My responsibilities in my work for The Permanente Federation include a great interest in two of Kaiser Permanente’s east coast regions, specifically Kaiser Permanente Georgia and Kaiser Permanente Ohio. I wrote about my Gemba Walk at Kaiser Permanente Georgia in November (you can read about that here). Last week I spent time in Cleveland, at Kaiser Permanente Ohio. In the intervening time, a lot of innovation has been happening across Permanente Medical Groups nationally, and I got to see it in action….
First a little background: The Kaiser Permanente Ohio Region has existed since 1969, which is the same year that the Colorado Region was also created. As with the rest of Kaiser Permanente, KP Ohio members have access to a fully deployed personal health record from wherever they live, work, and play, and the care they receive is facilitated by the national KP HealthConnect platform, also fully operational. The presence of Kaiser Permanente along with the well-respected Cleveland Clinic creates a significant epicenter of Health Information Technology here.
I had great hosts, Ron Adams, MD, the Chief of Internal Medicine, and Lydia Cook, MD, the Assistant Director of Primary Care. Both are active in practice and have extensive leadership experience within the Ohio Permanente Medical Group.
Because the innovation in primary care they are helping create involves all members of the care team, they created an experience for me that included shadowing physicians as well as nurses and clinical pharmacists. We should understand how every member of the team contributes, and this was great.
So what did I see?
- Data systems and the workflow to support it are maturing to the point that primary care teams can understand how to keep patients healthy whether or not they actually come in for appointments. Teams are alerted about patients with chronic illness proactively, not reactively, more quickly than ever before. Medical and Nursing staff are responding to this new ability by creating new workflows and partnership around supporting patients, families, and populations.
- Physicians are comfortable with the comprehensive electronic health record in practice: quote from an Ohio Permanente physician, “I don’t want the computer to get in the way (of the visit) but at the same time it’s a wonderful opportunity to share with the patient.”
- Participation of a wider array of team members including nurses and clinical pharmacists, to leverage their skills, whether it’s coaching/teaching, medication management, all connected electronically (now).
- Rethinking of the primary care practice altogether – including the idea that primary care physicians may see higher acuity patients as population management is spread across more staff, that they will use non-traditional communication methods including secure e-mail and telephone as part of what they do, and that managing a panel is work integrated into the day.
- My favorite After Visit Summary workflow – every member whose care I observed got one – physicians and nurses work together to create and go over information with patients, it is not just a task of one or the other. They use the electronic health record to signal each other consistently for the handoff, which happens reliably. This helps accuracy and efficiency for the member and the system. I’m a fan.
I think this work is not only useful for Kaiser Permanente, but for all of health care, because Kaiser Permanente’s financing model allows for this type of innovation, and sharing of such.
At the same time, there are major challenges here. The primary care provider shortage has affected Kaiser Permanente as much as the rest of health care. The good news is that this shortage is driving many of the innovations above, which I actually think will be portable to all of health care. In addition, the Northeast Ohio region is undergoing significant change due to the loss of major employers in the steel and auto industry.
In summary, I learned a lot (of course), and have great hopes for both KP Ohio and for primary care as a result of their work. Thanks again to the teams at Parma Medical Center and Cleveland Heights Medical Center for their time and expertise.
Another 21st Century Vision of Primary Care: Kaiser Permanente Ohio:
Kaiser Permanente Ohio Region, since 196.. http://tinyurl.com/dl5efu
Am I missing something, or is Dr. Eytan suggesting that good "population management" (as opposed to medical care) means that physicians should leave most direct contact with patients to lesser-trained ancillary personnel? They should get out of the examining room, abandon the traditional doctor-patient relationship, and put their telephones and computer screens between themselves and sick people?
If this is the conclusion you've come to from reading the above, then I'd say "yes, you are missing something," and I would say I am happy to fill in the gaps for you.
The idea behind population management is to reach people before they get sick, and reach them where it's convenient for them (the people) – where they work and live, rather than making them come in in person. If and when they do get sick, this approach allows less and less to get between them and great medical care because (a) via good population care, we prevented illness in the first place (b) there was more time available in the medical office because those who are receiving preventive care didn't have to come in and take those office visit slots.
One other comment I make before I ask you more about your question is about the idea of "lesser trained ancillary personnel." In the health care space, Registered Nurses and Clinical Pharmacists are not only highly skilled, but they are more skilled than physicians when it comes to helping patients reach goals with regard to their condition management. It's definitely a team effort and everyone is valuable – a health care system that only had doctors in it wouldn't keep people as healthy as one with multiple disciplines.
So, does that help and tell me more about your background/interest in this area or any other information you'd like to have. Are you in health care as a professional or as a patient (or both)? Thanks for the great question,