HIMSS10 – Andrew Wiesenthal (Kaiser Permanente)

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Dr. Andy Weisenthal, Associate Executive Director of the Permanente Foundation, describes Kaiser Permanente as an integrative health delivery system with over 8 million members. Dr. Weisenthal provides an excellent overview of how Kaiser Permanente implemented their robust EHR system called Kaiser Permanente Health Connect. Dr. Fishman and Dr. Weisenthal talk about the challenges and successes of such a large scale EHR implementation.

Category: HIMSS10, Tradeshows
Date: April 14, 2010
Views:7,434 views

Dr. Eric Fishman: This is Dr. Eric Fishman with EHRtv and today we're speaking with Dr. Andrew Wiesenthal, Associate Executive Director of the Permanente Federation. And as we find out soon, Andy Wisenthal knows more than a little bit about electronic health record implementation in a grand scale. So Andy, thank you spending a few minutes with us today.

Dr. Andrew Wiesenthal: You're welcome.

Dr. Eric Fishman: Tell us, just very briefly about Kaiser Permanente and then specifically how the IT component fits in because you've managed to automate records on a grander scale than I think any other entity in the world except possibly the federal government.

Dr. Andrew Wiesenthal: I'd be happy to. First of all Kaiser Permanente is, to a degree, unique in American healthcare. It's an integrated health care delivery system. And as such, it combines a number of different entities into one single delivery system so that we enroll members and in that respect perform health insurance functions for those members. We also deliver all of the healthcare so we provide the physician care, nursing care, ambulatory care, hospital care, pharmaceuticals. Ninety-six percent more or less of our members take their prescriptions from our pharmacies, imaging centers, our laboratories and the like. All of the care and all of the provision of care falls under our roof in so far as possible.

Dr. Eric Fishman: And you do that for over eight million members.

Dr. Andrew Wiesenthal: Yes, 8.6 million members, that's right.

Dr. Eric Fishman: Many years ago, you started to implement a rather sophisticated EHR product which is called KP Connect I believe?

Dr. Andrew Wiesenthal: Kaiser Permanente HealthConnect.

Dr. Eric Fishman: So a number of years ago, you started implementing what is called Kaiser Permanente HealthConnect, an extraordinarily sophisticated system which I understand has being completed today putting your 32nd hospital, the finishing touches seven years later. Is that correct?

Dr. Andrew Wiesenthal: That's right.

Dr. Eric Fishman: Describe that process if you would for a few moments.

Dr. Andrew Wiesenthal: Well, the process began with the conclusion that we had a lot of distinctive competencies as an organization but writing software probably wasn't one of them. We are different; we had often felt unique and we had done a lot of EHR software creation before February 2003 and with some success in various of our operating regions. But we had, as an organization, evolved to the point that two things became clear to us. Number one that there was vendor software we could use that didn't have to be customized that would be better for us to do than trying to continue to develop our own. And number two that we probably would be benefited by doing something as a national collective as opposed to operating region by operating region. So we did both and signed a multi-year licensing agreement with a vendor at the very end of February 2003. We then took that software and did all of the configuration that it allowed. We didn't write custom add-ons or force the vendor or ask the vendor to do custom things but we configured the database, created content, made all of the configuration decisions and so on.

Dr. Eric Fishman: Have you seen a lot of evolution in how that software is being used today as opposed to seven years ago?

Dr. Andrew Wiesenthal: Oh, absolutely. Several things have evolved. First of all, the vendor has evolved the tools so that they are very different today than what they were when we first licensed them. Secondly, our grasp of how to use the tools has evolved as we became experienced as users. The first people using the system were experiencing a different kind of software, a very different user interface if you will, different content, different approaches to the optimal use of EHR software than the people who are using it now. Now many of those people are the same people but they've been evolving and we had to learn how to circle back to them and support them through changes in their workflows and changes in their ability to use the existing functionality and helping them to integrate new functionality as a vendor made it available.

Dr. Eric Fishman: Since you're the largest such integrated delivery network around, I can't ask what advice you would give to another similarly situated entity since there is none of such stature, but what advice would you give to a smaller entity as to what they should do if they're just beginning the implementation selection process?

Dr. Andrew Wiesenthal: Well, I would say a couple of things. First of all that the real struggle isn't a technical issue. It is how to figure out how to use the tools that whatever vendor they select makes available to them to improve their practice. They can, if they want to, automate their practice as it is. What they will experience if they do that is a degradation of their productivity over a certain period of time.

Dr. Eric Fishman: I would expect there should be a significant amount of workflow redesign in order to take any meaningful benefit.

Dr. Andrew Wiesenthal: So then they have to come to grips with how they want to redesign their workflow and they don't have to think that they're the first people down that path. So there are places to look for advice about how to do that and we're among them. Even though we're very large, our physicians practice in small units just like everybody else and they might be slightly bigger than the two to three person practice but in some cases they're not.

Dr. Eric Fishman: So let's talk about the individual physician practices. How much time would it take for one physician to implement and learn how to use the software? And I'm going to ask how much time by way of how many weeks and months as well as how many hours of actual training that they receive.

Dr. Andrew Wiesenthal: What we eventually migrated to is a pattern of a small amount of formal pre Go Live didactic training whether it's on a computer or via the web or some classroom stuff. It varied to somewhere around 8 to 12 hours of that. It's probably more than enough because we're all adults and adults don't learn very well that way. You know, we learn by experiencing.

Dr. Eric Fishman: Doing.

Dr. Andrew Wiesenthal: We learn by doing and putting our hands and touching things and actually trying to do our work. The real learning happens as soon as you start to try to see patients. Wherever possible, if you can figure out -- and we had ways of doing it that are uniquely available to us but there are ways of doing this -- if you can figure out how to reduce your work load for a certain period of time, not a long time, but a couple of weeks, then you can cope with learning how to use the system in the context of your practice and begin to learn. Once you do that, then you could start to see how to take advantage of what's in there to change how you do your work. You could try to project that somewhat in advance but it's our observation that people who are not users, don't really see the potential but once they become users, then they're full of ideas about how to change their practice. Very good ideas, in fact.

We were able to offer at lot of what we call, "at the elbow support". So standing right next to me when I was learning, was another doctor or a nurse who would watch me try to do a particular activity and say, "you know, when I first start to see a new consult like you're trying to do right now, this is what I do." This is how you do that. You only have to have a little bit of that; it goes an awful long way. You begin to develop what you might call muscle memory about how to do your routine tasks. Once you get there then you can stabilize and build your productivity back up. In our experience, which we were very conservative about that. We thought it might take as much as two to three months for people to get back to full productivity. We had to pay handsomely for that because we couldn't afford to allow our service to our members to degrade so we had to figure out ways of delivering that service which you have to pay for to make sure that they were being seen timely and had their needs taken care of while we were letting people experience and learn the system.

Dr. Eric Fishman: You had mentioned earlier that that's maybe a soft cost probably a larger part of the installation, implementation cost control.

Dr. Andrew Wiesenthal: Training and the loss of productivity combined and the change management issues that go along with it are more than 50 percent of the costs. It's important to acknowledge that and it's important to acknowledge that you will take a hit in your productivity. You will not be able to see as many patients and if you try, you won't be able to learn as well.

Dr. Eric Fishman: I quote the aha moment where somebody says I'd never go back to paper. How long, in your experience, is that for your physicians?

Dr. Andrew Wiesenthal: Even though they struggle and even though they are full of critiques about what to do differently or better, almost from the very beginning.

Dr. Eric Fishman: Really?

Dr. Andrew Wiesenthal: Yes. I'll give you an anecdote. I had the misfortune, good fortune depending on how you look at it, of being in our Mid-Atlantic region - Washington, DC, Northern Virginia, Baltimore. About three weeks into their initial deployment, we had a massive catastrophic power failure at the datacenter where their software resided. Totally unanticipated, although maybe it should have been but that’s a different story. So the power went out; they had to go back to paper and we knew that we had a bunch of work to do to repair that datacenter to bring the servers back up. We knew that we could do it one of two ways, either in stages. We'd bring back up right away, get the system going and then take it down periodically to do some additional repair over the next couple of months, take it down for 8, 12, 12 hours, something like that. The clinicians and nurses were asked, you could do it a different way: we could just stop and take you back to paper for a couple of weeks. We'll do all of the work in the datacenter then it'll be finished and you go back to the system. And they refused.

Dr. Eric Fishman: The next year or two, what are you anticipating? You have three more years in your 10 year plan. What are you anticipating will happen in that interval?

Dr. Andrew Wiesenthal: What will happen is we have more upgrades to do as the software matures and becomes more powerful. We have a lot of work we want to do to promote health information exchange between ourselves and other entities. We've already started that with the VA and the DOD and we want to do that more because it's to the very great advantage of our members. We want to figure out how to optimally use the tools that we have. We're all about investigating how to change the way we deliver care - how to change the site of care, how to change the process of care, how to change the experience of care - so that it's better for our members and uses their premium dollars more wisely. So while that sounds like a run-on set of clichés, it's really true. That's what we're doing here. We have to be good stewards of the money that our members give us. The revenue we get is all from member dues, member premiums, period. If we don't use it wisely to take good care of them, then they suffer and if they suffer, we suffer. So we want to make it better. We're doing all kinds of things in prevention and population management that we could never have done before.

Dr. Eric Fishman: Andy, it's been a pleasure chatting with you. This is Dr. Eric Fishman. We've been speaking with Dr. Andrew Wiesenthal, Associate Executive Director of the Permanente Federation. Thank you.

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