John A. Merenich, MD, FACP, FNLA Session #22: Integrating Process and Informatics at CO Kaiser Permanente to Achieve Benchmark Cardiovascular Outcomes John A. Merenich, MD, FACP, FNLA Pre-Session Poll Question What is the biggest challenge/barrier in your care setting to prevent stroke and heart attacks? Inconsistent misunderstood changing guidelines Lack of timely and accurate metrics Dependence on physicians to do all the interventions Patient resistance and non-compliance Time and money Medical Director, Clinical Pharmacy Cardiac Risk Service, KPCO Medical Director, Clinical Informatics & Decisions Support, KPCO Associate Clinical Professor of Medicine, University of Colorado

Poll Question #2eful***? What is the priority of implementing a stroke and heart attack prevention program in your care setting? Top priority – Our current outcomes are known, and they are NOT optimal. Clearly more needs to be done. High priority – Our current outcomes are above average, but we feel there is need for improvement. Moderate priority – We are satisfied that we have done what is needed in this area but don’t plan to do anything different for now. Low priority – We would like to do more, but our outcomes and baseline metrics are unknown and/or our implementation challenges are overwhelming. Unsure or not applicable Poll Question #2

Key Messages The Kaiser Permanente of Colorado (KPCO) approach of the past 15 years has resulted in benchmark outcomes Technology/Informatics support has been essential, but people and process factors were /are the primary drivers of cardiovascular (CV) outcomes Docs can’t and SHOULD NOT be solely responsible for CV outcomes Cardiovascular GAPS are the bridge between Process and Technology Risk stratifying to match resources to appropriate level of patient need helps identify opportunities and prioritize resources Tools to increase individualized, personalized care and Shared Decision Making are critical Colby – These objectives will align with the “Lessons Learned”. John M. - Consider re-writing this slide to be more memorable.

Kaiser Permanente by the numbers Nation’s largest nonprofit health plan Integrated health care delivery system 9.1 million members 17,000+ physicians 49,000+ nurses 175,000+ employees Serving 9 states and the District of Columbia 37 hospitals 618 medical offices/ outpatient facilities $50.6 billion operating revenue* Scope includes ambulatory, inpatient, ASC, behavioral health, SNF, home health, hospice, pharmacy, imaging, laboratory, optical, dental, and insurance Integrated health care delivery system: Health Plans, Hospitals (in some Regions), Medical Groups with aligned incentives and shared governance. We own our hospitals in some Regions, but not all. Where we do not own hospitals, “integration” still encompasses health plans and medical groups with shared mission, incentives, and governance. In Regions where we do not own the hospitals, success factors include: close alignment between medical group and contract hospitals members represent a substantial portion of the hospital’s business # of hospitals / clinics / providers Healthcare model Mission Strategic focus Etc. 4 4

Colorado KP: Population Health Management Priorities in 2015 Get more members self(co)-managing their care Get personalized ACTIONABLE care gap information directly to the member Easy access to educational, coaching, support materials Focus on maintaining Health & Wellness Earlier detection and PREVENTION of chronic diseases Slowing the progression of chronic diseases Reduce cost of providing Health Care (Triple Aim) Reduced ED visits and hospital admissions Promote more efficient care team collaboration Transition from Quality to VALUE dashboards KP Philosophy basic principles Reduce costs or increasing value??

KPCO winning strategy over the years PROCESS PEOPLE TECHNOLOGY Guidelines and protocols Driver diagrams/Process maps METRICS/METRICS/METRICS ***GOVERNANCE*** PATIENT-CENTERED focus Integrated teams Coordinated Care Patient as team member Registries Electronic Medical Record Web and other resources ACTIONABLE data Speaker: John Merenich Total time: TBD minutes Focus on technology aspect 80%

Flashback to 1996: The first KPCO problem to be solved… Gap between what we know should be done (evidence base) and what was actually happening for patients with known CAD High recidivism even when meds for CAD started Focus of resources on high-cost classic rehab MDs seldom had time to convey messages, start, and monitor therapy

Collaborative Cardiac Care Service 88% Reduction in all-cause mortality Teams Physician Nurse Clinical Pharmacist Technology & Tools Electronic medical record Computerized disease registry Information Development of protocols to improve outcomes Rehabilitation Program Medication Management Prompts and reports to support protocols – accessible to all members of care team Within 24 hrs. of discharge, all CAD patients admitted w/ acute coronary event are enrolled in a 3-6 mo. educational and case mgmt. cardiac rehabilitation program focused on: Smoking cessation Diet & exercise Psychological support Use of cholesterol-lowering medications (statins) Clinical pharmacy specialist assigned to manage medication regimen for as long as patient is with KP All patient interactions, medication orders, & lab test recorded in EMR for sharing w/ care team Over an average enrollment period of 3.6 yrs., compared w/ patients who did not participate: 89% decrease in all-cause mortality (88% decrease in cardiac mortality) for patients enrolled within 90 days of their cardiac event and remained enrolled continuously 76% decrease in all-cause mortality (73% decrease in cardiac mortality) for patients enrolled at any time following cardiac event Health care expenditures for CCCS enrollees were, on average, $60 less each day for an annual average of $21,900 per patient, per year. Researchers calculated total health care expenditures by extensively reviewing health care utilization claims and electronic health record files. They also attributed an overhead cost to the staff and systems used to administer the population management program. The analysis found that enrollees in the CCCS had lower health care expenditures across the board, including the following key areas: Medications: $4 per day, compared to $5 per day Doctor’s office visits: $7 per day, compared to $8 per day Hospitalizations: $19 per day, compared to $69 per day 8

The solution In 1996, KPCO developed the Collaborative Cardiac Care Service (CCCS) with the goal of improving the health of patients with CAD. Team consists of a nursing team (the KP Cardiac Rehabilitation program), a pharmacy team (the Clinical Pharmacy Cardiac Risk Service), and Primary Care and Specialty physicians. Collaboration systematically occurs with patients, primary care physicians, cardiologists, and other health care professionals to coordinate proven cardiac risk reduction strategies for patients with CAD. Evidence-Based Intervention includes activities such as lifestyle modification, medication initiation and adjustment, patient education, laboratory monitoring, and management of adverse events. All are all coordinated through CCCS. Speaker: John Merenich Highlight the key aspects of the CCCS solution

HealthTRAC registry system (separate from EMR) with “slice and dice” stratification and drill-down function Speaker: John Merenich All members are in one of these buckets Demo of HealthTRAC or discuss screenshots Team What tools did they have (EDW? Quality improvement? Analytics? Resources? What was your initiative goal? (overarching initiative objective) and the specific AIMS (individual project objectives you chose)? What were the success measures you established up front and your targets to track and report? How did you collect, validate, and analyze the data? What was the intervention(s) chosen and why? How did the team collaborate with and get buy in from others (leaders, sponsors, clinicians, font line workers) to implement the intervention? How did you deploy and implement the intervention? (training, education, materials, etc)?

**Colorado Kaiser Quarter 1 2014 CV event analysis Data drove next steps: ICVH The majority of CVD events occur in patients without previous history of ASCVD events** **Colorado Kaiser Quarter 1 2014 CV event analysis “First event” patients 65% Age (21-98) Average 66 yr Not on statin 61% Smokers/unknown status 30% DM 17% BP not controlled 22% CV Risk Unknown 21% Low Framingham Risk 10% Moderate Framingham Risk Colby suggestion /John M. - New slide title - “From Reactive to Proactive”

Integrated Cardiovascular Health (ICVH) ICVH team has met quarterly for last 10+ years Replaced all the previously “siloed” governing groups Puts holistic patient back in the middle where it belongs Representatives: PATIENTS, MDs (primary and specialty), Nursing, Pharmacy, Operations, Lab, Informatics, Nutrition, Prevention Owns and prioritizes the Regional ICVH Driver Diagram Coordinates care across teams Determines Informatics needs/priorities

People and Process: You need a driver diagram “If you don’t know where you are going, you’ll wind up someplace else.” (Yogi Berra)

“Treat the un/under treated” The “keep it simple” version: Integrated Cardiovascular Health Focus Last 5 Years On Primary Prevention “Test the Untested” LDL screening and CV risk determination & Statin for patients with diabetes Statin, ASA, and BP control for high-risk groups Exercise as vital sign Encourage consideration of statin for moderate risk “Treat the un/under treated”

Initial request: I just need a list of my patients with… REALLY??? (The aspirin example) Patients on ASA …takes you only so far!!! Where is ASA use documented; how often to determine “current” user Who is at risk and needs ASA; what dose? Other antiplatelet/anticoagulation meds? Age, gender, risk factors, changing evidence base Risk/Benefit for individual On other CV-risk reducing agents?

FROM List and rules…… …TO GAPS: Aspirin Indicated One or more of the following: · Age 18-80 And ASCVD And Not On Aspirin(ASA) And Not On Anticoagulant Medication And Not On Antiplatelet Medication · Age 18-80 And CV Risk > 10% And ASCVD Equivalent And Not On Aspirin(ASA) And Not On Anticoagulant Medication And Not On Antiplatelet Medication · Age 18-80 And CV Risk > 20% And Not ASCVD or ASCVD Equivalent And Not Diabetes And Not On Aspirin(ASA) And Not On Anticoagulant Medication And Not On Antiplatelet Medication · Age 40 to 80 And Diabetes And CV Risk > 10% And Not ASCVD or ASCVD Equivalent And Not On Aspirin(ASA) And Not On Anticoagulant Medication And Not On Antiplatelet Medication · Male Age 45-69 And CV Risk 15-19% And Not Diabetes And Not ASCVD or ASCVD Equivalent And Not On Aspirin(ASA) And Not On Anticoagulant Medication And Not On Antiplatelet Medication · Female Age 55-69 And CV Risk 15-19% And Not Diabetes And Not ASCVD or ASCVD Equivalent And Not On Aspirin(ASA) And Not On Anticoagulant Medication And Not On Antiplatelet Medication Colby suggestion – Should the title be more derogatory? “Do you get these Useless Reports?” …TO GAPS: Does this Patient meet KPCO criteria for ASA today…… YES or NO??

Lists to Actionable Data Elements of a Patient List A set of patients sharing a common set of characteristics such as diagnosis or medications. Elements of a complete registry Integrated with HealthConnect Individualized care pathways Integrated data sources Flexible design Automated outreach Integration of data from multiple sources Rule transparency Actionable care gaps Legally compliant (HIPAA, HASP) Automating elements of clinical workflow Individualized Rules Actionable Data Clinical Decision Support Population Based Rules Value Population Management Cohort List Complexity

Go to the “GREEN (bottom) LINE”

From Lists to ACTIONABLE GAPS: These patients need to do something! Colby suggestion – slide title may need to change. - Do you need an aspirin or not?

Constantly update and revise CV GAPS Individualized for every adult, Yes or No for: Need to screen for lab or blood pressure or Statin needed High DOSE statin indicated Aspirin Blood Pressure Med Aspirin GAP NEW Smoking documentation and counselling Dietitian visit revision

Getting ALL the GAPS into the workflow…. HealthTRAC Landing Page Colby/Emilia - Make this slide larger for the presentation so people can read it.

The “World According to Gap” GAPS: Simplified output for complex decisions Individualized/personalized Can be cofigured to accommodate for patient preference Easy to aggregate and display across disease state Single source of (synchronized) truth for all patient actions Truly actionable What to do and NOT do (e.g. Choosing Wisely efforts) “Currency” and lead metric for Informatics tools and process effectiveness (i.e. how efficiently GAPS are closed) Correlate with cost both short- and long-term outcomes

GAP “Solutions”: “Auto” ordering” Problem list status Active MD Consent (Enrollment in Population Program) GAP Corresponding Lab or procedure to close the GAP automatically ordered in our Epic system

GAPS in the workflow: Transparency, utility, context, and one-stop shopping ...and real-time decision support

Dynamic, Individualized

Decision support for Aspirin Indication: (Age/Gender specific Risk vs Benefit Shown)

GAPS Drive right to the Member level and view: “Personal Action Plan” Patient with CV GAPS in the EMR: Clicks On Action Plan in KP.org…

Measure and share unblinded metrics often to stimulate friendly completion and cross sharing of best practice John M. – Consider possibly omitting this slide… Speaker: John Merenich Share example of KP dashboard Available on intranet Drill down to MOB, department (e.g., Family Medicine, Internal Medicine), physician Unblinded Touch on incentives

Poll Question #3eful***? What would help your organization improve CV care, and where would you focus? EMR process management tools Actionable lists (gaps) based on advanced decision support Direct to consumer/patient portal tools Lead metric outcomes measures (e.g. number of patients on statins, BP control) compared to benchmarks “Slicer dicer” including utilization data for discovery at all business levels Poll Question #3 Title - “What would help your organization and where would you focus?” Follow up group participation 1Would you like to participate in a follow up group on this topic that would meet 2-3 times next year to share progress, challenges and best practices? (Yes, No) ***Recognizing that they are all important and would all be included in an optima solution

Cardiovascular Disease Value Dashboard Prototypes Quality: Cholesterol Management for Patients with Cardiovascular Conditions (Screening), Cholesterol Management for Patients with Cardiovascular Conditions (Control LDL-C Level<100 mg/dL) Resource Use: Inpatient, E&M, Surgery and Procedures, excludes Pharmacy

Major Coronary Events in KPCO have decreased by more than 60% the past 10 years (THIS DOES WORK!!!) MCVE- Major Coronary Events and CVA- purple MCE- Major Coronary Events- green MHC- Million Heart Campaign (MI and CVA)- not age/sex adjusted- red CVA/CVA death- blue

MCE/MCVE costs saved in KPCO MI: 2,375 fewer events per year over the last decade (accounting per population growth) CVA: 165 fewer strokes per year over the last 3 years (accounting per population growth) | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

Lessons Learned Informatics and Decision Support must be developed and structured by processes and people implementing them Risk stratify, divide, and conquer! Measure, share, adjust…over and over CV outcomes are the purview of ALL providers—not just Docs Indeed, CV care is largely empiric and the purview of teams and non-MDs...including the patient!! Allocate tools and resources to based on CV risk Develop tools to highlight ACTIONABLE PERSONALIZED GAPS NOT creation of endless LISTS GAPS must be accurate, timely, specific to patient, delivered at the time and place needed Quality first….Value will follow for the most part Colby - Lessons learned: 1st point – people 2nd point – process and technology important 3rd point – governance and metrics. 4th point – gaps. Where governance and metrics meet up with people, process and technology. 5th point – Follow up group participation 1Would you like to participate in a follow up group on this topic that would meet 2-3 times next year to share progress, challenges and best practices? (Yes, No)

Analytic Insights Questions & Answers A

Choose one thing… Write down one thing will you do differently after hearing this presentation Follow up group participation 1Would you like to participate in a follow up group on this topic that would meet 2-3 times next year to share progress, challenges and best practices? (Yes, No)

Thank You Follow up group participation 1Would you like to participate in a follow up group on this topic that would meet 2-3 times next year to share progress, challenges and best practices? (Yes, No)

Session Feedback Survey On a scale of 1-5, how satisfied were you overall with this session? Not at all satisfied Somewhat satisfied Moderately satisfied Very satisfied Extremely satisfied Follow up group participation 1Would you like to participate in a follow up group on this topic that would meet 2-3 times next year to share progress, challenges and best practices? (Yes, No) What feedback or suggestions do you have?

Upcoming Sessions Breakout Sessions – Wave 4 (1:15 PM – 2:00 PM) Panel – How Community Hospitals Thrive with Analytics John Wadsworth, Vice President, Technical Operations, Health Catalyst Quality Improvement in Healthcare: An ACO Palliative Care Case Dr. Robert Sawicki, MD, Senior Vice President, Supportive Care, OSF Healthcare Roopa Foulger, Executive Director, Data Delivery, OSF Healthcare Linda Fehr, RN, Division Director, Supportive Care, OSF Healthcare Clinical Standards Work To Improve Evidence-Based Care Delivery: A How-To Workshop Charles Macias, MD, MPH, Chief Clinical Systems Integration Officer, Texas Children’s Hospital Terri Brown, MSN, RN, CPN, Assistant Director, Clinical Outcomes & Data Support; Research Specialist, Center for Research and EBP, Texas Children’s Hospital Five Months to Improvement: How Stanford Built an Improvement Program the Gets Results Spencer H. Kubo, MD, Associate Professor of Radiology (Pediatric Radiology), Stanford University Medical Center Breaking Down Silos: Resolving Academic, Medical, and Research Interests Once and for All Samuel L. Volchenboum, MS, MD, PhD, Assistant Professor of Pediatrics, Director, Informatics Program, The University of Chicago Medicine) Location Grand Salon Imperial Ballroom A Imperial Ballroom B Murano Follow up group participation 1Would you like to participate in a follow up group on this topic that would meet 2-3 times next year to share progress, challenges and best practices? (Yes, No) Venezia