Health Information Technology
Last Fall, a group from UCSD hosted a discussion of healthcare information technology (HIT) with the CEOs and CIOs of the healthcare providers throughout San Diego County, along with officers of SDCMS and the CEO of Qualcomm, Irwin Jacobs. Dr. Jacobs minced no words as he drove the agenda of the meeting. He politely but clearly chastised the entire gathering for failing to use HIT to support continuity of care for county residents, including his 8,000 employees. Specifically, he noted that whenever one of his employees changes from one provider organization to another, or is sick enough to require admission to one of our hospitals, we, collectively, did not provide adequate HIT support for the comprehensive and longitudinal care for that individual. Other CEOs across the country have echoed his laments.
In December, the CEOs of Wal-Mart and Intel formed a large consortium. They committed substantial funding to create a data repository that will house the personal health records (PHRs) of their employees and those of many other participating companies in a PHR repository, accessible by the patients themselves. A few large healthcare insurers followed suit with similar proposals. Some hail these efforts to create repositories of claims-based data in PHRs, owned by patients and managed by either employers or insurers, as progress. Others, including myself, regret that our collective failure as an industry to fund and drive the comprehensive use of HIT has created the vacuum that spawned this ill-conceived solution that calls for those outside of healthcare to be the guardians of key health information.
Ask the average person who they want to manage their longitudinal health record: insurers? employers? or the healthcare providers who actually deliver their care? Ask the average physician whether, upon seeing a new patient in the emergency room or office, she would prefer to see an incomplete record managed by the patient and retrieved from an employer-sponsored repository? Or would she rather see a comprehensive record generated by doctors in the course of caring for that patient?
The answers to both questions should be obvious. The historically slow adoption of HIT and the snail’s pace of adopting data exchange standards fuels these half-baked solutions. An article in the current edition of the Journal of the American Medical Informatics Association corroborates these common-sense answers and clearly illustrates the many disadvantages of using data generated from these proposed PHRs (administrative and claims data), rather than the clinical data generated directly by those caring for the patient.
So where does that leave us as providers of healthcare in this race to provide HIT support for continuity of care? The answer is simple: We need to drive our organizations quickly but carefully towards both comprehensive information infrastructures and support of facilitated data exchange across our institutions.
An irony exists for those of us in San Diego County and for our nation. Canada, Australia, and the United Kingdom have all specified that any vendor wishing to supply HIT software must be able to easily exchange clinical information (through adoption of HL7 version 3.x), yet the United States is slow to make the same level of commitment. Why is this ironic for San Diego? The data standard that forms the basis for this interoperability was the brainchild of two San Diego physicians over a decade ago: John Spinoza, MD, a Scripps Memorial pathologist, and myself. John was an intern at UCSD while I was chief resident, but our paths didn’t cross again until 1996, when we met accidentally one Saturday morning in a Bank of America parking lot. At that chance meeting, we realized that our separate career paths had converged on the same problem of sharing records across institutions. Together we plotted the origins of the XML-based clinical document architecture (CDA). We led that HL7 initiative, now recognized worldwide, so that we could begin sharing documents between our respective hospitals here in San Diego. Over a decade later, this country and its software vendors are finally beginning to implement this standard. The dream that John and I initiated can be realized, but is it too late? Have the Intels and the Wal-Marts pre-empted this with a “quick and dirty” solution? Hopefully not, but it will take substantial effort from all of us to ensure that a more comprehensive and clinically-founded approach prevails.
What specifically is Kaiser Permanente doing with HIT? In our SCAL region alone, we have committed over $1billion to deploy our comprehensive national system, named KP HealthConnect. It includes full automation of inpatient, outpatient, and practice management systems (scheduling, registration, billing, health plan functions, etc.) and will replace 80 percent of the software previously used at Kaiser Permanente. This largest civilian deployment of an electronic health record in the world is now over 65 percent fully implemented in Southern California. By the end of 2007, 100 percent of the outpatient application and six of eleven Kaiser Permanente hospitals in Southern California will be completely installed on all phases of the inpatient product. We already have 100 percent of the components implemented in our first site at Baldwin Park, and the results are astonishing.
Nationwide, KP HealthConnect will connect 8.6 million people securely to their healthcare teams, their personal health information, and the latest medical knowledge when it is fully deployed. Administrative support applications for scheduling, registration, and billing are now live across every one of Kaiser Permanente’s eight regions, and providers for more than four million members are actively using the outpatient medical record in their daily care.
In addition, more than 95 percent of Kaiser Permanente members have access to portions of their KP HealthConnect record via kp.org, including the ability to securely email their doctors and view most of their lab test results online. We are introducing numerous additional features for members online over the Internet throughout the remainder of this year
The implementation is the single largest change process that has ever taken place in the organization’s history. Teams have designed, built, and tested over 100 interfaces in Southern California alone between KP HealthConnect and other systems, and all are functioning effectively and supporting the integrated record for all users.
More people have been trained on this project than ever before in Kaiser Permanente’s history. In 2005, Southern California teams trained 15,532 people; in 2006 we trained 35,216 individuals in 4,030 classes. The cumulative classroom time is now over 529,000 hours with 353,000 of those in 2006.
The SCAL region has distinguished itself by working closely with Epic, the vendor for KP HealthConnect, to design and test the first enterprise-scalable version of the software. Several other large organizations are now purchasing the product, called “Care Everywhere,” that resulted from this collaboration to support their large-scale deployments.
We also helped design and test the first Web-based version of the Business Continuity Access System (BCAS) software, which allows facilities to view all pertinent clinical information in the event of a serious network or data center failure. Again, other Epic clients are anxiously awaiting their turn to implement this same functionality at their sites.
A “Decision Support” workgroup has been quick to implement evidence-based best practices at the point of care by deploying PAP, mammography, and hypertension alerts in primary care and specialty departments at multiple medical centers in 2006. Development continues for additional alerts for diabetes and lipid screening and control, smoking, asthma, and colorectal cancer screening. Our quality of care scores already rank at the top of numerous third-party evaluations based on existing systems, and KP HealthConnect is helping us drive those scores ever higher.
How do we at Kaiser Permanente intend to help both San Diego County and the country toward a solution that supports continuity of care between our many institutions, and minimize the kind of stop-gap proposals emanating from Wal-Mart and others? As noted above, we are driving the most rapid deployment of the largest civilian EHR program in the country. We are collaborating with the VA and DOD at the national level, working directly with Rob Kolodner, the new director of the Office of the National Coordinator for HIT, and actively participating in numerous standards organizations to advance the interoperability of data standards. One of our Kaiser Permanente physicians, Bob Dolin, MD, was recently appointed as co-chair of the national committee (HITSB) that determines which standards will be adopted at a national level.
How do we now collectively drive the progress of our individual institutions toward the holy grail of ensuring that anyone treated anywhere in San Diego County will benefit from a comprehensive record irrespective of where they have been treated? That work lies mostly ahead of us. With the support of individuals like Steve Carson, MD, at SDCMS, we have the opportunity to create one of the most advanced HIT solutions anywhere in the country. We must match our individual efforts to deploy comprehensive solutions within our walls to our commitment to collaborate and share information using international standards across our walls.
In the end, if we rise to the challenge articulated by Dr. Irwin Jacobs, every resident of our great county will be the direct beneficiary of our collective efforts.