An enhanced Appreciation of the connection between quality and coast has made the question of mass-market penetration of the EHR an issue of broad importance.
The delivery of healthcare has been largely unchanged in fundamental aspects for decades. Despite significant advances in science, medical diagnostic tools, surgical interventions and pharmacology, the basic transaction has remained almost solely face-to-face interaction between healthcare professionals and patients in institutional settings.
In almost all other spheres of business and industry, electronic information systems coupled with the Internet have driven fundamental shifts in how business is conducted and healthcare will not be different.
In 1999, the Institute of Medicine published To Err is Human followed by Crossing the Quality Chasm in 2001. These publications attracted broad attention to quality and safety problems in American healthcare and identified four key factors underlying these quality gaps: (1) The increasing complexity of science and technology, (2) The rise in the incidence of chronic conditions, (3) A poorly organised delivery system and (4) A lack of critical information technology supports. Concerns about the failure to deliver quality care have been linked with concerns about escalating costs in the minds of policy analysts, governmental agencies, purchasers and patients. Most recently, the US government forecast that healthcare spending will increase to 17.6 per cent of the economy in 2009. This combination of escalating costs, poor outcomes and 15 per cent of the population without health insurance is unsustainable and has drawn understandable scrutiny and criticism from many quarters.
Today, Electronic Health Records (EHR) has capabilities that can be brought to bear on the key factors that drive system quality. At the same time, an enhanced appreciation of the connection between quality and cost has made the question of mass-market penetration of the EHR an issue of broad importance. President Obama has included significant funding for the implementation of EHR as part of his healthcare reform plan designed to stabilise healthcare costs and extend health insurance coverage.
In the US, services for patients with chronic disease now account for 75 per cent of total healthcare expenditures. This is a consequence of the mastery of many aspects of the treatment of acute disease, and the increasing life expectancy of the populations we serve. Treatment of chronic disease requires longitudinal tracking of treatment and outcomes both for individual patients and identifiable populations made feasible via an EHR.
The increasing complexity of medical science creates a burden for individual physicians to stay current. As knowledge in diagnosis and treatment expands, the time and processing speed required to achieve an optimal level of quality performance exceeds any individual’s capability. The number of years it takes for a medical advance to be broadly adopted into regular practice has been estimated at 17 years. In contrast, the EHR with clinical decision support has the capacity to summon current information, recommendations and research instantly at the point of care.
Once an EHR captures and organises the clinical information, offering a secure Internet-based view to the patient has a multiplying effect on the value and changes possible with a Personal Health Record (PHR). Through My Health Manager, Kaiser Permanente patients can view key information in their medical records including office visit and hospital visit summaries, diagnoses and recommendations; send secure messages to physicians they have seen; view lab results; make appointments; and renew prescriptions. In the fourth quarter of 2008, 2.7 million (31 per cent) of our patients had secured access to these capabilities and generated 12.6 million among multiple, separate parties website visits for a variety of purposes including requesting 358,000 appointments, viewing 4.3 million test results, and sending 1.6 million secure emails to their physicians and other clinical team members. Almost a million patients visited the evidence-based health encyclopedia and 165,000 visited the featured seasonal health topic on colds and flu. Even when these website visits do not avoid a telephone call or office visit, our patients appreciate and benefit from the additional information and interchange at their convenience. Engaging patients in their care has long been an espoused value, but the PHR makes it a reality and the changes this will drive have only begun to become clear.
Beyond our walls
The home and other personal settings such as work or community have become the location of choice for much of care delivery. The care delivery system has expanded to include family and community locations and resources. New transaction options made possible with an EHR and secure Internet capabilities have resulted in over a 20 per cent decrease in office visits. In the KP Hawaii Region, the first region to fully implement KP HealthConnect in the outpatient setting, between 2004 and 2007, the annual total office visit rate decreased 26.2 per cent, the primary care office visit rate decreased 25.3 per cent, and the specialty care office visit rate decreased 21.5 per cent. Scheduled telephone visits increased more than eightfold, and secure e-mail messaging, which began in late 2005, increased nearly six-fold by 2007. Secure messaging and telephone visits have replaced office visits while increasing patient satisfaction, maintaining or improving quality outcomes, and increasing total patient contacts. Given our current experience and trajectory, our patients will likely choose alternatives to office visits to access care for well over a third of their interactions in the very near future. The rapidity and degree of patient adoption has been very strong, cutting across age, gender and socio-economic differences. Obtaining healthcare has become similar to the way many of us shop, bank and work every day.
Integration and leveraging
Healthcare is mostly provided in very loosely organised delivery systems. Whether coordinating care between physicians, nurses and other healthcare professionals in the same organisation or among multiple, separate parties across many organisations, the EHR supports the coordination of care. The 24-hour availability of patient information in a legible, organised format decreases medical errors, duplication of tests and other services including emergency room visits and hospitalisations.
At the same time that duplicative tests and services are eliminated, information technology can leverage scarce and specialised clinical resources via virtual consultations regardless of geography and time zone constraints. KP HealthConnect, combined with an integrated disease registry for chronic conditions has made it possible for a single nephrologist to oversee and consult on the care of the chronic renal failure patients for a population base of over 250,000, significantly improving clinical outcomes by delaying renal dialysis.
Reliability and customisation
Effective treatment for hypertension is well understood but only 40 per cent of the diagnosed patients receive the appropriate care in the US, resulting in needless complications and deaths. Diabetes affects a rapidly growing per centage of the population, accounting for a substantial burden of illness and expense. Yet only half of patients with diabetes receive care proven to reduce or prevent serious complications. Data from KP HealthConnect populates panel management tools to help clinical teams to track and manage patients with chronic conditions such as cardiac disease, diabetes and chronic renal disease. This allows each team to efficiently and proactively identify which of their patients are in need of additional care and interventions. The tools support mail, phone and email outreach; pre-visit preparation; and referrals to other specialists.
In 2005, the Institute for Healthcare Improvement in Boston, Massachusetts launched the ‘Saving 100K Lives Campaign’ to improve hospital care and prevent complications by ensuring the reliable delivery of evidence-based care. EHR-imbedded documentation templates and evidence-based orders make this task consistent and efficient. A recent study of 41 hospitals in Texas reported the correlation of the level of sophistication of the EHR used with lower mortality and complications, lower costs and shorter hospital stays. While many clinical processes will be vastly improved by standardisation and the EHR, patient involvement and customisation are also readily supported. The easy availability of information on medical conditions and recommended care helps patients and families make knowledgeable choices based on personal preferences, constraints and values.
Although the EHR can eliminate unwanted and unnecessary face-to-face encounters, healthcare is still fundamentally based on relationships. Patients and healthcare professionals alike need and benefit from in-person interaction, made richer by full availability of integrated longitudinal patient information coupled with the best knowledge and recommendations science can offer. By having complete information, every clinician contributing to the care of an individual patient has the advantage of providing a seamless experience for the patient. Valuable time during office visits, emergency visits, and hospital rounds can be devoted entirely to understand patient concerns, preferences and issues.
Transitions in care are a time of particular risk in healthcare. Nurse shift changes, general medicine referrals to medical or surgical specialists, and hospital discharges are all vulnerable times. Personal communication style, verbal versus written communication and variation in what information is conveyed and where it is documented all contribute to the risk that critical information may be omitted or misinterpreted. The EHR provides the vehicle and the opportunity to design a consistent information flow to enhance safety and efficiency. Dozens of staff nurses learned techniques to design a process for shift change that is now the standard process in Kaiser Permanente hospitals. After incorporating information from patient and family interviews, a template was developed that is now imbedded in the hospital EHR. All clinical staff can access a single place for the same information on each patient. A similar process is underway to redesign the hospital discharge process informed by over 100 interviews including patients and families at home after discharge as well as doctors, nurses and pharmacists both in the hospital and in their medical offices.
Fundamentally, the EHR has the capacity to integrate and organise all patient information, facilitate its instantaneous distribution among all participants in the healthcare system including patients, and inform and support the work of practitioners with the most current evidence. In doing so, it will simultaneously change industry work processes, improve quality, patient safety and satisfaction, and alter our understanding of the process and cost of delivering healthcare in the 21st century.
The experience at Kaiser Permanente
The experience at Kaiser Permanente in implementing and using an EHR may be instructive regarding the desired impact on advancing healthcare delivery. Kaiser Permanente provides health insurance and healthcare to 8.7 million people primarily in a fully integrated healthcare delivery system for a fixed monthly fee. It began the full-scale implementation of an integrated Electronic Medical Record (EMR) in 2004, covering over 420 medical offices and 36 owned hospitals and medical centres. We anticipated many changes, but significantly underestimated both the breadth and the challenge. To guide our work, we developed a set of principles to ensure that the implementation and use of the EHR, Kaiser Permanente HealthConnect would achieve the quality and strategic goals of the organisation. The past several years of implementation and use of KP HealthConnect has validated these principles and demonstrated the significant impact on the way healthcare is delivered.
Louise L Liang, a 25 year veteran in healthcare administration and operations, speaks, writes, and consults on a broad set of healthcare issues including electronic information systems, quality, safety, service, and practice redesign. From 2002 to 2009, Louise served as Senior Vice President, Quality and Clinical Systems Support, Kaiser Foundation Health Plan and Kaiser Foundation Hospitals, where she oversaw the national quality agenda and led development and implementation of a US$ 4 billion+ organisation wide electronic health record.