1. 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

2. 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

3. 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.

4. 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

5. 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??

6. 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%

7. 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

8. 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

9. 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

10. 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)?

11. **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 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”

12. 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

13. 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)

14. “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”

15. 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?

16. FROM List and rules…… …TO GAPS:
Aspirin Indicated One or more of the following:
· Age And ASCVD And Not On Aspirin(ASA) And Not On Anticoagulant Medication And Not On Antiplatelet Medication
· Age And CV Risk > 10% And ASCVD Equivalent And Not On Aspirin(ASA) And Not On Anticoagulant Medication And Not On Antiplatelet Medication
· Age 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 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 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??

17. 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

18. Go to the “GREEN (bottom) LINE”

19. 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?

20. 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

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

22. 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

23. 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

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

25. Dynamic, Individualized

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

27. 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…

28. 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

29. 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

30. 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

31. 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

32. 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.

33. 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)

34. Analytic Insights
Questions &
Answers A

35. 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)

36. 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)

37. 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?

38. 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