Improving the Health of Our Patients and Our Communities:

Jason Jones, PhD Executive Director Kaiser Permanente, Southern California Patti Harvey, RN, MPH, CPHQ Senior Vice President Kaiser Permanente, Southern California Improving the Health of Our Patients and Our Communities: Taking on the Broader Responsibility and Restoring Joy to Delivering Care

The Triple Aim : A Blueprint for A More Satisfying Future? Improving the Health of Our Population Improving the Care Experience Focus on Value and Cost Efficiency

Kaiser Permanente: The oldest group model health maintenance organization, serving 9 million people in eight regions across the country Kaiser Permanente s capitated payment model places as much emphasis on keeping people healthy as it does on caring for members when they are ill. Kaiser Permanente Programwide 9 Million Members 37 Hospitals 611 Medical Office Buildings 16,658 Physicians 172,997 Employees $50 Billion Annual Revenue $4 Billion Health Information Technology Investment 67 Years of Providing Care Focus on prevention of illness and disease Focus on Community Health Helps our Patients

Key Success Factors for Achieving the Triple Aim Full Alignment and Integration of Delivery and Payment System Meaningful, Real Time, Actionable Quality and Performance Information Transparency of Performance Especially for {Clinicians} Physicians with Internal and External Benchmarks Clear and Unambiguous Leadership Direction Willingness to Leverage Every Aspect of the Delivery System to Help Achieve Top Level Performance

Success with Triple Aim Requires Attention to Total Health Drivers of Health Health is driven by multiple factors that are intricately linked of which medical care is one component. Total Health is a comprehensive solution that addresses all components. Source: Determinants of Health and Their Contribution to Premature Death. JAMA 1993

Kaiser Permanente Clinical Information Systems Provide Better Patient Management Using Evidence-Based Medicine Labs Hospital Pharmacy Outpatient Appointments Outpatient Encounter Membership Emergency Department Immunizations Clinical Information Systems Registries Risk stratification of population Identify subgroups needing specific care Patient management tools Targeted panel lists Prompts, reminders for clinicians Letters and automated telephone outreach to members Monitoring and process improvement measures and reports Targeted health education and self-care support

Complete Care Systems Approach in the Ambulatory Setting

Proactive Encounters at Every Point of Contact Have Revolutionized How Kaiser Permanente Provides Total Health Pre-Encounter (Proactive Identification) Identify missing labs, screening procedures, access management, kp.org status, etc. Provide member instructions before visit Contact member and document encounter in KP HealthConnect Office Encounter Vital sign collection/documentation Identify and flag alerts for provider Room and prepare patient for necessary exams Pre-encounter follow up Post Encounter Immediate: aftervisit summary, after care instructions, follow-up appointments, Health Ed materials, how to access kp.org Future: follow-up contact and appointments per provider Back Office Support Letters E-mail Inbox Management All staff have responsibility for patient s total health. Not all patients see their primary care physician. Every office encounter has been redesigned to optimize each patient contact. Areas of need are identified and acted on.

Outcomes in KP Southern California for Better Total Health Using its information technology tools, KP Southern California has improved almost all major measures, including breast, cervical, and colorectal screenings; controlling high blood pressure, and osteoporosis management 90% 80% 70% 60% 50% 40% Breast Cancer Screening (52-69) Cervical Cancer Screening Colorectal Cancer Screening Controlling High Blood Pressure (Ages 18-85) Osteoporosis Management in Women Who Had a Fracture 2005 2006 2007 2008 2009 2010 2011 2012

Colorectal Cancer Incidence Rate and Colectomies Decline CRC Incidence Rate per 1000 members Colectomies 0,7 2500 0,6 0,5 0,4 0,573 1918 0,516 0,426 0,375 2000 1500 0,3 0,2 0,1 0 1137 1076 1026 2008 2009 2010 2011 1000 500 0

Outcomes: Proactive Measures Decreased Hip Fractures by more than 48% Hip Fractures Expected vs Actual Rate Kaiser Permanente SCAL 2011 48+% reduction in hip fractures 3,00% 2,50% 2,00% 1,50% 1,00% 0,50% Actual Expected (1999) Hip fractures in older men and women lead to many complications including: Lack of mobility Inability to provide self-care Expensive nursing home care Death 0,00% 60-64 65-69 70-74 75-79 80-84 85+

Clinical Strategic Goals Benefits Achieved (Lives Saved) 2004 Sept 2012 Metric Increase Savings Per Decade Cholesterol control 34.5% 2,707 Lives Blood pressure control 43.5% 5,972 Lives HbA1C < 9.0 13.5% 1,276 Lives Smoking cessation 17.0% 1,011 Lives Breast cancer screening 11.1% 555 Lives Cervical cancer screening 6.5% 65 Lives Colon cancer screening 35.8% 5,675 Lives Total 17,261 Lives

Similar Gains in the Hospital For Standard Reporting WE VE ACHIEVED SIMILAR TYPES OF PERFORMANCE GAINS IN THE HOSPITAL

Patient safety measures have improved steadily over the last few years and outperform some national measures Hospital-Acquired Pressure Ulcers TJC Core Measures 8% 100% 7% 95% 6% KPSC HAPUs, All Stages CalNOC Average 90% 5% 85% 4% 80% 3% 75% 2% 70% 1% 65% 0% 60% 2007 2008 2009 2010 2011 2012 1.6 1.4 1.2 1.0 0.8 0.6 0.4 0.2 KPSC ICU BSI Rate NNIS BSI Rate Average 0.0 2007 2008 2009 2010 2011 2012 2013 0.40 AMI Bundle Heart Failure Bundle Pneumonia Composite Surgical Care Composite 1Q07 3Q07 1Q083Q08 1Q09 3Q09 1Q10 3Q10 1Q11 3Q11 1Q12 1Q12 2Q12 3Q12 4Q12 Blood Stream Infections Mortality Rates 0.80 0.75 US Medicare Overall KPSC 0.70 0.65 0.60 0.55 0.50 0.45 2007 2008 2009 2010 2011 2012

HCAHPS Inpatient Satisfaction Scores (Overall Rate Hospital) 80% 70% Overall Rate Hospital 9-10 California Average 60% 50% 2006 2007 2008 2009 2010 2011 2012 2013 15

To Achieve a Similar Objective Sometimes Requires Different Gearing

What Is Different In the Hospital Increase Patient severity, complexity, heterogeneity, volume, & data Number of decision makers Parallel & asynchronous data Decrease Time Evidence Patient flow control (appointments) In the clinic, time is your friend. Things often go away on their own. In the hospital, time is your enemy. Many things get worse and sometimes very quickly.

Patient Voice Best Information Becoming the Best Hospital System Value 2015 2014 2013 2012 Integrate Patient Goals Specific Clinical Goals Clinical Protocols in KPHC Integrated and Shared Data Platform (IDR) Hospital Clinical Improvement Team (HCIT) The best hospital systems adapt to - Patients clinical presentation and goals - Evidence tools and knowledge of them - Environment physical, people, cost, reimbursement, and regulation To deliver excellent patient care - Clinical excellence individualized diagnosis, treatment selection, and execution to attain goals - Perceived value faced with the same circumstance, I would choose the same hospital

Execution Hospital Clinical Improvement Team Regional Leadership Aim: Safety, efficacy, patientcentered, timely, efficient, equity What are we trying to accomplish? Improve care for patients with pneumonia Sponsor Measure: Who, outcomes, process, balance How will we know that a change is an improvement? Adult ED patients w/ CAP, HFD-30, admit rate, bounce. HCIT Change: Feasible options and expected impact What change can we make that will result in improvement? Act Plan Decision support, post-ed follow-up, home health Chiefs Groups Nursing Pharmacy Representation Study Do Medical Centers http://www.ihi.org/knowledge/pages/howtoimprove/ Regional PI/Data Functions Service Provider

Bridging Forms of Decision Making Delivery Diffusion Decision Support Services HCIT Implementation Tools Techniques Organization Feedback Presentation Quality Improvement Value Setting & Alignment Action Analytics Observational Marketing & Education Ideas Data Interventional Management EMR

Deploying, Running, & Modifying CDS in an EMR Parameter Exploration Deployment Decisions (Outside EMR) Function/Formula Prediction Model Prediction Config Db Case Reviews Cases/Context Operational Characteristics Population/System Prediction Modeling Point of Care Decisions (Inside EMR) EMR End User Interaction EMR Config File EMR Limited Deployment EMR Full Deployment Predict Function IDR

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Supporting Purposeful Deviation 1 2 A B 3 4 C

Triple Aim: New Tools Expand Access Will They Cut Costs? Telephone, Email, Text Messaging Telehealth, Teleconsultations, Telemonitoring Digital Transmission of Images for Diagnosis (telederm, teleopthalmogy ) Social Media The Wisdom of Crowds Leveraging Relationships for Health Life Integration

Success with Triple Aim Requires Attention to Total Health Drivers of Health Health is driven by multiple factors that are intricately linked of which medical care is one component. Total Health is a comprehensive solution that addresses all components. Source: Determinants of Health and Their Contribution to Premature Death. JAMA 1993