1. ... a KAISER PERMANENTE Innovation IndiGO: Tailoring Guidelines to Individuals David M Eddy MD PhD Founder and Chief Medical Officer Emeritus Archimedes San Francisco, CA

2. The Problem Quality and cost of healthcare are largely determined by guidelines Current guidelines are clunky – Designed for groups of people, not individuals – Designed for one risk factor at a time  E.g. blood pressure, cholesterol, glucose, … – Use sharp cut-points  E.g., “Treat if BP>140” – No information about effects on health outcomes – No basis for informed decisions – Implicitly assume all interventions are equally important

3. Today’s guidelines are too simplistic Mrs. Smith and Mr. Jones Who should be treated for hypertension? Age Height Weight Smoker Diabetes History of MI or stroke SBP DBP LDL HDL FPG Currently on hypertension meds Mrs. Smith 42 5’6” 244 no 142 88 116 61 89 no Mr. Jones 45 5’11” 345 no 138 80 178 35 116 no Risk of MI or stroke in 5 years Absolute risk reduction if lower BP 1.2% 0.4% 7.1% 2.1%

4. “Individualized Guidelines” IndiGO Uses all the important information in a clinically realistic way Spans multiple conditions, risk factors, treatments in a single “integrated guideline” Takes into account more than 30 patient variables Identifies all potentially beneficial treatments Calculates and displays patient’s current risks, and effects of treatments – One-by-one and in combinations Made possible by EHRs – Gets patient-specific data from EHR – Presents results through EHR

5. IndiGO is based on the Archimedes Model Archimedes Model – Spans multiple diseases – Is “physiologically and clinically realistic”  Represents physiology pathways  Is continuous – Includes care processes, behaviors, utilization, costs … – Is built from and validated against publicly available data  National datasets (e.g., NHANES, NACS, NHDS)  Clinical trials (e.g. NIH diabetes trials)  Epidemiological studies (e.g. ARIC) – Can be customized to particular settings

6. Some uses of IndiGO Individual patient-physician decision making – During a patient visit – Direct patient access Prioritize outreach programs A personal health score A population-level health score

10. Independent evaluation by Care Management Institute High physician acceptance – “All doctors agreed it helped them make the best decisions.” High patient acceptance – “It was pretty impressive, the tools and the outcomes and how it could show what is going on in my life. It made an impact.” – “For me it was more like the doctor wants us to be a participant in our own health you know. I guess without us participating, the results aren’t going be very good.”

11. Independent evaluation by Care Management Institute Increases patient adherence – Candidates for statins showed 6-fold increase in use Improves outcomes – A 13% reduction in 5-year CVD risk, compared to EHR and panel support tool alone – For every 1 million members, 1400 heart attacks and strokes averted annually Reduces hospitalizations and costs – Estimated $98 million saved annually

12. Adoption is good Kaiser Permanente – Southern California – Colorado – Georgia Two ONC Beacon communities – Colorado – Tulsa ACO pioneer – Fairview Seven others in progress More than 15 others in active discussion

13. This afternoon: Uses of IndiGO for ACOs Individual patient-physician decision making – During a patient visit – Direct patient access Prioritize outreach programs A personal health score A population-level health score