Problem Addressed

• Inadequate time and resources: Studies suggest that the typical primary care physician would need to devote 18 hours each day to provide a panel of 2,000 patients with all recommended screenings and chronic disease care.^1,2 This large time requirement stems in part from a lack of resources in most primary care offices, which tend to have few support staff and little access to electronic systems and tools to help in identifying and addressing care gaps. For their part, specialists typically do not consider it to be their job to identify and address such needs; even if they did, most specialists lack the time, knowledge, and resources to do so.
• Failure to provide recommended care: Due to these time and resource constraints, physicians often fail to provide patients with needed services. For example, only about half (54.9 percent) of adult patients receive all recommended preventive care services.³

Pertinent Quality Measures

Description of the Innovative Activity

• Electronic support tools with protocol-based algorithms: Physicians and staff have access to electronic tools that use algorithms based on established protocols to identify patients in need of various preventive, screening, and chronic care services. These tools also assist in documenting the care provided. Before development of these tools, clinicians had to manually search through a patient's paper chart and use a paper checklist to identify needed care. Key functions within the electronic system include the following:
  • Checklists and pending order sets: Through HealthConnect [Kaiser's electronic medical record (EMR) system], clinicians have access to electronic checklists on the Permanente Online Interactive Network Tools (or POINT) database. The checklists cover adult primary care, specialty care, and pediatric care, providing a list of gaps to be addressed and recommended actions to be taken based on established protocols for when patients should receive various services. The system also includes shortcuts known as "SmartTools" that allow the clinician to scroll through a list of common preventive care needs and set up pending orders for needed examinations, supplies, immunizations, or laboratory tests.
  • Educational materials: The system allows the clinician to select and print appropriate educational materials on a variety of topics.
  • Documentation support: The system allows staff to easily document actions taken through a system known as "SmartPhrases."
• Standardized processes during each visit: For every patient visit (including those to primary care physicians and specialists), a care team member (usually a medical assistant or nurse) performs standardized work processes before, during, and after the encounter to identify and address preventive, screening, and chronic care needs, as outlined below:
  • Proactive identification before encounter: Before each encounter, the team member uses the electronic tools described above to identify needed laboratory tests and health screenings, and to determine whether the patient has registered with KP.org (which gives the patient online access to most laboratory results, prescription and immunization status, and the opportunity to e-mail the physician's office). As needed, the team member contacts the patient roughly a week before the visit to provide previsit instructions and documents this encounter in HealthConnect. Beginning in 2008, the program began making automated preencounter phone calls to patients in need of blood glucose, lipid, and/or microalbumin testing, with the call encouraging these patients to get the tests completed before the office visit so as to maximize the value of their upcoming time with the clinician.
  • Management of encounter: During the encounter, the team member reviews and updates documentation of the patient's chief complaint, vital signs, physical activity levels, medications, allergies, and preferred pharmacy. The team member uses the electronic decision support tools described earlier to confirm any gaps in care, including whether the patient qualifies for an "exclusion" (e.g., women who have had a bilateral mastectomy do not need regular mammograms) and hence needs a special code to be entered into the system. The team member uses the system to set up pending orders for the clinician to review and discuss with the patient during the visit. The physician retains the right to override any system-recommended care, with no need to document the reason for the override in the system. The team member prepares the patient and examination room for any preventive, screening, or chronic care services that can be provided right away (e.g., Pap smear, foot examination for those with diabetes) and assists the clinician in providing these services during the visit.
  • Post-encounter followup: Immediately after the visit, the medical assistant or nurse ensures that the patient receives relevant information related to needed care that could not be provided during the visit. The team member also provides information on how to address ongoing health issues, including an after-visit summary, after-care instructions, health education materials, information on accessing KP.org, and any needed follow up appointments, or referrals. The patient may be contacted after the visit at the clinician's direction.
• Monthly performance reports: Each month, the Southern California Permanente Medical Group e-mails a report, known as the Successful Opportunities Report, to regional, medical center, and local program leaders. This report monitors the performance of each medical center, measured as the percentage of identified care gaps that have been addressed within 30 days of the initial appointment. The report covers the following areas: blood glucose, microalbumin, and low-density lipoprotein testing; breast and cervical cancer screenings; osteoporosis screening; pneumococcal vaccinations; retinal screening for those with diabetes; documentation of height and weight to calculate body mass index; smoking cessation counseling; lead screening; chlamydia screening; asthma questionnaire completion; and health education class attendance.
• Incentives for specialists: Taking responsibility for preventive, screening, and chronic care services that fall outside of their given specialty represents a big change for many specialists; for example, many neurologists do not see why they should care about making sure that patients with diabetes receive regular blood glucose testing. To engage specialists in providing such services, a small portion of their incentive (at-risk) compensation depends on their performance in reducing care gaps, with payouts tied to specific metrics. Primary care physicians do not have incentives directly tied to performance in reducing these care gaps, but rather can earn significant bonuses based on their broader performance on HEDIS measures.

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Innovator Disclosures

Results

• Enhanced provision of preventive and screening services: Between 2006 (before implementation) and the end of October 2010, Kaiser Permanente of Southern California experienced the following improvements in performance on HEDIS measures related to prevention and screening:
  • Cancer screening: The proportion of eligible patients screened for colorectal cancer rose by 19.9 percentage points (from 52.5 to 72.4 percent). Similarly, screening for cervical cancer among eligible patients increased by 4 percentage points (82 to 86 percent) while the screening rate for breast cancer rose by 3.1 percentage points (85.6 to 88.7 percent). For both cervical and breast cancer, the high initial screening rates make it difficult for the program to spur large improvements.
  • Advising smokers to quit: The proportion of smokers receiving cessation counseling rose by 18 percentage points (53 to 71 percent).
  • Influenza vaccines for seniors: The proportion of seniors receiving an influenza vaccination rose by 11.4 percentage points (60.2 to 71.6 percent).
• Better management of chronic disease: Over the same time period outlined above, Kaiser experienced the following improvements in the management of chronic conditions:
  • Diabetes management: The program improved management of diabetes, including the proportion of diabetics receiving a retinal examination (which rose from 61.6 to 79 percent), blood glucose test (88.8 to 94.2 percent), and lipid screening profile (88.6 to 92.8 percent).
  • Blood pressure control: The proportion of hypertensive adults (age 18 to 85) with their blood pressure under control rose by 15.3 percentage points (70.4 to 85.7 percent). The percentage of enrollees with diabetes who had their blood pressure under control rose by 9 percentage points (76.1 to 85.1 percent).

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Getting leadership, clinician, staff buy-in: The program represented a significant cultural shift for both staff and physicians, particularly specialists. To promote this change, the program leadership team presented the concept on multiple occasions throughout 2007 to various internal stakeholders, including medical directors, chiefs, nonphysician administrative leaders, and department managers. To win clinicians and staff over, the program team decided to engage them emotionally by showing them how this expanded role can help patients. To that end, the team worked with Kaiser's multimedia department to produce videos of patients explaining how preventive services had made a difference in their lives. One particularly powerful video involved a patient describing how a screening test helped to detect her cancer early and hence save her life. These videos have been shown in internal meetings and can be viewed on Kaiser's Intranet. The videos also feature physicians and staff (e.g., receptionists, medical assistants, and nurses).
• Developing and refining electronic tools: Electronic tool development occurred over time. The Pharmacy Analytics Services Group within Kaiser Permanente first converted existing paper checklists to electronic versions on Kaiser's POINT database. Because POINT and HealthConnect (Kaiser's EMR) did not communicate with each other, the system initially created confusion and mistrust among clinicians, as alerts sometimes were inaccurate or redundant. As a result, use of the electronic tools was limited. The project team then worked with the Pharmacy Analytics Services Group and the HealthConnect team to resolve these issues by integrating the database into the EMR.
• Developing standardized work processes, training materials: Working with the central department that handles training and employee education, a regional leader developed standardized primary care work processes and training materials for clinicians related to both preventive screenings and management of chronic conditions. The standardized processes defined the appropriate role for medical assistants and nurses given scope-of-practice regulations. Some materials were drawn from practices within various Kaiser facilities across the region that already followed elements of the program.
• Designating and training local team leaders: Regional program leaders met on a regular basis with teams at each medical center to discuss how to implement the program in the local setting, including any adjustments and customization needed to fit the environment. Using a "train-the-trainer" approach, these regional leaders emphasized the key principles and expected outcomes for the program, leaving local implementation up to medical center-based teams that worked with local primary care physicians, specialists, and office staff (see next bullet).
• Staged training and rollout at local level: As appropriate, the local teams used the materials described earlier to provide extensive training to physicians, nurses, and medical assistants on how to use the tools and perform new tasks, such as communicating with patients about sensitive issues (e.g., weight) and preparing patients for specific procedures (e.g., a foot examination for a patient with diabetes). The program rolled out in stages, as outlined below:
  • Primary care: In 2007, all primary care offices completed training and began program implementation.
  • Specialty care: In 2008, many specialty care staff received training on and implemented a streamlined version of the program focused on a subset of services. Work on adapting the standardized work processes to individual specialties continues in several areas, including obstetrics, oncology, and nephrology.
  • Urgent and emergency care: In 2009, urgent care centers and emergency departments received training, with program deployment currently underway.
  • Inpatient care: At present, the program is being tested in the inpatient setting in four pilot studies.

Resources Used and Skills Needed

• Staffing: Upfront and ongoing staffing needs are discussed below:
  • For program development: The program required significant upfront time from Kaiser information technology (IT) and Pharmacy Analytic Services staff to complete programming activities; as the initiative expanded and protocols changed, additional IT staff time has been needed to refine the electronic tools accordingly. Kaiser also had to allow physicians, nurses, and medical assistants to take time away from frontline patient duties to attend training sessions. Department and medical group administrators oversaw the implementation and training at each medical center.
  • For ongoing program operation: On an ongoing basis, Kaiser has not had to hire additional staff for this program, as existing nurses and medical assistants incorporate the work into regular duties. Because Kaiser recently implemented a system-wide EMR, staff no longer have to perform certain duties, thus freeing up some time. On average, the program has added roughly 3 minutes to each patient visit at Kaiser. (This figure varies by population and specialty and might be higher for organizations without electronic support tools.) However, the program has reduced the need for follow up visits, which frees up some staff time. Any organization considering adoption will need to evaluate existing staff capacity and the likely impact of the program on workload; some may find it necessary to hire additional nurses or medical assistants.
• Costs: Data on program costs are unavailable. Upfront costs consist primarily of compensation for IT programmers for the aforementioned programming time and compensation to physicians, nurses, and medical assistants for time spent in training. Once the initiative is up and running, program-related operating expenses are minimal.

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• Evaluate financial impact: The financial impact of this program will vary considerably across organizations. For capitated systems such as Kaiser, the program may initially raise overall costs as patients receive more services than they had in the past. Over time, the provision of these services may pay financial (as well as quality) dividends by preventing disease and catching problems earlier (e.g., diagnosing cancer at an earlier stage), thus reducing treatment costs. Organizations paid on a fee-for-service basis face different financial considerations, as the program will likely increase both revenues and costs as patients receive more services. For any organization, the program's positive impact on performance on HEDIS and other metrics could result in increased pay-for-performance payments from Medicare and/or other payers.
• Commit to culture change: As noted, clinicians (particularly specialists) will likely find that this program requires a significant change in culture and may resist the idea of taking responsibility for something they see as outside their specialty. Overcoming this challenge requires strong leaders committed to changing that culture. Success requires frequent communication over a several-year period, with an emphasis on why this program represents the right thing to do for patients. After a few years, the program typically gets embedded into the organizational culture, thus reducing the need for ongoing involvement by leaders.
• Consider use of patient stories: As noted, the patient videos proved to be a powerful way to get clinicians—particularly specialists—engaged in the program.
• Leverage existing IT: Although the program can be run without an EMR and other IT systems (e.g., by asking the patient at every visit about certain tests or by reviewing paper records), electronic tools can greatly enhance both the feasibility and effectiveness of the program by reducing staff-related demands, preventing individuals from slipping through the cracks, and allowing for ongoing monitoring (see first bullet in next section).
• Set up reliable, standardized systems: Like a checklist used in the operating room before a procedure (or in the cockpit before an airplane takes off), this program depends on the creation of standardized, reliable processes that will be consistently followed by everyone.
• Start slow, expand over time: Consider starting the program on a limited basis, with a focus on only a subset of the most important services. The scope of the program can be adjusted over time based on available capacity and staffing. This incremental approach helps to avoid overwhelming staff with new responsibilities and may prevent the need to hire additional personnel.

Sustaining This Innovation

• Monitor and report on performance: The monthly Successful Opportunities Report keeps physicians and staff focused on the provision of needed services. During the program's early years, Kaiser did not provide this regular feedback. Instead, leaders simply asked physicians and staff to perform certain screenings outside of their specialty. This approach failed, as clinicians initially complied but then stopped performing the screenings after a few months.
• Consider use of specialist incentives: Program leaders have found that tying even very modest incentives to performance has served to engage specialists in the program.

Additional Considerations and Lessons

• This program won the 2009 James A Vohs Award for Quality. This internal Kaiser award recognizes region-wide or medical center–based programs that have a meaningful impact on quality and can be transferred to other parts of the organization.

Use By Other Organizations

• The principles of the Proactive Office Encounter program have spread to several other Kaiser regions.