HIMSS10 – John Mattison (Kaiser Permanente)

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Dr. John Mattison, Chief Medical Information Office of Kaiser Permanente, talks to Dr. Eric Fishman about Kaiser Permanent’s unique and highly integrated Electronic Health Record system. Kaiser Permanente is a care delivery organization, which manages patients at many points of care. Dr. Mattison discusses Kaiser Permanente’s journey though creating an integrated set of health information systems. After completing a very intensive study of the EHR market, Kaiser Permanente selected Epic to create its KP HealthConnect EHR.  Dr. Mattison explains that this tremendous investment was made with the goals to measure health and process outcomes, analyze the data, quickly transfer it into decision support, and communicate this to any provider/patient, anywhere, at any time. With 8.6 million members/patients and 16,000 physicians, the KP HealthConnect solution is a success story. Dr. Fishman and Dr. Mattison discuss interoperability, and how Kaiser Permanente is now embarking on innovative pilot projects to create an infrastructure for the safe and secure exchange of health information between different health systems/facilities.

Category: HIMSS10, Tradeshows
Date: March 26, 2010
Views:45,477 views

Dr. Eric Fishman: This is Dr. Eric Fishman for EHRtv and today, we have the pleasure of speaking with Dr. John Mattison, Chief Medical Information Officer of Kaiser Permanente based in Southern California. John, thank you very much for spending your time with us today at HIMSS10.

Dr. John Mattison: Pleasure.

Dr. Eric Fishman: I understand that you've had quite an experience in implementing a variety of EHR products both in small fee-for-service private practices as well as more recently at Kaiser Permanente. Let's start with Kaiser Permanente and briefly describe what can be described as a seven year process of implementing 32 hospitals and 16,000 physicians I believe and then, we'll talk about some of the lessons that you could provide to smaller practices based on that.

Dr. John Mattison: Be happy to. One of the unique things about Kaiser Permanente is that we're high integrated and we manage our patients in clinics, pharmacies, inpatient facilities across the entire spectrum of care. Given that we've been highly integrated as a care delivery organization for many years, it was very appealing to us to be able to have a highly integrated set of systems that would allow us to create a comprehensive record and deliver care no matter where the patient was being seen within our institution. We did a very deliberate and intensive survey of the vendor market to select a vendor that had a vision of comprehensive care, that had a vision of continuity of care, that had a vision like ours of quality improvement where we could rapidly study the results from our care protocols and enhance our ability to deliver high quality care through decision support tools. So we were looking for a very global kind of approach and a very futuristic vision which is why we selected the vendor we work with.

So HealthConnect has, at its core, a suite of systems from a single vendor that being Epic Systems. In addition, we do interface with our lab, pharmacy and radiology. Where we look like everyone else is that we don’t have the suite that covers entirely everything we do. We have a separate laboratory system, separate pharmacy system, separate radiology system and many other software applications in the mix. So a smaller group that has to deal with multiple laboratories, pharmacies, radiology groups, multiple hospitals, we share many of those same challenges as they do. The one thing I would say that was a real gratifying experience about this is that you can have a very ambitious goal of bringing all that information together to create a single record for every patient so that whenever that patient is seen anywhere in the system, no one has to ask them again, what are your allergies. I've talked to patients in particular in an inpatient stay who will say - this is before the health record - "You're the fourth person that's asked me for my allergies today. Didn't you write it down somewhere?" And in fact, people had written it down in the paper world but they were in multiple locations. Now with an integrated model like we have with HealthConnect, anybody enters an allergy anywhere, it shows up everywhere; same with problems, same with medications, same with the entire chart. So it is achievable. It is profoundly useful in terms of availing every physician of all the information for every patient and it allows us to do decision support so that we can make a new discovery, implement it and make it available to every physician essentially the same day. So one of the key business objectives that we had for the implementation, the reason that we felt it was important to invest billions of dollars in this program is that we wanted to go from the paper past where it takes years and decades to make a new discovery, to implement that discovery and transform that into a process where we can make new discoveries in a matter of days and weeks all the way through the implementation cycle. As Edward Denning said, you cannot improve any quality process unless you measure what you do. Our ability to measure everything we do, to analyze it and then be able to quickly transform that into useful decision support that’s relevant to that provider and that patient at that moment and time, anywhere across the system has been, in my mind, one of the greatest accomplishments of this project - reducing the quality improvement cycle from years and decades down to days and weeks. We've experienced that repeatedly since we've completed this program.

Dr. Eric Fishman: Clearly with 8.6 million members and 16,000 physicians you got a phenomenal amount of data (unintelligible) together.

Dr. John Mattison: Absolutely.

Dr. Eric Fishman: Talk about the integration and interfacing with the systems that are not Kaiser Permanente. Is that as far along.

Dr. John Mattison: The Health Information Exchange technologies, capabilities and implementations today are where health records were about10 years ago. Work in the health information exchange world is very much a leading edge activity. We have essentially completed our deployment of our health record.

Dr. Eric Fishman: Today I understand.

Dr. John Mattison: Today was the last hospital, right. We are now 100 percent complete with hospitals and clinics across the program so this is quite a day to celebrate. What we're doing now is, as Dr. Wiesenthal mentioned earlier, we are continuously improving all of our practices, all of our care delivery mechanisms, all of the clinical protocols and enhancing the software and implementing new enhancements every day to the process. But when you see a patient who recently changed employers and may have changed employers two years previously, they may have large components of their medical record locked away in multiple different institutions. If we really are determined, as we are, to provide a comprehensive program of care and a continuous program of care that operates on all of the available information, it is absolutely imperative that we can exchange information easily with other institutions with the patient's permission.

We have a pilot project in San Diego right now that began late last year where we are testing the ability to exchange records directly using international interoperability standards, the clinical document architecture and continuity care document which are recognized and used internationally, to take records out of the VA system with the permission of the patient and make them available to physicians on demand at Kaiser Permanente and vice versa. The DOD is joining into this now so that Kaiser Permanente, the VA and the DOD can, with a subset of patients who receive their care in any two of those three institutions can readily exchange their problems and medications and allergies using international standards, having the highest levels of security and privacy maintained throughout the exchange. Already we've had patients who have come who have benefited immensely from that exchange. As one example, we had one patient who hadn't been seen with us for a couple of years but had been seen recently at the VA. The physician at Kaiser Permanente requested the record from the VA hospital and in a matter of seconds, had a complete and current list of problems, medications and allergies. This particular patient had actually had two life threatening allergic reactions to a common anti-hypertensive medication and to a common cholesterol lowering medication both of which are in a family of medications where it would be quite easy for someone to have prescribed him another member of that class of drugs; precipitated perhaps even a worse life threatening allergic reaction after being sensitized with the first one. Yet in a matter of seconds, we had that information right in front of us. Turns out when he was seen, both his blood pressure and his cholesterol were not in control and we would have been inclined --

Dr. Eric Fishman: To have given him one of those medications.

Dr. John Mattison: --to have given him one of those medications but we had the information right in front of us. He had neglected to mention that he had two new allergies since he had last been seen. The only source of that information that we had was through this information exchange. We have many other similar examples of the profound clinical and safety benefits of sharing the information between institutions, with the patient's permission, that have directly and clearly benefited the care of the individual patients.

Dr. Eric Fishman: Like most physicians, I have worked in a VA hospital and clearly it wasn't my experience that information was able to be obtained from a VA hospital in seconds. It was weeks if that.

Dr. John Mattison: Precisely.

Dr. Eric Fishman: What percentage of the patients do you find are interested in giving permission and allowing participation in the process?

Dr. John Mattison: That's a great question because we first identified those patients who had been seen recently in both Kaiser Permanente and the VA. Then we sent a letter out from the medical directors of both the VA and Kaiser Permanente hospitals explaining to them that they had the opportunity to be early participants in this project. We expected a five or ten percent response rate which is fairly typical for this kind of authorization request and we got nearly a 40 percent response right off the top. So you might ask why would there be such a high response rate when people are so concerned about privacy and so sensitized about privacy. Well, these were people who had been seen at both institutions recently. They had directly experienced what you just described about saying oh, I just had a urologic surgery over at the VA hospital and now I'm at Kaiser Permanente and I'd like you to see my records doctor so you can have the full picture and then you initiate this process that takes weeks to copy the records and mail them and so forth. By that time, the key decisions have likely been made absent the useful information. So it was a group that was particularly sensitized to the value. They were probably average in terms of sensitization towards the privacy issues but they were really aware of the value.

So a couple of things. Once we have the ability to demonstrate, which we will soon, the value of this kind of exchange and once people understand that we're taking every precaution possible to protect the privacy information and we're only exchanging it with their permission, I believe that we'll eventually get around 90 percent. If you look at health information exchange in the state of Massachusetts where they use a similar opt in model, they have implemented a variety of mechanisms to make it easy for people to understand the option and to execute on the option and they've had a very high response rate. Finally, when we allow patients to be able to opt in at the point of care where the value is immediately obvious - so you're an orthopedic surgeon - the patient comes in, they've just fractured their tib fib and you want to get access to their records about their hypertension or diabetes and hypercholesterolemia to make sure you have things covered pre-operably, you'll be able to get that information. But you would then turn to the patient if they've not yet opted in and if you're working in an institution that has implemented the NHIN, National Health Information standards and they were recently seen and had the rest of the record in another participating institution, you can simply --

Dr. Eric Fishman: Can they give permission in real time?

Dr. John Mattison: Well, that's our goal. We have not yet implemented the ad hoc real time consent and authorization process but our expectation and our commitment is that we will implement such a process so that any patient, any consumer who finds himself in that situation can have access to their full record. Physicians can have access to the full record more or less instantaneously. So even if they hadn't opted in previously, at the point of need, they'll have the opportunity to do that. So that is one of the things that we have yet to develop as part of this project but if you look at the experience in Massachusetts and you expect, as we do, to be able to deliver an ad hoc instantaneous type of opt in process, we'll have that kind of consent and participation very broadly as we begin to roll this project out.

But I'd like to emphasize, this is a pilot. The reason we did a pilot was to find rough spots and there are a couple of rough spots that we have found and that's the good news because that was the purpose of the pilot. We are now directing our resources to solve each of these problems before we roll it out. Once we have those problems solved and really industrialize the entire software infrastructure because the VA has the same record across the country because Kaiser Permanente has the same record across the country and because the DOD has the same record across the country, we will be able to have a fairly trivial roll-out across the country because the technical work has been done and because all three institutions have signed a document called the DURSA, which stands for Data Use and Reciprocal Services Agreement, which is sponsored by the National Health Information Network and commits each organization to manage the privacy, confidentiality and security of records and the exchange mechanisms in prescribed ways in full compliance with HIPAA, in full compliance with the law. So we're taking a very, very conservative approach in every respect. The challenge ahead of us is in helping the rest of the community join into this NHIN infrastructure. Just as recently as last Thursday, the entire state of North Carolina submitted a RFP to the vendors to ask for a statewide NHIN solution that is completely based in the same interoperability standards. The Office of the National Coordinator of Health Information Technology under Health and Human Services has been doing a phenomenal job of supporting this entire enterprise around health information exchange and we now have the first state in California showing increasing interest. I'm helping nudge California in that direction for doing the same and using these NHIN standards. We envision the day when any willing patient can have their record from any source available to any other source to create a comprehensive view of what has happened to them in the past and what might be relevant to the present. So we're very excited about this.

Dr. Eric Fishman: That's why it's a very exciting time to be in this industry.

Dr. John Mattison: Very exciting time.

Dr. Eric Fishman: Let me move to the physician's perspective for just a moment.

Dr. John Mattison: Certainly.

Dr. Eric Fishman: You may know I have a particular interest in speech recognition Dragon Medical in particular. What is the physician's experience with input methodology? What type of input methods are they using?

Dr. John Mattison: It's fascinating because different physicians tend to have different patterns of how they interact with a patient and how they document. For some physicians, especially those that are speed typists, a keyboard and a mouse is incredibly efficient. I happen to personally be a speed typist so it's easy to do documentation with a mouse and using the templates that come with most of these health records. Then you fill in the gaps with the prosaic part which will always be there particularly around the history and the assessment those two areas. For others who are either two finger typists or who have been accustomed to a dictation style of entering data, voice recognition does work very well. There are a number of vendors in the field now that are bringing products to market that are quite interesting and integrating them with a health record. The key in my mind is that when you apply decision support, a lot of physicians are concerned and a lot of system designers are concerned about alert fatigue. There's this notion that you just get too many alerts and physicians are just not --

Dr. Eric Fishman: They ignore them.

Dr. John Mattison: --they ignore them, they blow through. Well, that's because there's a low specificity between the actual rule and that patient's clinical record at that moment and time. The way to overcome that is what I call the specificity of the match between the rule and the substrate. The important element there is to use the same international standards like Snowmed to build your rules as the way that you represent the information in the record. If you're using speech recognition as opposed to typing or using pick lists and templates, it's very important that you have the next step which is natural language processing to help disambiguate -

Dr. Eric Fishman: I like that word.

Dr. John Mattison: --yes, disambiguate the text into discreet, defined, data elements to that you have a very discreet substrate of clinical information on the record that is machine readable by the computer. Then when you have that rule that fires on that patient, it is not only relevant to that patient, it's relevant to that patient at that moment in their clinical course, at the moment in the work flow for the physician and physicians really welcome many rules as long as they're relevant to that patient at that moment and time. The only caution I have about using voice recognition to dictating notes is that unless you have a natural language processing engine to help create machine readable information, you will continue to have alert fatigue from the rules and you will underachieve the goal of having real time personalized health care at the point of care through the use of the combination of technology, decision support engines that use these international standards, the record itself that records the international standards and with the ability to have to granularity around the information so that there is a very high match between the two.

Dr. Eric Fishman: John, it's been fascinating talking to you. I wish I had hours and hours to spend. I'm hoping we do this again.

Dr. John Mattison: My pleasure, I hope so too.

Dr. Eric Fishman: This is Dr. Eric Fishman for EHRtv. We've been speaking with Dr. John Mattison, Chief Medical Information Officer of Kaiser Permanente based in Southern California. Thank you.

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