Kaiser's Long and Winding Road
Health Data Management Magazine, August 1, 2009
Electronic health records are in the spotlight, thanks to the federal economic stimulus package. Many hospitals and physician groups are scrambling to draft strategies to fully implement EHRs in time to qualify for maximum federal incentive payments. Relatively few have rolled out every component of a truly comprehensive EHR.
But Kaiser Permanente is entering the home stretch in what's turned out to be a seven-year drive to implement comprehensive EHRs, personal health records and related systems at all of its hospitals and clinics. The experiences of the Oakland-Calif.-based not-for-profit organization, which owns 431 medical offices and 35 hospitals plus a large health plan, provide valuable insights for others that aren't as far along.
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Key lessons learned along the long and winding road, says Andrew Wiesenthal, M.D., associate executive director of The Permanente Foundation, include:
* Training and related productivity losses represent more than 50% of the total cost involved in a big EHR project.
* Training of clinicians is more effective if it's done "on the job" rather than in classes before the EHR is rolled out.
* Deploying EHRs throughout a hospital in one "big bang" is more effective that phasing it in unit by unit.
* Organizations that own several hospitals can benefit from rolling out EHRs at one organization, studying what works and what doesn't, and then using the same implementation formula at all other hospitals.
But perhaps the biggest lesson of all, Wiesenthal says, is that implementing a clinical system is never really over.
"What we are doing now is going back to everyone who has been trained in the 'get along' phase of system usage and assessing what they know how to do and helping them learn how to do things better," he says. "The 'final' phase is learning how to change how we do things better for patients and transform care. We're just at the threshold of all sorts of wonderful stuff."
That "wonderful stuff" includes, among other things, using clinical data to identify what treatments yield the best results and then alter treatment protocols, Wiesenthal says. He serves as co-leader of the EHR effort in his role at the foundation, which is the parent company of The Permanente Medical Group, the group practice arm of Kaiser.
Kaiser's efforts to alter the practice of medicine by leveraging data in EHRs could provide a valuable example to other organizations down the road, says Laura Jantos, principal at ECG Management Consultants, Seattle. Although Kaiser "is so large and so complex" that its EHR technical strategies may not fit a number of other smaller organizations, Jantos says Kaiser's efforts to revamp care delivery offer lessons on true health care reform.
The Timeline
After many false starts on ambitious clinical automation projects, Kaiser announced early in 2003 plans to spend $1.8 billion over three years to implement a range of applications from Epic Systems Corp., Verona, Wis. These included EHRs, personal health records, computerized physician order entry, clinical decision support, scheduling and billing software for all its inpatient and outpatient settings.
The deal with Epic was groundbreaking. At that point, the company was known for its ambulatory systems and was still developing its inpatient systems.
The 2003 announcement came after Kaiser's earlier efforts at clinical automation moved along with limited success. Over the years, it had worked region by region with a number of other vendors. It also had tried to expand a regional homegrown system to serve other areas.
The revamped national effort ultimately grew into a seven-year, $4.2 billion project. Wiesenthal attributes the cost escalation and timeline extension to expansion of the project's scope. He says original plans called for implementing the Epic applications only at outpatient settings. But in media accounts of the original announcement and Kaiser updates, including those on the Health Data Management Web site, Kaiser executives repeatedly referred to the project as "enterprisewide" and encompassing all facilities.
Wiesenthal says the original three-year timeline "was a very aggressive statement on behalf of our CEO to get us to put our noses to the grindstone."
One significant source of delays, Wiesenthal notes, is that the state of California mandated that all hospitals meet rigorous new earthquake-resistance standards. So Kaiser delayed EHR implementation at many facilities while they were revamped or replaced.
Kaiser's not the first health care organization to encounter an I.T. project delay or cost overrun. Across the country, many large integrated delivery systems are discovering that the price tag for enterprisewide adoption of EHRs is higher than they originally anticipated, says Michael Mytych, principal at Health Information Consulting, Menomonee Falls, Wis. "It's not unusual to have an organization of this size and complexity to see a change in the size of their budget," he says.
In moving toward one cohesive, national strategy, Kaiser is building inpatient and outpatient records that populate one unified database, easing the way for doctors to access clinical information.
Kaiser completed implementation of EHRs at all of its 431 medical offices in the spring of 2008. Today, these clinics no longer have records rooms and use document imaging to scan in what little paper remains, Weisenthal says. Doctors at all these sites now place all orders electronically.
All but eight of Kaiser's 35 hospitals have fully implemented EHRs. Of those that have completed implementation, 12 already have been designated as achieving Stage 7 on the HIMSS Analytics scale of EHR implementation, a distinction attained by only one other health system so far (see page 43 for photo essay on NorthShore University HealthSystem, which has three Stage 7 facilities). HIMSS Analytics, a research unit of the Chicago-based Healthcare Information and Management Systems Society, ranks hospitals on a scale of 1 to 7 for clinical automation.
At each of its hospitals, Kaiser is implementing clinical automation in two phases, Wiesenthal says. In the first wave, the hospitals implement a wide range of clinical and financial systems. In phase two, they add computerized physician order entry and clinical documentation by physicians and nurses. Eight hospitals soon will enter phase two.
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