Taking care of the people who don’t come in to see you, Population Care Gemba Walk, KP Colorado, Day 2

Today is day 2 of an on the ground look at population care at Kaiser Permanente Colorado ( @KPColorado ). We focused on three areas – primary care , planned care / panel support, and breast, cervical, and colon cancer screening.

Skyline Medical Offices, Kaiser Permanente Colorado

Our first experience took us to the modern Skyline Medical Offices, where we shadowed Sean Riley, MD and Lynn Rooney, MD. It is here that we saw how population care is embedded into the primary care system. As I mentioned yesterday, the population care system (HealthTRAC – read more about it here) is integrated with the electronic health record such that the “traditional” functions of the electronic health record – documentation, order entry, and decision support, are given a huge boost with information about care gaps. These care gaps can be everything from smoking status, to needed cholesterol testing, to needed colorectal cancer screening. Because of the integration, physicians get a single-click view of prevention needs as they take care of patients with acute problems.  I watched Lynn do this and it was on the seamless side, and I would say this is probably what patients would expect, that a physician could include needed preventive care into a visit. Health TRAC makes this easy and quick.

The medical office is an important place where population care systems serve patients. At the same time, a lot of the magic of population health is possible where teams of experts are able to coordinate health-promoting activities even when the patients don’t seek care. This is where the Planned Care team comes in, and we spent time with them next.

“Have the Scope, Keep the Hope”

Janelle Scrivner, RN, MSN, CDE, and Linda Edwards, RN, MHS, CDE showed me how they supported primary care physicians by reviewing needed care gaps of patients that do not have scheduled appointments, and initiating appropriate care. This process actually starts with their colleague Debbie Chagolla, MA, who accesses lists of patients with care gaps and preps their electronic charts for review and action. Debbie formerly worked in the medical office setting, and now works at the population level. I asked why the change, she told me that she wants to take care of the people who don’t come into be seen. In most health systems, they can “get lost in their care,” because prevention is engineered to happen on demand from patients instead of from a coordinated system. That’s the problem that population care systems solve – they can surveil a physician’s panel and support a support team in connecting patients back to their personal physicians for preventive and chronic condition care.

One interesting insight from Debbie was that even modern EHRs don’t do a good job of consolidating evidence of preventive screenings like colorectal cancer screenings – these tests can be filed as “lab tests” or “pathology specimens” or “procedures” due to the way these tests are done (everything from FIT cards to colonoscopies).  I agree with this sentiment and I wonder if it’s because traditional health care, which these systems were produced for, didn’t prioritize prevention and its monitoring.

I enjoyed asking Linda, who’s been a diabetic educator since 1975, if she envisioned then that in 2011 she would be able to sit in front of a screen, review a whole physician’s panel of patients, and know which patients had care gaps and how they were managing them, right down to their adherence patterns. She told me that in 1975, there were no blood glucose meters, measurement of blood sugars was done with urine tests (!). We have come a long way.

We ended our day looking at systems to manage abnormal pap tests, mammograms, and colorectal cancer screenings. The efforts here are on the very impressive side – every abnormal test is followed by the system until the patient’s condition is resolved. What this means in practical terms is a woman with an abnormal mammogram is tracked across the spectrum of care, from primary care to specialty care, through surgery, chemotherapy and remission. Sometimes patients are asked to come back in for a clinical breast exam even though a mammogram does not show a clear abnormality. Joann Wisemann explained that even these are followed, because cancers have been found early through this diligence.

In colon cancer screening, the same thing is happening, with screening rates going from 44% in 2006 to 75-76% for 50-75 year olds now. The Medicare population screening rate is 85 %. 90th percentile for the United States are 72 % for commercial enrollees and 73 % for Medicare enrollees. So, a 30 % jump to best-in-nation class.

Not bad!

I am seeing a similar phenomenon here that I saw in Northwest and Southern California which is something of a last mile effect – now that these systems are so advanced they go beyond  identifying who’s in the population to identifying the engaged as well as the disengaged. With robust and integrated tracking systems in place, we spend less time trying to figure out how we are doing and more time figuring out how to do what we are doing better, and for the populations that need us most.

Tomorrow is the final day of our walk, taking a visit back to Parker, Colorado, to the Parker Medical Office for another view of primary care enabled with 21st Century tools. Thank you Skyline Medical Office, Planned Care, and Colorectal, Breast, and Cervical Cancer teams for the great teaching.

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