At Kaiser, a vision of the connected future

From exam room to radiology to pharmacy to checkout, a local area network keeps track of everything done for a patient.

By Lauren M. Walker

"Say I'm seeing a child who's had countless ear infections," says pediatrician Eric E. Brody. "I may ask the mother, 'What worked well in the past?' but she's likely to respond, 'Oh, the white stuff,' which doesn't really help me. With our electronic medical record, I don't have to dig through a file looking for a piece of paper to see what's worked best for this kid. I can pull up a complete list of the drugs he's had and all his office visits, and immediately see what worked."

Brody is health care team director and lead physician at the newest Kaiser Permanente Northwest (KPNW) clinic, which opened in October 2000 in Tualatin, OR. Physicians there can access electronic medical records on a flat-screen computer in every exam room. This gives them immediate access, not only to their own visit notes, prescriptions, and lab results, but also to all of the other patient information throughout the KPNW system.

"Everything on the patient is electronically available," explains internist Homer L. Chin, assistant regional medical director for clinical information systems at KPNW. "Whatever happens to the patient, including referrals, lab tests, and other orders, is entered in the system."

While Kaiser Permanente physicians have much more online connectivity than most other doctors do, they're using a technology that predates the Internet. Instead of accessing data on the Web, they pull it up on a local area network that links computers in KPNW clinics through dedicated data lines. Distant hospitals and doctors in remote locations can hook into the network by dialing up through their modems.

KPNW has no current plans to migrate to the Internet. It would rather keep its information system within a stable, protected environment, says pediatrician Andrew M. Wiesenthal, associate executive director of The Permanente Federation, which coordinates Kaiser Permanente's group practices.

Parts of KPNW's electronic record date back to 1991, and the comprehensive EMR has been available since 1996. This information is available throughout the KPNW system, including offices, clinics, Kaiser Permanente-owned hospitals, and even community hospitals that contract with KPNW.

"I happened to be working one weekend up at Kaiser Sunnyside, in the newborn nursery," says Brody, "and they called me down to the emergency room to see a dehydrated 3-week-old. I'd never seen that child before, of course. And bingo, everything I needed to know about that baby was instantly available to me."

KPNW has certainly made mistakes in building its information system. For instance, Chin allows that the group should have placed work stations in all its exam rooms at the start. It now hopes to have them in exam rooms at all 20 of its outpatient medical offices by the end of 2002.

Meanwhile, the electronic medical record is already an essential part of practice in KPNW's clinics and affiliated hospitals. Where the terminal is not in the exam room, it's available elsewhere at the site, usually in physician offices. Doctors can also dial up the information system from home.

Pediatrician Brody doesn't take call at home, but when he's on call in the hospital, he finds the system beneficial. "I will occasionally get a phone call at 3 in the morning from an advice nurse asking about a complex patient from another part of the region," says Brody. "As soon as I wake up, I can call up the record on the hospital computer and answer questions about that patient. Without this system, there'd be no way of dealing with that patient effectively, unless I happened to know the case."

It's obviously going to be a long time before most physicians across the country have this kind of access to patient data extending across the continuum of care. But many doctors are starting to see bits and pieces of it. Even if you aren't among them, KPNW's accomplishment shows what can be done in a highly integrated delivery system. Someday your group or hospital system may be able to function like this, after it has built sufficient connectivity.

Assembling the building blocks of the EMR

Before KPNW set up its EMR, it had a number of unconnected databases holding various kinds of patient information. "When I arrived in 1993," says Chin, "there were all these different systems for appointments, pharmacy, lab, membership, transcription, pathology, the tumor registry, and so on. We had to put it in some kind of overall system that would make it easily available to the clinician."

So KPNW linked these islands of data into a central repository, creating the Results Reporting System. RRS includes all dictated reports, including both inpatient and outpatient consults, imaging and pathology reports, ED notes, histories and physicals, and hospital discharge summaries. It integrates this with information on immunizations, labs, medications, appointments, demographics, and insurance, making it very easy for clinicians to access a wealth of clinical information on any given patient.

Assembling all this data into a central repository that interfaces with the enterprise-wide scheduling system was a significant step forward, notes Chin, but the clinical information was incomplete because the individual visit notes were still in paper form, and most of the ordering and prescribing processes were still paper-based.

In 1994, KPNW adopted a full outpatient EMR that uses the EpicCare software developed by Madison, WI-based Epic Systems Corp. It includes the doctor's notes from outpatient visits; orders for prescriptions, referrals, and tests; lab and other test results; and all the ICD and CPT codes generated by patient visits.

Besides replacing the patient chart, the EMR enables physicians to transmit orders and coordinate all of a patient's care. "Clinicians go into the exam room and see the patient and decide what to do," says Chin. "They then enter their orders into the computerized system, including prescriptions, referrals, and labs."

The system doesn't just log these transactions; it sets them in motion. A referral to a specialist initiates the appointment-making process, triggering a phone call from the specialist's office to the patient to set up the visit. The lab request authorizes a visit to the in-house KPNW lab, and the prescription automatically goes to all of KPNW's pharmacies, so the patient can pick up the medication at any of them. The system even keeps track of whether the patient followed the doctor's orders by filling a prescription, keeping an appointment, or getting a test.

After a patient visits a specialist, the consultant can automatically "send" the patient's file back to the primary care physician by clicking on a button. When he does that, the PCP is prompted to look at the file online. Likewise, when the PCP refers a patient, the system alerts the specialist with an e-mail message. But in none of this does the file move around. Instead, the system's notification pulls the recipient directly into the patient file.

The system also allows doctors to print out customized patient instructions. "Clinicians can enter their instructions in their own words: 'This is what you should do for your cough, or your bursitis,' or whatever it is," explains Chin. "At the end of the visit, the patient instructions are printed out, along with all the lab tests, referrals, and prescriptions that were ordered during that visit."

Because RRS includes a wealth of data that would be difficult to transfer into EpicCare, the two systems run in tandem, and doctors can toggle between them in their offices and exam rooms. "If they want a dictated report, they have to go to RRS, and if they want to look at the clinic notes, they have to consult EpicCare," says Chin. "We created a utility that makes it easy to go back and forth."

Despite having all this electronic data available, physicians still look at printouts of patient record summary reports because it's easy to scan them before visits. The summary includes the patient's problem list, allergies, medications taken in the past 12 months, and the reasons for his or her last seven encounters with the KPNW health care system, including a full report of the last two encounters. It lists the patient's immunization and screening history, along with age-appropriate guidelines.

"If there's a guideline that's changed, the summary will include the new information," Chin says. "If any of the last three blood tests were abnormal, it will print a little spreadsheet of those three, so you can see if that particular lab value is improving or getting worse. It lists appointments kept and those the patient missed."

KPNW is also using its computerized patient record to reduce variations in care by providing guidelines that appear as the physicians interact with the system. The embedded guidelines crop up everywhere­in the pre-visit summary, when drugs are prescribed, when tests are ordered. It lists screening recommendations appropriate to the patient's age, sex, and major diagnosis. For instance, the summary for a diabetic patient includes the guideline for retinal exams.

The learning curve is steep for physicians

When the EpicCare system was put into effect, KPNW gave its physicians 16 hours of training during work hours. In the first week of training, the physicians' patient load was cut in half; over the course of a month, it was gradually increased back to a full schedule. At the end of that month, however, many doctors were still working longer days, because they needed extra time to negotiate EpicCare.

"For the first six months to a year, it took most clinicians longer to do the same work with an EMR," says Chin. "They were seeing the same number of patients, but they weren't going home at the same time of day. They were spending more time in the clinic."

Some physicians had to learn to type, and many resented having to "feed the terminal," recalls Brody. "Some of the clinicians felt 'My job is to make clinical decisions, not to feed the terminal.' There was also the fear that the data would be used against the doctors, 'to find out how fast I'm working, to find out what I'm really doing.' "

Still, four months into the EpicCare implementation, 86 percent of KPNW's physicians said EpicCare was worth the time and effort required to use it. And in the seven years since then, physicians in general have become more comfortable with computers. The young physicians who have joined Kaiser Permanente in recent years, Brody notes, are much more computer-literate than the older doctors.

Part of the reason for wide acceptance of the system is that not everything has to be typed into the EMR. Drop-down boxes allow doctors to check off much of what they need to document. EpicCare also has a "smart text" feature that lets doctors generate phrases or sentences they frequently use by typing in a single word.

Within a year after their EMR training, says Chin, most physicians are up to their former speed. And the system enables them to do more for patients. As a result, he says, the number of annual visits per patient dropped from 5 in 1995 to 4.5 in 2000. And the number of outpatient lab tests declined from 17.4 per member per year in 1993 to 16.1 in 1997, primarily because of nonduplication of tests.

Kaiser's advantages in connectivity

The kind of connectivity found at KPNW isn't unknown elsewhere. For instance, physicians in the University of Michigan Health System, based in Ann Arbor, can electronically access a wide variety of patient data in their offices or at home.^* But the KPNW system is more comprehensive and incorporates a full EMR, which is unusual even in the most advanced integrated delivery systems. Even groups with EMRs generally don't have access to as broad a range of data as KPNW's clinicians do.

Of course, the system benefits tremendously from Kaiser-Permanente's closed-model structure. It's less difficult to collect a comprehensive patient record than it would be in most practice settings because KPNW patients receive virtually all their care—primary, specialty, hospital, pharmacy, and lab—at the group's facilities. The few services delivered outside the KPNW system—such as visits to EDs at non-affiliated hospitals and out-of-network care for members with point-of-service plans—generate paper reports that are scanned into the patient's electronic record. In a less integrated model, information would be harder to corral.

Also working in KPNW's favor is the fact that the group's doctors are salaried and work for an organization that's big enough to be able to shift workloads around. This made it relatively easy to give physicians two days of training and reduce their schedules for a month while they got up to speed.

KPNW's culture also plays a role in the success of the system. "One of the things I've always liked about Kaiser is that it nurtures early adopters, and it gives us an opportunity to have fun trying new things," says Brody.

Not the least of Kaiser Permanente's advantages: It could afford the $40 million cost of the EMR and its attendant learning curve. "We said, 'This is going to improve health outcomes and patient satisfaction, and it might reduce operating costs,' " recalls Chin. "We also thought it would improve revenue capture and support medical management systems. But it was going to be hard to quantify the benefits." KPNW went ahead with the experiment anyway.

Brody admits he was an easy sell, but says even the information system's critics wouldn't give it up now. "As soon as people—whether reluctant or adventuresome—find out about the system and really get to using it, nobody wants to go back to paper."

^*See "Clinical connectivity: The future is already here," The Connected Physician supplement, Nov. 20, 2000.

The author, a health care writer based in Cambridge, MA, is a former Senior Editor of Medical Economics.

 

Lauren Walker. At Kaiser, a vision of the connected future. Medical Economics 2002;3:52.