The title of this post comes from the words of local artist Mario Miguel Echevarria, who created the piece shown on the left for the staff at Central Support Services for Kaiser Permanente Colorado (KP regularly supports local artists in producing art for its facilities). Several of his pieces are on the walls here.
If you’ve had a serious medical event, like a heart attack, you need a strong relationship with a personal physician AND you need a system around and with both of you to protect and guide your progress in healing. An electronic health record by itself cannot do this. This is what population care does.
Kaiser Permanente Colorado has a national reputation for excellence in general, and in population care in particular. Its Clinical Pharmacy Cardiac Risk Service (CPCRS) has shown reduced cost and dramatically reduced deaths through EHR and population-care computerized systems used to enhance the abilities of clinical pharmacists, nurses and physicians. KP Colorado (@KPColorado) is also the 9th top performing health plan in the United States out of over 300, the first Colorado-based health plan to be in the top-10 in the United States.
CPCRS is where I started in the morning with Brian Sandhoff, PharmC, BCPS and Mary Beth Dowd, PharmD, BCPS, CACP, who supervise the service, and then by shadowing (of course!) Emily Zadvorny, PharmD, BCPS. The CPCRS service follows 14,000 patients with coronary artery disease, and forms lasting relationships with them. This service has been operational since 1998 – since then it has only become more capable, more integrated into primary care relationships.
Most recently, this program and the computerized system behind it has become more integrated into KP HealthConnect, the electronic health record, to the point that I am seeing the same phenomenon here that I saw in Oregon and California – the systems are so interoperable and cross-functional that practitioners cannot tell which system they are actually using. And to an extent it doesn’t matter – it’s the usability that counts.
A few key takeaways that I saw here:
#1 – if you call this a “disease management” program, it is the kind of program that works to bring patients closer to, rather than farther from, personal physicians. About 50% of the patients are now in the “maintenance (of success)” system, which means that they are still watched by the automated population care system, but under the care of their primary care physician for coronary risk reduction. If any lab test shows anomalies or hasn’t been done on time, actions are triggered in the system immediately that create communication back to patients and care teams to get things back on track.
Best of both worlds – strong primary care + comprehensive system.
#2 – this team is integrated into the patient’s health care, thanks to the KP HealthConnect electronic health record. This means that in all work, staff consider the patient’s entire health situation. A patient with a recent diagnosis of cancer is not going to get the same kind of outreach for their cholesterol. This is health information technology enabling empathy and compassion. The results speak for themselves – all-cause mortality down by 89% within 90 days of a cardiac event compared to not receiving this care.
Why choosing your physician is part of population care
I’ll be honest – when I came to personal physician selection service, my first thought that came to mind for me was, “why am I shadowing here?” I knew why pretty quickly. This service does what its name says it does, helps patients choose their personal physician. Not an unusual function for a health system, except this PPSS is tied to the population care system, which means that the physician choice and first appointment (if desired) now comes with reminders about needed primary care, such as mammograms, pap smears, bone mineral density, or colonoscopy. If you think about it, what better time to engage patients in preventive health, on a population level, than the time that they choose their doctor.
I shadowed Chanel Butler, and took a photo of the team – she’s going to review the photo and if her team likes it, I’ll post it here :). Another benefit of shadowing is meeting engaged and enthusiastic team – a team that voluntarily poses for a photo for a relative stranger is on the inspired side.
Watching population care take shape – Diabetes Care
We ended the day with the Diabetes Care Team and this turned out to be a treat for a specific reason, which was that we shadowed a forming team on a brand new service. Often when I shadow teams, I find a coordinated program that is well under way. This program has started in just the last 6 months, and is working to take comprehensive diabetes care to the next level of “super easy and intuitive” as well as successful and time saving for members.
This team provides navigation, access to services and personalized treatment for the 25,000+ patients who have diabetes at Kaiser Permanente. With the use of the advanced population care system here known as HealthTrac, the electronic health record itself has a consolidated view into the care gaps for a patient, based on multiple up-to-date data feeds.
As I have commented before, this is not a strong feature of most electronic health record systems, which often force users to do “forensic” searches through electronic charts to put data together. The mentorship part was watching Merrill Zierten, RN, BSN, MA, the manager of the Department assist this new team in figuring out the paths of patients being reached on the phone. Lynda Harsvick would reach out to a patient, understand their needs and preferences, caucus a little bit before they prepare a plan with appointments, resources, and touchpoints to keep patients on track (not necessarily in that order).
For the people with the point of view that “only Kaiser Permanente can do that innovation,” it was important to see this, because the truth is, KP doesn’t know how to do this work either until it does it. When I hear “only Kaiser Permanente can do that innovation,” I begin to think “Only Kaiser Permanente wants to do that innovation,” because these are not easy programs to create and maintain. And “not easy” because people know that members/patients expect that their work will be integrated and supportive of their current care delivery relationships – they must show “we know you.”
Yesterday was a view into the supportive system around and with primary and specialty care. Today is time at a medical office, stay tuned.
With great thanks to the teams at Clinical Pharmacy Cardiac Risk Service, Personal Physician Selection Service, and the Diabetes Care Team at KP Colorado!
Oh, and here’s the narrative that was on the wall next to the piece at the top of this post. It’s a nice story of partnership and respect for the work that people do to keep a whole population healthy. Enjoy.
- Taking care of the people who don’t come in to see you, Population Care Gemba Walk, KP Colorado, Day 2
- Being on their care, the personal health record helps populations, and chasing 100 percent- Population Care at Kaiser Permanente Northwest
- Gemba Walk: Kaiser Permanente Colorado
- Does your physician know how to lead? A view into the Kaiser Permanente / Group Health Physicians Medicine and Management Program
- “You have the information and I look out for you” – ONC Visits Kaiser Permanente West End Medical Center, Washington, DC