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Behind the Wires

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Andrew Wiesenthal oversees Kaiser Permanente’s massive effort to connect thousands of physicians and millions of patients on a single platform.

You could call it the mother of all electronic medical record projects. Touted by Oakland, Calif.-based health plan Kaiser Permanente as “the largest civilian EMR system,” KP HealthConnect is indeed big. Representing more than $3 billion in capital outlay, KP HealthConnect aims to link 13,000 physicians and 8.6 million patients on a common EMR platform. And square in the middle of it all stands Andrew M. Wiesenthal, M.D., the pediatrician turned associate executive director of the Permanente Federation, the health plan’s independently operated but tightly controlled medical group.

Wiesenthal serves as the medical group’s executive sponsor of the effort, which is linking Kaiser’s physician clinics and 30-plus hospitals. Launched in 2003, KP HealthConnect is a 10-year project that seeks “to transform how healthcare is delivered,” Wiesenthal says. “We want to put patients in as much control as they would like.” Ultimately, inpatient data from Kaiser’s hospitals and outpatient records from its physician offices would be shared by clinicians across Kaiser’s vast empire. Patients can access data from their records and initiate various transactions electronically.

On the technology side, Kaiser’s primary vendor is Epic Systems, which is providing the bulk of applications on both the hospital and office practice sides. Epic’s suite includes lab result reporting, pharmacy, orders, results viewing, registration, scheduling and billing, as well as documentation for clinicians. Epic is supplanting dozens of Kaiser’s clinical information systems, including its long-standing, homegrown inpatient clinical information system. Epic’s “integrated” software has lived up to its billing thus far, attests Wiesenthal, who dismisses reports that the project has run over-budget and has been hampered by downtime. “Most of our downtime in 2006 was caused by power failures, not the hardware or software,” he says.

Kaiser’s staff physicians may be employees of the medical group, he says, but that doesn’t mean their concerns about using IT in the office setting can just be dismissed. One of Wiesenthal’s biggest challenges is figuring out why one hospital’s adoption of EMR technology can go quickly, while another struggles with identical applications. Much of it boils down to culture, he says.

1. Complete Hospital Deployments

Kaiser has installed the EMR in all its physician offices, but its inpatient and ED documentation and order entry system is just getting under way. At the beginning of the year, the hospital clinical system deployment scorecard was two down and 29 to go. But Wiesenthal says Kaiser can meet its timeline and complete the hospital installations in three years. Most of the hospitals are California-based and must adhere to state law mandating that they meet new construction standards for earthquake resistance. The seismic retrofit makes an already difficult project even harder, Wiesenthal says. “At the same time we are putting in the EMR, we either must rebuild the hospital or build a new one. We have to mesh with construction schedules.” Some hospitals will be torn down as the result of the law, he says. But new Kaiser hospitals, such as one in Panorama City scheduled to open later this year, will not have a medical records room to house paper charts.

The fact that the software runs on a common database has facilitated the deployment thus far, Wiesenthal says. “This is not a series of applications with separate structures,” he says. “This is one database regardless of where the patient is.” Wiesenthal likens the various applications to separate views into the same underlying record. He says the Epic package overlays well with Kaiser’s “vertically integrated” delivery structure, meaning that labs, pharmacies and imaging suites are commonly owned and managed. A few tests may be sent out of Kaiser’s universe, but for the most part, all services are delivered by Kaiser-owned facilities.

Despite the common ownership model, Kaiser has faced some hurdles common to other hospitals with independent medical staffs. The primary challenge on the inpatient EMR has been implementing computer-based physician order entry, he says. “Building the flow sheets and documentation tools is a brand new science,” he says. “We are in uncharted territory.”

2. Optimize EMR in Office Setting

Kaiser’s physicians are using the Epic EMR in their clinics, but Wiesenthal says vast improvements await. His second goal is to better use the features of the EMR to capitalize on its potential to enhance care. For example, physicians can use the system to graphically portray a patient’s changing lab values over time, a visual tool that Wiesenthal says can be a powerful patient motivator. “It’s the difference between a spreadsheet and a single snapshot view,” he says.

Kaiser’s physicians use the EMR at fixed workstations in their exam rooms. The key, Wiesenthal says, is understanding how to bring patients into the fold when doing real-time charting. “If done correctly, using the EMR is an effective way to connect with patients,” he contends. “Patients can see how physicians document and what they are documenting. If they see the computer at the same time physicians are using it, they really like it and get more engaged in their healthcare. They understand what you are trying to accomplish.”

Discussing this issue, Wiesenthal returns to the age-old workflow dilemma: Incorporating technology into the office setting requires standardizing workflows, a concept that can be difficult to sell to physicians used to charting on paper. “It is one thing to teach physicians and nurses how to use the features of software,” he says “It is very different to teach them how to do work well using the features.”

To tackle the problem, Kaiser’s medical groups have adopted navigator bars that are built into the software. The navigator bars serve as visual cues to nurses and physicians about what steps must be taken next with a given patient. When a nurse completes her intake and evaluation, for example, the system automatically leads the physician to the next applicable screen. Although the medical groups now use standard navigator workflows, individual physicians still have considerable freedom in when and how they do things, such as reviewing available lab results and completing their charts.

To analyze the groups’ performance, Wiesenthal and his regional directors review system-generated usage reports that summarize physician adoption of the EMR. A few of Kaiser’s medical groups are attempting to analyze the individual performance level of physicians and offer remedial training as needed.

3. Expand Patient Portal

To solidify its relationships with its patients, Kaiser is looking to the Web. Once authenticated, patients can log on to the Kaiser portal to view their medical records, retrieve lab results and communicate with their caregivers. Some 2 million Kaiser patients have signed up, and Wiesenthal would like to grow that number. “We are trying to figure out how to best interact with our members,” he says.

Patients are enrolled in the online service through local medical offices, where they can receive a log-in and password in person. Patients can also enroll in the service online, gaining a temporary password while Kaiser verifies their request through the mail.

Through early January, Kaiser had released nearly 14 million lab results through the portal, although members have not necessarily retrieved them electronically, Wiesenthal says. Kaiser clinics still mail out lab results. According to Wiesenthal, the portal’s real value to Kaiser physicians can be in reducing incoming phone calls. Rather than calling a clinic, members can submit questions through a secure messaging function that can help them avoid unnecessary office visits, he says. The secure message exchange may be the precursor to full-blown “e-visits,” in which patients relay symptoms in an electronic message and in return receive medical advice without having to show up in person.

Other portal projects in the works include an automated health risk assessment. Using this technology, members would complete an online questionnaire and have the results flow right into their record. Caregivers would see the results and could send customized content to the patients. “If they have a chronic problem, we can tell patients how to keep it from getting worse,” Wiesenthal says. Also under development is proxy access to the medical records for children or aging parents. “There isn’t a mother in the country who would want to spend half a day in the doctor’s office to get their kids’ immunization record if she could look it up online,” he says.

Gary Baldwin is technology editor of HealthLeaders magazine. He can be reached at gbaldwin@healthleadersmedia.com.