal health record, all of them. This provides unparalleled ability to coordinate care by doing things like ensuring the outpatient medication list is accurate when the patient re-visits with their primary care doctor, and providing a knowing and personal bridge in the critical few days after a hospitalization.
• The ability to provide upstream feedback to hospital providers. As part of each call, the quality of the documentation and instructions are compared against the patient/family understanding. In addition, patients are asked an open ended question -Do you have any questions regarding the care you received in the hospital?” (updated 3/31/11 for accuracy) and the answer is listened to. Keep in mind that this is physicians and nurses asking these questions which means they have the ability to understand the impact and to contact their peers practicing in the hospital about gaps/improvements. As I have learned in my own Toyota Management System training, one of the most important aspects of learning is “seeing the impact of what you do,” and here, health care teams who discharge patients from the hospital can expect to see that impact and learn from it. Dan Huynh, MD, gave us the example of patients who were discharged home with instructions to use injectable blood thinners, but without sharps containers to dispose the needles in. These are the details that come from listening.

Denielle Miranda, RN, allowed us to shadow her placing calls to recently discharged patients. A hospital discharge is one of the most complicated procedures in health care, you can imagine how complicated it is for a patient. She told us she is getting ready to present her experience to the Kaiser Permanente surgeons whose patients she is supporting post-discharge; everyone wants to make sure these events maximize patients’ potential health, and their time in healing.

We ended our day at a “messaging grand rounds” – the work of achieving high performance and efficiency requires anchoring and persistence. In this session, ambulatory support team leads seated around a table were reviewing the quality, accuracy, and usability of electronic messages sent in the electronic health record AND personal health record (Kaiser Permanente My Health Manager). For example, what’s the best and most efficient way to let a physician or patient know about their test results via a written, electronic message? They didn’t teach us this in medical school….

One thing many people don’t realize until after their electronic health record is installed is that it matters how you use it far beyond whether the right thing is ordered or code selected. The requirement for high quality communication is not lessened by the installation of a high quality computer software, at the same the ability to support high quality communication is made available through the ability to see what others are saying/doing in the course of care delivery. As our hosts at Yorba Linda Medical Office explained to us, in the days of paper, communication wasn’t tracked for its timeliness, quality, and most importantly service and clinical outcome. All of that is now possible, again, with the leadership and interest in making it so.

Today is our last day at Kaiser Permanente Southern California; we’ll be learning how complete care is brought together in the entire Southern California Region, which serves over 3.3 million members at 13 medical centers and 145 medical offices.

With great thanks to our awesome host, Tim Ho, MD, and the members, staff, nurses, physicians who are working hard to perform well, be efficient, supporting patients when they are with their doctors and also where they live, work, and play.