[1] KP HealthConnect is an integrated electronic medical record and business system that aims to improve quality, service, and affordability. [2] It includes elements such as a patient portal, secure messaging, and connectivity between clinics, hospitals, and other providers. [3] Early results show increases in online access for members, reductions in office visits and calls, and high member satisfaction with virtual care options such as telephone visits.

1. 21st Century Care Innovation Project
Using InformationPrimary Care with KP Primary Care
Transforming Technology to Redesign
HealthConnect
Institute for Healthcare Improvement’s 8th Annual International Summit
on Redesigning the Clinical Office Practice
Nashville, TN, March 25-27, 2007
Charles Kilo, MD, MPH
CEO, GreenField Health, Portland, OR
Chuck.Kilo@GreenFieldHealth.com
Reginald Wallen, MD
Physician Director, MidAtlantic Permanente Medical Group
Reginald.Wallen@kp.org

2. Objectives
By the end of this session, participants will be able to:
• Describe the components of a practice IT system
• List considerations for workflow redesign during IT
selection and implementation
• Discuss critical aspects of using an IT system to
improve quality of care
• Challenge each other to think flexibly about their
practice and their patient’s future

3. Its not about the IT…
• We will discuss aspects of the technology, but we will
focus on what IT enables us to do for our patients
• Care and caring are at the center – the future is about
caring for the patient, not about the visit
• EHR implementation is a Trojan horse – it provides
the opportunity to question and redesign processes,
workflow, roles and how you interact with patients
Leverage the opportunity
Don’t pave the cowpaths
• Implementation is an ongoing journey, not a one time
event

4. Chronic Care Model: What are the challenges?
Community Health System
Resources and Health Care Organization
Policies
Clinical
Self- Delivery
Decision Information
Management System
Support Systems
Support Design
Informed, Productive Prepared,
Activated Proactive
Interactions Practice Team
Patient
Improved Outcomes

5. Basic Elements of IT for Primary Care
Foundations
• Practice management software for billing and scheduling
• EHR with integrated scanning, faxing, e-prescribing (integrated with PM)
• Decision-support (patient & practice)
• Disease Registry
• Clinic / Medical Group intranet
Systems for connecting with patients
• Patient facing shared record/personal health record
• Secure messaging
• Patient e-newsletter
System-basics
• High-speed internet connection
• Connectivity to other critical IT (e.g., hospital, lab, radiology)
• VPN for secure use from home
• System Software and Security – OS, antivirus, anti-spam, back-up

6. Organizing Principles
• Your primary focus in the design your practice system
will determine what your system will look like when
you’re done, including your IT.
• Options include, for example:
Improving physician efficiency/productivity
Improving clinical quality
Integration with colleagues
Market differentiation
Patient at the center

7. Organizing Principles – GreenField Health
Use our team and our system design to deliver on the
promises of:
• Relationships
• Service
• Clinical Reliability
Continually work to integrate care across boundaries

8. The GreenField Model TM
Relationship
Reliability
Service
Management
Systems
The Operating System
© 2007, Charles Kilo, GreenField Health

9. The GreenField Model TM
Customized Experience
Relationship
Reliability
Service
Management
Systems
© 2007, Charles Kilo, GreenField Health

10. GreenField Health’s IT System
1. GE Centricity EHR Relationship
2. GE Centricity PM
Service
3. Kryptiq’s Care Manager disease registries
Clinical Reliability
4. Kryptiq’s DocuTrak scanning
5. Kryptiq secure messaging and local RHIO
6. Kryptiq web portal with patient access to records
7. Kryptiq E-prescribing Integration using
8. Hospital interface for lab, x-ray, hospital documents ample supply of duct
9. Brentwood ECG – integrated tape and bailing wire
10. Midmark Spirometer – integrated
11. Clinical Content – encounter forms
12. GreenField intranet and web site
13. Electronic patient newsletter
14. Networking hardware & software
15. Knowledge sources – Epocrates, UpToDate, PubMed, Google
16. Remote access to hospital IS and our own IS
17. Network faxing
18. Network with backup, antiviral, antispam, and security software
19. Telecommunications – phone system, cell phones
© 2007, Charles Kilo, GreenField Health

11. Basic Elements of Medical Practice IT
Foundations
Billing / Scheduling software
EHR
Decision-support (patient & practice) Relationship
Disease Registry
Clinic / Medical Group intranet
Connecting with Patients Service
Web portal/personal health record
Patient e-newsletter
Secure messaging
The Network Clinical Reliability
VPN for secure use from remote locations
Connectivity to other IT (hospital, lab, radiology)
Connectivity network between practices (virtual integration)
Internet connection
Security including antivirus, anti-spam, back-up
Telecommunication systems
© 2007, Charles Kilo, GreenField Health

12. Basic Elements of Medical Practice IT
Foundations
Billing / Scheduling software
EHR
Decision-support (patient & practice) Relationship
Disease Registry
Clinic / Medical Group intranet
Connecting with Patients Service
Web portal/personal health record
Patient e-newsletter
Secure messaging
The Network Clinical Reliability
VPN for secure use from remote locations
Connectivity to other IT (hospital, lab, radiology)
Connectivity network between practices (virtual integration)
Internet connection
Security including antivirus, anti-spam, back-up
Telecommunication systems
© 2007, Charles Kilo, GreenField Health

13. Basic Elements of Medical Practice IT
Foundations
Billing / Scheduling software
EHR
Decision-support (patient & practice) Relationship
Disease Registry
Clinic / Medical Group intranet
Connecting with Patients Service
Web portal/personal health record
Patient e-newsletter
Secure messaging
The Network Clinical Reliability
VPN for secure use from remote locations
Connectivity to other IT (hospital, lab, radiology)
Connectivity network between practices (virtual integration)
Internet connection
Security including antivirus, anti-spam, back-up
Telecommunication systems
© 2007, Charles Kilo, GreenField Health

14. Hardware and the Network: The Basics
Application software Diagnostic Equipment (ECG,
EHR, PMS, Outlook®, MS Spirometer)
Office ® Messaging
Decision support Internal
Servers External
Application software Network
Images Local area network
Fax and email (LAN) within
User Devices Wide area network
Wired PCs (WAN) between
Wireless PCs Interfaces between systems
Scanners

15. What are the key adoption challenges?
1. Cost
2. Intimidation
3. Lack of management capability
4. Lack of IT experience
5. Lack of desire, will, compelling need

16. Environmental challenges
Where do I start?
Where do I get advice?
Are others going to pay me to have an HER, or
will others pay for my EHR?
What is the role of health systems and their
ability to provide IT to independent medical
practices?
What’s the role of QIOs?

17. 21st Century Care Innovation Project
Transforming Primary Care with KP
HealthConnect
Introduction to
KP HealthConnect

18. What is Kaiser Permanente HealthConnect?
• More than just an electronic medical record
• The development and deployment of a highly-
sophisticated information management and delivery
system
• A program-wide system that will integrate the
clinical record with appointments, registration and
billing
• A complete health care business system that will
enhance the quality of patient care and support the
KP Promise

19. KP HealthConnect Supports:
Quality Our Personal & Affordable
Patients Can Trust Convenient Service Health Care
High Quality Personal Affordable
• We have clinical information • We have and use up-to-date • We reduce the cost of care
available 24/7. clinical, social and patient and improve visit experiences.
• Our clinical outcomes are preference information. • We decrease the cost of paper
unsurpassed. • We provide patients information medical records.
• Our clinicians know in real- for shared decision making. • We maximize appropriate
time the recommended best • We enhance personalized care. revenue capture.
practices. • Our pricing matches our risk.
• We are the national leaders in Convenient • We administer benefits and
patient safety. new products both correctly
• We enhance our research to • Our patients access information and efficiently.
support evidence-based care. via telephone, Web and email. • We continually improve
• We actively support our patients’ operations.
participation in their own care.
• We minimize wait times and out-
of-pocket costs with efficient
access to care.
• We achieve superior integration
and continuity of care.

20. Program Scope
Web Access Portal
Ancillaries Care Delivery Core Health Plan Finance
Scope of KP HealthConnect Suite
Outpatient Inpatient
Outpatient Membership/ General
Pharmacy Admission, Discharge
Scheduling and Transfer
Benefits Ledger
Referral & Utilization Management
Health Information
Management
Lab Registration Claims Capital
Clinicals Processing Planning
Clinicals Pharmacy
Radiology/ Financial
Benefits
Imaging Emergency Reporting
Accumulation
Department
Billing
Others Operating Room
(immunizations,
Health Information Pricing
EKG, dictation)
Management Billing System
Data Warehouse / EDR Enterprise Data Repository

21. Members Can Actively Participate in Care
Care Delivery Core
www.kp.org Access medical record
Member Web Portal Scope of KP HealthConnect Suite
Outpatient Inpatient
Make/change appointments
Scheduling
Scheduling
Send messages to doctor Admission, Discharge
And Transfer
Registration Clinicals
Check lab results
Pharmacy
Access health Information Clinicals Emergency
Department
Review eligibility & benefits Operating Room
Billing
Billing
Account summary

22. Member’s View Through members.kp.org

23. Member’s View Through members.kp.org

24. Progress to Date
Nearly 5 million members have a partial or complete KP
HealthConnect ambulatory record
All members will have one by mid-2008
Access to KP HealthConnect through kp.org is live in 7
of our 8 regions
More than 1.7 million members are currently registered on
kp.org
Two KP hospitals are now live with KP HealthConnect
A total of 36 hospitals will be live by the end of 2009
(including hospitals currently under construction)
By the end of 2006, the KP HealthConnect practice
management deployments will be complete

25. Percentage of KP Population Coverage by
Year/Suite
100% 2007
2008
2007
90% 2009 2006
80%
2007
70% 2006
60%
2008
50%
2005
40% 2006
2005
30%
20%
2005 2007
10% 2004
2004 2006
0%
Practice Management Outpatient Clinicals and Inpatient Clinicals KP HealthConnect Online
Billing & Registration Decision Support
Population coverage based on actual & planned finish dates

26. “Blue Sky”
In 2015, the care delivery
model is a consumer-centric
paradigm where the
consumer presumes choice.
Members will characterize KP
as providing customized and
fully integrated/leveraged
services with secure and
seamless transitions from
person to person with care
that can occur in their homes
for an affordable cost.

27. Our Blue Sky Vision

28. Members are Utilizing KP.org Features
As of July 2006
Number of kp.org registered users: 1,706,009
Lab tests released online: 4,529,426
Test viewed online: 1,437,699
Member messages sent: 624,461
Average messages sent per member: 2.0
Visits to past office visits: 85,846
Visits to Your future appointments: 279,857

29. Online Access Is Improving Member
Experience
Preliminary research in the Northwest region
shows that member usage of online features is
resulting in statistically significant:
Reductions in primary care visits
Reductions in telephone calls
High member satisfaction with online
alternatives

30. 21st Century Care Innovation Project
Creating a Patient-Centered
Focus, where the care team and
work flow are organized to meet
the needs of the population
Empowering Members to be the
“real” primary care provider with
the care system providing people
and tools to support the member
Supporting Panel Ownership by
the primary care provider which
enables caring for a person as a
total being; earlier intervention in
disease progression; and greater
oversight of members with
chronic disease
Offering Alternatives to 1:1 Face-
to-face Office Visits which can
build capacity and give members
choice

31. Telephone visits are enabled and enhanced
by KP HealthConnect
While telephone visits could have been (and were on a small scale)
provided previously, Whittier has found that KP HealthConnect
enables greater ease, efficiency, and scale.
With KP HealthConnect…
All the relevant patient information
are easily accessed by the
provider during a telephone visit.
“Real-time” processing (notes,
lab-orders, Rx orders) is possible
during a telephone visit.
Work is completed during the
telephone visit with few or no
hand-offs required.
Case: Telephone Visits @ Whittier

32. Providers report that telephone visits are a
better way to manage patient demand
Case: Telephone Visits @ Whittier
Whittier Family Medicine Provider Survey, 4/2006
(10 Providers, 1: strongly disagree; 5: strongly agree)
5
4.7 4.6 4.6
4
3
2
1.5
1
0
Model makes Better way to manage Model gives me I want to go back to
my day easier patient demand for more control over old system
care my day
Whittier Family Medicine providers report that the phone visits gives them more
control and is a better way to manage patient demand.
The Medical Assistants for the physicians doing a higher quantity of phone
visits can use that time to assist in Population Care Management duties and
outreach for clinical strategic goals (PAP, Mammo, & Pneumonia vaccine
reminders)

33. Members are very satisfied with the telephone
visits.
Members Satisfaction with Telephone Visits
Members who had a telephone visits are
highly satisfied.
8%
87% ranked their satisfaction with the
5%
telephone visits a “5” on a scale of 1-5
(low/high). 87%
80% of members surveyed would be willing
5 = Highly Satisfied
4 = Satisfied
to “pay” something for a telephone visit. 3 = Neutral
Whittier is learning that members need to
be made aware of their options. Members' Willingness to
Pay for Telephone Visits
Whittier is working on “educating”
Percent Responding
members of their options and recently 25%
20%
had a test where all calls coming in for
15%
a physician was triaged first by an RN. 10%
Almost 40% of all calls resulted in a 5%
telephone encounter. 0%
$0 $5 $10 >$15 $ - Uncertain
how much
Dollar Amount
Note: KP is pursuing detailed surveys with Whittier members in July/August 2006 to get in-depth understanding of member reaction to telephone visits.
Case: Telephone Visits @ Whittier

34. Whittier is not doing the same work differently
but different work.
Old Model New Model (in testing)
1. Most patient-provider interaction 1. Patient has option to speak to
occurs face-to-face in the office. provider over the phone or email if
appropriate.
2. Medical Assistants spend the 2. Medical Assistants are able to use
majority of time processing their time to help proactively care for
patients, even those coming in patients with chronic conditions, e.g.
for “inappropriate” office visits. lab reminders, outreach, etc.
3. RNs triage and book follow-ups 3. RNs triage and offer members on
for nearly all patients requesting alternative care options and handle
appointment with physician. appropriate calls themselves.
We believe we are building capacity in our care team.

35. Access: Increasing capacity to touch more of
patients on our panel
Camp Springs Touches (Visits & Telephone) / Physician FTE
1050
791
~ 42 touches/
850 day/physician
650
292
~14 touches/
450 day/physician
250
Nov-06
Jan-06
Jun-06
Jul-06
Feb-06
Mar-06
May-06
Dec-05
Apr-06
Aug-06
Sep-06
Oct-06
Dec-06
From 2006 utilization for Camp Springs membership,
•Office Visit rate = 0.16
•Telephone rate = 0.27
Source: Clarity Warehouse. Report run by: National Analytical support. Note: Telephone includes TAVs and telephone encounters.

36. Access: Increasing capacity to touch more of
patients on our panel
Comparison of 21st CCI teams
Percent of Panel Touched - Office or Phone Encounter
2006
100%
Team 1 Camp Springs
Team 2
80% 73% Team 3 76%
69% Team 5
62% Team 4
56%
60% 51%
40%
20%
0%
Camp Springs IM - % of paneled members with
•76% of CS IM members engaged by
PCP encounter by month
office visits and phone encounter during
2006. 25%
20%
15%
10%
5%
0%
Jan-06 Feb- Mar- Apr-06 May- Jun-06 Jul-06 Aug- Sep- Oct-06 Nov-06 Dec-
06 06 06 06 06 06
Source: Clarity Warehouse. Report run by: National Analytical support. Note: Telephone includes TAVs and telephone encounters.

37. More Touches -- Less Visits
Average daily ‘Touches’ Average Daily ‘Touches’ with
before panel management panel management
80 80
70 70 US mail contacts
60 RN and HCT contacts
60
No. of Daily Contacts
No. of Daily Contacts
Email contacts
50 50
Phone contacts
40 40
Annual health goals
30 30
quot;Fast Trackquot;'s
20 20
Group visits
10 10 Office visits
0
Office visits
1 0 1
CEC Presentation 5/2/2005 Gerard F Livaudais MD, MPH Kaiser Permanente Hawaii Region

38. “Many Hands Make Light Work.”

39. What can we do?
Demo Site: http://devinternal.or.kp.org/im/demo/login.cfm

41. GreenField Health
Primary care practice
Research and development on delivery system design
Leadership in local and national performance
improvement initiatives (e.g., ACP, AAFP, IHI, AAMC,
etc.)
Services:
1. GreenField Health – 6 physicians
2. Practice management services
3. Teaching and consulting in practice performance
improvement

42. Physician Workspace
User Devices:
Wired PCs Telephones
Users

43. Staff Workspace
User Devices:
Digital Wired PCs +
Vitals Printers Telephones
Users

44. Devices for Clinical Users
Pen Tablet Convertible
•Battery
•Battery
•Screen
•Screen
•Stylus for point and click
•Stylus for point and click •Wireless Antennae
•Wireless Antennae •Physical keyboard like
•Virtual Keyboard Docking Stations notebook
•Voice files •Power •Voice files
•Handwriting recognition •Battery recharges •Handwriting recognition
•All Applications on the network •All Applications on the
•Node on the network
•All network devices (printers, network
•Nothing without a computer (either
fax) •All network devices
above)
(printers, fax)
Options that connect to Docking Station:
LCD Screen (no touch) Physical Keyboard Physical Keyboard
w/Touch Pad (plus mouse)

50. Beyond the Visit at GreenField Health:
Distribution of Patient Encounters
Number of Encounters by Type per Patient per Year
E-mail Phone Care
4.8 4.9
Office Visit
1.7

51. E-visits
The Myths are Not True
• Patients are very respectful of clinician time
• Managing challenging patients
• Patient are connecting to us as the trusted source, not
besieging us with garbage from the internet
• A great opportunity for managing challenging patients
• Doctors will not participate
Visit Prep
• Eliminates the need for some visits
• Makes visits shorter and more satisfying
• Eases documentation

52. Secure Messaging and E Visits
Issues of Reimbursement
• Easiest in integrated models
• Spreading adoption by insurers
• In addition to direct payment, consider:
Impact on overall productivity
Stickiness – patient allegiance to your practice
The energy of innovation
It’s the right thing to do

53. Knowledge Management
• Access to the right information at the right time to
support the continuous healing relationship
• Understanding the needs of our patients if they are
in the office or at home – population management
• Decision support to make the right thing the
easiest thing to do

54. “We Know You”
• Numerous options exist within the EHR to
allow providers to better “know” their patients.
Snapshot
Demographics
Problem Lists
Social Documentation
Health Maintenance Alerts
Flowsheets
Questionnaire

55. Prescribing

56. Refills

57. Knowledge Management

63. Summary
• Redesigning our practices around our
patients’ needs is our goal
• IT enables changes that we have always
wanted to make
• The EHR is a Trojan horse - Use the great
magnifier at the moment of flexibility to
improve all of your processes, clarify roles
and responsibilities and be more patient
centered

64. Thank You!
GreenField Kaiser
Health Permanente
Questions?