OPMG Update Winter 2008

8/14/2019 OPMG Update Winter 2008

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IN THISISSUE

I have two simple objectives for this

column: 1) invite you to read up onthe efforts that will help KP Ohio

transform our delivery system, and

2) to say thank you for all the hardwork that has occurred these past few

years and particularly during 2007.

Ill do that by listing just some of themany incredible accomplishments that

could not have occurred without thehelp of many dedicated individuals.

But first, a good portion of this

issue focuses on the advancedcare management for care delivery

transformation effort, with specialfocus on some of its key features.

Many of you may have heard mention

of the advanced care managementeffort, and it is a critical component

of our turnaround and sustainabilitystrategies, so the goal of this issue isto provide a helpful overview of the

endeavor and its implications.

Advanced care management isbeing largely shepherded by

Charles DeShazer, MD, who joinedKP Ohio last spring as associate

medical director for quality, clinical

performance improvement andresearch. Dr. DeShazer is helping lead

the effort to harness our technologicalresources to aid and strengthen

proactive panel management,

particularly among members withsignificant disease burden, and to

precipitate outreach efforts that buildtrust with membership and help them

collaborate on disease management

challenges. I encourage you todelve into his article explaining the

advanced care management effort,

as well as the companion pieces

that explain the 21st Century Care

Collaborative and the advanced car

panel (formerly the mini panel).

And now, let us review some of our

key accomplishments over the past

to 18 months.

In the whirlwind that is the Kaiser

Permanente Ohio turnaround, its

easy to overlook the fact that we

have made significant strides and

that we have much about which

we can be proud. As I have said on

more than one occasion, progress is

not an accident. It occurs because

people agree to make it happen. Th

examples below underscore that

commitment as well as the progressthat flows from it.

This is a partial list, of course, but an

important one; in fact, the first four

items are updates on key turnaroun

projects. But beyond showcasing

notable achievements, the list also

serves as reminder that none of our

accomplishments occur without the

hard work of many individuals who

are dedicated to, and believe in,

OPMG and KP Ohios shared missio

of providing the best health careat the best price. Nor could OPMG

exist without the dedication and

loyalty of its physiciansveterans an

newcomers alikewho despite all o

the challenges, believe that what we

have is unique and worth preserving

and advancing.

continued on page

Plenty to be proud of,but we must press onRonald L. Copeland, MD, President and Executive Medical Director, OPMG

Winter 2008

OPMGUPDATEThe Ohio Permanente Medical Group Newsletter

Plenty to be proud of,

but we must press on . . . . . . . . . . . . . 1

Advanced care management for

care delivery transformation . . . . . . . 4

21st Century Care Collaborativeaids effort to improve

member health . . . . . . . . . . . . . . . . . 6

Fishing: 21st Century cares

key to creating capacity . . . . . . . . . . 7

Advanced care panel: using the

house call to improve

management of chronic disease . . . 8

Members embrace

health coaching . . . . . . . . . . . . . . .10

Ball is rolling for physician

work life committee . . . . . . . . . . . . 11Be on the alert for

CMS welcome letters . . . . . . . . . .11

Patient safety programs strengthen

communication skills . . . . . . . . . . .12

Patient safety and quality care . . . . . 14

Abramsons anecdotes:

What makes a good doctor? . . . . . . 15

Encryption effort protects

health information . . . . . . . . . . . . . . 16

Kaiser Permanente encryption:A five-phase program . . . . . . . . . . . 17

Medical Library services update . .18

Referrals management and

clinical review updates . . . . . . . . . . 18

Performance improvement

efforts moving forward . . . . . . . . . .19

Ohio Permanente Medical Group, Inc.


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WINTER 2008

Diabetes complete careOne of the objectives of advanced

care management is developingproactive population-based

initiatives to improve the health

of the KP Ohio membership. The

diabetes complete care program

is one such project and involves

the efforts of dedicated staff from

pharmacy, primary care medicine,

health care teams (i.e., medical

office nurses) and population care

management. Among members

diagnosed with diabetes, the goal

of the program is to maximizethe number of those who use the

aspirin, lovastatin, lisinopril (ALL)

regimen. Launched in September

2007, the program is fueled

in part by electronic medical

record analysis and subsequent

telephone outreach, which is used

to encourage members to begin

adhering to the ALL regimen, or to

get them scheduled for overdue

blood testing, office appointments

or both. As of November 30, 2007,2,835 members (among panels from

10 facilities) have been identified

and contacted. (Contacting a

member invariably requires multiple

attempts, and as of December

2007, the total number of touches

currently exceeded 5,400.) Among

those contacted, more than 1,220

members had agreed to begin

the ALL regimen. The diabetes

complete care effort is a sterling

example of how our integratedmodel can be leveraged to enhance

coordination of care to achieve

stronger outcomes. Such efforts

require sustained collaboration by

an array of teams and departments,

not to mention relentless attention

to detail, but these are exactly the

types of endeavors our model is

tailor-made for.

Redirecting referralsIn 2006, one of the close the gapefforts involved reducing costs

through proactive management

of utilization and optimization

of appropriate use of medical

resources. A key component of theeffort involves redirecting, whenever

possible and appropriate, referralcases back into the OPMG realm

of expertise. Thus far, the redirect

program has been quite successful,

particularly since the process now

occurs inside KP HealthConnect. As

of October 2007, more than 4,200

referrals were redirected to OPMGspecialties. The redirect effort

focused particularly on areas that

historically see high rates of referral:cardiology, neurology, urology and

orthopedics. Referrals also are

common when special services are

needed for members. These includeGI related services, sleep studies,

liver biopsy, physical therapy,

dermatologic services and nuclear

medicine services. As of October

2007, more than 11,800 service

referrals were redirected back

into OPMG. Without the redirect

effort, OPMG would have incurredsignificant costs for those specialty

services referred to non-OPMG or

non-contracted providers. Without

KP HealthConnect, no ready-to-use

options exist for automating the

referral process, nor would we havethe ability to track referral activity

and outcomes as they occur.

Case management hubThe emergency case management

hub, launched in January 2007, isa centralized command center

designed to manage hospital

and ambulance utilization that

arise from emergent scenarios. In

addition to providing members

24/7 telephone access tophysicians who can dispense

advice and assistance, the hub

helps keep members inor

brings members back totheOPMG care network. It also helpsthem avoid unnecessary ED visits

(and attendant co-pays). Hubphysicians provide consultationfor non-KP practitioners who

have KP members in their care,field priority calls from KP advicenurses, and work with emergencydepartment staff to select theappropriate hospitals for members.Also, any member who calls canspeak directly with a hub physician.As of October 2007, the huborchestrated 3,001 repatriations

(directing a member to contractedcare) and 5,708 prepatriations(determining the most appropriatelevel of care for members beforethey present at an emergencydepartment or hospital).

Coding anddocumentationAnother key thrust of theturnaround effortand vital tosubstantiating the true health statusof our membershipis the quest toimprove coding and documentationaccuracy and improve the diagnosisrefresh performance for the

Medicare population. Steppedup training, education andawareness efforts, complementedby quarterly reporting, has helpedmake a significant impact incoding/documentation accuracy.For instance, in first quarter2005, OPMG was at a 45 percentaccuracy level. For the same periodin 2006, the accuracy level was73 percent. For the third quarter2007, coding/documentation

accuracy reached 80 percent. Thisis great progress and we are onour way to the 90th percentile. Thediagnosis refresh effort is provinga bit more challenging, althoughwe are making definite headway.Physicians now receive diagnosisrefresh reports (i.e., a running tally

Plenty to be proud of,but we must press oncontinued from page 1

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of diagnosis refresh opportunities)

daily to aid the effort. With the

diagnosis refresh, we have two

key goals: refresh diagnoses thatare still relevant and resolve old

diagnoses that are no longer

pertinent. (Note: In Medicares eyes,

credit is only given for a diagnosis

refresh when it results from a

face-to-face visit.) To help make

diagnosis refresh a proactive rather

than passive pursuit, an outreach

pilot was established to identify and

contact KP Ohio Medicare members

due for diagnosis refreshes, office

visits, or both. Thus far, the outreachpilot, which focuses on KP Medicare

members with a comparatively

high chronic disease load, has

helped boost diagnosis refresh

performance. Overall, we have

made commendable progress in

boosting our refresh numbers, but,

given the higher disease burden

among our Medicare members,

we still have plenty of room for

improvement.

CME accreditationIn 2007, KP Ohio earned

provisional accreditation to present

continuing medical education

(CME) programs. In addition

to making it more convenient

for OPMG physicians to meet

mandatory CME requirements,

an internal CME program helps

showcase our multispecialty

clinical expertise in the northeast

Ohio medical community. Andbecause our clinical care is driven

by evidence-based medicine,

CME programs can be used to

strengthen our delivery efforts.

The accreditation effort also

accommodates our ongoing need

as practitioners to acquire new

clinical knowledge and continually

hone clinical skills.

Laboratory re-accreditationKP Ohios laboratories at theChapel Hill, Cleveland Heights,Parma, and Willoughby medicalcenters earned accreditation fromthe Intersocietal Commission

for the Accreditation of VascularLaboratories through January 2010.By participating in the accreditationprocess, the facilities demonstratea commitment to the performanceof quality vascular testing and striveto meet nationally recognizedstandards. During the accreditationprocess, vascular laboratories mustsubmit documentation on everyaspect of their daily operations.

KP HealthConnect OnlineIf we want members to activelyparticipate in their care, thenwe need to give them access toinformation that can help make thathappen. And thats exactly whatwe did with KP HealthConnectOnline, the component of ournew electronic medical recordthat gives members access to keyhealth information. In addition toreviewing lab results, immunizationhistory, office visit history, andoffice visit summaries, memberscan view, request or cancelappointments, request updates tothe medical record and email anyOPMG provider they have hadface-to-face contact with or withwhom they have had a telephoneencounters within the last threeyears. This empowering tool willaid our quest to optimize diseaseprevention and management.

KPO physicians helpsolve medical mysteryThis spring, OPMG physiciansRonald Adams, MD and LawrenceScott, MD appeared in an episodeof Mystery Diagnosis, a programproduced by Discovery Health. EdLeighs cancer symptoms surfacedin 1997, but it wasnt until August1999, after having become a KP

Ohio member and a patient of Dr.

Adams, that Leigh was diagnosed

with stage III colon cancer. The

Mystery Diagnosis episode tells

Leighs story and recounts how Drs.

Adams and Scott helped save his

life. The episode is still airing.

Sustaining themomentumThis impressive sampling

underscores in part the Herculean

effort under way to prepare us

for the critical challenges ahead.

The efforts also underscore the

momentum we have developed in

just a short period of time.

I, and all of my colleagues on the

OPMG board of directors, extenda genuine thanks to all of you for

persevering, for pressing forward

with the effort to transform OMPGs

care delivery capacity and capability

from good to great for 2008 and

beyond. In short, 2008 will be a

defining moment, because how

well we fare in 2008 will largely

inform our existence and outlook for

the years that follow.

The test now is to sustain themomentum so that we achieve

our objective of providing optimal,

coordinated care for our members.

That means parlaying the strengths

of our integrated model, but more

important, continuing to pursue

market leading excellence in

quality, service and affordability,

for that is how we distinguish

ourselves as a medical group and

in the marketplace. For all of us

within OPMG, the quality of ourprofessional life and career security

we seek is directly proportional to

our commitment to excellence

excellence in preserving health,

managing disease, communicating

with our patients, achieving effective

stewardship and inspiring each other

to be the best we can be for our

patients, each other and ourselves.

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Plenty to be proud of,but we must press oncontinued from page 2


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A special message from:

Charles DeShazer, MD

Associate medical director, quality, OPMG

Its no secret that the KP Ohioregion faces significant economicand market challenges over thenext several years. Those challengesinclude coping effectively withnortheast Ohios stagnantpopulation, the imminent change inthe way well be reimbursed for our

Medicare members, ever-evolvingmember expectations regardinghealth insurance offerings, increasedfocus by employers on health caredelivery report cards (such asthose produced by NCQA), risinghealth care costs, attaining codingand documentation proficiency,optimizing the tracking of servicedelivery and ensuring accuratepayment of it, and optimizing useof the clinical expertise within theOPMG network.These are challenges that will testthe creativity, ingenuity, and resolveof everyone in the medical groupand the health plan. For the pastyear, however, key leads from themedical group and health planhave collaborated to develop acompelling strategy to help lockin KP Ohios long-term future. Theclinical portion of this effort is calledadvanced care management (ACM),and it will meld the strengths of

KPs integrated model of healthcare delivery with its burgeoningstrengths in information technologyand parlay those not just to meetthe aforementioned challenges,but to allow KP Ohio to leapfrog itscompetition.

Parts of the ACM effort have beenunderway for months in pilotingprojects at the Bedford facility.

Overall, the ACM program has fourmain components and they will bebriefly discussed here.

1) Member engagement

The overall focus of this effort ison improving relationships withour members and facilitating orimproving their access to healthinformation and health care. A maindriver of this effort will be proactivemember outreach. Well use a few

key tools to identify members whocan benefit from more vigilantcare and then well use some newresources and different approachesto contact those members anddeliver their care. For instance,physicians and members will nothave to rely solely on the office visitto communicate with one another.The new KP HealthConnect Onlinefeature (launched in November2007) offers members the optionof communicating with theirphysicians via e-mail. Well alsouse telephone visits as partof the care delivery effort. Formembers who are interested init, KP Healthy Solutions offers theopportunity to collaborate with ahealth coach on achieving goalsset by the primary care physician.Health coaches also are trainedto help educate members abouthealth and medical issues, offerguidance about treatment options

for certain conditions, and provideencouragement and guidance tomembers challenged by diseasemanagement goals.

2) Care management support

Care management support involvesidentifying care gaps and using(or developing) the expertise,tools, and resources to address

those care gaps. We know, forinstance, that a comparatively smallportion of the population uses adisproportionate percentage ofhealth care resources. By refocusingour attention on KP Ohio memberswho have single or multiplechronic disease, by using proactiveoutreach to contact them, and byredoubling our efforts to ensureevidence-based management oftheir care, we can make a significantimpact on their health statuses.Improving their health, in turn,reduces use of resources. Wevealready set our sights on memberswith diabetes and heart failure;that undertaking will be followedby similar efforts directed towardcoronary artery disease, chronicobstructive pulmonary disease,asthma and depression.

3) Advanced practicemanagement

Perhaps what most distinguishesthe KP model from its competitorsis its ability to make rapid andsweeping changes with regardto care delivery. Unfortunately,this capability has not been usedeffectively nor aggressively enough.But that is quickly changing in Ohio.Advanced practice management(APM) involves redesign of thehealth care team with the objectivesof achieving benchmark levelperformance in cost, quality, serviceand workforce satisfaction. It willrely on harnessing data-driven panelmanagement systems, leveragingtechnology and connectivity fornew workflows and processes,and creating improved flexibility,control, and support for the healthcare team to adapt its expertise

Advanced care management for caredelivery transformation

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and efforts to the needs of theirpatient panel.

For the past several months,KP Ohios Bedford facility hasbeen piloting a project called21st Century Collaborative Care,a key component of the APM.The 21st Century Collaborativeexemplifies the potential KP hasto use unconventional approachesto improve disease management.This is a highly proactive approachto managing chronic disease andpreventing events precipitated byor associated with them. Members

at high risk for chronic diseaseand members diagnosed withchronic disease are targeted forproactive, vigilant care. They areliterally mustered into the KP Ohiosystem to ensure they receiveoptimal, timely care and that theyget guidance about managingtheir condition. Another feature ofadvanced practice managementis the advanced care panel. (Seepages 6-8 for more details on 21stCentury care and the advanced care

panel.)

4) Infrastructure

The infrastructure componentrefers to the resources, tools,and processes that will supportimplementation and maintenanceof member engagement, caremanagement support andadvanced practice management.These efforts depend on ouraccess to accurate and timely

data as well as our ability to finetune or overhaul structures andworkflows when necessary. Datacapture and reporting tools includeKP HealthConnect and POINT(Permanente Online InteractiveNetwork Tools). POINT alreadyis helping us identify and moreeffectively manage members withchronic disease. POINT and other

data reporting tools will allow usto identify and resolve care gaps,improve panel management,and optimize use of office visittime. Putting data to work forus proactively will enable clinicalteams to improve overall membercare, optimize care for memberswith chronic disease, minimize thelikelihood of undertreatment andaid the coding, documentation anddiagnosis refresh efforts.

Ambitious effort

To be sure, this is an ambitiouseffort with an equally ambitioustimeline. Advanced caremanagement has to be up and

running with wrinkles resolvedin time to accommodate thetransition well undergo regardingreimbursement for our Medicaremembers. Under the new plan,we become the primary payer for100 percent of the care we deliverto KP Ohio members eligible forMedicare. The program, MedicareAdvantage, will be fundedprospectively by the Center forMedicare & Medicaid Servicesbased on member data we provide.If that data is incomplete orinaccurate, the costs for treatingour Medicare members will exceedwhat CMS has allotted us for thatcare. Essentially, we will be givingaway care for which we are entitledto reimbursement. Thats whyaccurate coding and documentationand annual diagnosis refreshes areimperative; without them, CMSgets an inaccurate reading on thetrue health status of our members.

(Inaccurate member data alsoconstitutes Medicare fraud.) Onthe other hand, the combination ofhighly accurate member data andproactive disease management thatresults in more effective preventionand control of chronic disease andof adverse events associated withthem, greatly improves our abilityto preserve cost-of-care dollars.

The other point to keep in mind isthat success of the ACM programdepends on effective execution ofall the program components andtheir respective elements. Eachpart of the effort supports another.And though clearly a key to oursustainability mission, preservationof cost-of-care dollars is just oneof several payoffs the ACM effortwill yield. It also will allow us topractice better medicine andimprove the health statuses of ourpatients. Quality of care will beenhanced. We will become expertsat managing chronic diseaseand comorbidity proactively. Themember experience will improve.Member trust in us will build. Our

expertise will attract the attentionof employers grappling withhealth plan costs and interested inproactive rather than reactive healthcare. All of that means securing ourfuture in the region.

Success of the ACM program alsodepends on support and embraceof it by everyone in OPMG andthe health plan. To be sure, therewill be wrinkles and recalibrations,

but the overall plan is sound,and the early indications are thatthe program offers tremendouspotential for us to take our caredelivery to a new level and make itone that others will emulate.

The ACM program sponsorsinclude Ruth Langstraat, MD,vice president, health systemsdesign and performance, KaiserFoundation health plan (KFHP);Belva Denmark Tibbs, vice

president, medical operations,KFHP; and Walid Sidani, MD,vice president and associatemedical director, medical affairs,OPMG. All of them deeplybelieve in this endeavor and haveworked tirelessly to help lay thegroundwork for it.

Advanced care management for caredelivery transformationcontinued from page 4

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One of the key features of theadvanced care managementeffort is the 21st Century CareCollaborative. At its core, 21stCentury care is an effort to improvethe health of the KP membershipand to give the care teams morecontrol over the means andmethods they use to deliver careand manage daily schedules.Achieving those two goals willhave a ripple effect of improvingmember satisfaction and improving

the work life of the clinical teams.In the 21st Century Care model,technology, teamwork, memberoutreach, creative care delivery,and proactive disease managementmerge to create a more patientcentered system. This approachinvolves not just reviewing thecare needs of members, butunderstanding what works best forthem in terms of communicatingand interacting with the care team.It also takes account of patients

interpretations of their health.And where possible, the patient isenlisted to become a more activeparticipant in the care plan.

The 21st Century CareCollaborative grew from adesire inside Kaiser Permanenteto improve care delivery (asreflected in internal and externalmeasures) and to develop newapproaches for managing thehealth of KP members. In part, itwas the acknowledgement that

the traditional model for diseasemanagementthe office visitisvaluable and necessary, but, byitself, is not an adequate meansof achieving the goals of offeringthe most effective and affordablecare, particularly in a changingand increasingly complex healthcare world, and particularly one inwhich technology will be a staple.For instance, in addition to the

electronic medical record, KaiserPermanente now has at its disposalseveral powerful electronic toolsthat can aid the task of proactivedisease management.

A second impetus is improvingmember satisfaction. Data showthat most members feel betterabout their health care experiencewhen they are proactively andpositively engaged in the task ofcare management.

Another catalyst for 21st CenturyCare is the desire to improvethe work life of the care teams.In addition to the day-to-daychallenges they facein particular,a member population that presentswith multiple diseasesa recurringissue is the feeling of loss of controlover the work day. In the 21stCentury model, however, clinicalteams have the opportunity torecapture some of that control.

For instance, the traditional officevisit model is passive rather thanproactivethe care team waitsfor patients. The model also istemperamental and imperfect.Patients cant always get toappointments on time; some showup late or not at all, some showup unannounced. Moreover, theface-to-face visit often involves theexchange of fairly basic information.

Yet between the member andprovider staff, a significantamount of time and energy must

be expended to make that visithappenappointment scheduling,negotiating time off from work,making travel arrangements (thentraveling), handling the copay,waiting for the appointment tobegin (or waiting for the memberto arrive), getting the patientroomed, etc. But what if analternative existed that couldeliminate much of that expenditure?

With 21st Century care, there arealternatives, and several of theseare outlined below.

The 21st Century CareCollaborative will be rolled out ina way similar to the launch of KPHealthConnect, in phases and withthorough training and guidance.Bedford got underway in April 2007and thus far is having great success.

Two key components of the21st Century program are thechange package and the rapidimprovement model, or RIM. Thelatter consists of pilot-like studiesthat test elements of the changepackage or variations of them. Thegoal is to allow each facility to usethe change package partly as astarting point; team members thencollaborate on developing pilots totest strategies and ideas informedby member demographics as wellas the attributes, strengths andweaknesses of the care team and

facility.

The change packageelements are as follows:

1) Build the care team

The goal is to create a patient-centered focus, where the careteam and work flows are organizedto meet the needs of the teamsmember population. One key isthat care team members agree toshare accountability for managing

the health of all members of thepanel; another is using informationresources to proactively analyzethe needs of the panel.

2) Develop relationship based care

Successful disease managementin part depends on an awareness

21st Century Care Collaborative aidseffort to improve member health

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of who is in the panel and thenbuilding relationships with thosemembers using an array of

strategies. In relationship basedcare, the care team really knowsits members; the electronicmedical record is used not just todocument and store nuts and boltshealth information, but also torecord information that improvesthe task of providing individualizedcare. The medical record canthen be reviewed in advanceof appointments to improvethe office- or telephone-visitexperience and make them more

productive. Another objective ofrelationship based care is ensuringthat members have signed up

with or are assigned to a primarycare physician.

3) Use alternatives to thetraditional office visit

Offering alternatives to the one-

on-one, or face-to-face officevisit accomplishes several goalssimultaneously: it gives membersand care team staff options forcommunicating; it allows the careteam to have member toucheswhere none existed; and whereappropriate, an alternative visitcan replace the office visit. Thisrelieves the member of theattendant burdens and stressesassociated with an office visit.Offering alternatives to thetraditional office visit also allowsthe care team to achieve morecontrol over panel managementusing a tactic called fishing. This

in turn creates capacity in thework days; that capacity, and theability to create it, is one of thekeys to care teams gaining morecontrol over, and deriving moresatisfaction from, work life. Fishingis integral to the 21st Century

effort and is explained in moredetail in the sidebar below.

Alternative visits include telephonecalls and emails between physiciansand members; group visits and otheroptions are under consideration.

4) Achieve total panel ownership

The essence of total panelownership is providing the bestpossible care to the highestpercentage patients in a given

panelin short, optimal panel andpopulation care management. The

21st Century Care Collaborative aidseffort to improve member healthcontinued from page 6

A key component of panelmanagement is fishing,a strategy that involvessurveying the appointmentschedule hours or days into

the future and determiningwhether some of theappointments can be managedwith a phone call. Manyappointments involve routinefollow-up or the exchange ofbasic information and plentyof members would prefer toget that information withouthaving to take precious hoursfrom their day to show upfor an office visit. Fishingtakes advantage of those

opportunities.

Fishing occurs at pre-established times during thework day, and can be doneby a physician alone, or bya physician and nurse. Thefirst step is to review medicalrecords for select membersscheduled for office visits.

Once identified, the physicianplaces a call to the memberand the conversation goes likethis: Mrs. Quentin, this Dr.Kaiser, your physician. I see

that youre coming in on Fridayand Im calling to preparefor your visit. That sets thestage for a discussion thatcan determine whether theappointment is still necessary.The goal is not to convincethe member to cancel, ratherit is to establish contact,relay helpful information, andthen let the member decidewhether the appointment iswarranted. Experience has

shown that if both memberand physician feel comfortablethat the phone call resolvedany outstanding issues,the member will cancelthe visit. Of course, if themember prefers to keep theappointment, that is fine. Thephone contact is still valuablefor both parties because both

exchange valuable information.And from the health careteams vantage, the callrepresents an important touchpoint that would not have

occurred otherwise.

When a member does cancel,a physician hold is placed onthe now open appointmentslot. The physician and healthcare team can then decidehow best to use that newlyacquired capacity. Thatcould mean more fishing,mammogram outreach, orcare planning with an RN, forinstance for diabetes complete

care. Or the time could beused to see a member whohas complex disease, maintainmedical records or performadministrative tasks. In short,fishing allows the medicalteam to create capacity thatis used to fulfill the goals of21st Century Care and regionalperformance measures.

Fishing: 21st Century cares key to creating capacity

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The advanced care panelrepresents one of severalinitiatives underway in Ohio tohelp significantly improve thehealth of Kaiser Permanentemembers. And like the the 21stCentury Care Collaborative, itpresents an alternative to thetraditional approach to diseasemanagement. Because what isbecoming increasingly apparentis that the traditional model ofcareregularly scheduled office

visitsworks well for healthypatients, but not so well forthose sick from one or morechronic diseases.

The advanced care panel,or ACP, initiative occurs incollaboration with KaiserPermanentes Care ManagementInstitute, created in 1997 tohelp Kaiser Permanente improvethe quality of care and healthoutcomes for members. ACP

also is a pilot project for allof Kaiser Permanente. WayneOpalk is project manager forthe effort, and Ann L. Scott,director of primary care, andNicholas Dreher, MD, assistantmedical director, primary care,are the clinical leads.

Modern house call

The essence of the advancedcare panel is proactive, vigilant,individualized care that is

brought to the patient. Inshort, its a house call, but amuch more modern versionof it, because in this case thephysician is part of a teamresponsible for the membershealth. The team includes anRN, social worker, PharmD,and scheduler, who manages

the appointment schedule (thephysician and RN positions arefull time, the others part time).

The team approach is key becausemembers of the advanced carepanel are complex patients, thatis, individuals with multiple chronicdiseases and at high risk foremergent events or hospitalizationbecause of their conditions.

These also are patients whoseconditions, for a host ofreasons, are not well controlled.Ineffective management ofchronic disease is not so much afunction of lack of effort or lackof good intentions on behalf ofphysician or patient. Rather itsa function of forces that bothmay be up against: poor healthliteracy, lack of transportation toand from an appointment, notfeeling well enough to make anappointment, inability to leavework for an appointment. Forsome patients, the responsibilityof managing a chronic diseasecan be overwhelming andimmobilizing. Depression alsois a common companion tochronic disease. Both variablescan squelch the will or sapthe energy required to followthrough with self-managementresponsibilities, includingmaking it to office visits. Andface-to-face visits are crucialfor effective management ofchronic disease.

Recruiting members, creatingthe panel

The initial effort seeks tocreate an advanced care panelof 150 members. Inclusioncriteria for this first panel are:

age 55 to 64, diagnoses ofdiabetes and congestive heartfailure, and high likelihood ofhospitalization.

Members were identified forparticipation in the ACM panelusing a predictive modelingtool created by DxCG, Inc., asoftware company based inBoston, MA. DxCG specializesin tools that aid managementof health care and utilization

costs and Kaiser Permanentehas used their tools for severalyears. The ACM projectuses DxCGs Likelihood ofHospitalization Model, whichcan assess risk among definedpopulations. Churning throughmultiple variables includingdiagnoses, medication use,health care costs, and utilizationhistory, the tool can predictwhich members are mostlikely to need hospitalizationwithin a given time frame, forinstance 6 or 12 months. It hasa 35 percent accuracy rate.Kaiser Permanentes northernCalifornian department ofmanagement information andanalysis runs the LOH model forOhio.

Once identified, members aremailed a welcome letterexplaining the ACP programand inviting their participation.The letter is followed within

a week by telephone contactfrom one of the ACP teammembers. KP members whoexpress interest in the programare scheduled for an officevisit, but in the 21st Centurymodel, that visit occurs at

Advanced care panel: using the house callto improve management of chronic disease

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9

the members home and isperformed by a physician, RN,or both, depending on thepatients health status. Thehouse call makes moot theissue of transportation, which

can be a significant barrierto care, particularly amongolder persons. In the wake ofthe house call, which is theequivalent of a first office visit,the ACP team convenes to mapout a care plan for the member.

Communication also occursbetween the ACP physicianand the primary care physiciansof members being recruitedto the panel: once at the time

a welcome letter is sent to apatient and again if the patientagrees to join the new panel. Inboth cases, the ACP physicianuses KP HealthConnectmessaging. In the first case,the message notifies theprimary care physician that a

welcome letter has been sentto a patient about joining theACP; in the second case, themessage informs the physicianof the patients decision to joinor not join the new panel.

The ACP physician, in turn,becomes the members newfull time primary care doctor.

If patients have a change ofheart, they are free to returnto their original primary carephysicians. Otherwise, it isexpected that memberswill stay on the ACM panelindefinitely. The panel also willcollaborate with behavioralhealth, in the event theirexpertise is warranted.

Nuts and bolts

For the time being, theACM team will be based atWilloughby. Team membersinclude Bill Schwab, MD; WillaPugh, RN; Kathleen Skerl,MSW; and Jill Arnold, PharmD.

The team will meet on a regularbasis to discuss the health

status of patients, to fine tunecare plans and to troubleshoot.

Batches of 10 letters havebeen sent out weekly since themiddle of September 2007 andthis will continue until the teamcontacts the 150 membersidentified by POINT. Ifachieving the target enrollmentof 150 proves elusive because

of member disinterest, theinclusion criteria may bebroadened.

The physician, RN, and socialworker are outfitted withlaptops that have wirelesscapabilities; they also getBlackerrys (a brand of personaldigital assistant). Bothtools will have access to KPHealthConnect. Clinicians alsocarry blood pressure kits and

otoscopes for house calls.

Documentation is a key partof the effort, so theres closecollaboration with informationtechnology to ensure thatall of the care efforts can becaptured accurately throughKP HealthConnect.

Advanced care panel: improvingmanagement of chronic diseasecontinued from page 8

goals include earlier intervention inor prevention of disease, greateroversight and stepped up care of

members at high risk of medicalevents associated with chronicdisease, and proactive outreach tomembers who are not connectedwith, or have been out of touchwith, their primary care physiciansand care teams. These tasks will beaided by information technologyresources like POINT, the panelmanagement tool that makes iteasy to stratify panel membersaccording to one, several or many

filtering criteria. One example of atotal panel ownership effort is thediabetes complete care program,which involves using POINT toidentify members whose medicalstatus warrants commencement ofthe aspirin, lovastatin, lisinopril, or

ALL, regimen.

5) Collaborative care planning

This objective recognizes that1) the medical office can be a launchpad for disease management,but sustaining the effort meanstapping an array of tools to helpkeep members and care teamsconnected and communicatingand 2) collaborating with membersabout their care can significantly

aid the disease management effort.In fact, the goal is to empowermembers to become their ownprimary care providers and touse Kaiser Permanentes deliverysystem to supply the expertiseand resources to help make thathappen. Rather than being passiveparticipants, members are engagedin management of their health careand collaborate with the care team.They are cognizant of their caregoals and take the necessary stepsto help ensure a healthy future.

If you have questions about the 21stCentury Care Collaborative, contact KrisPilarski, project manager, at 98-330-4483 or216-635-4483.

21st Century Care Collaborative aidseffort to improve member healthcontinued from page 7


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KP Healthy Solutions is the healthcoaching service launched inJuly 2007 to complement the

disease management efforts ofOPMG physicians. The goal ofthe coaching is to encouragecommercial (non-Medicare)members to become activeparticipants in the managementof their health and to spurmeaningful discussions betweenmembers and their physicians.

According to a recent activityreport for the period July 16September 15, 2007, KP HealthySolutions coaches have made

more than 1,900 telephoneconnections with members andnetted more than 2,000 keyimpacts. A key impact refers toa coach helping a member at akey decision making point, forinstance, making an appointmentfor an overdue office visit,pledging to take up exercise, orcommitting to be more vigilantabout taking medications.Thus far, the opt out rate (i.e.,the percentage of membersdeclining the health coaching) iscomparatively low at less than 1percent of those contacted.

The results tell us that membershave responded positively to theKP Healthy Solutions offerings,says Ronald Adams, chief, primarycare and primary care lead, KPHealthy Solutions. I encouragemy colleagues to continueassisting in building awarenessamong members of this resource.

Physicians play a key role in thecoaching effort by activating aservice request throughKP HealthConnect: they identifypatients likely to benefit from useof the service and fax a request forpatient contact to the KP HealthySolutions health coach center.There are many ways to activate aservice request, says JoAnn Kahl,RN, MBA, project manager, KPHealthy Solutions. Service requests

can originate from an array ofsettings where patients havecontact with KP Ohio medical team

members (primary care physicians,specialists, hospitalists, in-patientcare coordinators), includingmedical facilities, emergencyrooms, contracted hospitals, andcontracted skilled nursing facilities.

Kahl also says that cliniciansfiling service requests throughKP HealthConnect can increasethe likelihood of successfulcontact between a memberand health coach by verifying

the members phone number,asking when the best time tocall is (and documenting it), andproviding the member with theHealthy Solutions 800 number(1-800-574-8460), for instanceby including it in the after visitsummary. (For members interestedin the coaching but uncomfortablewith phone contact, coaching canoccur via email; members shouldregister at the secure Web site:kp.org/healthysolutions.)

The KP Healthy Solutions healthcoach communications systemis set up such that members arenever far from their KP roots, so tospeak. The coaches, for instance,have the technical capability totransfer members to KP Ohiosmember service center (e.g., torelay messages to physicians,make appointments, or obtaininformation on KP Ohio healtheducation and wellness classes),customer relations (e.g., to get

benefits information), or to nurseadvice (e.g., to have clinicalquestions/concerns addressed).

Were closing the circle, in a sense,with the coaching, says Dr. Adams.And were increasing the likelihoodthat our members become moreinformed and educated abouttheir conditions and appropriatemanagement of them.

One important point to keep inmind about KP Healthy Solutions,says Kahl, is that it is just one

of many resources available toKP members. For instance, sheencourages KP clinicians to remindmembers to seek out the arrayof valuable tools and resourcesthat are available online, via theKP.org Web site. These includea health encyclopedia, conditionand disease encyclopedia, drugencyclopedia, natural medicinesdatabase, live healthy guide(which includes health videos andaudio files), and the HealthMedia

healthy lifestyle programs.

In addition to Dr. Adams and JoAnnKahl, KP Healthy Solutions also ischampioned by Mike Nowak, MD,surgeon, specialties lead.

Healthy Solutions bythe numbers:(July 16 launch throughSeptember 15, 2007)

Nearly 2,000 members havehad phone conversations withKPHS health coaches.

More than 3,800 telephonecontacts were attempted byhealth coaches, including 582outreach calls and 214 follow-up calls.

Kaiser Permanente Ohioproviders made 281 servicerequests for health coaching.

KP Healthy Solutions sent morethan 150,000 mailings (i.e.,introductory, chronic conditionoutreach and health educationmaterials) to KPO commercialmembers. Materials includedflu vaccine reminders andoutreach letters for preventivecare to members with chronicconditions.

Members embrace health coaching


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OPMGs regional coding compliance department

asks that physicians be on the lookout for provider

welcome letters generated by the Centers for

Medicare and Medicaid Services and sent to new

providers. The letters open with a statement

similar to, We are pleased to have you on board

as a Medicare provider. The letter goes on to

request a sampling of copies of medical recordsfor which claims have been submitted to CMS for

reimbursement.

All physicians who receive such letters should,

as soon as possible, forward copies of them to

the regional coding compliance department. The

address is:

Kaiser Permanente

Regional coding compliance

North Point Tower, Suite 1200

1001 Lakeside Ave.

Cleveland, OH 44114-1153

Please direct the correspondence to the attention

of the coding compliance specialist. OPMGphysicians are not responsible for submitting, nor

should they attempt to submit, claims to CMS

for care provided to Kaiser Permanente Medicare

patients. Documentation and submission of

CMS claims are the responsibility of the coding

compliance specialist. If you have questions,

contact Lynn Brady, RHIT, coding compliance

specialist, at 98-328-5938 or 216-479-5938.

Be on the alert for CMS welcome letters

11

Its a simple equation: work life

satisfaction=high productivity, high

morale, low turnover and high

customer satisfaction. Making thatsimple equation work, however,

is no easy task, particularly in an

arena as complex as health care

delivery and particularly at a time

when health care providers face so

many challenges.

Nevertheless, improvement of work

life satisfaction continues to be a

priority for the Ohio Permanente

Medical Group. To that end, early

in the summer of 2007 the OPMGWork Life Committee was formed.

The committee was created to

help minimize the possible impact

on work life satisfaction by various

OPMG initiativesfor instance

KP HealthConnectand to study,

address, and resolve work life

issues raised in People Pulse

Opinion Surveys, which began to

be administered annually in 2005.

Gabriel Obi, MD, internist andOPMG board member, chairsthe steering committee, whichdevelops the work life agenda.Eddie Wills, Jr., MD, associatemedical director, is executivesponsor. A focus group aids the

effort by providing feedback fromstaff on work life issues.

The Work Life Committees missionis to help identify areas of worklife that are not optimally balancedand report on those to the OPMGBoard, which serves in part as abridge between OPMG physiciansand KP operations. Sometimestheres a disconnect between thetwo groups and that can lead to

resentment and frustration, whenin fact, our goals and objectivesare really the same, says Dr.Obi. He also says that physiciansand management sometimeshave different perspectives whentheyre looking at work life issues.

In fact, after becoming a boardmember in 2005, Dr. Obi sayshe has a new perspective onthe limitations and challenges ofaddressing such issues, particularlygiven that Kaiser Permanentesbusiness model is distinctlydifferent from those used by itscompetitors who have significantfootholds locally and regionally.

Ball is rolling for physician work life committee



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Last year, Performance Improvement and Patient

Safety (PIPS) launched two separate efforts to help

improve patient safety. One, the highly reliablesurgical team (or HRST) project, is an instructional

course designed to strengthen communication

skills among surgical team members. Data

show that when surgical team members feel

free to communicate and voice their expertise,

perioperative error rates decline. Another effort,

the perinatal safety project, is designed to build

communication and troubleshooting skills among

OB/GYN birthing team members. In this innovative

program, sophisticated mannequins stand in for

mother and baby, and participants have clinicalscenarios thrown at them. The perinatal safety

project offers training on a monthly basis at

Fairview and Marymount Hospitals. The PPSPs

15-member implementation team included KPOs

Kerry Dease, RN, BSN, Sharon Zahtilla, RN, and

Charles Zonfa, MD. Last March, the program was

recognized at the Cleveland Clinics Patient Safety

Forum with a Peoples Choice Award.

Patient safety programsstrengthen communication skills

Once up and running, preliminaryquerying of OPMG staff by theWork Life Committee revealed

a spectrum of concernswork-day duration, clinical effortsgoing unrecognized, opinions notcounting, too little control oversupport staff hiring. Dr. Obi and hisWork Life colleagues decided thatrather than trying to address manydiscrete issues individually, some ofwhich are uncontrollable and wouldbe encountered no matter whereor for whom a physician practiced,the committee would take a more

strategic approach.

We wanted the greatest impactpossible on work life improvement,and we concluded that wouldoccur by taking a broader viewof the situation, says Dr. Obi.The question was, what can wedo systematically to bring aboutchanges that resolve or addressmany of the issues raised? How dowe have the greatest impact in theshortest amount of time and makework life better for everyone?

The answer lay in two of the People

Pulse indexes. The committee

concluded that by focusing efforts

on addressing these two issues,

they would in turn be addressing

multiple work life areas ripe for

improvement. The two indexes are:

1) When clinicians have good

ideas about improving the quality

of care delivered to members,

management usually makes use of

them.

2) I would recommend KP to a

close friend as a good place to get

health care.

Results from People Pulse 2006

showed that just 60 percent ofOPMG docs would recommend

KP to a close friend. A separate

internal survey, commissioned by

Charles DeShazer, MD, associate

medical director, quality, showed

that just 54 percent would

recommend KP. The 2006 People

Pulse findings represent a drop of

3 points from 2005. As for ideas for

improving quality of care, just 24

percent of OPMG docs feel their

ideas are used. That is also downfrom 30 percent in 2005.

Two-thirds of our physicians feelwe dont listen to their ideas,says Dr. Obi. When you feel noone is listening, you stop offeringsuggestions, possibly even stopcaring about the organization. So itis crucial that we address this.

One of the challenges forOPMG leadership is that we donot always communicate in aconsistent and empowering way,and that hurts us, says Dr. Wills.When we dont do a good jobproviding context and rationale fora business decision or explaininghow we arrived there, when adecision may seem to arise outof the blue, that objective cancome off looking disconnected or

unrealistic. Moreover, problemscan also arise when messages getdelivered to the front lines bychiefs and leads as edicts. Theresan opportunity there to havean informed discussion, to say,heres the challenge, and I needinput from everyone as to how wemight address the challenge, andif there are barriers, we need tocommunicate those to leadership.Those conversations, says Dr.

Ball is rolling for physician work lifecommitteecontinued from page 11



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Work Life Committee: Ideas for improvingphysician performance and cultivatingownership

Broaden the scope of productivity metrics toinclude non-office visit encounters; for instanceinclude telephone contact and e-mails. Also,focus on outcomes rather than the number ofpatients seen in a given time frame.

Make more aggressive use of clinical coachingto help physicians and support staff identifyopportunities to increase efficiencies,productivity.

Increase opportunities for health care teammembers to build relationships with one anotheroutside the workplace, for instance by creating asports league.

Address staffing and coverage issues in thehospitals with which KP holds contracts. Forinstance, use a ratio formula to arrive at a staffinglevel that more appropriately aligns with thenumber of hospital contracts, so that work loadsand travel time allow for optimal care.

13

Wills, need to be the rule ratherthan exception when chiefs andleads address their staffs. That

empowers people and gives thema greater sense of ownership andstake in the enterprise

With regard to addressing the

low score on the recommending

KP to a close friend index, some

efforts already are underway.

These include a service initiative

launched in June 2007 at Cleveland

Heights and the piloting in spring

2007 of the 21st Century Care

Collaborative. (For examples of

initiatives designed to respond toideas offered to improve qualityof care delivery, see table 1. Inaddition to addressing PeoplePulse indexes, the Work LifeCommittee has also assembledideas for improving physician

performance; see table 2.)

Initiatives like the 21st CareCollaborative will be key to helpingcare teams develop a bettersense of ownership and controlover the work day, says Dr. Wills.The 21st century model allowsthe physicians and care teams toorganize their expertise as theysee fit and distribute work loadscreatively across team members.

It allows the team to run a much

more proactive medical practice so

that they can better serve members

and better manage their patients

with chronic disease. That also

supports OPMGs and KPs mission

to improve performance on NCQA

metrics like CAHPS and HEDIS.1

1 In pursuing its mission to measure and

improve health care quality, the National

Committee for Quality Assurance, or

NCQA, uses two tools: the Healthcare

Effectiveness Data and Information Set

(HEDIS) is used to monitor the quality of

care in health plans; Consumer Assessment

of Healthcare Providers and Systems

(CAHPS) surveys are used to accurately

and reliably capture information from

consumers about their experiences with

care in health and Medicaid plans.

Ball is rolling for physician work lifecommitteecontinued from page 12

Table 1

Work Life Committee initiatives,recommendations

The Work Life Committees mission is to helpidentify areas of work life that are not optimallybalanced and report on those to the OPMG Board.The committee has an array of recommendationsand initiatives on the drawing board or in the works.Shown here are examples of ideas generated to

help improve quality of care delivered to members.

Allow practitioners to finance purchase oftools or resources that can aide clinical dutieswith study leave funds. For instance, speechrecognition software, which would be usedinside KP HealthConnect, could aid physicianswith limited typing skills. (In fact, the request forspeech recognition software was approved at theOctober 2007 board meeting.)

Broaden the selection of training and educationalprograms that are practitioner friendly (e.g.,programs that are Web-based, CME accredited,doable on study leave time).

Table 2


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14

Verbal consent cautionadded to policy on bloodproduct administration

Nursing administration, the bloodbank, and laboratory servicesrecently revised Kaiser PermanenteOhios regional policy on Bloodand Blood Product Administration,and Management of TransfusionReactions. The revised policy wasendorsed by the clinical operationsleadership team (COLT) and thenurse practice council. The result isa precaution regarding obtainingverbal consent from a patient whoneeds blood or blood products.

Ideally, administration of blood orblood products should only occurafter a physician has carefullydiscussed with the patientface-to-facethe risks and benefitsassociated with the procedureand the patient has provided, withthe physician observing, writtenconsent for the procedure.

Because it is difficult to reliablydocument, verbal consent isdiscouraged; however, there are

situations that arise that maywarrant obtaining verbal consent.For example, a physician mightreceive a critically relevant labresult after the patient has leftthe medical office and mustthen arrange for the patient toreceive a blood transfusion whilethe patient is off-site/away from/outside the Kaiser medical facility.In this case, the physician mustrelay the findings to the membervia telephone and discuss the

need for blood or blood productadministration. The physician canthen obtain verbal consent, so longas the requirements outlined beloware met:

The physician must have a licensedstaff member (RN, NP, LPN, PA,etc.) listen to the explanationof risks and benefits associatedwith receiving a transfusion of

blood or blood products. Then,

both parties must document the

interaction with the member in KP

HealthConnect. This confirms thata two-party process has occurred:

the physician and a licensed staff

member listened to the consent via

telephone, and the physician and a

licensed staff member documented

that the patient understood the

explanation. (Note: The patient

should be made aware that a staff

member has been asked to listen in

on the conversation.)

If you have questions about theverbal consent precaution , please

contact Lynn Shesser, RN, MSN,

lead, nursing quality and systems

management, at 98-332-4616 or

440-975-4616.

To view the revised policy online, from

the Ohio Intranet homepage, click on

the following links: Policies, Ohio Joint

Regional Policies, Patient Care.

Patient safety and quality care


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15

Abramsons anecdotes

What makes a good doctor?Scott Abramson, MDClinician patient communicationconsultant

If we were to ask ourselvesthat great clinical questionwhat makes a gooddoctor?I bet that some ofour answers would includewords like knowledgeable,conscientious, hard-

working, and compassionate.But what if we posed the samequestion to our patients? Whatare the qualities that theybelieve make a good doctor?

Recently, I attended acommunity focus group meetingand had the extraordinaryopportunity to hear lay peopleweigh in about what makesa good doctor and otherimportant clinical questions.

This particular group wasmade up of Indians whohad immigrated from thatsubcontinent.

All agreed that the mostimportant factor in choosing ahealth plan was ensuring thatthey would have access to agood doctor. When askedto elaborate on what makes adoctor good, here is what someof them said:

When you first see him, hesmiles.

As he walks into the room, hemakes you feel good.

Hospitality, was another ofthe descriptors used that nightby the focus group.

Well, mea culpa. Im guilty ofdoing exactly the opposite ofwhat these individuals say theywant from a physician. I cantbegin to count all the timesI have walked into an examroom, chart in hand, seriouslook on my face, ready to getdown to business. On theother hand, we are physicians.Were driven, focused, task

oriented. We dont much likeanythingdistraction, diversion,pleasantriesthat get in theway of office visit momentum.Surely our patients understandthese basic facts of our clinicallives. Surely they comprehendthe incredible pressuresphysicians and their staffs faceon not just a daily basis, butan hourly basis. Surely theyunderstand that were in theircorner, that despite our matter-

of-fact, down-to-businessdemeanors, foremost on ouragenda is providing the carethey seek. Right?

Well, not to downplay thediagnostic expertise nor thedesire to always move forward,but perhaps we need to thinkabout the answers that cameout of this humble focus group.

Perhaps before walking intothat exam room, we need topause just for a second or two,and remind ourselves whatbrings patients to us in the firstplace. Im not talking aboutthe obvious forces that bringthem to our officesthe aches,pains, or coughs, or the myriadsymptoms that they believe

must be this, that, or anotherdisease. Sure, they want theseissues addressed. But whatmost patients want initially is1) to feel safe (in other words,they trust us) and 2) to bereassured.

If you think about it, thats nota lot to ask, particularly giventhat the office visit is a very

personal interaction and oneduring which many patients feelvulnerable or exposed.

So, when we walk into thatexam room, before anythingelse, perhaps we need towelcome our patients first witha genuine smile and even a fewkind words or some gesture thatrelays a message of hospitality.Because with those actions, weare saying to patients, You

are welcome here. You are safehere. Well do our best to sortout whats bothering you.

Our reputation as a gooddoctor may depend on it.

(This column first appeared in April

2007 in CPC Consultants Corner,

a publication of The Permanente

Federation Clinician/Patient

Communication effort, online at

http://kpnet.kp.org/cpc .)

Dr. Abramson is a neurologist at the

Hayward Medical Center in Northern

California and is celebrating his 27th

year with The Permanente MedicalGroup. He has spent all of his 27 years

of service at the Hayward Medical

Center, where he continues to learn

about the art of communication from

patients and colleagues.


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During the past year, KaiserPermanente of Ohio has beenengaged in an encryption effortto ensure that patient medicaldata (also known as healthinformation) is protected fromunauthorized viewing or use.This is a joint effort betweenthe Information Technology andNational Compliance, Ethics andIntegrity offices.

Protecting health informationis mandated by the HealthInsurance Portability andAccountability Act of 1996,better known as HIPAA.Unprotected health informationputs KP at risk for punitiveaction and could jeopardizeits ability to participate in theMedicare program, which isadministered by the Centers forMedicare and Medicaid Services(CMS). Also, because theft orloss of electronic devices areinevitable, an active encryptionprogram minimizes the riskof health information gettinginto the wrong hands and then

being used maliciously or tocommit fraud, behavior that alsocould result in punitive actionagainst Kaiser Permanente.In fact, Kaiser Permanentepolicy prohibits storage ofhealth information on laptops,desktops and other electronicmedia, but in the event thatprotected health information isinadvertently placed on storagedevices, encryption protectsunwarranted access to it.

Health information meansany information, whether oralor recorded in any form ormedium, that a) is createdor received by a health careprovider, health plan, publichealth authority, employer, lifeinsurer, school or university,or health care clearinghouse;and b) relates to the past,

present, or future physical ormental health or condition ofan individual, the provision ofhealth care to an individual,or the past, present, or futurepayment for the provision ofhealth care to an individual.1

The encryption effort plays outin five phases, two of which areexplored in detail here. (For anoverview of the effort, see thesidebar, Kaiser Permanenteencryption: A five-phaseprogram, on page 17.)

Protection of e-mail thatcontains health information

Any Kaiser employee, includingthose on contract, who sendsan e-mail outside the KP e-mailnetwork (i.e., to a non-kp.orgaddress) that includes anypatient health information isresponsible for ensuring that thee-mail is encrypted. Encryptingan e-mail is simple and involvestyping one of three keywordsphi, encrypt or mpiiintothe subject field of an e-mail.

The keyword must be flankedby parentheses or brackets, forexample: (phi) or [phi] or {phi}.The keyword can be used aloneor it can accompany a regulartext subject, for instance:

Subject: Blood test results

(encrypt)

The external recipient of anencrypted e-mail will receivedecryption instructions,that is, guidance on how to

open the encrypted e-mail.This process includes therecipient registering at a secure,KP-managed Web site. Toavoid confusion, KPs officeof information technologyrecommends contacting theintended recipient beforesending an encrypted e-mailand explaining the procedure.

No special software is neededby the sender or the recipientto send or receive encryptedcorrespondence. Encryptiondoes not work, nor is it requiredfor, e-mails sent within thekp.org network. The e-mailencryption procedure alsois outlined on KPs NationalCompliance, Ethics and IntegrityWeb site, accessible via the KPintranet. From their homepage(kpnet.kp.org/national/compliance), click through thispathway: Our Program, Privacy& Security, Secure E-mail.

Secure electronic storage ofhealth information.

This component of theencryption effort involvesprotection of KP workstations,that is, lap- and desktop harddrives and other computing orinformation storage devices.The program to encryptworkstations was completedduring summer 2007; it alsooccurs proactively any time anew workstation is issued. Oncea lap or desktop is encrypted,the information stored on itcan only be accessed with alegitimate Kaiser Permanenteuser ID and password,according to Paul Graca, leadproject manager, KP informationtechnologyenterpriseengineering. Even if thievesextract the hard drive from aunit and reinstall it elsewhere,theyre not getting anyinformation from it, says Graca.

Unless you can log in with theauthorized password, youre notgoing anywhere.

Again, Kaiser Permanenteprohibits storageeventemporaryof any healthinformation on the hard

Encryption effort protects health information



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17

drive of a workstation. Thatinformation should always be

stored or saved within KPscomputing network and datacenters, on KP network servers,shared drives, or servers thatotherwise meet KP-IT securitystandards, says Barbara J.Martin, privacy/security officer,KP Ohio Regional Compliance,Privacy and Security Office.However, if such information

is inadvertently saved to a harddrive, encryption minimizes therisk of it getting into the wronghands should the workstationbe lost or stolen. Users can

verify that a device has beenencrypted by locating thePointsec for PC icon thatdisplays on the Windows toolbar (or task bar). Its a P thatslants to the left, set against acircular, green background.

A related initiative involvesprotecting health informationthat gets stored on personal

digital assistants, or PDAs,such as Blackberrys and Palms.Details of this effort are stillbeing finalized by the IT and

compliance offices.

1 From Health Insurance Portability

and Accountability Act of 1996; public

law 104-191, Aug. 21, 1996; via the

United States Department of Health and

Human Services Web site, http://aspe.

hhs.gov/admnsimp/pl104191.htm#1177.

For more information about the Secure

Electronic Storage (SES) Program, go to

http://kpnet.kp.org:81/security/ses/.

The program to protect member/patient identifiable information,or MPII, is a joint effort betweenthe Kaiser Permanente InformationTechnology and NationalCompliance, Ethics and Integrityoffices. The goal is to preventunwarranted access to protectedhealth information should astorage device, such as a desktop,laptop, or personal digital

assistant, be lost or stolen.

Once outfitted with encryptionsoftware, data on a hard drive orother storage device can only beseen when a user logs in withthe proper access credentials.Encryption protects the dataregardless of the tactic used toget at it, says Justin W. DiGrazia,lead project manager, EnterpriseEngineering, EngagementServices, Kaiser PermanenteInformation Technology.Regardless of the ploy usedhacking into the computer, usingbrute force (repeated log-inattempts), removing a hard driveand reinstalling it on a differentdeviceencryption protects thedata, says DiGrazia.

The five-phase effort was launchedin 2006 and primarily occursremotely: that is, the AES-256 bit

encryption software is pushed todevices via the local area networkfrom information technologyservers in California. Phases 1 and2 are complete; phases 3 and 4are in progress; phase five is in thedevelopmental stages. The phasesare outlined below.

Phase 1: Completed inearly October 2006, phase 1focused on protecting laptopsused by KP home health carestaff based in the California,Colorado and Northwest regions.These individualsnurses andoccupational, physical and speechtherapists, and other licensedmedical professionalsprovidehome-based care to older personsand those who are disabled.Collectively, this effort involvedencrypting more than 850laptops to meet state and federal

requirements.

Phase 2: Completed October 31,2007, phase 2 protected Kaiserowned and managed desktop andlaptop PCs. Preliminary effortsgot under way in October 2006,though the actual encryption ofdevices kicked off in June 2007.Nationwide, more than 170,000laptops and desktops received the

encryption software; roughly 2,900of those were in Ohio.

Phase 3 focuses on safeguardingpersonal digital assistants, forinstance Blackberries or Palms.Following a pilot to test strategies,phase 3 is slated for completionsometime in 2008.

Phase 4 focuses on safeguarding

removable media, for instanceflash or thumb drives, as well asCDs, DVDs, and floppies. Phase 4is slated for completion sometimein 2008.

Phase 5 focuses on providing aprotected computing environmentfor KP staff, affiliates, and alliancepartners who work from theirhomes on their on devices. Onesolution under investigation isa kind of virtual desktop, which

would involve logging in remotelyto a protected system. Onceinside, a user could tap intocommonly used applications aswell as stored (and protected)health information.

To learn more about KaiserPermanentes secure electronicstorage program, go to http://kpnet.kp.org:81/security/ses/.

Kaiser Permanente encryption: A five-phase program

Encryption effort protects healthinformationcontinued from page 16


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18

Online technology has changed

the way that organizations,including Kaiser Permanente,conduct business and deliverservices. The most recent entityat KP Ohio to respond to onlineopportunities is the MedicalLibrary. For the last several years,the trend has been toward KPOmedical professionals doinginformation searches online ratherthan requesting searches to beconducted through our MedicalLibrary. After reviewing the usage

of the Medical Library, in relationto the cost associated withcontinuing to provide this serviceinternally, the decision was madeto cease offering internal MedicalLibrary services as of January 1,2008. However, Kaiser Permanentestaff have access to a wealth offree clinical resources via twointernal urls:

kpLibraries

http://cl.kp.org/pkc/kplibraries/

This is your connection to allof Kaiser Permanentes healthsciences libraries, giving youaccess to the Kaiser PermanenteLibraries online catalog as wellas access to books, journals,audiovisuals, and electronicresources.

Clinical Library (Permanente

Knowledge Connection)http://cl.kp.org/portal/site/national/

This is KPs online resource forclinical guidelines, membereducation handouts, drug and labinformation, online CME, and full-text journals and textbooks. (Youcan also access this from Kaiser

Permanentes portal site

http://insidekp.kp.org. Click onDeliver Health Careleft-handindex area-and then on ClinicalLibrary.)

If you have not visited these sites,please log on and give them a try.

Because some medical informationsearches need to be conductedoff-line, other avenues forrequesting and conducting suchsearches are being explored

and updates on this effort willbe provided accordingly. If youhave questions regarding thecessation of internal MedicalLibrary Services, contact RonaldCopeland, MD, president andexecutive medical director, OPMG,at 98-328-8781, 216-623-8781 orvia Lotus Notes [email protected].

Medical Library services update

Michael Nowak , M. D.Medical director

Maureen Kane R.N., Manager

The Kaiser Permanente ReferralsManagement and Clinical Review(RMCR) office is a division ofMedical Management, thedepartment whose mission is tocollaborate with practitioners toensure that services rendered aremedically necessary, covered by

the health care plan and renderedin the most appropriate settingand in a timely fashion.

One of RMCRs goals is tomaintain regular communicationwith practitioners by relaying

up-to-date information aboutthe referral process (also knownas utilization review), as well asinformation about any proceduralchanges that might impactthose processes (e.g., federal/state mandates or accreditationrequirements relating toinformation required on a referralrequest).

Referral fundamentals

Referral decisions are basedin part on nationally accepted,evidence-based clinical criteriadelineating appropriate levels ofcare for a given clinical scenario.Thus, utilization managementdecisions reflect whether a service

or treatment is deemed medicallyappropriate or whether the

members coverage allows it. (To

view the appropriateness criteria,

see OPMG, March/April 2006,

page 9.)

All referral decisions based on

medical necessity (i.e., member

has appropriate coverage, but the

service is medically unwarranted

based on clinical review criteria) are

made by a board-certified physicianadvisor. No monetary incentives

are associated with the utilization

review process. Physicians are

Referrals management and clinicalreview updates



19/20

OPMGUPDAT

Communication skills are anintegral component of gooddoctoring and just like medicalskills, they have to be learned,developed and honed. Because ofthat, OPMG is moving ahead withtwo efforts to support physiciansinterested in guidance andtraining designed to help improvecommunication skills. Bothsupport programs are elementsof the performance improvementendeavor that is part of the

OPMG turnaround plan, whichamong other objectives, seeksto boost Art of Medicine andCAHPS (Consumer Assessment ofHealthcare Providers and Systems)scores. Select practitioners whoseAOM scoring falls below theexpected level of performanceare invited, on a volunteer basis,to participate in the supportprograms.

The first program is designed

as the foundation forimproving AOM scores. TheCommunications Skills Intensive,or CSI, is a thorough trainingprogram of communications skillsbuilding developed by Terry Stein,MD, director, clinician-patientcommunication, PermanenteMedical group, regional offices,Oakland, CA. Since its pilotingin 1996 in northern California,several other KP regions havedeveloped CSI training efforts,including Colorado and the Mid-Atlantic states. The programteaches relationship-centeredcommunication strategies thatcan be used in the real world butthat are particularly valuable inclinical settings. CSI was createdin response to communicationsissues identified through patientsatisfaction surveys.

The second program involvesoffering a diagnostic reliabilityassessment of practitioners bya representative from KP OhiosPerformance Improvement andPatient Safety (PIPS) office.The diagnostic assessmentinvolves observation of patientinteractions, interactions withstaff and office work flows. Thegoal is to first identify and resolvecommunication and other issuesthat can negatively impact the

member experience and thenconsult with the physician andstaff about resolving them.

Introduction of the CSI programinto KP accomplished severalgoals. First, it addressed alongstanding need to helpclinicians who are technicallycompetent although less adeptat relating to patients. Second,the credibility and visibility ofclinician-patient communicationeducation was enhanced whencolleagues and chiefs observedthe often dramatic transformationof some of the participantsskills and attitudes after thecourse. Third, and perhaps mostimportant, each year since CSIwas launched, patient satisfactionscores of the cohort of cliniciansattending the course haveshowed significant improvement.In short, CSI training works.

Soon, the CSI program willbe available in Ohio throughOPMGs human resources andorganizational developmentdepartment. They plan to offerthe first course in February2008. The intensive is presentedoffsite, over 3.5 days and takesattendees through a spectrum ofinteractive instructional exercises.

A good chunk of the intensiveinvolves practitioners interacting

with actors posing as patients.

Videotaping of the interactions

allows clinicians to see themselves

in action and to observe and

discuss communication strengths

and weaknesses with course

facilitators and clinical peers. At a

later date, participants are invited

to a one-day follow up to review

skills objectives.

In preparation of the launch of

CSI training in Ohio, this past

fall, several OPMG staff members

attended a CSI session hosted

by Dr. Stein and her staff in

Northern California. Attendees

included Eddie Wills, Jr., MD,

associate medical director for

human resources, professional

and organizational development;

Iris Hale, SPHR, director,

OPMG human resources andcredentialing; and Roger Lightner,

RCC, senior human resources

and organizational development

consultant.

CSI is built around the four

habits model of effective

clinician-patient communication

(invest in the beginning, elicit

the patient's perspective,

demonstrate empathy, and invest

in the end). Its a big investmentby the organization and of

yourself, but theres a big return

for that investment says Lightner,

and Kaiser has the data to back

that up.

If you have questions about these

programs, contact Roger Lightner

at [email protected].

19

Performance improvement effortsmoving forward


20/20

WINTER 2008

We look forward to working with youon this very important endeavor.

During his 16years with KaiserPermanente, Dr,DeShazer hasfocused muchof his energy onusing information

technology to help improve theway KP delivers care and managesits operations. At the SoutheastPermanente Medical Group in Atlanta,GA, where he was director of clinicalinformation systems, Dr. DeShazerdeveloped an automated medicalrecord abstract application that

produced one-page summaries ofpatient records. The effort, used toexpedite more than 500,000 annualpatient visits over a 10-year period,helped improve provider and membersatisfaction scores, lowered thecost of medical record maintenanceand lowered malpractice costs. Dr.

DeShazer also co-led KP Atlantasprimary care redesign project, one ofthe first models in the country thatemphasized team-based primary care.In 1997, he became vice presidentand national director of the KP mid-Atlantic business processes and

computing division, directing theinstallation of a $42 million claimsprocessing system that yielded a40% reduction in per claim costs.He also co-led care managementand community provider integrationimprovement initiatives.

Advanced care management for caredelivery transformationcontinued from page 5

not rewarded for referring or not

referring, and utilization reviewers

are not rewarded for approving or

denying referral requests; any of

these scenarios can result in over-

or under-utilization of services.

Incomplete forms meanprocessing delays

Submitting an incomplete referral

request delays the review process,

because a request cannot undergo

review or be approved withoutthe required referral information.

Valuable time can be lost for

practitioners, review staff and

members when review staff have

to contact practitioners to retrieveinformation that should have been

included in the referral request.

To help minimize turnaround time,

please fax, rather than mail, all

referral requests to: 216-529-5533

or 98-326-5533.

Requesting areconsideration

OPMG physicians can request a

reconsideration for denials basedon medical necessity, that is, amember has appropriate healthplan coverage, but the serviceis medically unwarranted basedon clinical review criteria. Also, arequest for reconsideration canonly be made with the member'swritten permission and can onlybe made for initial or concurrentdeterminations (not post service).

To request a reconsideration,

please call the RMCR at216-529-5588 or 98-326-5588;please also have available anynew information that supports therationale for the reconsiderationrequest. A decision will be madewithin three business days ofreceipt of the reconsiderationrequest. Practitioners requestingthe reconsideration can also speakdirectly about the case with thephysician reviewer.

Pre certificationdocumentation and KPHealthConnect

Please be sure to use theprecertifcation, or precert,service if members requirehospitalization or need to bescheduled for a surgical procedure.If a specialty consult is requiredurgently, please contact the chiefof the relevant specialty prior tocalling RMCR. The precert phonenumber is: 216-529-5588 or 98-326-5588. (Beginning in January2008, authorizations provided viathe RMCR precert phone line will

be documented and available forviewing in KP HealthConnect, viathe Letters tab.)

Provider satisfactionsurveys

Many thanks for a very robustresponse to the request forsurvey completion. A summary ofresults and any actions/changesas a result of your comments willbe forthcoming.

Referrals management and clinicalreview updatescontinued from page 18

Suite 1200

1001 Lakeside Ave

Cleveland, Ohio 44114-1153

OPMG Update Winter 2008

Documents

Transcript of OPMG Update Winter 2008