In early
February 2003, George Halvorson, Chairman and CEO of Kaiser Foundation
Health Plan and Hospitals, Inc, and Jay Crosson, Executive Director
of the Permanente Federation, announced that Kaiser Permanente (KP)
was purchasing an integrated suite of electronic health record and related
applications from Epic Systems (Madison, WI) to deploy programwide.
The decision to purchase the Epic products changed the direction set
four years earlier for development of an electronic health record system
at KP. The decision to change direction in 2003 was made after months
of careful analysis and is best considered in the context of KP's previous
work to develop electronic health records.
History of KP Regional
Electronic Health Record Systems
More than
a decade ago, leadership of most KP regions recognized the need for
electronic health records. Every region--including some that no longer
exist--invested time and money to collect information relevant to patient
care and to display that information at the location where care was
provided (the "point of care"), usually clinician offices.
Each region had episodes of success and failure in these efforts and
attempted to learn from these experiences.
Some effort
was made in the early 1990s to coordinate these projects. First--and
true to the KP culture--each Permanente Medical Group (PMG) needed to
define its goals and find the most direct path to those goals. We describe
the results of these efforts, most of which remain in use today.
In the
KP Ohio Region, Allan Khoury, MD, led development of an operational
data store (ODS) of information derived from ancillary systems (eg,
for storing pharmacy orders and laboratory results). These data were
combined with data extracted from progress notes written after each
outpatient encounter and then scanned into the computer system. The
ODS is used to generate point-of-care alerts and reminders, which have
been extremely effective in helping Ohio PMG clinicians to improve care.
This highly successful medical automated record system (MARS) was recognized
with the Nicholas E Davies Award for Excellence, a national award granted
(formerly by the Computer-Based Patient Record Institute and currently
by the Healthcare Information and Management Systems Society) to promote
adoption of the electronic medical record throughout the United States.
In the
KP Mid-Atlantic Region, development of the PACE system was led first
by Andrew Barbash, MD, and more recently by Mark Snyder, MD. PACE, too,
is based on an ODS, and PMG clinicians in the KP Mid-Atlantic Region
type their progress notes into the system.
In Southern
California, John Mattison, MD, led development and implementation of
a highly innovative process: entering structured data (as distinguished
from free text) as progress notes. This effort advanced development
of a structured vocabulary for clinical data that is rapidly becoming
an international standard. This clinical data vocabulary formed the
heart of SCPMG's WAVE application used in clinical settings in the KP
Southern California and Hawaii Regions. WAVE was the core documentation
tool in KP's first effort to collectively develop an electronic health
record, the National Clinical Information System (NCIS). The key lessons
learned during development of NCIS still apply as KP continues to develop
tools and templates for charting that will both speed entry and foster
the collection of clinical data that can be used by many different computer
systems.
The KP
Northern California Region developed an effective, widely accessible
repository of clinical data and a system to present it, the Clinical
Information Presentation System (CIPS), on which all clinicians in the
region rely. The project has been led by several clinicians over the
years, including George Peredy, MD, and Steve Bornstein, MD. CIPS contains
data from key ancillary systems and problem lists; summary data related
to outpatient visits, hospitalizations, and emergency department visits;
transcribed reports; preventive health services information and prompts;
and much more. The repository is used by another application, Preventive
Health Prompts (PHP), to display and print point-of-care alerts about
preventive health and chronic disease management. Clinical outcomes
have clearly improved as a result of these reminders.
In the
KP Northwest Region, Homer Chin, MD, led internal development of an
electronic health record. In 1992, the KP Northwest Region purchased
Epic's ambulatory health record product (EpicCare) and integrated it
with the region's existing ODS and results-reporting system. Implementation
was complete by 1997, and the system won the Nicholas E Davies Award.
In the
KP Colorado Region, Jeff Rose, MD, and (more recently) Andrew Lum, MD,
led development and implementation of the Clinical Information System
(CIS) in partnership with IBM (White Plains, NY). By the end of 1998,
all outpatient encounters were documented using CIS and the structured
clinical data vocabulary developed in conjunction with the work being
done by SCPMG. Most data entry occurred in examination rooms, a process
resulting in the first large-scale KP experience with examination room
computing. The KP Colorado Region stopped using paper health records
six months after the last clinician's office was connected to CIS; the
KP Colorado Region has since been essentially paperless. The KP Colorado's
CIS also won the Nicholas E Davies Award. This was the third time KP
had won this award; no other organization had received this award more
than once.
Creating a Programwide
Standard
In 1999,
leadership in the national KP organization decided to stop internal
development of NCIS except for the population care registry application,
forms of which are still used by the KP Hawaii, Northern California,
and Georgia Regions. KP management assessed two existing examples of
ambulatory electronic health record systems used in the KP Colorado
Region (CIS) and in the KP Northwest Region (EpicCare). After intense
analysis and discussion, the decision was made to alter CIS for programwide
deployment.
Although
the effort to alter CIS proved considerable, it led to implementation
of CIS in parts of Hawaii and in building infrastructure to interface
to all of the ancillary systems in use programwide--185 at last count.
In addition, the structured clinical vocabulary that originated in the
KP Southern California and Colorado Regions was expanded, and the PMGs
made important collaborative efforts to develop content (eg, templates
for documentation, for order sets, and for decision support). The Interregional
Clinical Content Team (IRCCT) of the Care Management Institute is now
responsible for ongoing content development. In the summer of 2002,
when George Halvorson requested reassessment of KP's approach to development
of an electronic health record system, the CIS implementation team had
already prepared to upgrade the version used in KP Hawaii, to implement
CIS in KP Southern California, and to replace the outdated version used
in KP Colorado.
Reassessment Leads to
New Programwide Standard
The software
reassessment showed that several vendors--most notably, Cerner Corporation
(Kansas City, MO) and Epic Systems Corporation--had dramatically improved
the functionality and breadth of their products since 1999, when KP
last evaluated them. Further, these products were integrated into suites
of applications: Data from a database or other data repository could
be transferred easily between applications in the suite without requiring
interface development.
Evaluations
of Cerner's and Epic's products by potential users at KP clearly showed
that these products had surpassed the CIS products developed jointly
by KP and IBM and that the rapid pace of product evolution was likely
to continue. Consequently, although KP's potential users concluded that
either Cerner's or Epic's software could be used effectively at KP,
these users clearly and consistently preferred Epic's products. This
preference was seen among all categories of users and for all products
that might be used at KP. The KP Northwest Region had adopted EpicCare,
Epic's ambulatory health record product, early; the region's influence
on improvement in quality and features of Epic's products was clearly
substantial.
The assessment
team concluded that the underlying architecture of Epic's products and
proposed technical solutions were sound and that adopting Epic's applications
would have several important advantages resulting from Epic's extensive,
well-codified implementation experience. On the basis of Epic's experience
with organizations like KP (and with KP directly, ie, through Epic's
long association with the KP Northwest Region), Epic's staff concluded
that KP could rapidly implement much of Epic's product suite if KP staff
collaborated on basic configuration tasks across regions.
The CIS
implementation team had projected programwide deployment of the ambulatory
electronic health record system within seven years; instead, Mr Halvorson
is challenging the organization to achieve four major goals within three
years:
- programwide
deployment of the ambulatory electronic health record system;
- deployment
of hospital information systems in regions where these systems are
needed;
- creation
of a Web presence for clinicians and another for members;
- implementation
of integrated electronic patient registration, billing, and appointment
scheduling systems.
The three-year
goal will probably be accomplished fully throughout KP (except, perhaps,
in California, where great progress toward the goal will have been made
nonetheless). Potential impediments--in particular, the need to coordinate
implementation of the hospital information systems and mandatory seismic
retrofitting--may keep California from fully realizing the goal within
three years.
In addition
to their speed and breadth, the functions inherent in Epic's software
products are more extensive than would have been possible after three
years with CIS, particularly with regard to decision support for clinicians
and Health Plan members. Preprogrammed rules and templates created by
KP for charting and ordering will trigger this decision-support mechanism.
All KP regions will benefit from the KP Northwest Region's experience
with the decision-support features of EpicCare, and KP will reuse the
CIS work done previously by KP in preparation for EpicCare deployment.
Because Epic's clients routinely share this work among themselves, KP
will not need to reinvent decision-support rules and templates already
built elsewhere.
In the
end, the decision to change from CIS to Epic products was easy, even
for those of us who had invested substantial personal energy making
the CIS project successful and who were proud of what had been accomplished.
In 2003, KP negotiated a contract with Epic Systems that took into account
the increased risk and difficulty of implementation created by KP's
size and organizational complexity.
Because
Epic continues to develop its suite of products, our contract includes
the rights to annual updates for products currently licensed to us.
Our agreement also includes a favorable pricing structure for any new
Epic products that KP acquires. On a formal, regular basis, Epic will
solicit KP's input about possible modifications or additions to Epic's
products. This contract structure and solicitation of feedback are routine
for Epic's clients, who uniformly view Epic as a good organization to
conduct business with. The entire project team sees Epic as a capable
partner for KP.
Looking Toward the Future
What advantages
will KP reap from this partnership with Epic? The practical answer is
contained in the catalog of products posted on KP's Intranet site: From
the intranet home page, http://kpnet.kp.org, click on "Use Technology"
in the left navigation bar; click on the "Kaiser Permanente HealthConnect"
link; and click on the "Epic Product Catalog" or the "Epic
Product Documentation" link. Epic's products and services are also
shown on the Epic Systems Corporation Web site, www.epicsystems.com.
In general, KP will benefit from having a proven, highly functional,
computerized system for gathering, storing, and presenting clinical,
operational, and business data that supports clinical and administrative
operations and serves our members well. Most observers feel that the
system is user-friendly and fits well with the way people think and
practice.
Once fully
deployed, an integrated information technology support system within
an integrated health care delivery system has many transformational
possibilities. The basic reason for using an electronic health record
system applies also to using an integrated information technology system;
to have complete, accurate clinical data immediately available for use
in patient care. The greater challenge, however, will be to use this
integrated information technology system and integrated health care
delivery system to improve patient care in ways we cannot yet foresee.
Implementing
the entire suite of Epic's products licensed to KP will be challenging,
but changing our processes of patient care to take full advantage of
these products will be even more challenging. If we do it, given the
inherent advantages of Permanente Medicine and its integrated health
care model, the result should be extraordinary. To paraphrase the motto
of the medical unit depicted in the hit movie and television show, M*A*S*H,
our Health Plan members will get "the best care anywhere."
Acknowledgment
George
Peredy, MD, of The Permanente Medical Group, reviewed the article.
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