Hal Wolf, Senior Vice President and COO at Kaiser Permanente, USA, presented Kaiser Permanente and the massive change we are facing with the introduction of telemedicine and electronic communication in health care at the consortia meeting in Patient@home, May 23rd 2013. 

 

- Effectively Kaiser Permanente have three components in the organization: The Hospitals, the Permanente Medical Groups, which are the doctors that take care of our patients, and the Health Plan, which acts as an insurance company, that sign people up to get care from our facilities. That's what we call close network. Almost all of the care takes place within the Kaiser Permanente environment.

 

- We are nonprofit. We do not do care in order to make money from shareholders. We do our care for the people who are part of our caring environment, and then we take the profits with the money which are left and reinvest it back in our facilities.

 

- Kaiser Permanente is the largest care provider in the United States as a single entity. We take care of about 9,2 million people. We have 17,000-ish physicians, 37 hospitals and over 600 centers in the US. We are in nine states (Washington, Oregon, California, Colorado, Ohio, Maryland, Virginia and Georgia) plus District of Columbia.

 

- One of the main points is, that we have a single integrated electronic medical record. That's really one of the most incredible advantages we have. If you went back ten years ago, we were clinically not integrated. And what that mean is, that until we had a single record and a single data streaming that always connected the patients into our system no matter where they touched it, we could never do what we basically do today in the way we do our care, which is an extremely high touch concentrated risk gratification.

 

Primary and Secondary Prevention, Acute Care and Chronic Care

- At Kaiser we think of four areas of care: Primary Prevention; which is the prevention services of doing regular check-ups and taking care of people before something goes wrong. We spend a lot of money and a lot of time focusing on this area and Secondary Prevention. Secondary Prevention it is an example of someone who's had an episode; they have been diagnosed from high blood pressure or they have something going wrong. The Secondary Prevention is keeping them on a regiment so that it doesn't happen again.

 

- Then we have basic Acute Care in our hospitals, just like you have in any other hospital. And then of course Chronic Care Disease, which starts to follow into a different aspect of Secondary Prevention and real time prevention; because as we all know, it's very rare to have someone with just one chronic care disease. It starts to get into comorbidities very fast. So when you start to think about the complexities of comorbidities and taking care of someone in a multi-disciplinary environment it's really a challenge, because it's just not so simple as to send them to a GP or a cardiologist. There will be other people in between.

 

-If you look at someone above the age of 60 who has four or more comorbidities, the average in the United States is, they will be on up to 50 prescription drugs and have contact with up to 17 different doctors. So you can imagine the integrated record. What we use are clinical pharmacists sitting in the middle and looking at everything that is being done. You run tremendous risk: conflicting drugs, conflicting treatments, and so the use of a single record for us, and for our members, are just absolutely critical in the way we handle care.

 

The GP is the hub

At Kaiser Permanente the GP is the hub and the fundamental applicant for what is taking place.

 

- The GP is making sure that the touch points are happening appropriately and backed up by an entire set of electronic environments, but the programs and resources are not controlled by the GP. So if you walk in and have your blood work done in the morning, by the end of the afternoon you're blood work will be posted. You will receive an email letting you know it is in record, and you can see your results. An email will go in your doctors email inbox at the exact same time. So there's a quick load of electronic information. The GP will see that, even if they're not the primary requester of that information.

 

- All of this is wrapped around evidence based medicine. So sitting behind this are teams of doctors, specialists and nurses having really intense discussions about how are we going to treat individuals with these particular circumstances, and those are put together in care pathways and followed with all reasonable recommendations by the staff.

 

Electronic Medical Record

- We think of our electronic medical record as much more than just a place where information is held. The information filed is really extensive. We have multitude systems that are impacting us every day. Lab systems, financial systems, pharmacy systems and systems of picking up energies, just to name a few, are bringing data in from different environments, and we are accumulating these data in an absolute incredible way.

 

- The problem is that data fundamentally is absolutely useless until we take the data and begin to bucket it and turn it into information. So if you think about just accumulating data: datacenters, servers, infrastructure to support it, cooling systems, cooling towers, buildings, infrastructure has to exist to hold all this data.

 

- Now if I start to bucket my data, we have information. The information gives me something to look at and start to do comparisons. We are comparing it with a much smaller subset of information we call knowledge: national targets, evidence based protocols, etc. Finally the doctor or the practitioner create clinical utilities and we use these clinical decisions, the applications and the care management tools to look at the people we are taking care of. So if I'm a physician working inside this environment, then I'm going to have disease registries; lists of people that fall in to the buckets that I'm looking for. From that list I have unique pathways that are going to be followed.

 

- This gets to the heart of why we are here. This is where Patient@home starts to come in. Because everything we are doing is to figure out, how do I control demand management? How do I use electronic tools and different methodologies and say: "How do I use these things to control demand management and use it within the framework targeted patient goals"? Because if I can do that, then I can avoid hospitalization. I can avoid someone coming into a clinic to a face to face encounter. I can avoid unnecessary costly tests, but I have to know how to use the data.

 

People, Process and Technology

- The easiest thing we have at our disposal is the technology - it's shiny, it's cool, and we are making advancements at an amazing rate. But - I have to have the processes in place to use it. I have to get to the culture change for people to be able to take care of it. Culture change is huge. It has a lot to do with the patients expectations. The expectations of YOU as a patient, is the same in medicine now, as it is in almost all aspects of society. It's called instant gratification. "I can get what I want, on my own, now, why do I have to go to the library to look it up"? "Why do I have to go to your facility, to get a little piece of information that I can take care of with an email"? It doesn't make any sense.

 

- When you go in as a patient to have an encounter, to the doctor that might be a ten minute moment, for you, the patient, probably three hours. You have to leave work, you got to drive over, you may have to fill out another formula with information they already have, and you sit in the waiting room looking at a magazine that is three years old. This is what the experience is like. You finally get in, and they go: "Oh, you know - I really can't help you. You need to go somewhere else". This is what we give patients. Let us get past that. We need to be able to send an email to our primary physician and say: "My foot hurts. This is what I'm feeling - what do I do"? And that's actually what we (Kaiser Permanente) are trying to do.

 

- All of our touch points encounters with patients is electronic. 25% of the communication is now either through email or video. What is interesting is that the number of encounters with the doctor has not gone down. But the number of people in the waiting room might have gone down. What you have done is opened up an entirely new channel of communication with the doctors.

 

Culture Change

- This is a part of the fundamental culture change that is happening. No one has gone through a greater culture change than the physician. In the industrial age we cared of one patient at a time. For 250 years we have trained doctors to do one thing: Take care of the person in front of you. Wait for them to come to you, and if they are sick, you tell them what to do or take care of them in the OR.

 

- Now we are talking about using extenders which are all these capabilities you have and you are developing to take care of people without forcing them to come in. This is really big.

 

- Change management is the hard part of this.

 

- Imagine before you (the doctor) used to enter the room, a nurse practitioner handed you a piece of paper, which said: "Hello. The foot hurts, and don't forget to ask about Eric, - who's in junior high". That's what they've been doing for 25 years. Then an IT brat walks in one day, takes the paper away, puts a laptop in front of you, there's 15 minutes of testing and training and says: "Good luck - and while you're talking to your patient, don't forget type everything in, so we can keep track of it". Think about what that is like. It is a massive change management - and by the way, you're charged with all this stuff: patients, coordinating care with the hospitals, what going on with social services, lots of new drugs are coming along, 4.000 articles a year. It's a lot to throw in. Totally against the way they (doctors) were trained. So within that environment we are all going to invent more technologies to bring in. It's going to be great!

 

- The GP, the primary care, specialist, mental health, case managers, pharmaceutical, nursing facilities, homes. All of this now has to be coordinated. How the heck do you do this if you don't have a coordinator record? I beg people to realize you need to create a common record methodology to get into it and someone going to pay.

 

Incentives and innovation at Kaiser Permanente

- At Kaiser we pay our doctors, not by what they produce per say. We pay on a straight salary. They have expectations of what they need to deliver, but the more they cut, they don't get paid more. We say: "Here's your patients, monitor them, this is what you do". This is called preventative capitation. And then we push by creating some small incentive. The problem is, the second you start incenting a group through bonuses you will run into a situation, where they will do absolutely nothing, unless they know what bonuses they are going to get. And that's not the point of medicine. You have to get people to do what they are trained to do in their job to do.

 

- What we try to do with innovation is, you have to approve, you have to transform and you have to spread any particular innovations and moving them forward. To support that, we have a lot of techniques that we use in an innovation aspect. Take products and services we are all producing, and then we bring them together. We have to constantly integrate these new technologies. You have to bring them forward.

 

- We have innovation and advance technology teams and we take your products and services and test them in home settings. We have innovation hunters that sit in every single region, and their only job is to go from unit to unit and find innovations that occur to save money and time and to bring them forth.

 

- All of these different aspects including our ventures fond where we find companies and actually invest in them, because that way we can share, take a small piece and see what they do. All of this is a critical part of learning innovation and updating the environment.