Innovation
People
Using Technology to Transform Care:
The 21st Century Care Innovation Project |
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By Hannah
King, MPH; Ruth Brentari, MHA; Leslie Francis, MBA, MHA; Charles M
Kilo, MD, MPH
I
feel like this is the 'doing things differently' that we've been talking
about for the past 20 years.
Sandra Barton, MD, Tualatin, Oregon (Northwest Region)
What
is Dr Barton talking about and how is this possible? Dr Barton and
many other primary care clinicians across Kaiser Permanente (KP) are
part of a pilot project called the 21st Century Care Innovation
Project. The purpose of this project is to leverage the use of
KP HealthConnect (an organizationwide electronic health record system)
to transform care and create thriving physician practices.
The Health
Plan and delivery systems of KP, like the rest of the nation's health
care systems, are facing significant cost pressures from employer
groups and the largest single purchaser--Medicare. There is increasing
risk of losing customers who can't afford insurance premiums. Adding
pressure to KP's cost position in the market is its multibillion dollar
strategic investment in KP HealthConnect and the need to rebuild aging
facilities.
For primary
care practitioners, the model for delivering care is still based on
a production model where patients move through a complex system. The
majority of work for physicians and staff revolves around dealing
with what is in front of them in the moment. There is little time,
room, or incentive for changing work to create flexibility and capacity
to meet the growing needs of members. Now more than ever, there is
a need to transform care delivery so that health care is more cost
effective, convenient, and satisfying for KP members and provides
a fulfilling work environment for clinicians and staff.
Design
In September
2005, the KP Partnership Group (KPPG)a chartered the 21st
Century Care Innovation Project in collaboration with the Institute
for Healthcare Improvement (IHI). The project outcome is
to improve patient care delivery by making primary care more patient
centered, and simultaneously developing a more fulfilling and sustainable
work environment for physicians and staff (Table 1 and Figure 1).
This collaboration of KP labor partners and nine innovation teams
from five KP regions and Group Health Cooperative focuses on changing
the work they do, not just improving efficiency (Table 2). The overall
direction for designing a new primary care model was established by
leaders from the Permanente Medical Groups and Kaiser Foundation Health
Plan and Hospitals and built from the tenets of the Blue Sky vision.1
Innovation
Teams
While
each of the multidisciplinary 21st Century Care Innovation teams works
locally on redesign, representative team members meet together frequently
by phone and in person to share ideas, successes, and failures. This
collaboration speeds the rate of change and multiplies the innovative
ideas that teams test and transfer. IHI facultyb attends
team meetings and works individually with each team to understand
their work and help them refine their changes.
At least
one labor representative participates on each team, and regional labor
partners have been involved in all the teams' work. "The Strategic
Labor Management Partnership is extremely important when introducing
an innovation project. The 21st Century Care Innovation Project has
been successful because people are working in an integrated fashion.
People on the frontline have great ideas for improvement and they
are giving those ideas to their team to make changes," says
Claudine Salama, National Project Coordinator-- KP HealthConnect,
Coalition of KP Unions, AFL-CIO.
The innovation
teams also include one or more KP members who attend weekly meetings
to ensure the work stays patient centered. "Just having a
member in the room changes the conversation. I can no longer say,
'Our patients want X; I need to ask first," says Internist Sean
Riley, MD, of the Skyline team in Colorado. Members' suggestions
have included: the expected response time for return messages, what
they want accomplished in group visits, and how clinicians and staff
can develop stronger relationships with them.
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Figure
1. The 21st Century Care Innovation Project model.
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What
is Changing?
After
12 months of quality improvement work, a new paradigm for primary
care delivery is emerging. By leveraging KP HealthConnect the teams
have created new workflows that have resolved some patients' problems
without a face-to-face encounter. This creates capacity by reducing
the demand for traditional office visits. Health care teams now organize
the work of the day, week, and month instead of reacting to the daily
visit schedule.
1. The Telephone
Appointment Visit
In Hawaii,
Internist and Pediatrician Todd Kuwaye, MD, and Family Practitioner
Samir Patel, MD, used to start each day with a room full of patients
waiting to see them and the pressure of multiple member messages and
appointment requests building up throughout the day.
Today,
these physicians spend the first two hours of their clinical day returning
messages from patients who either want an appointment or have some
other need. The doctors resolve many medical issues on the phone,
and, if necessary, schedule a telephone or office visit for later
in the day. "I love the variety ... It's not all one-to-one,
face-to-face visits anymore. We are doing a lot more visits by phone
and group visits and therefore there are fewer office visits. This
helps keep things fresh and different," explains Dr Patel from
the Nanaikeola Clinic. "I feel like, as a team, we can
meet the needs of the panel much more adequately than before. We're
able to be proactive. Our job isn't to just take care of the people
in front of us. We can meet more needs, even the needs of people who
haven't contacted us, and we can feel good about this."
In the
Southern California Region's Whittier facility, José Goncalves,
MD, a family medicine physician, has a similar experience. He now
spends one 1/2-day per week on scheduled telephone visits. This approach
allows him to care for 15 patients in a half day versus 11-12 in the
old system. His patients are satisfied that they have greater access
to their primary care physician (PCP) and they avoid a copay and avoid
travel on Los Angeles's crowded freeways.
"The
new work of the 21st Century Care Innovation Project has increased
my flexibility. I feel closer to my patients," says Dr Goncalves.
"When they don't need to come in, I can take care of them by
phone or e-mail. When they do need to come in, I can say, 'Why don't
you come in right now; I have time.'"
The
Evolution of the Telephone Appointment
While
most physicians have made telephone calls to patients throughout their
careers, there are some important changes the teams are testing. In
some cases, patients are being offered a choice of a scheduled office
visit or a scheduled telephone appointment visit (TAV) when they call
the call center. TAVs are also being scheduled by the clinic staff
for a follow-up visit. Internist and Pediatrician, Chris Shaw, MD,
from the Longview-Kelso, Washington team (Northwest Region) says,
"What's nice with booked telephone visits is they say, 'Dr
Shaw will call within this time period,' so it gives me a cushion
and I don't feel the pressure of people waiting in the waiting room.
This makes my day better and patients think phone visits are great."
In other
cases, patients are offered a call back from their physician (in a
one-to-four-hour time period) instead of immediately booking an appointment.
TAVs are also occurring on an ad hoc basis when a physician looks
at his/her schedule several days in advance and notices a scheduled
appointment for something that could be handled over the phone. The
teams call this "fishing." Patients who have received these
calls express surprise and are thrilled to talk to their doctor and
resolve their problem quickly versus having to come in to the medical
office to receive care.
In general,
telephone visits are increasing and office visits are decreasing (Figure
2).
Figure
2. Trend of office visits and telephone visits at the Nanaikeola Medical
Office in Hawaii.
2. Secure Messaging
Use of
secure messaging (confidential e-mail) by clinicians and patients
is similarly changing demand for care and creating new capacity. Teams
are experimenting with sending previsit e-mails to patients to begin
a dialogue prior to the office visit, to better plan the visit, and
to nurture their relationship. Patients are pleased to converse with
their PCP through secure messaging. Physicians have commented that
they can resolve patients' needs through secure messages. With the
resulting reduction in office visits, more time is available for patients
who need a face-to-face visit. This experience is consistent with
the formal secure messaging study conducted in the Northwest Region.
3. Population
Care Management
Missed
opportunities for better patient care now appear through the use of
tools like the Panel Support Tool (PST), KP HealthConnect, and registries.
With the increased capacity through the use of the telephone and secure
messaging, the 21st Century Care Innovation teams are exploring ways
to care for their whole panel of patients. Medical assistants who
previously spent considerable time rooming patients for office visits,
now have time with clinician team members to experiment with patient
outreach (population care management) and engage patients in their
own care (collaborative care management).
The PST--a
sortable, Web-based member database populated with the medical information
of a physician's entire panel of patients--was codeveloped by Northwest,
Hawaii, and KP-Information Technology to provide a stratified snapshot
of unmet medical and preventive needs for each patient.2
Currently available for the Hawaii and Northwest teams, this tool
assists the physician and the care teams in prioritizing the outreach
activities for the physician, nurse, and medical assistant to improve
patient care.
Dr Shaw
says "MAs and LPNs are calling members (on behalf of the physician)
who are overdue for a mammogram, cholesterol check, or Pap smear."
He continues, "On a short-term basis, we are doing more
so it isn't saving time, but in the long term, taking care of all
of the patient's needs will reduce enormously the unfilled care needs,
or even worse, complications."
Stacey
Johnson, Clinical Assistant on the Camp Springs, Maryland team (Mid-Atlantic
States Region), says, "The patients are surprised when I call.
Working with them outside of the office makes them more comfortable
with me. I like it because I get to do more in my day than checking
blood pressures and weights; I'm more connected to the patients."
Involving the
Entire Care Team
As the
teams' gain a better understanding of caring for their whole panel,
they are also trying to utilize all the members of their care team
within their licensure to address unmet needs. Nurse Practitioners
are taking a key role in providing group appointments and outreach
for patients with multiple comorbidities. Nurses are making outreach
calls regarding medication compliance and relaying lab results. Many
MD/RN/MA teams are now located in close proximity, often in the same
office, to exchange information more easily, which equips the team
to more effectively handle questions and messages from patients.
In addition,
KP HealthConnect ensures all medical and health care is documented
and available to team members when they need it. This has served to
increase the competence and confidence level of everyone on the team.
"Having
a nurse share my office has really increased our team work. We can
share information and I don't feel like I alone have the responsibility
to provide care to my entire panel. I can count on any member of our
team to pitch in. Everyone works at their highest scope of practice
and potential," states Dr Samir Patel from the Nanaikeola
Team.
Dr Shaw
concurs, "We are sharing the workload. When there are complex
health care issues to talk with the patient about, I make the call.
When there are suggested tests and advice, others on the staff are
making the calls. We all help patients get what they need. The big
benefit of working as a team is to be able to do more with limited
time and resources. We have the flexibility to double, sometimes triple,
how many problems we can solve for patients."
Many
of the teams are extending the traditional view of the care team beyond
the MD, RN, LPN and MA, to include receptionists. At one facility,
the Medical Intake Specialists (MIS), who greet and register patients,
remind them of overdue preventive care needs and, with the patients'
permission, schedule an appointment with the ancillary department
on the spot. Teams are also experimenting with expanding team membership
to integrate other caregivers, including pharmacists, phlebotomists,
nutritionists, behavioralists, and call center agents.
The Voice of
Members
Although
member satisfaction with telephone visits is being evaluated using
a new survey developed by KP National Market Research, the results
from existing Medical Office Visit surveys demonstrate that the changes
the teams are making have an impact.
The Whittier
team has shown improved satisfaction in "Seeing a Provider When
Needed," Appointment Access, and Overall Visit Experience (16%,
8% and 7% respectively) between September 2005 and June 2006. The
Longview-Kelso team has seen similar patient satisfaction improvement
during the same time frame with an increase in Overall Care (from
71% to 86%), Receptionist Courtesy and Respect (89% to 92%), and Physician
and Clinician Interest and Attention (83% to 91%).
Where Do We
Go From Here?
Can we
draw conclusions about primary care transformation from the 21st Century
Care Innovation Project work today? The nine months of available feedback
and data indicate short-term improvement, but to effectively evaluate
the impact of the changes requires more results.
The project
team is collecting a consistent set of utilization, cost, quality,
and member and physician/staff satisfaction data across all of the
teams. These results should be available in the first quarter of 2007.
The innovation teams are refining their new workflows to validate
that they are sustainable over time. Teams will continue to test new
ways to engage members in managing their health including more expansive
use of KP HealthConnect Online features. In 2007, the package of changes
developed by the original nine teams will be given to a new set of
medical office teams to determine if the experience can be repeated
and even improved.
Teams
are in the early stages of transformation: something new is taking
place. The 21st Century Care Innovation teams are gaining confidence
that the changes they are making build upon each other to provide
a new and better care system for members, and a more satisfying, sustainable
work life for physicians and staff. Physicians and staff are energized,
and members are very interested in the new ways KP can deliver care.
With support from their local and regional leaders, the teams have
had the opportunity to understand what the work is and should be,
rather than simply accepting inherited processes. "I feel
like this is the 'doing things differently' that we've been talking
about for the past 20 years. We have preliminary data to show that
we are meeting the needs of our panel with fewer office visits and
that they are not going to other PCPs or urgent care. We are 'touching'
more patients than we used to be able to," says Dr Barton,
MD, internist. "I can say, 'I love my job.' I wouldn't have
said that before. If we spend the time to perfect this over the next
6-18 months, it will be sustainable."
For more
information contact project co-leads Ruth Brentari at ruth.brentari@kp.orgor
Leslie Francis at leslie.francis@kp.org.
a The KPPG chartered a subgroup to oversee the work. The subgroup
includes Louise Liang, MD, Senior Vice President of Quality and Clinical
Systems; Jack Cochran, MD, Executive Medical Director, Colorado Permanente
Medical Group; Bruce Perry, MD, Executive Medical Director, The Southeast
Permanente Medical Group; Mary Ann Thode, President, Northern California
Kaiser Foundation Health Plan and Hospitals; Claudine Salama, National
Project Coordinator--KP HealthConnect, Coalition of KP Unions, AFL-CIO.
b
IHI faculty include Marie W Schall, MA, Director; Kevin
Nolan, MA, Senior Fellow; Charles M Kilo, MD, Greenfield Health System;
and Gordon Moore, MD, University of Rochester Department of Family
Medicine.
References
- Brentari
R, Garrido T, Mittman R, et al. Blue sky care delivery 2015, Part
1. Perm J 2003 Fall;7(4):47-50.
- Livaudais
G, Unitan R, Post J. Total Panel Ownership and the Panel Support
Tool--"It's all about the relationship." Perm J 2006 Summer;10(2):72-9.
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What
is it about KP HealthConnect that makes this Work Possible?
"See
the work. Share the work. Change the work."
While
telephone visits could have been (and were on a small
scale) provided previously, the teams have found that KP HealthConnect
enables greater ease, efficiency, and scale. With KP HealthConnect
all the relevant patient information is easily accessed by the
provider during a telephone visit. "Real-time" processing
(notes, lab orders, Rx orders) is possible during a telephone
visit. Work is completed during the telephone visit with few
or no hand-offs required.
KP
HealthConnect makes handling incoming patient messages
more efficient. Each member of the team can access and resolve
any request or problem within their scope of practice when s/he
has time. For example, a physician can attach to messages in
the RN/MA's in-basket between seeing patients in the office
and resolve problems then and there. For requests requiring
communication among team members that communication can happen
asynchronously--eliminating the need for both parties to be
available at the same time in the same space.
For
patient outreach and population care management, addressing
health maintenance alerts can become more than just the clinician's
responsibility. The receptionist can schedule overdue screening
appointments for patients. MAs can pend orders for the physicians
that will address care whenever they have an interaction with
the member (eg, flu shot clinic). In addition, health maintenance
information available to the care team is simultaneously available
to the member via kp.org.
For
collaborative care planning, teams are experimenting
with using the After-Visit Summary to provide patients with
documentation of their goals and personal action plans. Colorado
is leading the development of a simple tool for recording (via
drop-down menus) personal action plans in the chart (aka a "smart
widget").
For
e-Visits, one Hawaii team is experimenting with sending
electronic questionnaires to patients to more effectively capture
key clinical signs/symptoms from the patients via secure messaging.
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