Special Journal Supplement A Focus on KP … · future of Kaiser Permanente (KP) using this new set...

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Special Journal Supplement

A Focus on KP HealthConnect

EDITORIAL COMMENTS1 Kaiser Permanente

HealthConnectCrossing the Quality Chasm.Louise Liang, MD

INTRODUCTION2 This is Getting Serious.

Andrew M Wiesenthal, MD

THE PROMISE3 Reengineering Care with

KP HealthConnect.George C Halvorson

7 KP HealthConnect: Fulfillingthe Vision of KP’s FoundingPhysician.Tom Debley

9 The Driving Vision:Pioneers of the EMR.Morris Collen, MD; AllanT Khoury, MD, PhD; PeggyLatare, MD

12 Entering the Decade of HealthInformation Technology.Brian Raymond, MPH

IMPLEMENTATION14 Adopting an Enterprise

Health Care Automationand Information System:The Initial Implementation.Peter DeVault

18 The Reality of EMRImplementation: Lessonsfrom the Field.Homer L Chin, MD, MS

24 Computers in the ExamRoom—Friend or Foe?Ward R Mann, MSN, FNP;Joanne Slaboch, MBA

Special Journal Supplement

A FOCUS ON KP HEALTHCONNECT

Guest Editors: Andrew M Wiesenthal, MD and Jon Stewart

As the KP HealthConnect system is rolled out across the regions, the editors of The PermanenteJournal gathered some of the significant participants in the development of the electronic medicalrecord (EMR) to share their thoughts, processes, insights, and learnings. This Special Feature delvesinto the history of the EMR at KP, the process for implementation throughout the regions, somevaluable lessons on using the computer in the exam room and as a clinical tool, on the interfacewith the Clinical Library, and the potential to transform the medical encounter.

PermanenteJournalThe

The Permanente Journal500 NE Multnomah St, Suite 100,Portland, Oregon 97232www.kp.org/permanentejournal

SOPHISTICATION27 Making the Right Thing

Easier to Do.Paul Wallace, MD

29 Population Care InformationSystems (PCIS): Managingthe Health of Populationswith KP HealthConnect.Joel Hyatt, MD; Warren Taylor,MD; Leslee Budge, MBA

32 The Clinical KnowledgeManagement Process BehindKP HealthConnect.Karen Woods; Melodi Licht, RN,MS; William Caplan, MD

35 A Universe at Your Fingertips:The Clinical Library andKP HealthConnect.Brad Hochhalter; Tom Stibolt,MD; Aaron Snyder, MD; DavidLevy, MD; Robert H Dolin, MD

TRANSFORMATION38 KP HealthConnect as a

Transformational Tool.Allan Weiland, MD

1The Permanente Journal/ KP HealthConnect Supplement 2004

Louise Liang, MD,Senior Vice President,

Quality and ClinicalSystems Support

Kaiser FoundationHealth Plan and

Hospitals Co-ExecutiveSponsor, KP

HealthConnect

Dr Liang was theFounding CEO andPresident of GroupHealth Permanente

adly, most of us have become used to practicingmedicine with incomplete information. Thanks to the

significant effort and investments that The PermanenteMedical Groups have expended over the years, we havefar better information than most physicians have avail-able to them. However, it still falls short of a fully inte-grated information system that parallels our integratedstructure. Our integrated structure is the core of who weare and is our strongest competitive advantage. KPHealthConnect will significantly increase our ability tomanage care across all settings, including the patient’shome. It will strengthen our partnership with our pa-tients and help them take ownership of their health.

The Care Management Institute has spent years un-derstanding what is truly evidence-based medicine. Thisknowledge will now be available literally at our finger-tips when we are making decisions in the exam roomwith our patients. Health information, patient instruc-tions, and self-care tools to support patients will be eas-ily available. Busy patients will have a more efficientoption than an office visit or phone call via secure mes-saging. Our experience at Kaiser Permanente Northwest(KPNW) and Group Health Permanente has taught usthat patients are very judicious in their use of this optionand will stay with us because of it. Phone call visits willbe more effective with immediate access to all clinicalinformation. Clinicians and staff will be able to person-alize care for patients based on their recorded prefer-ences. Testing and diagnostic results will always be avail-able, eliminating repeat studies and delays in care. Myriadadverse drug events because of unreadable or unavail-able information will be eliminated.

The experience of KPNW and Colorado PermanenteMedical Group with electronic medical records has taughtus that we have the potential to improve our alreadynationally recognized clinical performance to world-classlevels. No other health care organization in the world isbetter positioned to cross the quality chasm so well de-scribed in the Institute of Medicine’s recent reports.1 Ourcomprehensive longitudinal database will enable us tomake significant contributions to medical knowledge tohelp other health care organizations “cross the qualitychasm.” Each of us chose medicine knowing that wewere embarking on a lifelong journey in search of thebest care we could provide our patients. ImplementingKP HealthConnect will help us reach that goal.

At the same time, as we are poised to attain clinicalexcellence, we are beleaguered by demands for lower-cost health plan coverage. Hardly a week passes with-out a newspaper story describing the burden that healthcare costs place on individuals, employers, and govern-ment programs. Even employers and purchasers who be-lieve that integrated, comprehensive care is the best modelhave been demanding information that demonstrates thevalue we add. KP HealthConnect will give us both thedata to document our added value and the administrativeprocesses to administer deductibles and other cost-sharingproducts the market demands. This will ensure that we cancontinue to make care available to millions of patients.

But KP HealthConnect is not primarily about technol-ogy. It is about leveraging our integrated structure andchanging how we work with each other and with ourpatients. Like most very important work, it will be chal-lenging and difficult. Each of us will learn new skillsand processes. I recognize the personal stamina it takesto change such a fundamental part of how we practice.In addition, your clinical team will look to each of youfor leadership in this change. You can help provide theimportant clinical and competitive context for the $3.2billion investment that we are making over the next tenyears. We hope that this issue of The Permanente Jour-nal will give you a view of the many ways that weexpect KP HealthConnect to affect your work life, yourteam, and your patients.

The KP HealthConnect national team works very closelywith your regional team, Medical Group, and Health Planleadership to support the regional goals you have estab-lished. Together we are committed to ensuring as smoothan implementation as possible. Nonetheless, we are un-dertaking a very complex transition and there will besetbacks, frustrations, and long days for everyone involved.Despite this, I have not met a single physician who wantsto stay with our current fragmented systems. In the end,our shared commitment to the excellence we can achievetogether will vault us over the quality chasm. ❖

Reference1. Institute of Medicine, Committee on Health Care in

America. Crossing the quality chasm: a new health systemfor the 21st Century. Washington (DC): National AcademyPress; 2001. Available from: http://www.nap.edu/books/0309072808/html/ (accessed September 28, 2004).

S

Kaiser Permanente HealthConnect

Crossing the Quality Chasm

editorial comments

KP HealthConnect

2 The Permanente Journal/ KP HealthConnect Supplement 2004

health systems

Special Feature

This is Getting Serious

t a recent meeting, my boss,Jay Crosson, MD, was heard

to say, “This is getting serious.”Indeed it is. Some time during

2004, every region will havelaunched a part of the KPHealthConnect suite of systems. Is-sues and problems that were theo-retical in 2003 now have real op-erational significance. Everyone inthe organization will need to learnnew software, learn new ways ofperforming their work, and beginto think about how to build thefuture of Kaiser Permanente (KP)using this new set of tools.

The implementation of complexsoftware like KP HealthConnectcan usefully be divided into threephases: adaptation, sophistication,and transformation. Adaptation isthe process by which people getcomfortable with the basics—per-forming the essential tasks of pa-tient care and other parts of ouroperations through a limited, “get-through-the-day” approach tolearning the software. “I’ve got todocument my work, write orders,and manage results, and I prob-ably won’t learn anything else un-til I learn how to do those things.”Once a user has adapted to the soft-ware, they can move on to sophis-tication. This advance involves aricher exploration of all the featuresand functions of the software, mak-ing it possible to perform thosebasic tasks and produce better re-sults—of higher quality, safer, ormore efficient. Transformation oc-curs when a user or group of us-ers figures out how to do some-thing completely new, somethingperhaps that couldn’t have beendone before, by using the new tool.

All of us who have worked toimplement electronic health recordsoftware in KP during the past twodecades have expended a greatdeal of energy making sure that allusers adapt. Adaptation is essen-tial. If people cannot use the sys-tem to do their basic work, theimplementation will fail. We alsoknow that most users remain atthat stage, because additional in-vestments in training are requiredto help them progress to a moresophisticated level of use. Sophis-tication is desirable because thesystem will not benefit membersor staff in any substantial way ifall that is achieved is limited au-tomation of current processes. Wewant users to take the fullest ad-vantage possible of the capabili-ties of the software.

The real goal is transformation.What we really want is to do newand better things as we work withmembers, abetted by the software.Here, it is more a question of cre-ating an environment that fostersthe creative use of the tool, ob-serving the impacts of that creativ-ity, and widely propagating thesuccessful ideas while pruning outthe unsuccessful ideas or the oldprocesses that the new ap-proaches have supplanted. Whentransformation becomes our rou-tine, the implementation of KPHealthConnect can truly be char-acterized as successful.

We have asked some notewor-thy experts to help describe ap-proaches to moving our KPHealthConnect users through ad-aptation to sophistication and be-yond to transformation. GeorgeHalvorson shares his vision for the

A

future and how KP HealthConnectplays a key role. Peter DeVault,from Epic Systems, gives us thebenefit of our vendor’s broad ex-perience in implementing their sys-tem, and Homer Chin, MD, whohelped lead implementation ofEpic in the Northwest, shares somevaluable lessons learned from theirexperience. Paul Wallace, MD, Ex-ecutive Director of KP’s Care Man-agement Institute, describes howKP HealthConnect combines withour capacity to understand medi-cal evidence to enable our clini-cians to do the right thing. Thereare also some historical tidbits,

By Andrew M Wiesenthal, MDAssociate Executive Director, Clinical Information Support

The Permanente Federation

The dynamic duo of KP HealthConnect, Drs Andy Wiesenthal andLouise Liang have served as point persons for the top leadershipof the medical groups and the health plan in ensuring a successfulimplementation of KP HealthConnect in all of KP’s regions.

commentaries from various cham-pions of KP’s implementation ini-tiatives, and more. We thought youwould enjoy having the benefitsof all these experiences, and wewelcome hearing from you aboutyour own.

Thinking about my role in thedevelopment and implementationof electronic health records at KPbrings to mind a Jerry Garcia quote—“What a long strange trip it’sbeen.” I have been on it for a longtime, and, as I contemplate the richpossibilities described in the articlesthat follow, I am excited about thenext leg of the journey. ❖

I N T R O D U C T I O N


health systems

KP HealthConnect

Reengineering Care with KP HealthConnectBy George C Halvorson

Many of America’s health care costs, finan-cial and otherwise, result from its current pa-per-based approach to maintaining patientrecords. This nonsystem often leads to incon-sistencies in patient care (poor quality) anddysfunctional information transmission systems(inefficiencies). It is an outmoded, ineffectivesupport system for caregivers. A fully comput-erized system, including patient-specific medi-cal records, reminders, and treatment protocols,is needed to provide complete informationabout each patient to the caregiver in the examroom. That electronic tool is the missing linkbetween current inconsistent care and best care.After years of experimentation and develop-ment, these tools are now ready for practicaluse by caregivers, and multispecialty grouppractices (including prepaid group practices)are the logical environment for the initial large-scale use of these approaches.

Poor Quality andInconsistencies

Evidence compiled by researchers fromseveral high-profile organizations—includingthe Institute of Medicine, the National Com-mittee for Quality Assurance, RAND, and theDartmouth Atlas Project—points toward thefact that the actual delivery of health care inthis country too often varies from science-basedbest practice.1-6 Study after study of health careperformance shows wide variations in bothtreatment approaches and care outcomes—with levels of performance inconsistency thatwould be unacceptable in any other area ofthe American economy.

Some specific examples of variation frombest practice include the following:

• Heart disease is America’s number onekiller (approximately one person dieseach minute from a coronary event),6 yetnearly half of America’s heart attack pa-tients do not receive the most effectivefollow-up care.1

• More than 6% of the American popula-tion has diabetes,6 but fewer than halfof America’s diabetics receive the levelsof care necessary to reduce or preventcomplications.5

• High blood pressure (hypertension) isthe most treatable cardiovascular disease;however, roughly 40% of America’s hy-pertension patients do not receive themost current and appropriate levels ofcare, resulting in 68,000 prematuredeaths each year.5

Another sad fact for the currentpractice of medicine is that withrare exceptions, no one externalto the caregiver or patient has anongoing quantitative sense ofwhether or not the approachesused are effective or add optimalvalue for a given patient or forpopulations of similar patients.Unless care is so out of line as toconstitute malpractice—an extremely rareevent—there is almost no process in mostsettings for determining what is or is not work-ing in any comparative sense for individualsor groups of patients or for any aggregationof caregivers.

In fact, using today’s nonsystematic meth-ods of communicating new medical science,it can take many years for a valuable new bestpractice to become the routine standard of care.As noted, the normal compliance level withbest practice typically falls short for manyimportant care approaches. No other indus-try or portion of the economy takes anywherenear this long to disseminate new approaches.Most industries retool yearly, if needed.Reengineering is a constant fact of life. Healthcare has been a glaring exception to that rule.

Dysfunctional InformationTransmission

Quality deficiencies and inconsistencies areexacerbated by the fact that the noncomputerizedcare improvement processes used by most pro-viders and health plans rely on the distributionof paper-based patient status reports and in-formation about best care. Attempting to dis-tribute pieces of paper about these topics toeach caregiver is at best inconsistent and atworst expensive, time-consuming, and frus-

trating. Care sites are typicallyunconnected, and passing onbest-practice information at aone-on-one, doctor-to-doctor,teacher-to-caregiver level canbe a logistical nightmare evenin a group practice setting.

Health care is an informa-tion-dependent profession thatis operationally handicapped bya remarkably dysfunctional in-

formation transmission nonsystem. In an erawhen practically every other major segmentof the economy relies on computers for dataflow, decision support, and production im-provement, health care still stores all-importantpatient-based data on inaccessible, incomplete,

Excerpted from Epilogue: Prepaid Group Practice and Computerized Caregiver Sup-port Tools; Toward a 21st Century Health System: The Contributions and Promise ofPrepaid Group Practice by Alain Enthoven and Laura Tollen, editors. (April 2004;$30.00; Cloth) by permission of Jossey-Bass/A Wiley Imprint

George C Halvorson is Chairman and Chief Executive Officer of Kaiser FoundationHealth Plan, Inc, and Kaiser Foundation Hospitals. He is a frequent lecturer and writer

on health care topics.

Reengineeringis a constantfact of life.

Health care hasbeen a glaringexception to

that rule.

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health systems

Special FeatureReengineering Care with KP HealthConnect

sometimes inaccurate, and frequently illegiblepaper files. Filing systems are almost alwaysset up and segregated by individual care pro-viders or treatment sites, not by individualpatients. In this country, a patient who re-ceives care from three separate doctors gen-erally ends up with three separate paper fold-ers, with different contents, located in threeseparate metal file boxes.

Dysfunctional informationtransmission means that neitherphysicians nor patients nor re-searchers can benefit from thefull spectrum of useful or timelydata. Keeping up to date on cur-rent best practices is difficult.Doctors who want to keep upon medical research in theirspecialty are confronted by in-formation overload; an esti-mated 1500 medical articles arepublished each day, and thereare about 4000 health-relatedjournals to choose from.7 It is simply be-yond the ability of any single physician tokeep up with all this information, let aloneremember it when confronted with a patientfor whom that information would be relevant.

As a result, when the typical solo-practicedoctor enters an exam room to see a patient,s/he often has no systematic tools at hand toremind him/her of the patient’s specific needsor the full scope of care most appropriate tothe patient’s particular diagnosis, condition, andtreatment plan. The physician typically relieson memory for large portions of each patient’scurrent and future treatment regimen—includ-ing dosages of drugs and duration of thera-pies. The physician seldom, if ever, receivesany systematic follow-up information aboutthe patient or the patient’s compliance withcare. The patients themselves often leave theexam room trying hard to remember the fouror five key points that the doctor told themabout their follow-up care.

The Solution: ComputerizedCaregiver Support Tools

Anyone who looks closely at the inconsis-tency of health care practice must concludethat computerized caregiver support tools—

including “electronic,” “automated,” or “com-puterized” medical or patient record systemsand treatment protocols—are the best way ofachieving optimal care for large numbers ofpatients. These tools can make best care easierand more likely to occur.

Giving physicians, other health care practi-tioners, and researchers appropriate access to

this information is the key tomoving care delivery andquality to the next level of per-formance. Each physicianshould be able to quickly trackthe care given to each patientagainst the very best and mostcurrent protocols. This systemshould enable them to remem-ber what tests need to bedone, what drugs need to beprescribed, what follow-upcare needs to be accom-plished, and even when refer-ral to specialty care is advis-

able. The data system also needs to beaccessible to medical researchers so that theycan tell, on an ongoing basis, which drugs areworking, which procedures are creating valuefor the patient, and which technologies areleading to the very best improvements in pa-tient outcomes.

Another critical function of a clinical infor-mation system is to generate complete andeasy-to-use information for patients abouttheir condition and their care. The informa-tion for each patient can be programmed tobe culturally competent and multilingual, re-ducing the misunderstandings and miscom-munications that now occur far too often inan increasingly diverse society. In the bestsituation, the system should also provide pa-tients with direct, confidential access to theirown medical history and information—alongwith patient-focused medical protocols andbest practice information.

Benefits of ComputerizedCaregiver Support Tools: TheEvidence

New and more reliable computerizedcaregiver support tools (or clinical informa-tion systems) have the potential to achieve

many of the ideal system qualities describedin the Institute of Medicine’s Crossing theQuality Chasm report.1 In a comprehensiveanalysis of the peer-reviewed literature,Raymond and Dold found strong evidenceto support the notion that such systems doin fact improve safety, efficiency, timeliness,and quality.8-12 They also found that thesesystems have potential for improving serviceand patient satisfaction through enhancedcommunication and information sharing.

In their review of nearly 100 published stud-ies spanning 30 years of research, Raymondand Dold document improvements in preven-tive health services, disease management, drugprescribing and administration, documentationof data, access to clinical information, andavoidance of medical errors—all resultingfrom the use of clinical information systems.8

Clinical information systems also showpromise for increasing administrative efficiencythrough improved work flow and time sav-ings, streamlined information storage and ac-cess, and enhanced billing efficiency.8 Use ofelectronic medical records saves resources, in-cluding physician and clerical staff time,13 stor-age space,14 and ultimately money.15

The successes have all resulted from at leasta partial computerization of care: in each case,the computer was used to enhance a particularaspect of care delivery. But the impact of acomplete care support tool has yet to be fullytested. There is every reason to believe that themore complete systems will achieve even moresuccess than the partial systems tested to date.

Pioneers of ClinicalInformation Systems

Although most health care practitioners andinstitutions in the United States are not yet readyto implement clinical information systems, a fewhave positioned themselves as pioneers intheir use of such systems.9 Multibillion-dollartechnology investments are being made byKaiser Permanente (KP), the Mayo Clinic, In-termountain Health Care, the Henry FordHealth System, and Geisinger Clinic, amongothers.a Group Health Cooperative has dem-onstrated through research the value of auto-mated records in improving chronic care man-agement; in particular, diabetes care.

Health care isan information-

dependentprofession thatis operationallyhandicapped by

a remarkablydysfunctionalinformationtransmissionnonsystem.

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health systems

KP HealthConnectReengineering Care with KP HealthConnect

KP’s own work with clinical information sys-tems dates back over 40 years to 1961 whenMorris Collen, MD, a founding partner of ThePermanente Medical Group and the first direc-tor of the organization’s research arm, piloted acomputerized medical records system in SanFrancisco (see page 34). This effort ultimatelyprovided researchers with a vast database ofmember health conditions, which is still usedby researchers today to study care delivery.16-17

Although withdrawal of federal fundingprevented the regionwide deployment of DrCollen’s automated record system, KP has con-tinued to innovate in the use of informationtechnology to improve care.17 Within the or-ganization, computer-based technologies haveincluded an automated appointment bookingand registration system (PARRS) piloted in 1977;a computerized hospital information system(ADT), in place by 1985; an outpatient phar-macy dispensing and tracking system (PIMS)implemented in 1988; and theClinical Information PresentationSystem (CIPS), which began de-livering real-time, patient-spe-cific, clinical information to phy-sicians’ desktops in 1993.

Fulfilling Dr Collen’s vision ofa truly automated medicalrecord, KP is currently investingnearly $3 billion over the nextseveral years to build an inte-grated clinical information sys-tem for its more than eight mil-lion members nationwide. Thissystem moves beyond electronicmedical records and includeselectronic documentation of pa-tient visits, order entry for medi-cations and procedures, and link-ing of inpatient and outpatientcare. Kaiser Permanente estimates that whenfully implemented, the new system will resultin annual savings of approximately $500 mil-lion, due to cost avoidance, cost savings, andimproved and more accurate reimbursement.b

Although only a small portion of the indus-try is currently on track to implementsystemwide clinical information technology, acritical mass of multispecialty group practiceusers are choosing the same software vendor,

including KP, Cleveland Clinic, Sutter Health,University of California at Davis, and Palo AltoMedical Foundation.c These developments maylead to increased opportunities forinteroperability among care systems. Under theauspices of the Council on Accountable Phy-sician Practices, some of these group practicesare beginning to meet with each other to stan-dardize data flow and share learning.d

ConclusionJust about every informed observer of the

health care system now recognizes and deploreswhat the Institute of Medicine identified as avast and dangerous inconsistency of care.1 Wecan reduce some of that inconsistency by mak-ing improvements in the context of our currentmedical processes and paper-based patient in-formation systems. But we can’t have highlyreliable, up-to-date care and optimal value forthe health care dollar until we have a com-

plete electronic medical recordfor each patient and until wemake usable, efficient clinicaltools and information abouteach patient available to thephysician at the exact pointand time of care. Without suchclinical information technology,the current cost burden willcontinue to grow, and vastnumbers of patients will con-tinue to receive inconsistent, of-ten inadequate, and sometimesdangerous care.

Once best care has beendemonstrated—through theuse of computerized caregiversupport tools by America’sleading multispecialty andprepaid group practices—

market competition will force the rest ofAmerican caregivers to follow (particularlyif employers and government create appro-priate market conditions). This will not hap-pen until best care is thoroughly demon-strated, however. Because of their inherentadvantages, prepaid group practices are natu-ral laboratories for learning about the ben-efits and uses of these systems.

Reengineering of care support is an evolu-

tion, as opposed to a revolution. Once thebenefits of clinical information systems be-come obvious to policymakers, purchasers,and the public, it is logical to expect that majorsegments of the health care deliverynonsystem will figure out how to work withpayers or each other to create functionalequivalents of the integrated approach. Thisshould ultimately result in the building, inmultiple settings, of virtually integrated groupsand plans. Delivery systems with the size,scale, and incentives to overcome the barri-ers to technology adoption will likely emergefrom mergers, acquisitions, and affiliations.Technology diffusion will accelerate as theclinical information system business case isrepeatedly validated with measurable and sig-nificant return on investment and as success-ful strategies are replicated and found to betransferable across organizations.

Narrowing the performance gap betweenintegrated and fragmented care will clearly re-quire greater information connectivity, whichdoes not come easily or cheaply. The ultimatebeneficiaries, however, will be patients. ❖

a See also: Coddington DC, Fischer EA, MooreKD. Strategies for the new health caremarketplace: managing the convergence ofconsumerism and technology. San Francisco:Jossey-Bass, 2001.

b The total estimated annual savings is expressedin current dollars. The programwide estimate isbased on an extrapolation from two board-reviewed business cases developed by KaiserFoundation Health Plan, Inc: National ClinicalSystems Planning Consulting, “SouthernCalifornia Outpatient AMR Business Case”(February 2002) and “Regionalized HISBusiness Case” (August 2003).

c The software vendor chosen by many of theseorganizations is Epic.

d For information about the Council of Account-able Physician Practices, go to: www.amga.org//CAPP.

References1. Institute of Medicine, Committee on Health Care

in America. Crossing the quality chasm: a newhealth system for the 21st Century. Washington(DC): National Academy Press; 2001. Availablefrom: www.nap.edu/books/0309072808/html/(accessed September 28, 2004).

2. Kohn LT, Corrigan JM, Donaldson MS. To err ishuman: building a safer health system.

KaiserPermanente

estimates thatwhen fully

implemented,the new system

will result inannual savings

of approximately$500 million,due to cost

avoidance, costsavings, and

improved andmore accurate

reimbursement.

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Special Feature

Washington (DC): National Academy Press;2000. Available from: www.nap.edu/books/0309068371/html/ (accessed September 28,2004).

3. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ,Lucas FL, Pinder EL. The implications ofregional variations in Medicare spending. Part1: the content, quality, and accessibility of care.Ann Intern Med 2003 Feb 18;138(4):273-87.

4. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ,Lucas FL, Pinder EL. The implications ofregional variations in Medicare spending. Part2: health outcomes and satisfaction with care.Ann Intern Med 2003 Feb 18;138(4):288-98.

5. McGlynn EA, Asch SM, Adams J, et al. Thequality of health care delivered to adults in theUnited States. N Engl J Med 2003 Jun26;348(26):2635-45.

6. National Committee for Quality Assurance.The state of health care quality: 2003.Washington (DC): National Committee forQuality Assurance; 2003. Available from:www.ncqa.org/communications/State%20Of%20Managed%20Care/SOHCREPORT2003.pdf (accessed September28, 2004).

7. Crosson J. Patient safety and the group practiceadvantage. Perm J 2001 Sum;5(3):3-4.

8. Raymond B, Dold C. Clinical informationsystems: achieving the visions. Oakland (CA):

Kaiser Permanente, Institute of Health Policy;2002. Available from: www.kpihp.org/publications/briefs/clinical information.pdf(accessed September 28, 2004).

9. Crane RM, Raymond B. Fulfilling the potentialof clinical information systems. Perm J 2003Winter;7(1):62-7.

10. Austin SM, Balas EA, Mitchell JA, Ewigman BG.Effect of physician reminders on preventivecare: meta-analysis of randomized clinicaltrials. Proc Annu Symp Comput Appl Med Care1994:121-4.

11. Balas A, Austin SM, Mitchell JA, Ewigman BG,Bopp KD, Brown GD. The clinical value ofcomputerized information services. A review of98 randomized clinical trials. Arch Fam Med1996 May; 5(5):271-8.

12. Shea S, DuMouchel W, Bahamonde L. A meta-analysis of 16 randomized controlled trials toevaluate computer-based clinical remindersystems for preventive care in the ambulatorysetting. J Am Med Informatics Assoc 1996 Nov-Dec;3(6):399-409.

13. Garrett LE Jr, Hammond WE, Stead WW. Theeffects of computerized medical records onprovider efficiency and quality of care. MethodsInf Med 1986 Jul;25(3):151-7.

14. Renner K. Cost-justifying electronic medicalrecords. Healthc Financ Manage 1996Oct;50(10):63-4,66,68 passim.

Reengineering Care with KP HealthConnect

15. Evans J, Hayashi A. Implementing on-linemedical records. Document Management1994 Sep-Oct;12-7.

16. Putting research and innovation into practice.TPMG Forum 2003 May-Jun;15(3). Availablefrom: http://cl.kp.org/portal/site/ncal/index.jsp?epi-content=FRAME&url=http%3A%2F%2Fcl.kp.org%2Fpkc%2Fncal%2Fclib%2Fnews%2Ftpmgforum%2may jun 2003%2Findex.htm&beanID=1015122182&epi baseMenuID=null&epi menuItemID=1f123709700a26b91af671918f07dea0&epimenuID=700371804081a0691af671918f07dea0http://cl.kp.org/portal/site/ncal/?epimenuItemID=1f123709700a26b91af671918f07dea0 (accessed September 28, 2004).

17. Kaiser Permanente. KP pioneer honored byHealth Care Congress. Inside KP: California.2001. Available from: http:kpnet.kp.org/California/insidekp/special/dr_collen_10_2001/index.html (accessed September 28, 2004).

18. The automated medical record: from virtual toreality. TPMG Forum 2003 Jul-Aug;15(4).Available from: http://cl.kp.org/portal/site/ncal/index.jsp?epi-content=FRAME& url=http%3A%2F%2Fcl.kp.org%2Fpkc%2Fncal%2Fclib%2Fnews%2Ftpmg forum%2Fjul aug 2003%2Findex.htm&beanID=1015122182&epi baseMenuID=null&epi menuItemID=1f123709700a26b91af 671918f07dea0&epi menuID=700371(accessed September 28, 2004).

Notable WinnersHistory has demonstrated that the most notable winners usually

encountered heartbreaking obstacles before they triumphed. They wonbecause they refused to become discouraged by their defeats.

BC Forbes, 1880-1954, financial journalist, founder Forbes

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a moment in time

KP HealthConnect

KP HealthConnect: Fulfilling the Visionof KP’s Founding Physician

By Tom Debley

and diffusion, and … we should begin to take advan-tage of the potential of electronic digital computers.”2

Early on, the vision developed of an electronic medi-cal record that could serve patients across the nation—far ahead of any capability of early computer systems.In 1965, Cecil C Cutting, MD, then Executive Directorof The Permanente Medical Group (TPMG), predictedit in a speech to scientists at a meeting of the AmericanAssociation for the Advancement of Science at the

University of California Berkeley.“Each member,” he said, “would auto-

matically and periodically be called infor service. All histories and findingswould be recorded by computers andmade available to the physician wher-ever members go for needed definitivemedical care.”3

As interesting as the story is of the re-search and implementation of projectsthat evolved—including development ofboth new hardware and software for thejob—equally fascinating is the vision ofDr Garfield in historic retrospect. He sawthe potential for tracking medical infor-mation that could help patients achieve“optimal health”—a vision being taken

into the 21st century with KP HealthConnect.“… The great promise of computers for medicine lies

in making an entirely new medical care system possible,”Garfield wrote in 1974.4 “Such a new system is just nowbeginning to take form and emerge from the old.

“… Health care [emphasis in original] is a new divi-sion of medicine that does not exist in this country orany country. Its purpose is to improve health and keeppeople well.

“The system holds great promise for the provision oftruly preventive care. We need no longer generalize,but instead we can instruct each individual about whathe should do for optimal health on the basis of his

Tom Debley is Director of Heritage Resources for Kaiser Permanente. Heritage Resources is a ProgramOffices endeavor launched in 2003 to continue to collect, preserve, and share the history of Kaiser

Permanente. Mr Debley has been with KP since 1995. E-mail: [email protected].

When the centenary of the birth of founding KaiserPermanente (KP) physician Sidney R Garfield is markedin 2006,a full implementation of KP HealthConnect thesame year will be a fitting tribute. The reason: It wasDr Garfield who first urged KP to embrace computertechnology in May 1960 “to acquire and store medicalinformation.”1

Dr Garfield’s call came at KP’s first interregional man-agement conference in Monterey, CA, which focusedon forecasting and planning for the de-cade of the 1960s. Dr Garfield argued—in the words of John G Smillie, MD—that KP “should not be a sick plan but ahealth plan in the full sense of the term:an ongoing commitment to the mainte-nance of health in the membership.”1

To accomplish this, he envisioned infor-mation technology as part of a three-pronged approach described by Dr Smillie:

“New methods of providing health careas opposed to sick care must be tested.

“New technology must be used to ac-quire and store medical information.

“Non-physician medical personnelmust be brought further into the healthcare process, under physician supervi-sion, so as to extend the scope and efficiency of phy-sician treatment.”1

Over the decade, Dr Garfield’s technology challengetriggered a proliferation of early research and imple-mentation—first in Northern California, led by MorrisF Collen, MD, but quickly expanding into NorthwestPermanente (NWP) and the Southern CaliforniaPermanente Medical Group (SCPMG) and, in the ensu-ing decades, across KP.

The first step was to dispatch Dr Collen to a nationalcongress on medical electronics in New York. He re-turned “to confirm that Dr Garfield was correct: medicalelectronics was beginning a period of great innovation

Dr Garfield …saw the

potential fortracking medicalinformation that

could helppatients achieve

“optimalhealth”—a visionbeing taken intothe 21st century

with KPHealthConnect.

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a moment in time

Special Feature

own updated profile. Such personalized instructionshould lead to maximum motivation and cooperationon the part of patients.

“This change from episodic crisis sick care to pro-grammed total health care forces a new look at therecording and processing of medical information …

“Continuing total health care requires a continuinglife record for each individual …. The content of thatlife record, now made possible by computer informa-tion technology, will chart the course to be taken byeach individual for optimal health.”

In another article, Dr Garfield concluded, “Matchingthe superb technology of present-day medicine withan effective delivery system can raise US medical careto a level unparalleled in the world.”5

It was quite a prediction more than a quarter of acentury ago—one confirmed in the view of some to-day. As Richard Feachem, Executive Director of theGlobal Fund to Fight AIDS, Tuberculosis and Malaria,recently told The Economist: “There is no perfect sys-tem in the world; every one has serious flaws and makesserious mistakes which people suffer from, but Kaisercomes closer to an ideal than any system I know.”6 ❖

a Sidney R Garfield, MD, was born April 17, 1906, inElizabeth, NJ.

References1. Smillie JG. Can physicians manage the quality and costs of

health care? The story of The Permanente Medical Group.New York: McGraw-Hill; 1991.

2. Collen MF. History of the Kaiser Permanente Medical CareProgram, an oral history interview conducted by SallySmith Hughes, Regional Oral History Office. The BancroftLibrary. University of California, Berkeley: 1988. p 175.

3. Cutting CC. Trends for medical practice in 1975, address,annual meeting, American Association for the Advance-ment of Science. University of California, Berkeley: 1965Dec 29.

4. Garfield SR. The computer and new health care systems. In:Collen MF, editor. Hospital computer systems. New York:Wiley & Sons; 1974. p 24-31.

5. Garfield SR. The delivery of medical care. Sci Am 1970Apr;222(4):15-23.

6. Wasting disease: A tale of poor quality and inefficiency. TheEconomist 2004 Jul 17; 372(8384):Special Section 12.

SmokescreenThe Wright brothers flew right through

the smokescreen of impossibility.

— Charles Franklin Kettering, 1876-1958, engineer-inventor

KP HealthConnect: Fulfilling the Vision of KP’s Founding Physician

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KP HealthConnect

The PioneeringPhysicianMorris Collen, MD

Our original vision (of clinical in-formation systems) started withSidney Garfield, MD, as always, andmy objective was simply to carryout Dr Garfield’s vision. He’d comeup with all these wonderful ideas.He always said, “We can never beperfect, and so we must continu-ally try to improve our program.”

Dr Garfield knew that I had a de-gree in electrical engineering in ad-dition to medicine. So he asked meto attend the first congress on medi-cal informatics in New York and tocome back and advise him. I remem-ber getting all fired up at that con-gress about what was happening andthe great potential for computers inmedicine. So he and Cecil Cutting,MD (then Medical Director of ThePermanente Medical Group) set up anew department so that I could de-vise and test computer applications,and that was the Medical MethodsResearch Department, which later be-came the Department of Research.

At that time, about 1960, we werealready doing multiphasic healthscreenings for the Longshoremen’sUnion, but we were doing it manu-ally, and that seemed like the idealway to test computers on essentiallyhealthy people. Everything aboutthe multiphasic screening programwas routine. People would gothrough the tests, and I would sit atthe end of the line and check themoff and arrange whatever follow-

up they needed. After a year of that,I got tired of it, so I asked our resi-dent physicians to do it, and after afew months they got tired of it andasked the interns to do it, and theygot bored with it because it was sucha routine chore. It was exactly thekind of process that computers weresuited for. And so automatedmultiphasic health testing becameour first application of computersin medicine for patient care.

The government was impressedenough that they gave us somemoney to build a separate buildingfor it. The computer alone was sobig it took up a whole room with itsown air conditioning, and it had lesspower than we now have on ourdesktop computers. We used punchcards, and as the patient went fromstation to station the information waspunched in a card and at the end ofthe line we printed it all out and gaveit to the physicians. My objective wasto use these tools to provide betterquality technically and to save phy-sicians’ time by not having them needto ask 200 questions when only 10%of them would be answered yes. Sothe physician would get a report oneach patient with just those ques-tions to which the patient had an-swered yes, and he wouldn’t haveto ask all the others.

Later on in the 1960s, we got an-other grant for the Medical CareDelivery System program, which in-cluded computerizing the impatientand outpatient service at our SanFrancisco Hospital. We were going

The Driving Vision: Pioneers of the EMR

The Permanente Journal asked some of the pioneers of KP’s com-mitment to the electronic medical record to talk about the vi-sions that drove them to dedicate much of their careers to trans-lating the promises of the EMR into reality.

T H E P R O M I S E

anytime. It was a giant step, andwe visualized essentially doing whatthe new EpicCare system will dofor us today.

Then, in 1970, the country hadan economic recession and ourgrants were eliminated and that ter-minated our program. The Emer-gency Room physicians in San Fran-cisco almost wept because they lostthis great service. Donald Lindberg,MD, who was the director of theNational Library of Medicine, saidthat at the time, we had the leadingsystem in the whole world.

And so that’s how it got started.

to have the computer do essentiallythe beginnings of what is happen-ing now, including physician orderentry and results reporting. Wedidn’t have it all, but we were look-ing forward to the time when wecould. It was our goal to provide acomprehensive medical informa-tion system for all of our facilities,with patient records available nomatter where the patient presented.For our San Francisco patients, wehad every outpatient visit, everydrug dispensed, every lab test—itwas in the computer to be calledup in the middle of the night or

For more than 40 years, Dr Morris Collen, a founding physician ofThe Permanente Medical Group, has been a driving force inbringing the electronic medical record from dream to reality inKaiser Permanente, and throughout American health care.


health systems

Special FeatureThe Driving Vision: Pioneers of the EMR

Clinical InformationTechnologyAllan T Khoury, MD, PhD

We started planning for ourclinical Information Technology(IT) implementation in 1988. OurMedical Director at the time wasRon Potts, MD, and he realizedthat computers were going toplay a big role in medicine. Heasked me to explore the field.

I’ve always viewed clinical ITas a great way to improve thequality of care we deliver to ourmembers. I thought this couldhappen in two ways: first, byproviding a synopsis of crucial,relevant information from eachpatient visit, so the doctorwouldn’t be treating the patientblindly. Second, it had becomeclear by the mid-1980s that com-puters could en-hance quality bygenerating remind-ers to physicians atthe moment ofcare—so-called de-cision support—about things thatneeded to be donebut were simply be-ing overlooked. Weset out to build ourown system thatwould do these twothings. The initialgoal was not to re-place the paperrecord but to use the computeras a quality improvement tool.

We started with the printedchart summaries in 1990; andin 1993, we printed remindersat the point of care. We wereon a shoestring budget, just$83,000 the first year. That is

probably one of the reasons wewere successful; since the num-ber was small, we were allowedto experiment. Our early suc-cess led to deployment of amore complete electronic medi-cal record, starting in 1994 and1995, when we realized that byusing scanning we could cap-ture progress notes and prob-ably eliminate the need for thepaper chart entirely.

When I took this on, I did iton the condition that I retaincontrol of disease managementand prevention activities, be-cause it was clear to me thatunless we could move quicklyto improve quality, the ITproject would be seen as some-thing that consumes lots ofmoney without much benefit.

Without having thatdual role, diseasemanagement andcl in ica l IT, wewouldn’t have beenable to demonstratebenefit as quicklyas we did.

What I’m lookingforward to in KPHealthConnect isthe robust decisionsupport capability,such as drug-drugand drug-diseaseinteraction remind-ers generated by

the order entry system. Our cur-rent system doesn’t have thisfunctionality. We should beable to reduce admissions fromerrors in outpatient drug order-ing by as much as two thirds.That’s pretty compelling.

There are some things that KP

HealthConnect won’t do. I’dlike there to be an artificial in-telligence engine overlookingwhat the physician is doing.Since KP HealthConnect will beable to code patient symptomsand capture test results, itshould be able to evaluate thediagnoses recorded by the doc-tor and, if necessary, suggest al-ternatives. Also, I think as thehardware gets better, we’ll even-

With an initial budget of just $83,000, Dr Allan Khoury (shownhere in front of KP-Ohio’s “GuitarMania II” art piece) lead thecreation of a home-grown electronic medical record for KP Ohioa decade ago. His vision of the EMR as a key tool for qualityimprovement has helped pave the long road to KPHealthConnect.

We shouldbe able to

reduceadmissions

fromerrors in

outpatientdrug

ordering byas much astwo thirds.

That’s prettycompelling.

tually have notepad computersthat are light enough to carryaround, permit charting any-where, and allow clinicians todraw pictures, which will helpdermatology, ophthalmologyand some other specialties.We’re not there yet, but all thisis possible.

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KP HealthConnectThe Driving Vision: Pioneers of the EMR

The Dream:Availability ofInformation 24/7Peggy Latare, MD

In this day and age, with thenumber of diagnostic tests andthe complexity of medical sci-ence being what it is, it feels sobackward to try to still practicemedicine in the way we did be-fore we had a clinical informa-tion system, when the only in-formation we had was what wecould piece together from themainframe system and what thepatient might remember. That’sreally the prize that I’ve kept myeyes on for so long—that avail-ability of information 24/7. Nomatter what else the electronicmedical record does, that’s thedream: to have that informationavailable and to have people outthere making decisions with allthe information they need.

Here in Hawaii, we’re on ourthird implementation of an Infor-mation Technology solution—two less robust technologies pre-ceded the KP HealthConnect

implementation—and it’s quiteremarkable that people still havethe energy and the excitementto do it one more time. But it’sbecause of the power of havingthat information available andthe connectivity from primarycare to specialty care, from smallclinic to large clinic and from is-land to island, that the excitementis still there.

Since we first be-gan to implementthe earlier CIS sys-tem here, the objec-tives have evolved.Although the avail-ability of the medi-cal record is stillkey, the amazingdecis ion-supportcapabilities in Epiccompared with theearlier systems isnow a key driver—the ability to reducevariation and track results andoutcomes. The other thing that’sdifferent now is that Epic hasbrought our business colleagues

and inpatient colleagues intothe picture, and so now the vi-sion of truly being able to fol-low information across the con-tinuum of inpatient/outpatientand ER is a major part of theexcitement.

In terms of transformation, wesaw that even within three or fourmonths of implementation, some

really innovativethings were happen-ing—such as physi-cians spending anhour or two a fewdays a week on thephone, just doingtriage to handle pa-tients’ concerns andavoid some ap-pointments. Thatpractice is still dif-fusing, so that in anumber of our clin-ics three or fourdays a week, one of

the doctors will be on the phoneworking on follow-up questionsthat are easily handled on thephone. Eventually, I see that

Peggy Latare, MD, is theKP HealthConnect ProjectExecutive for the HawaiiPermanente Medical Group.

happening all over the regionand not just in primary care butin specialty care, where we canoffer a lot more alternatives tocare. And with the MyChart andmessaging capabilities of KPHealthConnect, we’re going toend up having a good deal ofour care happen virtually. That’svery exciting. ❖

… with theMyChart andmessaging

capabilities ofKP

HealthConnect,we’re goingto end uphaving a

good deal ofour carehappenvirtually.

The FutureThe future belongs to those who dare.

— Anonymous

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Special Feature

Entering the Decade of HealthInformation TechnologyBy Brian Raymond, MPH

Health information technology (HIT) is the under-pinning of a vision for the future of American medi-cine that is gaining consensus among public and pri-vate policymakers nationwide. As envisioned today,Americans will one day experience a health care sys-tem in which disparate providers across an otherwisefragmented delivery system will share health recordsin real time by means of a national network of elec-tronic medical record systems. The architects draftingthe IT blueprints for an interconnected electronic healthinfrastructure represent a public-private partnership thatis actively paving the way toward what the Bush Ad-ministration calls the “decade of health informationtechnology.”

A National Health InformationInfrastructure

The National Committee for Vital and Health Statistics(NCVHS) has set forth perhaps the clearest articulationof the vision for health information technology in its de-scription of a National Health Information Infrastructure(NHII). It is described as “a comprehensive knowledge-based network of interoperable systems of clinical, pub-lic health, and personal health information that wouldimprove decision making by making health informationavailable when and where it is needed.” The NHII is notjust a network of information systems but the standards,applications, and rules that support all facets of indi-vidual health, health care, and public health. The NHIIas envisioned by the NCVHS is based on decentralizednetworks of voluntary health information.

The federal government has ramped up its leader-ship role in accelerating health information technol-ogy, and recent national policy developments target-ing rapid HIT adoption are worth highlighting.

• On March 21, 2003, the federal government an-nounced the first set of uniform standards for the

electronic exchange of clinical health informationto be adopted across the federal government aspart of the Consolidated Health Informatics (CHI)initiative.

• On July 1, 2003, the Department of Health andHuman Services announced its purchase of a li-cense that allows all public and private sectorparties to use a medical vocabulary known as theSystematized Nomenclature of Medicine, ClinicalTerms (SNOMED-CT) at no cost.

• On December 8, 2003, the Medicare PrescriptionDrug, Improvement, and Modernization Act of2003 (MMA) was signed into law. The landmarklegislation establishes a voluntary electronic pre-scribing program and creates financial incentivesfor acquiring information technology and autho-rizes several demonstration projects on using in-formation technology to improve quality.

• In January 2004, President Bush emphasized theimportance of electronic records in his State ofthe Union address stating that “by computerizinghealth records, we can avoid dangerous medicalmistakes, reduce costs, and improve care.”

• On February 25, 2004, the Food and Drug Admin-istration issued a rule that requires “barcodes” onmost prescription drugs and on certain over-the-counter drugs as a means to reducing medicationerrors in hospital settings. Barcodes on drugs andbarcode patient wristbands reduce the potentialfor medication errors when used with a barcodescanning information system.

• On April 26, 2004, President Bush established agoal for every American to have a personal elec-tronic medical record within ten years as part ofan aggressive health information technology plan.He created the new Office of the National Coordi-nator for Health Information Technology withinthe Department of Health and Human Services tolead the national HIT effort. In addition, the Presi-

T H E P R O M I S E

Brian Raymond, MPH, is a senior policy consultant in the Kaiser Permanente Institutefor Health Policy where he analyzes emerging policy issues and supports the healthpolicy decision-making process within KP. E-mail: [email protected].

… Americanswill one dayexperience ahealth caresystem in

whichdisparateprovidersacross anotherwise

fragmenteddelivery

system willshare health

records inreal time bymeans of a

nationalnetwork ofelectronicmedicalrecord

systems.


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KP HealthConnect

dent doubled funding to $100 million for demon-stration projects on health information technology.

• On July 21, 2004, Health and Human ServicesSecretary, Tommy G Thompson, and the new Na-tional Coordinator for Health Information Tech-nology, David J Brailer, MD, PhD, unveiled a stra-tegic plan1 for health information technology pro-motion over the next ten years. The plan identi-fies four major goals:- “Inform clinical practice” by bringing informa-

tion tools to the point of care, especially byinvesting in EHR systems in physician officesand hospitals.

- “Interconnect clinicians” by building a healthinformation infrastructure.

- “Personalize care” by using technology to giveconsumers more access and involvement inhealth decisions.

- “Improve population health” by expanding thecapacity for public health monitoring and by imple-menting research advances in public health care.

Although health care still lags far behind other in-dustries in information technology investment, manyobservers view the recent policy development as a signof new momentum gathering the critical mass neededto galvanize the HIT vision. Whether we are at or nearthe “tipping point” for HIT—where the technologyadoption rate suddenly switches from incremental toexponential growth—is yet to be determined. Never-theless, the health policy community has clearly movedfrom talk to aggressive action on health care transfor-mation with information technology. ❖

Reference1. Thompson TG, Brailer DJ. The decade of health

information technology: delivering consumer-centric andinformation-rich health care: framework for strategicaction. Washington (DC): Department of Health andHuman Services, National Coordinator for HealthInformation Technology; 2004. Available from: http://www.hhs.gov/onchit/framework/hitframework.pdf(accessed September 28, 2004).

T H E P R O M I S E

Entering the Decade of Health Information Technology

Lessons of WisdomWhen you make a mistake, don’t lookback at it long. Take the reason of thething into your mind and then look

forward. Mistakes are lessons ofwisdom. The past cannot be changed.

The future is yet in your power.

— Hugh White, 1773-1840, US politician


health systems

Special FeatureI M P L E M E N TAT I O N

Adopting an Enterprise Health Care Automationand Information System: The Initial Implementation By Peter DeVault

Epic’s experience in implementing a wide variety ofclinical, access, and financial systems extends back 25years. As a growing company dedicated to changingthe way health care is delivered for the better, much ofwhat we encounter is necessarily new and challeng-ing. There are, however, as in any field, certain con-stants and useful propositions that can be shared andemployed to the same profit in new endeavors as wellas they were in the old. Although the idea—and, evenmore so, the fact—of an enterprisewide health careinformation and automation system is relatively recent,successfully installing one depends on many of thesame facts as other implementations. We would like toshare with you what we have learned during the manyyears of implementation.

The initial implementation of a health care automa-tion and information system forms part of the founda-tion for the transformation of health care. It is not thattransformation itself. Although it is important not toreplicate inefficient workflows or poor data collection,the focus of the initial implementation should not beto explore brave new worlds but it should be on build-ing the ship and learning to navigate.

More concretely, the proper focus of the initial imple-mentation should be on those things that will allowthe greatest long-term benefits: achieving widespreaduse of the system across as many care settings, special-ties, and departments as possible; standardizing datarepresentations; and establishing long-term interactionand communication plans with the user community. Ifthese three goals are achieved, an organization will bewell poised to take advantage of sophisticated toolsand techniques that will change the way health care isdelivered.

Three major areas of an implementation must be wellunderstood in order to maximize the chances of itssuccess: standardization, variations across care settings,and training strategies.

Adaptation and StandardizationThe process of implementing a health care automa-

tion and information system begins with modeling theorganization in software. The degree to which adapta-tion of the system to the organization is successful placesan upper limit on the degree to which adoption will besuccessful. A mature and well-designed system willallow an organization to dictate how the software worksrather than the other way around, and the system willallow for a great deal of variation in how different partsof the organization operate. Although that is the case,choices must be made about how detailed a model isnecessary for a complex organization. In a very largeorganization, a precise model is far too expensive tobe a realistic proposition.

We can liken the software modeling phase of theimplementation to making a map of a geographic re-gion. The more details there are, the more topogra-phy represented, the larger the map must be, and thelonger it will take to create it. Its size may make itimpractical to wield as a tool; its expense in time andresources may make it impossible to afford. A pocket-sized map giving a general but accurate knowledgeof the terrain is much more useful and can be createdin a reasonable amount of time, making it also afford-able. It won’t indicate every tree root to step over orevery stream to cross, but if you know how to stepover roots and cross streams, you don’t usually needthat information anyway.

With a health care software system, you don’t need aspecialized workflow or data collection form for everypossible clinical presentation or registration situation.You need a few tools that encapsulate the variation ina majority of your work practices, some special toolsfor infrequent but important situations, and the abilityto branch away from standard templates in the remain-ing situations. That means that you can model the large-scale features of the organization, mapping them tosystem functionality and tools, teach users how to

Peter DeVault helped develop Epic’s implementation methodology and contributed to thedesign and development of Epic’s clinical systems. He is also very active in the development ofindustry standards for electronic health records and interoperability and is an author of HL-7’sFunctional Model of an Electronic Health Record System. E-mail: [email protected].

… the focus ofthe initial

implementationshould not be

to explorebrave new

worlds but itshould be onbuilding the

ship andlearning tonavigate.


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KP HealthConnect

handle unknown terrain, and get them using the sys-tem in a reasonable amount of time.

The question inevitably arises—which organizationto model, the existing one or an ideal one? This ques-tion leads to a discussion of standardization and ratio-nalization. Standardization, improperly pursued, is of-ten the rock on which good implementation founders.Two kinds of standardization deserve attention: that ofworkflow and that of data representation.

Standardizing WorkflowWorkflow standardization simply means taking two

or more similar parts of an organization and havingthem perform some work function in the same way.As a result, people in similar roles in the different partsof the organization perform the same tasks in the samesequence using the same tools and interact with usersin other similar roles in the same way.

Two kinds of motivation generally exist for standard-izing workflows during an implementation. The first isthat it is easier for an implementation team to design asystem around one workflow for everybody rather thanaround everybody’s individual workflows, even thougha properly designed workflow automation system willallow for a great deal of practice variation. The secondmotivation exists when there is an agreed-upon bestpractice workflow that the organization would like toadopt or when there is reason to think that such aworkflow might be discoverable.

The ease-of-implementation motivation typically leadsan organization to analyze workflows to find common-ality in the component steps and wherever there iscommonality to make it standard. The sum of thesesteps then becomes the standard around which aworkflow system is modeled. In this form, workflowstandardization can be highly artificial and abstractedfrom the concrete realities of the clinical workplace.Lacking any real motivation to comply with the stan-dard, users of the system will find ways to subvert thestandard to reproduce necessary pieces of the originalworkflow or pieces perceived as necessary. In manycases, this will lead to a breakdown in the standardiza-tion of data representation as well. The tradeoff in thismethod of standardization is between ease of imple-mentation and risking the integrity of the design andthe data generated during the execution of theworkflows.

The second motivation to standardize workflows as-sumes there is a best practice or that one is discover-able. Agreement on a best practice or even the neces-sary criteria in the organization is very rare prior to the

implementation. The larger the organization and the morevague the criteria for what counts as a best practice, themore difficult it is to arrive at this level of agreement. Amore difficult tradeoff is involved here: implementingbest practices for clinical care, shorter registration times,or reduced billing cycle times are often key factors indeciding to implement a system. On the other hand, arequirement to implement best practices in a large orga-nization, whatever the criteria, can easily increase thetime to go live beyond an interval that will be consid-ered acceptable, successful, or affordable.

Epic’s experience suggests that workflow standard-ization should play a minor role during the initial imple-mentation. This isn’t to say that there aren’t someworkflows that couldn’t be standardized: if there is al-ready general agreement on some key workflows, theyshould be standardized. In general, however, standard-ization, especially in the best-practice sense, is bestaddressed during subsequent optimization efforts ratherthan during the initial push to go live and rollout.

Workflow standardization can usefully be contrastedwith workflow rationalization. The latter involves ana-lyzing a process into information and patient flows,analyzing these into their component steps, and thenimproving efficiencies or removing redundancies. Oncethis has been accomplished, system modeling shouldaddress the rationalized workflow.

Rationalized workflows need not be the same acrossan organization. Although a good argument could bemade that only rationalized workflows should be stan-dardized, it does not follow that all rationalized workflowsshould be. There may well be defensible reasons be-hind workflow variations across the organization, butthere is usually no justification for redundancies.

Standardizing Data RepresentationAlthough workflow standardization serves a minor

purpose during the initial implementation of a successfulhealth care automation system, the standardization ofdata representation should occupy a large slice of thesystem modeling time. Data representation determineshow information that is collected during patient care,registration, or other use of the system is stored andretrievable at a later time, how it can be comparedwith other data, and the ease with which both of thesecan be done.

Let’s take the example of a lab test. We’d like a redblood count value to be stored the same way in theinformation repository whether it was obtained in thehospital, in a clinic, in California, or in Ohio. Similarly,when we query the system for all of a patient’s red

I M P L E M E N TAT I O N

Adopting an Enterprise Health Care Automation and Information System: The Initial Implementation


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Special Feature

blood count values, we’d like to retrieve them all—regardless of their origin—and be able to trend themover time. This task requires a common vocabulary fordescribing lab values. We would also like a commonvocabulary for describing flowsheet rows, care planinterventions, diagnoses, and any number of other dataelements. Standard vocabularies are available for samedata elements, such as CPT codes for performed pro-cedures or ICD for diagnoses. Many data elements,however, require standardization during the course ofimplementation.

But data retrieval at the point of patient care is notthe only purpose for standardizing vocabularies. A stan-dardized vocabulary is also a prerequisite for sophisti-cated clinical studies, population management, solv-ing billing problems, and a number of othertransformational activities that can be pursued after theinitial implementation and rollout are complete.

Care Setting VariationsInstalling an enterprise typically involves two or more

care settings, including hospitals, physician offices, orancillary service departments. Many of the systems’ userswill work in more than one care setting. For example,physicians often work in their offices and one or morehospitals. Different care settings obviously have differ-ent workflow and data collection requirements. A well-integrated system will account for this variation by us-ing similar pieces put together in different ways ratherthan as different pieces altogether, as you would findin a nonintegrated or interfaced system solution.

Another variation to account for is that of the linear-ity of workflows. For example, a physician office visitis typically very linear, flowing from registration tocheck-in to collecting vital signs, placing orders, writ-ing a note, and signing an encounter. During the courseof a hospital admission, however, many caregivers andother users will interact with the patient in an unpre-dictable sequence. Nor will the data collection and datapresentation requirements of these interactions be com-pletely predictable.

When analyzed, it is typical that component piecesof these interactions show themselves to be linear, eventhough the course of care may not be. An enterprisesystem should account for these variations in linearityby using similar workflow navigation tools as in linear-ized care settings but to allow for easy departures fromlinearity. For example, a rounding navigator can col-lect together all of the component pieces of system in-teraction required for a physician doing rounds (review-ing meds and vitals, placing orders, writing a progress

note) while keeping I&O flowsheets, results review, andthe interdisciplinary care plan for the patient one clickaway from the navigator. The rounding navigator willbe instantly familiar to someone who sees patients inthe office, having similar components but with the re-quired variations in order and content.

An enterprise system should also use similar datarepresentation methods in different care settings. Eventhough the data originates in a variety of settings, it isoften very similar data and should be represented com-parably. For example, vitals taken at home, in the of-fice, or in the ICU should all be represented in theenterprise information system in a way that allows theirdirect comparison. The same is true of lab values, al-lergies, and medications.

A well-integrated enterprise automation and informa-tion system will reduce training time by using similarnavigation and data collection tools across the variety ofcare settings and will allow viewing and interaction withdata, regardless of its source, in a comparable fashion,thus improving patient care and the user experience.

Training StrategiesDifferent training strategies are suited to the nature

of different care settings. In a typical physician office,the users are to some degree a captive audience. Thereis not a need to teach the users everything at once be-cause you only have one shot at getting their time. Indi-vidual groups of physicians may come up on the systemindependently of their neighbors. In a hospital, on theother hand, there are many shifts of users, some of whommay only be in the hospital a few hours a week or evenless. Furthermore, so many different clinicians and otherpotential system users interact with a patient that itbecomes very important for all of them to be using thesame system to document their patient care.

The virtues of a well-integrated enterprise health careinformation system allow an organization to tailor thetraining experience to fit the needs of users in thesedifferent care settings. Importantly, a system that usessimilar or identical tools and navigation methods regard-less of care setting allows a user to become comfortableusing the system in one care setting and then leveragethat knowledge using the system in other care settings.

For ambulatory sites, Epic has developed over sev-eral years a highly successful incremental training ap-proach. During the course of three to four weeks, clini-cians learn incremental sets of functionality. Duringthe first week, basic navigation, chart and resultsreview, and “In-Basket” tools are taught and used forthe duration of the week. The following week, clini-



The virtues of awell-integrated

enterprisehealth careinformation

system allowan organization

to tailor thetraining

experience to fitthe needs ofusers in thesedifferent care

settings.


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KP HealthConnect

cians learn to place orders and document diagnoses.Finally, general charting and more advanced function-ality are taught the third week. The training is typicallya combination of classroom-based scenario develop-ment and one-on-one support. Computer-based train-ing may also be a useful adjunct.

In the hospital setting, it is important that clinical us-ers in particular learn most of the basic functionality fora given phase of the implementation before seeing pa-tients. Longer blocks of training are required to supportthis strategy, and large sections of a hospital typically golive all at once on a particular set of functionality.

However, because tools are so similar across caresettings, if clinicians go live first in their offices or clin-ics, the transition to using the same system in the inpa-tient setting is much easier. If it is possible to stage therollout in this fashion, the benefits can be substantial—both with regard to training time as well as to ease ofadoption by users.

In any case, it is important to keep the scope of thetraining narrowed to the basics required for day-to-daypatient care and related work. More sophisticated useof the system can be nurtured through regular usergroup meetings, online forums, or other forms of com-munication. Maintaining a manageable scope is just asimportant for training as it is for standardization andother aspects of the implementation.

Setting and Managing Expectationsand Scope

Armed with this information about standardization,variation, and training practices, an implementing or-ganization should spend some time thinking aboutwhat will and what will not be accomplished during

successful implementation? This must be defined atthe outset. Decide that, and then set the expectationsto match the definition. Expectations set too low willresult in employees asking pointed questions aboutthe expense of the implementation and the scope ofthe changes they’ll be asked to make in their workpractices. Setting expectations too high will result inincredulity during the implementation (and unwill-ingness to be associated with it) as well as inevitabledisappointment after the system is live.

Although “internal sales” is an important activity dur-ing an implementation, it is possible to oversell thesystem being implemented, thus raising expectationsbeyond what is reasonable. The implementation’s cham-pions should publicly recognize the system’s weak-nesses as well as its strengths. For example, some taskswill definitely take longer using an electronic system(think CPOE). Acknowledge this, and also stress theworkflow points where time will be gained, such as inlocating clinical information, rather than downplayingjustified worries about extra time spent placing orders.

Managing expectations is inseparable from manag-ing scope, which describes the schedule of modulesand functionality as well as the breadth of user interac-tion expected at key points during the implementationtimeline. It has been Epic’s consistent finding that asuccessful implementation is one that defines a man-ageable scope for the initial implementation with theidea in mind that it will be the foundation for moresophisticated practices later. Focusing on the right kindand level of standardization and the encapsulation ofvariation across care settings will ensure that the imple-mentation scope, in addition to being manageable, willalso lead to success. ❖



Vacuum TubesWhere a calculator on the ENIAC is equipped with

18,000 vacuum tubes and weighs 30 tons,computers in the future may have only 1000vacuum tubes and perhaps weigh 1 1/2 tons.

— Popular Mechanics, March 1949


health systems


The Reality of EMR Implementation:Lessons from the FieldBy Homer L Chin, MD, MS

Kaiser Permanente Northwest(KPNW) has more than a decade ofexperience working with Epic Sys-tems in the development, implemen-tation, maintenance, and continuedimprovement of the electronic medi-cal record (EMR). EpicCare was ini-tially implemented in two primarycare clinics in 1994 and was com-pletely rolled-out to the rest of theregion by year-end 1997. This ar-ticle will describe the most salientlessons that KPNW has learned inthe interest of informing other KPregions as they embark on imple-menting KP HealthConnect (KPHC).

Some of these lessons were learnedthe hard way. Some things we“lucked into” naturally. Some of theselessons are backed up by hard data;some were gleaned through our ex-perience and have been reinforcedby similar learnings from other orga-nizations. We have learned manymore lessons than we are able to en-capsulate in this short article. For any-one who has additional questions thatare not answered here, please con-tact me directly and I will share what-ever experience and knowledge wemight have in a particular area. Thereare very few aspects of implement-ing an outpatient EMR with whichwe have not had some experience.

OverviewKPNW began the implementation

of the EMR by developing and de-ploying an extensive Results Report-

ing System in 1992. In 1993, after anextensive evaluation of vendors,KPNW chose Epic Systems as ourpartner to deploy EpicCare, a com-prehensive outpatient EMR. In 1994,we began a pilot deployment ofEpicCare in two primary care clinics,involving approximately 50 primarycare clinicians. After Epic Systemsenhanced their system in response toour requirements, we embarked ona rollout of EpicCare to the rest ofprimary care, clinic by clinic. In 1996,we started the rollout of EpicCare toour specialty clinicians, departmentby department. After additional soft-ware enhancements, including theimplementation of a prenatal record,we completed our rollout to our Ob/Gyn clinicians and to the rest of thespecialty departments in 1997. In1998, we implemented our Emer-gency Department and installed adocument scanning system for anyresidual paper. At that time, we fullyretired the paper chart. For memberswho have joined us since 1998, nopaper record is created. Over theyears of implementation, our geo-graphically based chart rooms weregradually downsized and consoli-dated, and the personnel were re-trained for other roles and functionsthroughout our organization.

EpicCare is not only an electronicversion of the outpatient medicalrecord; it also automates all informa-tion transmission processes in theoutpatient setting. Health care pro-

viders use this system to document,order, refer, and message other healthcare staff. EpicCare has a two-wayinterface for order and results trans-mittal to our lab and pharmacy sys-tems, giving our clinicians a completeand accurate picture of the labora-tory and medication status of a pa-tient. Guidelines, information, andmedication suggestions are provided“in-line” to clinicians as they use thesystem to provide care for their pa-tients. With the implementation ofEpic’s MyChart and Epic’s HomeHealth System, we are extending se-cure access to the medical record andmessaging into our members’ homes.

Lessons LearnedI have organized our experience

and learnings under the followingthemes: Organizational decisionmaking and project management,system deployment, applicationsoftware, benefits realization, con-tent management, and other insightsthat transcend categorization.

OrganizationalDecision Making andProject ManagementEmpower Project LeadersWho Are Close to TheGround

Although the high-level budget-ing and direction were set by theleaders of the Health Plan and Medi-cal Group, the project team wasempowered, within broad bound-

Homer L Chin, MD, MS, is the Assistant Regional Medical Director for Clinical Information Systems for theKaiser Permanente Northwest Region and Assistant Professor in Medical Informatics and Clinical Epidemiology atthe Oregon Health and Sciences University. A Board Certified Internist, he completed fellowship training inMedical Informatics at Stanford University, prior to joining Kaiser Permanente in Northern California in 1988. Hemoved to the NW Region in 1992 to help lead their clinical systems efforts. E-mail: [email protected].

For memberswho have

joined us since1998, no paper

record iscreated.


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ment it without significant problemsthe first time. In the deployment,be prepared to make changes “onthe fly” in response to identified is-sues. Trying to reach perfectionprior to go-live will add effort andprecision that is not warranted forthe situation.

Pilot and Improve, Rolloutand Improve

As a corollary to the “don’t try forperfection,” the flip side is don’troll it out further until the systemis at least “good enough” in thelocations that you have alreadyimplemented. In other words, ifyou have identified significantproblems or issues, fix them anddelay further roll out until those

aries, to make decisions—enablingquick resolution of issues that aroseduring system deployment. Many ofthe project team members were endusers of the system, providing aclose link between decisions madeand the impact of those decisions.

The Three-Legged StoolThe close coordination and coop-

eration of Operations, PermanenteMedical Group, and InformationTechnology in joint managementand decision making was an im-portant factor in our success. Forefforts in which we had only oneor two legs of the three-legged stool,progress was often slow, the resultsomewhat off-target, or the effort un-successful. The close coordinationof Operations for project manage-ment expertise, the Medical Groupfor the clinical expertise, and In-formation Technology (IT) for tech-nical expertise was an important in-gredient in our success.

Beware “Scope Creep”As an information systems project

progresses, it is easy for additionalfunctional requirements to creepinto the project. Most additional re-quirements that are added in thisway appear benign at first but havesignificant hidden downstream im-pacts. For large, complex projects,scope creep may introduce a lackof clarity that may result in signifi-cant delays and rework. Althoughsome increases in scope cannot beavoided, it is important to under-stand that any change in scope mayreduce the probability of success ofthe overall project.

Begin With the End in Mind(and Think of Everything inBetween)

It is important to think throughall the steps in a project from be-ginning to end. We embarked on a

number of efforts only to find thatwe had not thought through the in-termediate steps required to reachour goal. If we had done a morecomplete analysis of all the stepsnecessary to achieve an objective,we would have realized that our ap-proach was missing critical steps,dooming it to failure from the start.

BridgersBridgers are special people who

are able to bridge the gap and thecultural divide between the enduser, the organization, and IT. Thesepeople are able to think systemati-cally and can understand and trans-late between end users, the projectteam, and the organization. They areoften able to trade-off the benefit ofa specific functionality against theeffort and risks in developing andimplementing that functionality. Byfocusing on the end goal and think-ing globally, they are often able tofind the 80/20 solution—where 80%of the benefit can be achieved at 20%of the effort. These Bridgers are of-ten able to identify easy-to-imple-ment functionality that will have sig-nificant benefit and distinguish themfrom requests for functionality thatare difficult to implement and haveunclear long-term benefits.

System Deploymentand Roll-outYou Won’t Get It Right(Don’t Try For Perfection)

Implementing an EMR is analo-gous to trying to find your waythrough a dimly lit forest. You havea general sense of the direction tohead in and a general timeframe asto when you will reach the otherside, but you would not be success-ful if you charted a rigid course inadvance. Implementing an EMR isstill more art than science. Tried andtrue methods for implementation donot exist. And you will not imple-


The Reality of EMR Implementation: Lessons from the Field

Homer Chin is the medical group leaderresponsible for the pioneering implementationof EpicCare in the Northwest Region in the1990s. His continued persistence in demon-strating success helped lead the way for theeventual adoption of KP HealthConnect asthe information system strategy for the KPProgram. His firm belief is that KaiserPermanente is in a unique position toleverage information systems technologyto support its unique strength—integratedcomprehensive health care.


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Special Feature

issues or problems are sufficientlyaddressed. Another way to put itis to “put out the fire” before roll-ing the system out to further loca-tions. Keeping to a rigid schedulefor rollout before “putting out thefire” in implemented locations mayresult in an uncontrolled blaze thatwill eventually engulf the entireproject in flames.

Value the CurmudgeonsEnd user critics of an implemen-

tation are a godsend. Listen to, care-fully evaluate, and respond to anycomplaints about the system. By thetime you hear of a complaint, manyothers will probably have silentlysuffered through similar problems.Although each of these problemsand issues may be small, the cumu-lation of a large number of these“small problems” can be over-whelming. Some organizations havegone as far as to add a “complaint”button to their system, allowing endusers to complain at any time andat any point in their use of the sys-tem. Although these complaints areoccasionally misdirected, they areoften warning signs as to where theroad may be in need of repair. Ig-nore these signs at your peril!

Get Feedback and Use ItA corollary to “value the curmudg-

eons” is to solicit feedback aboutan implementation early and often.The system will not be perfect, andit will need improvement. If you arenot hearing from clinicians, activelysolicit feedback so that you canimplement improvements in ad-vance of significant problems.

Look for the Opportunityand the Easy Win

In implementing a system, you willoccasionally come across an oppor-tunity where a “tweak” to the systemor use of the system in a way that

these changes will keep a projectteam “implementing” at all times.

Your Users Are Beta-TestersIt is impossible to completely

replicate the production use of asystem in a test environment. Thisresults in a system that is not fullytested prior to deployment. At thetime of an initial go-live or signifi-cant upgrade, your end users be-come beta-testers of the system.It is not unusual for hundreds ofissues, problems, and bugs to sur-face soon after go-live.

Jack Be Nimble, Jack BeQuick

In systems that are used for pa-tient care, problems and “bugs” mayhave patient safety and medical-le-gal implications. The project teamwill need to be nimble and quick tofix identified problems—especiallythose that affect patient safety. Slowresolution of clearly identified prob-lems may also demoralize end usersand result in loss of credibility in theproject team. A quick identificationand resolution process is critical dur-ing the first few weeks of go-live.

Clinician EfficiencyComes First!

Implement the system in a waythat tries to maximize a clinician’sefficiency at first. After successfulimplementation, additional tasks canbe gradually added as clinician ca-pacity to absorb these additionaltasks increases. If a clinician issaddled with many additional tasksat go-live, the clinician may neverlearn the system well enough toachieve a good level of comfortand efficiency.

Application SoftwareKeep It Simple!

With EMR software, transparency,reliability, and simplicity are impor-


was not previously foreseen may re-sult in significant improvements in ef-ficiency or quality. An example of thiswas in our development of theSmartRx functionality within EpicCare.EpicCare had an Alternative Medica-tion functionality that would alert cli-nicians to potentially better alterna-tives to the medication they wereprescribing. Our pharmacists tweakedthis functionality slightly by addingdisease conditions to our medicationfile (Acute Sinusitis SmartRx, for in-stance) that allowed clinicians to en-ter a disease name in the medicationfield to get guidance on recom-mended therapy while improving theefficiency of the prescribing process.

Training Never EndsMany people believe that the

training task is done when a clini-cian has undergone initial trainingand is using the EMR. In our experi-ence, clinicians know enough to “getby,” but most quickly forget muchof what they learned in the initialsystem training. In an evaluation ofour clinicians, we found that morethan 50% of our clinicians remem-bered less than 50% of what we feltwas essential material taught to themin the initial system deployment. Inaddition, information systems and ca-pabilities are constantly changing.Ongoing and continued evaluation,education, and training are necessaryto optimize clinician efficiency andeffectiveness.

Implementation Never EndsMany system implementers believe

that once a system is implemented,their work is done. The truth of thematter is that these systems are con-stantly changing. Application soft-ware, operating systems, hardware,technology, and medical knowledgeabout diagnosis and treatment areconstantly changing. The myriadcombinations and interactions of all


In anevaluation ofour clinicians,we found that

more than50% of ourclinicians

rememberedless than 50%

of what wefelt wasessentialmaterialtaught to

them in theinitial systemdeployment.


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KP HealthConnect

tant characteristics that should bevalued over system sophistication.In some cases, EMR software is be-coming so complex that it is diffi-cult to tell in advance what thesystem will do in a given situa-tion. When it comes to an EMR,transparency, reliability, and sim-plicity allow easier detection oferrors that may adversely affectpatient safety.

Efficiency and ResponseTime

The top three important factors inan EMR are: 1) Clinician Efficiency,2) Clinician Efficiency, and 3) Clini-cian Efficiency. Having a quick re-sponse time is a prerequisite to sup-porting clinician efficiency.

Clinical ContentSimple and Effective Waysto Embed Decision-SupportContent

With an EMR, the opportunityexists to use an order requisition asa way to communicate not onlyfrom the clinician to the ancillarydepartment but also as a way forthe organization to communicate tothe clinician at the time of order-ing. By embedding guiding infor-mation in an order requisition,guidance can be provided to theclinician seamlessly during the or-dering process. Another exampleof a simple but effective way to em-bed useful content is to automati-cally print patient information re-lated to an order on the after-visitsummary that is given to the pa-tient at the end of the visit. Deci-sion support can also be embed-ded through Alternative Orders,Smart Orders, Alternative Meds,and SmartRxs. Medication contentand decision support include for-mulary and cost information formedications, drug-drug and drug-allergy interaction checking, and dis-

teach designated end users how tobuild content and to make them re-sponsible and accountable for de-veloping useful content for a givenconstituency of users. One of ourareas of success is in developingand maintaining pharmacy content.Decisions made by our Pharmacyand Therapeutics Committee areimmediately programmed intoEpicCare by a pharmacist that sameafternoon. We are attempting to dis-seminate that model of increasedend user accountability for contentto our clinician group.

Content MaintenanceNever Ends!

Because medical care is con-stantly advancing and changing, thecontent within an EMR will needconstant updating. Because contentis embedded in many differentways and in varied loca-tions in the EMR, the needto determine all the areasin which a change in con-tent needs to be propa-gated is not a trivial task.KP is in the process ofworking with Epic Systemson tools to improve ourmaintenance of embeddedcontent within KPHC.

Benefits RealizationImplementation ofInformation Technologyis Just a Tool

It is important to realize that theimplementation of informationtechnology, in and of itself, is notthe goal. The goal should be to im-prove the efficiency and effective-ness of our health care delivery sys-tem. One of our goals is to improvethe efficiency of our clinicians. Wehave found that for some tasks, re-viewing information on paper isstill the most efficient way to im-part information quickly and effec-


ease-specific interaction checking.Additional types of decision supportinclude Order Panels, Smart Text,Smart Phrases, and Smart Sets. Ingeneral, the goal is to embed deci-sion support in a seamless way thatmakes doing the right thing the easi-est option in most cases. EpicCareallows the easy embedding of con-tent in a myriad number of waysthroughout the system.

Content that SupportsClinician Efficiency

Report formatting, layout, andcontent can have a significant im-pact on efficiency and effectiveness.For instance, our Previsit Summaryautomatically scans the last three labtest results for each lab test type. Ifany of the last three CBCs, for in-stance, are abnormal, a spreadsheetof the CBCs is printed. In this way,the system supports a quick and com-prehensive review of the laboratorystatus for the patient. Other contentareas that support clinician efficiencyinclude key word synonyms that sig-nificantly improve the efficiency ofordering, prescribing, and diagnosisentry and well-thought-out depart-mental preference lists that improveclinicians’ ability to find the terms theyare looking for. Careful thought andwork in these areas will yield sig-nificant benefits in clinician effi-ciency and system usability.

Keep a Tight Loop BetweenContent Management andthe End User

End users determine the successor failure of content that is imple-mented in the system. Because thecontent in the system directly af-fects the end user, it is importantto have a tight loop between theend user and the content embed-ded in the system. Content manage-ment in EpicCare is easy enough tolearn and use that it is possible to


Decisions made byour Pharmacy and

TherapeuticsCommittee areimmediately

programmed intoEpicCare by a

pharmacist thatsame afternoon.


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Special Feature

tively. Because of this, our costsfor paper (for Previsit and After-visit summaries) have gone uprather than down.

Organizational PoliciesShould Reinforce theBehavior Promoted in KPHC

Programming functionality intothe system without supporting or-ganizational policies and effortsyields less than optimum results.EpicCare clearly and effectively in-forms the clinician of the formularystatus of medications. However, be-cause our organizational policies donot enforce restrictions around for-mulary ordering, our compliancewith formulary prescribing is notwhere we would like it to be.

Enabling a More EffectiveData Warehouse

With the implementation of anEMR, the ability to evaluate orga-nizational performance and to sys-tematize health care is significantlyenhanced. New paradigms andmodels for case identification,tracking, monitoring, alerting, andproviding feedback are possible.Regions must look carefully at thesenew capabilities and leverage thosethat will improve cost-effectivehigh-quality care.

Clinicians Are Not Optimizedfor Population Care

Clinicians are optimized for one-on-one care for members. With theimplementation of the EMR, signifi-cant capabilities to systematize carethrough care, case, and disease man-agement are enabled. Because thesepopulation care approaches are aneffective way to reduce cost and im-prove quality, it is possible to off-loadwork from the clinician by system-atizing care, leaving the clinician moretime to devote to the one-on-one carefor which they are essential.

Seeing the systematic benefits of anEMR in improving the care of a largepopulation of members, however, isa gratifying experience that makes theeffort of EMR implementation worth-while. Even after a decade of EpicCareexperience, we continue to learn andfind ways to use information technol-ogy to more fully realize the poten-tial of our integrated health care de-livery system. ❖

Acknowledgments

I would like to thank the clinicians andstaff of Kaiser Permanente Northwest andEpic Systems. Their partnership,teamwork, dedication, mutualaccountability, and commitment to theend-user are responsible for our success.I would also like to thank Allan Weiland,MD, Medical Director, and Mike Katcher,the Regional President who, in 1993,made the courageous decision to moveforward with EpicCare when there werefew other examples of success in EMRimplementation.

The lessons that we have learned fromour EMR implementation have beengradually compiled through years ofexperience on the part of many people.I would like to especially thank the“thought leaders” who have contributeddirectly or indirectly to this article. LarryDworkin, MD; Dawn Hayami; BradHochhalter; Michael Krall, MD; MichaelMcNamara, MD; Nan Robertson; DeanSittig, PhD; Nick Socotch, RN; andmany others through the years,identified and labeled many of thelessons described above. Thanks toMichael Kirshner; Nan Robertson; TomStibolt, MD; and Allan Weiland, MD, fortheir help in editing this manuscript.

Suggested Reading• Ash JS, Stavri PZ, Kuperman GJ. A

consensus statement on consider-ations for a successful CPOEimplementation. J Am Med InformAssoc 2003 May;10(3):229-234.

• Ash JS, Gorman PN, Lavelle M, et al. Across-site qualitative study of physicianorder entry. J Am Med Inform Assoc2003 Mar-Apr;10(2):188-200.

• Ash JS, Stavri PZ, Dykstra R, FournierL. Implementing computerizedphysician order entry: the


Other InsightsClinicians Won’t NecessarilyBe Faster, But They ShouldBe Better

It was often assumed that unlessthe EMR made the clinician “faster”it would not be accepted. In our ex-perience, clinicians are initiallyslower after EMR implementation.Over time, some clinicians will be-come faster than they were before,but many will remain slower. Eventhe slower clinicians recognize thevalue of information technology—and given the choice, would notwant to return to the pre-EMR days.Our theory is that clinicians are ableto trade-off their own increasedworkload against the improvementin care and professional satisfactionthat they see with the use of the EMR.With changes in the paradigm of caredelivery that the EMR enables, eventhe “slower” physicians will be moreefficient in their overall care of agiven population of members.

The Great MagnifierThe EMR is the “great magnifier.”

If an organization already doessomething very well, then theimplementation of informationtechnology will probably furtherimprove its performance in thatarea. However, if an organizationis dysfunctional in an area, then theimplementation of an EMR willprobably magnify that dysfunction.Identifying and addressing poten-tial areas of organizational dysfunc-tion prior to implementing the EMRmay improve the overall results ofEMR implementation.

ConclusionImplementing an EMR is a complex

and difficult multidisciplinary effortthat will stretch an organization’s skillsand capacity for change. It will be achallenging and occasionally stress-ful continuous learning experience.



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importance of special people. Int JMed Inf 2003 Mar;69(2-3):235-50.

• Ash JS. Factors affecting the diffusionof the Computer-Based PatientRecord. Proc AMIA Annu Fall Symp1997:6:82-6.

• Chin HL, Dworkin L, Krall MA, et al.The comprehensive Computer-BasedPatient Record (CPR). Perm J 1999Sum;3:13-24.

• Chin HL, Wallace P. Embeddingguidelines into direct physicianorder entry: simple methods,powerful results. Proc AMIA Symp1999:221-5.

• Chin HL, Krall MA. Successfulimplementation of a comprehensivecomputer-based patient record systemin Kaiser Permanente Northwest:strategy and experience. Eff Clin Pract1998 Oct-Nov;1(2):51-60.

• Chin HL, Brannon M, Dworkin L, etal. The comprehensive computer-based patient record in KaiserPermanente Northwest. In: OverageJM, editor. Proceedings, FourthAnnual Nicholas E Davies Award,CPR Recognition Symposium. NewYork: McGraw-Hill; 1998. p 69-129.

• Chin HL, Krall MA, Lester S.



Adapting clinical coding systems forthe computer-based patient record.Proc AMIA Annu Fall Symp1997:849. Available from:www.amia.org/pubs/symposia/D004086.pdf (accessed September30, 2004).

• Chin HL, McClure P. Evaluating acomprehensive outpatient clinicalinformation system: a case study andmodel for system evaluation. ProcAnnu Symp Comput Appl Med Care1995:717-21.

• Dykstra R. Computerized physicianorder entry and communication:reciprocal impacts. Proc AMIA Symp2002:230-4.

• Krall MA. Clinician champions andleaders for electronic medical recordinnovations. Perm J 2001 Win-ter;5(1):40-5.

• Krall MA. Achieving clinician useand acceptance of the electronicmedical record. Perm J 1998Winter;2(1):48-53.

• Krall MA, Chin H, Dworkin L,Gabriel K, Wong R. Improvingclinician acceptance and use ofcomputerized documentation ofcoded diagnosis. Am J Manag Care

1997 Apr;3(4):597-601.• Krall MA. Acceptance and perfor-

mance by clinicians using anambulatory electronic medical recordin an HMO. Proc Annu Symp ComputAppl Med Care 1995:708-11.

• Kirshner M, Salomon H, Chin H. Anevaluation of one-on-one advancedproficiency training in clinicians’ useof computer information systems. IntJ Med Inf 2004 May;73(4):341-8.

• Marshall PD, Chin HL. The effectsof an Electronic Medical Record onpatient care: clinician attitudes in alarge HMO. Proc AMIA Symp1998:150-4.

• McDonald CJ. The barriers toelectronic medical record systemsand how to overcome them. J AmMed Inform Assoc 1997 May-Jun;4(3):213-21.

• Sittig DF, Stead WW. Computer-based physician order entry: thestate of the art. J Am Med InformAssoc 1994 Mar-Apr;1(2):108-23.

• Tierney WM, Overhage JM,McDonald CJ. Computerizingguidelines: factors for success. ProcAMIA Annu Fall Symp 1996:459-62.

Inspiring a Shared VisionA leader who Inspires a Shared Vision is one who describes

ideal capabilities; looks ahead and communicates the future; isan upbeat and positive communicator; finds common ground;

communicates purpose and meaning and/or is enthusiasticabout the possibilities.

— The Leadership Challenge, J Kouzes and B Posner, Jossey-Bass


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At first, it might be hard to imag-ine how using an electronic medi-cal record in your practice and inthe exam room could improve com-munication with patients. In fact, itmay be easier to see the computeras just another thing that gets in theway of our having meaningful in-teractions with patients—a thirdwheel, so to speak. Because patientsview communication as the mostimportant factor in the clinician-pa-tient relationship, we certainly don’twant to compromise it in any way.1

Does the computer in the examroom assist or hinder good clinician-patient communication?

The ExperienceOur experiences in Kaiser

Permanente’s Northwest and Colo-

rado Regions have shown that pa-tients give a positive rating to clini-cians’ use of computers in the examroom. Initially, clinicians experi-enced a period of time in which theywere not as efficient as they werewith the paper record. There mightbe some discomfort with the newequipment, with necessary newcomputing skills, with the changesin workflow and, importantly, dis-comfort in the conversations withmembers related to the computer.

We learned that this discomfortfades as confidence is gained in newskills, in a sense of consistency andreliability about critical patient data,and in satisfaction with the compre-hensive level of care that the clini-cians are able to provide. The infor-mation available from computers helps to demonstrate comprehensive

knowledge of the patient. Addition-ally, exam room computing helpsinvolve patients in decisions aboutmedical care, something patientshighly value. As reflected in the chart,A Synthesis of Recent Evidence (Fig-ure 1), shows ample evidence thatexam room computing can enhancethe overall clinician-patient interac-tion in the exam room.

Personal ChallengesWhat about you and your prac-

tice? How are you supposed tomaintain good communication with

Table 1. Interregional Clinician-Patient Communication HealthConnect work group membersSara Faulkner, MD (Group Health)Rich Frankel, PhD (Indiana University)Diana Burks-Goodman, MPA (Southern California)Jim Hardee, MD (Colorado)Charles James Kinsman, BA (Garfield Memorial Fund)Peggy Latare, MD (Hawaii)Maureen Leahy, MBA, MPH (Mid-Atlantic States)Ward R Mann, NP, Chair (Northwest))Debra Mipos, MPA (The Permanente Federation)Jan Nedin, MS, CCDC, CEAP (Ohio)Vivian Nagy, PhD (Southern California)Joanne Slaboch, MBA (The Permanente Federation)Sue Hee Sung, MPH (Garfield Memorial Fund)Richele Thornburg, MS (Hawaii)Robert Tull, PhD (Group Health)Elizabeth Wu, MA (Southern California)

Ward R Mann, MSN, FNP, (left) is a clinician and consultant for NWP in Portland, OR. Most recently he’s helpedto create curriculum for regions to use as they implement KP HealthConnect. E-mail: [email protected] Slaboch, MBA, (right) has been a Project Manager for the Care Experience Council since 2001, focusingon issues related to technology-enabled cared. E-mail: [email protected].


Computers in the Exam Room—Friend or Foe?By Ward R Mann, MSN, FNPJoanne Slaboch, MBA


health systems

KP HealthConnectI M P L E M E N TAT I O N

Background

With the introduction of KP HealthConnect programwide, use

of computers in the exam room could have a significant impact on

the care experience. The Care Experience Council has compiled

information from four internal research studies (based in the North-

west, Colorado and Hawaii Regions) to serve as a foundation for

building evidence about patient satisfaction with exam-room com-

puters and guide future implementation efforts and research.

Key Findings

• Patients’ perceptions toward exam-room computers are for

the most part positive, and integration of computers into the

delivery of care has resulted in improvements in patient sat-

isfaction.

• Effective use of the computer can support a positive clini-

cian-patient interaction.

• Key clinician behaviors promote the patient’s involvement

with the computer during the visit and establish the clinician’s

familiarity with the patient.

• The patient’s and the clinician’s attitudes toward the com-

puter can all affect overall satisfaction with the visit.

• A small portion of patients with low patient satisfaction scores

who also express concerns about privacy and security of

medical information.

Implications for Improving Member Satisfaction

with their Care Experience

In order to enhance members’ care experience with exam-room

computers, operational leaders should offer clinicians multi-fac-

eted training and implementation support programs that address

clinician-patient communication, organization and multi-tasking

skills as well as technical training. Based on the existing research,

programs would be more effective if they emphasize clinician

behaviors that

• Promote patient involvement during the visit by:

– Maintaining eye contact with the patient

– Providing a verbal description of what is being entered

– Showing information on the computer screen to the

patient

• Demonstrate clinician familiarity with patients by:

– Reviewing the record before entering the exam room

– Indicating knowledge of the purpose of the visit

– Referring to previous history

• Demonstrate a positive attitude toward the computer

• Address privacy and security issues

Sources• Clinical Systems Planning and Consultation: Northwest

Exam Room Computing Project—Final Report. MichaelMcNamara, MD; Kathy Poterah, RN; Carl Serrato, PhD(July 2002).

• Crossing the Digital Divide: Preliminary Findings from theINTERACTION Study. John Hsu, MD, MBA, MSCE; RichFrankel, PhD; Kathy Poteraj, RN; Bob Tull, PhD; CareExperience Council (Nov 2002).

• Clinical Systems Planning and Consultation: CISIntegrations Project. Robert J Miller, MD (July 2002).

• AMR as a Relationship Tool Interview (KPCO, KPHI,KPNW), sponsored by the Care Experience Council(Feb 2003).

• Automated Medical Records and Patient Satisfaction: ASummary of Key Finds from Kaiser Permanente-Sponsoredresearch, Technology-Enable Care Work Group, CareExperience Council, March 2004.

Figure 1. A synthesis of recent evidence—member satisfaction with exam room computers

Leadership/Mgmt –––––– Work environment –––––– Member satisfaction –––––– Business results▼ ▼ ▼

KP Results Model

your patient and deal with this new“thing” in the exam room? Will yoube able to make eye contact andtype your note? Will you be able tokeep the patient involved and notbe distracted by the computer? Willyou remember to secure the screen?Sound a little overwhelming? Webelieve that you will find the fol-lowing suggestions helpful to makecertain that the computer becomes

a solid friend of yours in the examroom, and definitely not a foe.

SolutionsThe Interregional Clinician-Patient

Communication (IRCPC) Leadersof Kaiser Permanente (Table 1)have pooled their collective expe-rience and understanding aboutclinician-patient communicationand exam room computing. As a

result they have identified five keycommunication behaviors to fos-ter smooth integration of comput-ers into practice:

Let the patient look onEye contact with the patientValue the computer as a toolExplain what you are doingLog off and say you are doing soThe accompanying chart, Do Your

LEVEL Best With the Computer in

Computers in the Exam Room—Friend or Foe?


health systems


the Exam Room (Figure 2), appliesthese five communication behaviorsand details some recommendedactions to use and scripts to say toeffectively integrate the computerinto your exam-room interactionwith your patient. The IRCPC hasdeveloped five courses to help cli-nicians and support staff integratethe computer into the patient visitusing these LEVEL skills (Table 2).

By including a few new commu-nication behaviors into everydaypractice, a computer in the examroom will enhance the overall careexperience for the patient. ❖

Reference1. Worthlin Group. Communication

and the physician/patientrelationship: a physician andconsumer communication survey.West Haven (CT): Bayer Institute forHealth Care Communication; 1995.

L

Skills Actions What to say

et thepatientlook on

• Move the screen for patient to see.• Invite the patient to move closer to the

screen to view information.• Ask the patient to verify information

as you type.

(This builds trust, actively involves the patient,and demonstrates “we know you.”)

“Let’s look at the lab results to see howyour cholesterol is doing.”“Let me show you this part of themedical record so we can confirm someinformation together.”“Here are the injections we have in ourrecords. Have you had other injectionsoutside KP that we need to add?”

Eyecontactwith thepatient

• Greet the patient. Make a personalconnection away from the computer

• Keep that connection throughout thevisit by:- Maintaining eye contact with the

patient.- Turning toward the patient when

the patient speaks or engaging inconversation.

(Maintaining eye contact promotes activeinvolvement.)

“Good morning, Mr Jones. I see youhurt your ankle.”“Let’s spend a few minutes discussingyour options.”

Value thecomputeras a tool

• Acknowledge the computer.• Let the patient know how the

computer improves care.• Stay positive when faced with

computer challenges.

(From the patient’s perspective,great medical technology is equatedwith great medical care.)

“The computer makes getting andsharing information with other healthcare team members so easy andefficient.”“This computer is great. I have all your background information at myfingertips—medications, prior visitnotes, and lab results from all KP visits.”

Explainwhat youare doing

• Keep the patient informed about yourthought process and actions.

• As you are documenting, let the patientknow what you are doing—enteringinformation you have just discussed,ordering lab tests/medicines, accessingpatient information.

(Patients who receive no explanation aboutwhat you are doing may think you are workingon unrelated business.)

“I am printing some instructions, whichwe can go over together in a moment.”“I am recording the details of your sorethroat so our records will be complete.I’ll order the medication we justdiscussed, so it will be available at thepharmacy.”“I’ll add the leg swelling to yourproblem list, so we can keep it in mindfor future visits.”

Log offand sayyou aredoing so

• Tell the patient that you are “loggingoff the computer” to safeguard theirinformation.

(Some members are concerned aboutprivacy and confidentially. If their concerns arenot addressed, satisfaction may decrease.)

“I’m logging off the computer now tokeep your information private.”

Figure 2. Do your LEVEL best with the computer in the exam room

Table 2. Courses for clinicians and health care team membersIntroduction to CPC Issues and Future Support 10-15 minutesLEVEL Tips for Technical Training 5-15 minutes

Connected Communicating and Computing in the Exam Room Web-Based Training Coursehttp://internal.or.kp.org/cis/training/erc.html

30 minutes

CONNECTED CONDENSED a two-hourworkshop session

Course for Exam Room Coaches RECONNECTED

Computers in the Exam Room—Friend or Foe?

© 2004, The Permanente Federation LLC


commentary

KP HealthConnect

Making the Right Thing Easier to Do

t the Care Management Institute (CMI), our guidingphilosophy is to make the right thing easier to do,

and the implementation of KP HealthConnect expandsdramatically the possibilities for us to make this philoso-phy a reality. With the advent of KP HealthConnect,we have at our disposal new tools to answer our pe-rennial question: How can we most effectively sup-port clinicians and members in having the best pos-sible information they need, when they need it?Assembling and clearly presenting the right clinicalinformation and knowledge—what’s known as wellas what isn’t—is the core of evidence-based medicine (EBM). CMI has beenable to benefit from and complementdecade-old efforts within the KP Re-gions to rigorously engage in devel-oping and disseminating EBM. Ourmultiple and evolving efforts seek al-ways to improve health outcomesthrough the identification, implemen-tation, and evaluation of nationally con-sistent, evidence-based, population-ori-ented, cost-effective health careprograms. To the extent that we bringthe right information to the right peopleat the right point in a clinical encoun-ter, clinicians and members can be op-timally prepared to make key decisions.

Knowledge ManagementThe process of knowledge management is vital to

providing content for KP HealthConnect, and the in-put and experiences of practicing clinicians in the KPRegions are foundational at every step. Knowledge man-agement assembles existing knowledge in medicineand identifies concerns and inquiries that are critical toclinicians. We investigate the degree to which evidenceexists to answer these pivotal clinical questions andidentify key elements of evidence that should be avail-able during practice.

Once knowledge has been assembled and distilledinto core elements, it must be “triaged” into an appro-priate level of decision support. What point in the clini-cal encounter is the right one at which to present theevidence? Is it appropriate to “intrude” in the visit withalerts, reminders, and redirection of care? What infor-

mation needs to be just “a click away”?The answers are evolving out of an increasingly clear

understanding of the process of clinical decision-mak-ing. Clinical decision-making involves understand-ing the evidence and interpreting its implications de-pending on individual circumstances as well as onthe preferences and values of the involved parties.When rigorous evidence is readily available at theright time and in the right way, clinicians are liberatedto address preferences and values—theirs and those ofmembers—in clinical encounters.

With the homework of discoveringand distilling the evidence addressedbefore the clinician even begins workwith a patient, visits can be increasinglydevoted to the unique aspects of indi-vidual situations. For this reason, EBMis a key enabler of the ultimate goal ofpatient-centered care.

Visit WorkflowWorkflow—how exams and discus-

sions proceed—is of central importanceto both clinicians and members. Theunique relationship that goes on behindthe closed door of an exam room mustalways be respected. KP HealthConnectoffers a system with a range of ways toprovide evidence and support decision-

making within the clinical encounter.Some clinical issues are important enough to justify

interrupting workflow in order to present pertinent in-formation. For instance, missed screening tests and medi-cation incompatibilities are generally worth interruptingthe flow of a visit to prompt clinicians and members todo something differently. Alerts and reminders repre-sent the first order of intrusiveness. Instances like these,in which the evidence is strongest and the risks of over-looking it are highest, are relatively rare.

The second order of intrusiveness makes informationavailable the instant a question is posed within the visitworkflow. For instance, one medication may be morecost-effective or appropriate than another initially se-lected. Redirection can be provided with the option topreserve the original order. References are providedon demand, supporting the clinician’s need for more

Paul Wallace, MDExecutive Director

Care ManagementInstitute

S O P H I S T I C AT I O N

A

When rigorousevidence is

readily availableat the right timeand in the right

way, clinicians areliberated to

addresspreferences andvalues—theirsand those ofmembers—in

clinicalencounters.


commentary

Special Feature

details about options and choices. In KP HealthConnect,an alternative medication functionality provides this typeof information and facilitates redirection if the clinicianagrees this is best for the patient.

The third order of intrusiveness provides facilitatedaccess to decision supports such as clinical guidelinesand other references. One example is treating acidpeptic disease caused by H pylori, which requires amixture of antibiotics that changes frequently and is dif-ficult to remember. KP HealthConnect can leverage whatseveral KP Regions have previously achieved throughprotocols and clinician agreement to field and help fill apharmacy order for treating H pylori that brings all cur-rently recommended medications up for approval. Ad-ditionally, a clinician may have started to order a diag-nostic test and have a question about it. Within the orderform, s/he can find links out to general reference infor-mation on the Web through the Clinical Library.

Alerts and reminders, redirection and reference ondemand, and general reference availability support thewhole range of clinical inquiry, and the flexibility of theKP HealthConnect system allows us to triage evidence

into the appropriate level of decision support. Most im-portant, the leverage of knowledge, including the de-gree of intrusiveness for knowledge within the encoun-ter—like the actual guidelines themselves—is under theguidance and oversight of practicing KP clinicians.

Quality Assurance ProcessCompleting the knowledge management cycle is the

need for a consistent quality assurance process in whichwe ask the question: Does the information that ap-pears in KP HealthConnect accurately represent theevidence on which it is based? The ability to makesomething easier carries with it the accountability toinsure that facilitated care is indeed the right care.

Involving the MemberAn integrated knowledge management process needs

to also take into account the fact that members must havea view into existing knowledge. This is key for self-careof some acute illnesses, such as uncomplicated respira-tory infections; support for members in sharing in deci-sions about their care; and support and engagement ofmembers in their own self-management of chronic medi-cal conditions such as diabetes, heart failures and asthma.Patient information concordant with that available to cli-nicians is being made readily available to members. Themember functionality (referred to as “MyChart” by Epic)creates a new forum for communicating medical knowl-edge with our members and empowering them to deter-mine their own health status.

Final CommentsFinally, although our efforts to date have focused on

putting the right thing into KP HealthConnect to sup-port care for our members, as we look toward the fu-ture, we can anticipate harvesting an expanded andextended knowledge base about our members and theirclinical experience from KP HealthConnect. Despitethe best efforts of CMI, regional experts, and trustedthird-party sources, gaps in the evidence base persistand will continue to do so for the foreseeable future.KP HealthConnect will generate an unprecedented datastream reflecting the clinical paths of millions of people.It is incumbent on all of us to use it optimally for re-search purposes to address these gaps.

It is, in short, the right thing to do. ❖

Making the Right Thing Easier to Do


“Making the right thing easier to do” has been the guidingphilosophy behind Dr Paul Wallace’s inspired leadership inbringing information technology to bear in realizing the promisesof evidence-based medicine within Kaiser Permanente, first inthe Northwest Region, and now as director of the KP CareManagement Institute.


health systems

KP HealthConnect

Population Care Information Systems (PCIS):Managing the Health of Populations withKP HealthConnect

By Joel Hyatt, MDWarren Taylor, MD

Leslee Budge, MBAKP HealthConnect creates an op-portunity for Kaiser Permanente (KP)to practice population care manage-ment (PCM) on a scale unparalleledelsewhere on the planet. The CareManagement Institute (CMI) is spear-heading an effort to make sure thatthis potential is realized.

PCM, conducted by the KP Re-gions in collaboration with CMIleadership and support, is alreadya core strength of KP. Regions, learn-ing from one another and buildingon innovations, have developedPCM programs that demonstrate aclear impact on health outcomes.1

Information systems that identifyand stratify populations, supportinreach decision support (member-specific point-of-service messages toproviders that prompt certain ac-tions) and outreach (communicationto members by mail, telephone, ore-mail), and track outcomes are keyto PCM. All eight KP Regions inde-pendently developed PCM informa-tion systems and migrated towardinterregionally consistent populationdefinitions and outcomes measures.From a KP Program perspective, re-gional information systems currentlysupport PCM in patchwork fashion.The advent of KP HealthConnect, onthe other hand, represents an oppor-tunity to create a finely woven tap-estry of PCM that covers every KP

member programwide—consis-tently, effectively, and efficiently.

What’s PossibleAs an example, consider impor-

tant research findings like those ofthe recent Heart Protection Study.2

The finding that a moderate doseof lipid-lowering statins protectsagainst adverse cardiovascular (CV)events in members with coronaryartery disease and diabetes has clearimplications for managing the popu-lation at risk for adverse CV events.Currently, ongoing outreach effortsin all KP Regions seek to make surethat every member at risk for anadverse CV event has the opportu-nity to benefit from the protectiveeffect of statins. Outreach effortsvary between the Regions; so, too,does the rate at which the percent-age of members with diabetes onstatins increases.

Once KP HealthConnect—andcustomer relationship management(CRM) software—is fully in place,every KP member throughout theprogram could receive notificationin the manner of their choosingabout the importance of taking newmedication, such as statins. Mem-bers would also benefit from thebest and most recently publishedresearch as soon as it became ac-cepted policy; PCM staff could send

prescriptions for the newest appro-priate and affordable medication tohundreds and even thousands ofmembers at a time—with little effortor technical expertise. Similarly, de-pending on their preferences—which would be available in the elec-tronic health record—some KPmembers would receive personal-ized outreach messages by mail orphone. Others would prefer to ac-cess them through MyChart, themember interface into KPHealthConnect.

Depending on their pref-erences, which would bestored in the electronichealth record, some KPmembers would receivepersonalized outreach mes-sages in the mail or over thephone. Others would re-ceive them throughMyChart.

MyChart has significantpotential to enhance PCMby helping individuals ac-cess both the informationand health resources totake the steps they need to managetheir own health care. Particularlyin chronic disease, the member andthe member’s family must take keysteps toward lifestyle modificationand improving health status.

MyChart also holds the potential

Joel Hyatt, MD, (right) is the Assistant Associate Medical Director, SCPMG. E-mail: [email protected] Taylor, MD, (not pictured) is Director of Chronic Conditions Management, KPNC. E-mail: [email protected] Budge, MBA, (left) is practice leader for cardiovascular disease for KP Care Management Institute. She co-facilitated the

development of CMI’s Coronary Artery Disease, Secondary Prevention guidelines. E-mail: [email protected].

The advent ofKP HealthConnect,on the other hand,

represents anopportunity tocreate a finely

woven tapestry ofPCM that covers

every KP memberprogramwide—

consistently,effectively, and

efficiently.



health systems

Special Feature

to liberate some health care from theconfines of inpatient and outpatientsettings. Although clinic visits andhospital stays will continue to benecessary elements of health care,the potential for fast, direct commu-nication between clinician andmember means that some care cantake place outside both traditionalsettings. One likely scenario is indiabetes care. If members are ableto electronically transmit data onblood glucose home monitoring andclinicians can recommend insulin ororal hypoglycemic changes via e-mail, the member’s home becomesthe locus of care.

KP HealthConnect will also cre-ate the largest and most diversedatabase in the country—and in theworld. Cradle-to-grave data will beavailable on eight million people.The potential for research into dis-ease risk factors and causative fac-tors, including genomics, and foreffective treatment is staggering.

But none of this will happen over-night—or without concerted effort.

Population CareInformation Systems

To make sure that KP receives themaximum PCM benefit from KPHealthConnect, an interregionalgroup of stakeholders, KPHealthConnect management, andrepresentatives from Epic, KP-IT,and the Regions assembled to ad-dress the question: How can KPHealthConnect support PCM in thenear future and over the long term?The process of finding answers iscalled Population Care InformationSystems (PCIS). Co-led by Joel Hyatt,MD, Assistant Associate Medical Di-rector (SCPMG), and Warren Taylor,MD, Regional Director of ChronicConditions Management (KP North-ern California), PCIS involves CMIstaff and regional contacts.

It was clear to PCIS members that

KP HealthConnect supports encoun-ter care superbly. However, thepotential for population-based func-tions within KP HealthConnecthadn’t been addressed by Epic, KPHealthConnect’s vendor, in any pre-vious application. Nor was there aprecise picture of the key elementsof PCM that KP HealthConnect, orany enterprise-level information sys-tem, should support.

Defining the ElementsA first step for PCIS was to define

core requirements for PCM. Thatrequired a close examination of theexisting PCM mix, including visitsto all eight KP Regions, interviewswith more than 100 staff and clini-cal and operational leaders, obser-vations of over 30 population caremanagement systems, and docu-mentation of more than 300 PCMrequirements. Led by CMI PracticeLeader Leslee Budge, the exhaus-tive investigation yielded a clear ideaof what KP HealthConnect needs todo to support PCM well.

As a result, PCIS specified eightkey functions needed to supportPCM in the KP HealthConnect en-vironment:

• population identification—de-termining population member-ship through reproducible pro-cesses and criteria

• population stratification—identifying population subsetsaccording to level of illness orrisk

• member tracking—followingmembers through episodes ofcare

• care/case management—careplan documentation, commu-nication, prioritized list ofmembers, and smart algorithmsto maximize care/case man-agement efficiency

• inreach—alerts and reminderstriggered at any point of ser-

vice (decision support)• outreach—individual or mass

communication with membersby telephone, mail, or Internet

• member data entry into KPHealthConnect—input of datafrom MyChart, devices, orquestionnaires

• monitoring and reporting—generating reports to meet stra-tegic and quality needs

In partnership with Epic and KP-IT,PCIS began a process of matchingthese functions to KP HealthConnect.Where gaps existed, the group identi-fied KP HealthConnect functionalitiesthat could be adapted to meet PCMneeds. Epic proved robust and flex-ible; as members of PCIS brought de-tailed questions to the table, they foundfunctionalities to support many iden-tified PCM needs. Where there weregaps, analysis of alternative solutionsyielded a workplan, which was ap-proved and funded by the Care De-livery Portfolio Approval Council.

Several groups within KP are col-laborating with and supporting theefforts of PCIS. For example, theclinical data warehouse project isworking with PCIS to create aprogramwide dataset, starting withdata for Clarity, Epic’s database, andother sources such as some lab andclaims data. PCIS is working in part-nership with that project and withInformation Management to selectsoftware for back-end data-miningfunctions. Enterprise Architecture-Health Plan Operations is workingon the applicability of CRM softwareto support outreach efforts. CRM willeventually hold all member infor-mation, including contact prefer-ences, and be able to supportcampaignlike marketing efforts toreach members. PCM will be ableto take full advantage of CRM ser-vice capabilities to target specificpatient audiences and receive feed-back on the results. Patient encoun-

Population Care Information Systems (PCIS): Managing the Health of Populations with KP HealthConnect



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KP HealthConnectS O P H I S T I C AT I O N

ters through CRM will be stored inthe medial record.

An important byproduct of PCISis a meeting of minds about PCM.For the first time, operational andclinical leaders from the KP Regionshave gathered with staff and con-sultants from CMI, PCM’s homewithin KP, to develop a shared vi-sion of what PCM could look likein an integrated health care deliv-ery system and what functionalitieswithin KP HealthConnect supportthat vision. Regional and CMI lead-ers collaborate frequently; untilnow, they’ve focused on best prac-tices for clinical priority areas. PCISis their first opportunity to lookacross the PCM landscape and to-ward the horizon.

Between Here and ThereThere are some intermediate land-

marks between the current state ofPCM at KP and the PCIS vision out-lined above.

For one, consider the impact ofKP HealthConnect on communica-tions. When the electronic healthrecord is live, information about careplans for individual members will beshared instantaneously and continu-ously. This represents a quantumleap in communications at KP.

Take the care of a member withchronic pain, for instance. The careteam may consist of a behavioral

medicine specialist, a physical thera-pist, a care manager, and a painspecialist, in addition to the primarycare provider. Often, documentationabout care management is siloedfrom the medical record and main-tained separately. Primary care pro-viders often find it difficult to havea clear picture of the plan of carefor chronically ill members. With theadvent of KP HealthConnect, thecare plan will be readily availableto the primary care provider, mak-ing that clinician an active part ofthe team and ensuring that his orher time is well spent.

Increased communication canonly improve PCM. So, too, willSmartTools that incorporate clinicalpractice guidelines improve PCM.

Back end data queries will allowcare managers or support staff toidentify population members who,for instance, need better glucose orlipid control or who need to be onan ACE inhibitor.

EpicCare’s Reporting Workbenchwill enable providers to easily createqueries that provide panel-level in-formation about members who maybe at risk and need some form of in-tervention or monitoring. As this pro-cess gets refined, the health care teamwill be able to produce a summaryon specific subsets of members.

As KP HealthConnect rolls outover the next few years, it’s essen-

tial that population care manage-ment activities continue uninter-rupted. To that end, the KP Regionswill maintain parallel PCM systemsuntil the last regional medical cen-ter goes live with KP HealthConnect.

A methodical approach totransitioning from existing systemsto KP HealthConnect-based PCMsystems will ensure that, while pro-viders are busy learning the ins andouts of the encounter-focused elec-tronic health record, PCM contin-ues. CMI will take a leading role inensuring that no members fallthrough PCM cracks. IndividualPCM resources, like care manage-ment summary sheets, will betransit ioned gradually to KPHealthConnect-embedded informa-tion. The vision of PCIS is that fromthe perspective of care providers,the transition from current systemsto the PCM of the future will be in-cremental and seamless. ❖

References1. Pheatt N, Brindis RG, Levin E. Putting

heart disease guidelines into practice:Kaiser Permanente leads the way.Perm J 2003 Winter;7(1):18-23.

2. Heart Protection Study CollaborativeGroup. MRC/BHF Heart ProtectionStudy of cholesterol lowering withsimvastatin in 20,536 high-riskindividuals: a randomized placebo-controlled trial. Lancet 2002 Jul6:360(9326):7-22.

Population Care Information Systems (PCIS): Managing the Health of Populations with KP HealthConnect

When theelectronic health

record is live,information

about care plansfor individualmembers will

be sharedinstantaneously

and continuously.This represents aquantum leap incommunications

at KP.

DiscoveryThe real voyage of discovery consists not in seeking

new landscapes but in having new eyes.

— Marcel Proust, 1871-1922, French novelist


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Special Feature

Clinical Knowledge Management andPatient Care Intersect in SmartTools

SmartTools are the part of clinical knowledge man-agement that clinicians will see as they use KPHealthConnect. Some SmartTools, like preference lists,SmartTexta and SmartListsb streamline workflow for cli-nicians by, for instance, reducing repetitive documenta-tion or making orders or diagnoses easier. Others offermore pointed decision support. SmartSets, for example,bring together diagnoses, lab and imaging orders, medi-cation and procedure orders, patient information, andsupporting documentation in a template.

The Care Management Institute (CMI) is coordinat-ing an ongoing effort to make high-quality knowledgeavailable to clinicians at the point of care in these tools.

Creating Clinical ContentThe primary focus of the clinical knowledge man-

agement process behind KP HealthConnect is the col-laborative creation of rigorous, evidence-based con-tent for clinicians to use at the point of care.

The CMI clinical knowledge management process iswell established. Interregional workgroups consistingof clinical experts from medicine, pharmacy, and nurs-ing, evidence-based methodologists, and CMI care man-agement consultants have created clinical practice guide-lines for a core set of conditions and health care issues:asthma, coronary artery disease, chronic pain, cancer,depression, diabetes, elder care, heart failure, and self-care and shared decision-making. These guidelines havebeen approved on a national level by the Guideline Di-rectors Group and are revised at least every two years.

Clinical practice guidelines appear in a variety ofprint formats, including full-length technical and sum-mary documents, as well as on the Clinical Library (CL),(http://cl.kp.org) formerly called Permanente KnowledgeConnection (PKC). CMI care management consultants alsodeveloped clinician-friendly tools, like trifold brochuresand pocket cards, to facilitate guideline implementation.

For conditions outside its core list, CMI is facilitatingthe work of interregional domain (specialty) groups.Each domain group, consisting of clinical experts,chooses three clinical conditions to address with KPHealthConnect SmartTools. Within these conditions,domain group members submit questions or clinicalissues for the evidence consultants to research. Forexample, the rheumatology domain group chose toexamine the efficacy of recently introduced medica-tions compared with long-standing treatment options.

A CMI evidence consultant, working under a physi-cian evidence-based medicine methodologist, then fol-lows a specified procedure for synthesizing availableevidence on the topic. The knowledge synopsis is de-livered to the domain group, whose responsibility itthen is to build clinical content in collaboration withregionally based KP HealthConnect builders.

CMI also facilitates design, build, and validate (DBV)sessions (see sidebar). DBV sessions bring together phy-sicians, nurses, pharmacists, evidence methodologists,coders, representatives from patient safety and healtheducation, and other experts from across the programto Oakland to create content for KP HealthConnect.

The effort to create high-quality, evidence-basedknowledge and decision support for KP HealthConnectalso extends to the emergency department and inpa-tient settings. More than 40 people, including emer-gency room physicians, hospitalists, and nurses, areworking on the inpatient content to support KP Re-gions with KP hospitals.

The goal of all processes is the synthesis of the bestavailable evidence and information. The domain group,DBV—or the CMI core condition workgroup—thenconsiders how to represent it within KP HealthConnect.

Plugging it into the Right Point of CareOnce an evidence synopsis exists, the recommenda-

tions are integrated into the process of care. Statins, forinstance, are indicated for the prevention of acute car-


Karen Woods, (top), is Director of Clinical Quality and Process Management, CMI. E-mail: [email protected] Licht, RN, MS, (left), is Director of Knowledge Management, CMI. E-mail: [email protected] Caplan, MD, (right), is Director of Clinical Development, CMI. E-mail: [email protected].

The Clinical Knowledge ManagementProcess Behind KP HealthConnectBy Karen WoodsMelodi Licht, RN, MSWilliam Caplan, MD


health systems

KP HealthConnect

diovascular events in members with diabetes over theage of 55. A prompt should appear at some point in aclinic visit to alert the provider if an appropriate candi-date for treatment isn’t receiving a statin.

CMI priority area workgroups and domain groupsmake sure that the processes of care drive the creationof tools—not the other way around. The focus is oncreating solid knowledge and making it available atthe right point in the process of care by using the pos-sibilities that SmartTools present.

All this means thinking about guideline content in anew way. Even though previous tools like pocket cardshave aimed at making guideline implementation easyfor clinicians, the process of creating SmartTools re-quires content experts to think in great detail aboutthe moment-by-moment flow of care within a clinicvisit. At exactly what point in the visit should a statinalert appear? When the provider is reviewing the list ofcurrent medications? When he or she is signing off onany orders or plans? Within domain groups, clinicians,pharmacists, nurses, and representatives from utiliza-tion management and health education also discussthe flow of clinic visits at the same level of detail.

With a solid understanding of the process of care, KPHealthConnect builders can begin to create documen-tation and decision support tools that support the pro-cess and reflect the evidence.

A good understanding of the process of care allowsboth consistency and flexibility. Consistent standardsabout documenting orders and plans must be main-tained across Regions; at the same time, local prefer-ences for KP HealthConnect tools must be accommo-dated. For example, some users might want a pull-downmenu for documentation; others might prefer aSmartText module that they can further personalize toreflect their individual practice patterns.

Validating the ToolsQuality assurance (QA) is a key part of the process

of creating KP HealthConnect content, and QA’s pri-mary aim is to ensure that SmartTools reflect the evi-dence on which they are based. In 2003, more than400 SmartSets from the KPNW EpicCare system werereviewed for consistency with CMI-generated evidence-based summaries and clinical guidelines.

For content created de novo, validation sessions takeplace as Web and teleconferences, at which the builderresponsible for creating the SmartTools posts themonline for participants to view. Domain group mem-bers review each section, making sure that their input


The Clinical Knowledge Management Process Behind KP HealthConnect

has been accurately translated. Constituent members,such as lab, pharmacy, utilization management, andevidence-based medicine methodology representatives,sign off on the SmartTool or request changes.

To shorten the feedback loop, the builder respondsto requests for changes in real time. The goal is torevise the SmartTools to the satisfaction of all partici-pants during the course of the Web conference.

Lively discussions can arise, all leading to the even-tual betterment of the SmartTool. Notable recent de-bates included the utility of MRIs for diagnosing early-stage breast cancer and the routine use of brainnatriuretic peptide (BNP) for diagnosing heart failurein inpatient settings; both tests were ultimately removedas default options from the SmartTool being discussedon the basis of the published evidence.

Design, Build, ValidateClinical decision support tools for ambulatory KP HealthConnect are

created in three-day sessions called Design/Build/Validate. Physicians,nurses, pharmacists, utilization management representatives, evidencemethodologists, regionally based KP HealthConnect clinical contentbuilders, and representatives from Epic meet to plan, build, and performquality assurance on KP HealthConnect tools. Adult primary care wasthe topic of a DBV session in February 2004; a July session targetedpediatric ambulatory care. These sessions yielded content for 10 to 20conditions.

DBVs are also conducted for the inpatient application. These DBVstypically run one to three weeks and address workflows, configurationdesign, documentation tools, and order sets. Starter sets have been com-pleted for hospitalists, general surgery, medical/surgical nursing, andemergency departments. An integrated inpatient/outpatient DBV to ad-dress obstetrics is planned for October/November.

Lengthy preparation on the part of involved clinicians and represen-tatives precedes the meetings. Evidence synopses and clinical practiceguidelines, posted on the Clinical Library and the I KNOW Web site,form a critical foundation. Armed with this information, participants de-termine how best to incorporate recommendations into workflow bymentally walking through a clinic visit moment by moment. “There’sonly so much time in the flow of care. Our goal is to prioritize the keypoints in a clinical practice guideline. We focus on creating SmartToolsthat clinicians will find easy to use and that also support them in makingthe right decisions,” says Michelle Wong, MPH, MPP, CMI Care Man-agement Consultant.

Builders then create the suggested tools, and the entire group vali-dates that their input has been accurately translated into KPHealthConnect. Clinicians participating in the process feel their time iswell spent. “Clinicians are really energized and excited, despite the verytight timelines involved,” says Ms Wong.


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Special FeatureS O P H I S T I C AT I O N

The Clinical Knowledge Management Process Behind KP HealthConnect

When—and How Much—to Roll OutContent for KP HealthConnect is built in the order in

which it’s needed. In April of 2004, the Hawaii Regionwent live with HealthConnect in internal medicine, fam-ily practice, pediatrics, gynecology, and behavioral health.As medical and surgical specialties come online, clinicalcontent will be ready.

The efforts to date don’t yet cover the vast array of clini-cal conditions that KP primary and specialty care providersmay encounter. Clinical knowledge management in thecontext of KP HealthConnect is best thought of as a pro-cess, not an end. As clinicians become familiar with theelectronic health record and its potential for offering deci-sion support, the clinical knowledge management processeswill already be in place to meet accelerating demand formore SmartTools. New technologies under study, like ac-tive guidelines and Web-enabled documentation templatesand order sets, will also enable new kinds of SmartTools.

Regional VariationsThe process described above will yield a collabo-

rative national version of KP HealthConnect, which

maximizes the economies of scale involved. How-ever, KP Regions can customize it to create ver-sions sensitive to local conditions and preferences.

The ultimate goal of the KP HealthConnect clini-cal knowledge management process, though, is stan-dardized, high-quality care and improved health out-comes throughout the KP Program. Members withdiabetes, asthma, coronary artery disease, or anyone of the conditions identified by the domaingroups should receive the same standard of careacross all the regions. The SmartTools within KPHealthConnect are a key mechanism for making thathappen. ❖

a Standardized text templates that streamline documenta-tion by presenting prewritten elements of patient carenotes. They can also include patient care instructions,care protocols, or other text-based information.

b Predetermined lists of symptoms, physical findings,pertinent patient history, and the like. They can alsoappear within SmartText as options for individualizingpatient care notes.

Walk Into The FutureYou need people who can walk their companies into the

future rather than back them into the future.

— Warren G Bennis, b 1925, Professor of Business Administrationand author of books on leadership


health systems

KP HealthConnectS O P H I S T I C AT I O N

A Universe at Your Fingertips:The Clinical Library and KP HealthConnect

By Brad HochhalterTom Stibolt, MD

Aaron Snyder, MDDavid Levy, MD

Robert H Dolin, MD

Brad Hochhalter, is Director, Clinical Library. E-mail: [email protected] Stibolt, MD, is Senior Physician, Medical Informatics, KPNW. E-mail: [email protected].

Aaron Snyder, MD, is Director, Clinical Decision Support, KPCO. E-mail: [email protected] Levy, MD, is Associate-Physician-in-Chief, Information Technology and Innovation, Diablo

Area, KPNC. Email: [email protected] H Dolin, MD, is Department of Internal Medicine, SCPMG Physician Lead, National

Terminology Team, KP HealthConnect. E-mail: [email protected].

Imagine you’re in the middle of aKaiser Permanente (KP) clinic visitand wondering if there’s any evi-dence for using aspirin in memberswith heart failure. Or when you nextneed to see the person for whomyou’re prescribing an antidepressantmedication. Or how long your pa-tient with diabetes needs to be NPObefore a colonoscopy.

What Do You Do?Here’s a likely scenario—before the

implementation of KP HealthConnect.You instantly decide how importantyour question is. You only have timeto pursue critical information, be-cause three more patients are wait-ing to be seen. So the question aboutaspirin gets sidelined; you’ll look itup later. You guess that six weeks isabout the right interval for a returnvisit. But you have to know how tohelp your patient adjust insulin, soyou leave the exam room and makea quick call to the GI lab.

Thanks to Web-based resourcesprovided by KP’s National ClinicalLibrary (http://cl.kp.org), KPHealthConnect can provide the an-swers to these questions—and aninfinite number of others—almostinstantaneously. In the exam roomwith your patient, you run a quickGoogle™ search of the site and findno evidence to support adding as-pirin for your patient with heart fail-

ure. You click on a hyperlink withinthe visit page to go directly to thesection of the depression clinicalpractice guideline pertaining to fol-low-up, then ask your patient toreturn in a month. You click on alink to your personal home page,MyEpic, and find links to depart-mental home pages. Two moreclicks take you to the prep instruc-tions for colonoscopy.

The Clinical Library (CL) makessure that all the information cliniciansneed is only a click or two away.From a single user interface, KP careproviders can deliver and documentcare and quickly find reliable, up-to-date medical knowledge.

Portal to ResourcesThe KP CL, sponsored by the Care

Management Institute (CMI) and theRegional Permanente MedicalGroups, is a clinical knowledge Webportal and the Web-based referencelibrary in the KP HealthConnect en-vironment. Formerly namedPermanente Knowledge Connec-tion (PKC), CL has long been thereference library resource link forKP clinicians. In keeping with theCMI mission of “making the rightthing easy to do,” CL/PKC houses arapidly expanding base of clinicalknowledge that is available to KPclinicians, researchers, and employ-ees KP Programwide. The new name

reflects a merger between PKC andonline clinical libraries in KP North-ern California (KPNC) and KP North-west (KPNW) and a nod to regionalconstituencies that both use and fundcentralized CL resources.

Long before KP HealthConnectwas identified as the electronic healthrecord vendor, CMI staff ensured thatthe CL would be compatible withwhatever application eventually sup-ported patient care documentation.Instead of embarking on a plan toembed CL resources into KPHealthConnect, planners pursued aportal strategy. While a Web site hasstatic pages that are designed andposted, a portal links users to othersites as well as having content di-rectly on the site. The CL functionsas the gateway between KPHealthConnect and an expandinguniverse of medical knowledge.

It’s a largely invisible gatewaythough. Unlike previous versions ofPKC, no log-in is required exceptfor online continuing medical edu-cation. The CL provides a seam-less interface between the pro-cesses of caring for KP membersand finding rapid, precise, and re-liable medical knowledge.

That knowledge is in the form ofKP-created clinical content like na-tional, CMI-sponsored clinicalpractice guidelines, content fromthe KPNC, KP Southern California,

The ClinicalLibrary

functions asthe gatewaybetween KP

HealthConnectand an

expandinguniverse of

medicalknowledge.


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Special FeatureA Universe at Your Fingertips: The Clinical Library and KP HealthConnect


and KPNW regional clinical li-braries, and other internal con-tent. The CL also provides third-party resources such as morethan 1200 full text journals and180 textbooks, OVID, and a se-cure link to Clin-eguide, a pro-prietary subsidiary of WoltersKluwer Health with evidence-based and consensus guidelinesfor 300 conditions that are tai-lored specifically to PermanenteMedicine. Ultimately, the Clin-eguide content alone will bring84,000 pages of KP-modifieddocumentation to clinicians.

In terms of cancer care alone, forinstance, clinicians can access CMI-generated tools like an oncologyresources page with links to inter-nal and external sites and contentresources. There are guidelines;member education resources; andreference links to textbooks, data-

home page from which clinicianscan link directly to the Web-basedinformation and services most im-portant to them. Access to the CLwill appear here, and in hyperlinksthroughout the KP HealthConnectenvironment.

CL is rendered as one of eightregional and a single national ver-sion, depending on the physical lo-cation from which clinicians accessit. All sites have the same look andfeel, but each Region decides whatto put on their version of the MyEpichome page. For example, the KPNWCL site emphasizes protocols andprovides call lists to serve up the kindof operational information cliniciansneed (see sidebar). With MyEpic,individual clinicians can furthercustomize their Web access byadding links to clinical practiceguidelines, OVID, or any otherWeb-based resource.

Early on, the CL Advisory Board asked a fundamentalquestion. What kind of information do clinicians need? ACMI-sponsored study examining the information-seekingbehavior of KP clinicians provided insight. Researchersfound that clinicians sought four general kinds of infor-mation, as depicted below.

Patient-specific Nonpatient-specific

Medical Patient medical record Medical science

Nonmedical Social/demographic Operational

• Patient Medical Record—Medical questions about the

individual patient in a clinical visit

• Social—Nonmedical questions about a specific patient

• Medical Science—Clinical questions of a general nature.

This is the domain of most decision-support systems. Most

previous studies of clinical questions have been limited to

this question type.

• Operational—General nonmedical questions that often have

to do with workflow issues.

KP HealthConnect will provide patient-specificmedical information key to any clinical encounter.How important to clinicians are the other types ofinformation?

Operational information about topics like how torefer a patient for a particular service, which physi-cians are on call, and what services are covered isthe most frequent type of query for clinicians. Thisfinding helped identify priorities for the MyEpic pageof KP HealthConnect.

Social information is also quite important, allow-ing clinicians to ascertain whether they’ve seen aparticular member before, to plan care that’s ap-propriate to the context of the member’s life, andto build effective relationships.

When medical science information was sought, itwas important to clinicians that the process reli-ably yielded meaningful results. To that end, theCL assembles top-of-the-line medical resources andmakes them optimally accessible to cliniciansthrough hyperlinks embedded in KP HealthConnectand familiar search tools like GoogleTM.

What Kind of Information Do Clinicians Really Need?

bases, and all noteworthy nationalorganizations—all focused on on-cology and hematology care.

The CL functions as a database thatlinks to all these data sources. Eachsource document is categorizedalong criteria such as keywords, ap-proving body, clinical category, in-tended audience, type of document,and so forth. Whereas Google™ re-turns results ranked by relevance, theCL search functionalities can returnresults sorted by any of these crite-ria in combination. One particularlyuseful search process pulls up docu-ments by type. For example, a clini-cian could quickly find diabetes-related documents that are patienteducation tools.

PersonalizableKP HealthConnect includes a page

called MyEpic within the visit navi-gator. MyEpic is like a personal


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KP HealthConnectA Universe at Your Fingertips: The Clinical Library and KP HealthConnect


InteroperabilitySimultaneous computer applica-

tions typically run in parallel fash-ion; you can’t work on a PowerPointpresentation, for instance, fromwithin a Word document.

Interoperability is the opposite ofparallel operation, and maximizinginteroperability between KPHealthConnect and the CL is theultimate goal. Users can already runWeb-based searches from within theKP HealthConnect environment,and much work has gone into mak-ing that happen.

For a start, the two programs havea vocabulary that allows them to“talk” to each other with precision.Convergent Medical Terminology(CMT) is the lingua franca betweenKP HealthConnect and the CL. CMTis the result of nearly a decade ofwork within KP that began as an ef-fort to create a terminology databaseto serve the needs of KP Colorado’sclinical information system. Leadersin that effort embarked on a collabo-ration with the developers ofSNOMED (Systematized Nomencla-ture of Medicine) to enhance its use-fulness for KP, so CMT and SNOMEDdeveloped as closely related systems.Years later, SNOMED CT emerged as

the lexicon of choice for electronichealth records and resources.

This base of common terminol-ogy forms the foundation for morecomplete interoperability betweenKP HealthConnect and the CL,which, in turn, offers considerablepotential for streamlining high-qual-ity patient care.

The Future of theClinical Library

Active clinical guidelines are aninteroperability function looming inthe not-too-distant future. Here’show they might work: A clinician,working in KP HealthConnect whileseeing a patient with diabetes, en-ters SmartText pertaining to thepatient’s cardiovascular status. Anicon labeled “evidence-based guide-line” pops up. The patient clicks onit and goes directly to the portionof the diabetes clinical guideline ad-dressing the role of aspirin,lisinopril, and lovastatin in prevent-ing adverse cardiovascular events.

Referring to the guideline for statinuse, s/he decides it’s indicated forthe patient and clicks on the sug-gested medication and dose. Thisinformation appears in the patient’srecord as a pending order. The cli-

nician signs off on it, and a prescrip-tion is generated in the pharmacytwo floors down.

Still working in the patient’srecord, s/he initiates a patient-spe-cific CL query built automatically byKP HealthConnect, selecting patienteducation tools as “document type”from a pull-down menu. S/he findsa handout that covers starting statinsand prints it out for the patient.

Building the interoperability to en-able this scenario takes imagination,time, and clinical and informationtechnology expertise, but this kind ofworkflow-integrated knowledge re-source is the ultimate goal of the CL.

Initially, users may feel hard-pressed to use even the Web portalfunctions available when KPHealthConnect goes live. Their pri-orities will necessarily be on mas-tering key tasks: accessing the pa-tient record, charting care andentering orders, diagnoses, andlevel of service. As their comfortwith KP HealthConnect grows,though, they’ll find more use forthe knowledge efficiencies built in.And, as user sophistication in-creases, so will the sophisticationof interoperability between KPHealthConnect and the CL. ❖

A MomentThere’s a moment coming. It’s not here yet.

It’s still on the way.It’s in the future. It hasn’t arrived.

Here it comes. Here it is …!It’s gone.

— George Carlin, b 1937, comedian


health systems

Special FeatureT R A N S F O R M AT I O N

Allan Weiland, MD, is President of Northwest Permanente.He is also Co-Chair of the Care Delivery Portfolio ApprovalCommittee. E-mail: [email protected].

KP HealthConnect as a Transformational ToolBy Allan Weiland, MD

A Vision of Better Health Care Enabledby Information Technology

Telemedicine applications are commonplace. Specialists use videoconferencing and telesensingmethods to interview and even to examine patients who may be hundreds of miles away. Com-puter-aided surgery with Internet-based video is used to demonstrate surgical procedures to oth-ers. Powerful high-end systems provide expert advice based on sophisticated analysis of hugeamounts of medical information. Patients are empowered in making decisions about their owncare through new models of interaction with their physicians and ever-increasing access tobiomedical information via digital medical libraries and the Internet. New communicationsand monitoring technologies support treatment of patients comfortably from their own homes.1

We are early into the information age of healthcare, and Kaiser Permanente (KP) is investinglarge sums of money and effort to implementKP HealthConnect to lead American health careinto this new age. Since the late 1950s and early1960s, when Permanente pioneer Morris Collen,MD, developed his computerized medicalrecord prototype, we have been trailblazers inthe use of just about every type of clinical in-formation technology to improve medical prac-tice (see Debley article, page 32).2

IntroductionIn this article, I will call on work done by

the Blue Sky Vision group for the KP CareDelivery Portfolio, the KP research commu-nity and many others, to paint a picture ofhow clinical practice could be transformedthrough the use of these technological toolsover the next few years. Technology has thepotential to change health care drastically byincreasing access to patient and medical in-formation, by increasing efficiency and time-liness of care, by simplifying complex tasks,by reducing medical errors, and by facilitat-ing the tracking of outcomes and develop-ment of outcomes-based research.3

Imagine the health care system of the fu-ture. Every encounter is “paperless” from the

reception desk to the exam room, laboratory,and pharmacy. All data are electronic, andmost data enter the system automatically. Alarger system, or data warehouse, stores thedata and generates reports about patients andpopulations (across conditions and over time)as well as longitudinal studies of diseases andtreatment patterns. Communication is seam-less, with orders and test results transmittedalmost instantaneously across departmentsand with real-time sharing of informationamong clinicians, no matter their physical lo-cation. Clinical encounters aren’t confined tothe clinic—they meet patients’ varying needs,including “virtual” visits with clinicians andhome-based monitoring of chronic conditions.

As attributed to William Gibson, a sciencefiction author, “The future is already here,it’s just not evenly distributed yet.” Much ofwhat I described above is happening rightnow in many KP regions and elsewhere.

AssumptionsIn order to describe potential transforma-

tions achieved through KP HealthConnect,first we need to make some assumptionsabout the delivery of health care in the fu-ture. These are extensions of current trends,with no major discontinuities.

Assumption 1: Health care infor-mation continues to grow at anexponential rate and is widelyaccessible via the Internet.

This is a safe bet and recognizes currentgrowth trends of health care information plusthe increasing amount of knowledge spinningoff from the Human Genome Project. Not onlyis the rate of knowledge creation increasingbut also accessibility of knowledge to consum-ers, primarily through the Internet and WorldWide Web. In several markets, at least 70% ofKP members have computer access, and thenumber of “hits” on health-related Web sitesis now well over 100 million annually.

The amount of medical knowledge availableto clinicians is also increasing dramatically. Ontop of newsletters, updates from specialty soci-eties, and online information, about 1500 medi-cal articles are published each day.4 In this ageof medical malpractice, physicians are expectedto keep current on best practices, yet the amountof medical knowledge that we have gained inthe last 20 years surpasses humankind’s totalprior understanding of medicine.3

Assumption 2: Point of care (home-based) testing and therapeuticinterventions will grow rapidly.

Multiple home monitoring systems are cur-rently available, all linked to information net-works, including “smart houses” that moni-tor physiologic functions and “smart toilets”with diagnostic capabilities. Remote cardiacand uterine contraction monitoring have beenavailable for years, and other types of moni-toring are possible. NASA, for example, con-ducts remote physiologic testing on its astro-nauts in space, monitoring an enormousamount of information. Additional home-based interactive capabilities are being de-


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KP HealthConnectKP HealthConnect as a Transformational Tool

T R A N S F O R M AT I O N

veloped all the time and will shift much ofour office-based care to the home setting.

Assumption 3: Many specializedtechnologies will be “global,”bridging both time and space.

Electronic transfer of information nowmakes it possible to read imaging studies inother locations, regardless of where the im-age was generated. Robotics, miniaturizationof cameras into swallowable or implantablesizes, and nanotechnology will all allow re-mote diagnostic and therapeutic care interac-tions. We will move information, not people.Individual experts can be housed anywhereand connected everywhere to support spe-cific technologies. We are already using re-mote radiologic-imaging reading services ina number of regions.

Assumption 4: KP will have suc-cessfully implemented the entiresuite of HealthConnect productsacross the whole program.

HealthConnect will unify existing and newtechnologies across all KP regions and willdo more than just digitize current informa-tion. Although it includes a unified electronicmedical record for each patient, which spansthe spectrum of care and can be immediatelyaccessible, HealthConnect is more than that.It will be supported by robust data warehous-ing, allowing aggregation of information byepisode of care, diagnosis, treatment, com-plication, cost, frequency, and individual. Theinpatient and outpatient clinical decision sup-port and other functions enabled byHealthConnect will create synergies that moveclinical care into a new realm.

TransformationsAssuming the above, one can imagine ma-

jor transformations over the next few years inthe nature of clinical interactions at KP: inter-actions between clinicians, members, and theorganization as a whole, clinician-clinicianinteraction, and clinician-patient interaction.

Organization-Member InteractionMember interactions with the organization

will be much closer to seamless. Billing, sched-

uling, prescription refills, and benefit infor-mation will all be accessible online atwww.kp.org. Each new member will be en-rolled in a primary care panel and take ahealth risk assessment that allows us to tailorservices to add value to their care. All mem-bers will be automatically enrolled in chronicdisease registries, health education classes,and medication counseling sessions, as ap-propriate. In the not-to-distant future, mem-bers will have interactive audio-visual capa-bilities in their home, through which they canaccess a variety of KP services.

KP will be considered a reliable source ofinformation about care, and the existence ofthe technology itself will give members con-fidence in the care they receive. We will pro-vide members with training on accessing andinteracting with their medical records, librar-ies of medical knowledge, and clinical guide-lines for all health conditions. Use of currentinformation sources, such as the HealthWisehandbook, will be much expanded and en-hanced by interactive triaging of questionsto the appropriate KP resource. We will usetechnology to enhance communication withmembers about how we can provide assis-tance in acute situations or with chronic ill-nesses, and what resources are available tooptimize health. Interactions with KP will besupported with a robust technologically en-hanced system that helps members more eas-ily navigate the complexities of care.

Organization-Clinician InteractionThe interaction between KP and clinicians

will be transformed to better support provi-sion of care in the “information age.” The grow-ing body of medical knowledge adds complex-ity, which can be simplified using technology.KP will provide tools that integrate the mostup-to-date and relevant practice data, drug in-formation, patient history, clinical guidelines,and screening recommendations into electronicreminders and prompts, enabling clinicians toprovide informed and specific care. When apatient has a specific question about their health,clinicians will be able to draw from a databaseof aggregate experience to provide the evidencefor a recommendation. For instance: “In yourspecific circumstance, with your genetic

makeup, this is the probability of a future prob-lem, and these therapies are consistent withbeing effective for you.”

KP will create new models for organizing thedaily work of all KP employees, as technologychanges the way care is delivered. Supportstaff may be trained to manage informationflow, more and more triage will occur elec-tronically, and many needs will be met re-motely. Instead of call centers, KP may have“information centers” or “electronic patientcare centers” that can match the type of issueto the appropriate resource, no matter wherein the system it happens to be.

Clinicians will also be supported by the fur-ther automation of many care processes. Labo-ratories can do “cascades” of diagnostic test-ing, using guidelines and algorithmsestablished from our enormous data captureand analysis. Instead of ordering one test andwaiting for the result, the lab could automati-cally do all subsequent tests based on the re-sults of the first one, until the full complementof testing is done to get to the diagnosis onthe first specimen. This specific and member-ship-wide data will also tie into care proto-cols that enhance clinician decision-making.

Clinician-Patient InteractionThe basis for creating value in the health

care interaction between clinicians and pa-tients is the transfer of knowledge, in a formthat is customized to the needs of the pa-tient. The majority of health care decisionsare made by individuals, in their homes, withthe advice of trusted others, not in our tradi-tional doctor/office milieu. These technolo-gies will enable us to use what tools we haveavailable to bring the best evidence of effec-tiveness and cost-effectiveness to our patientsin the “teachable moment,” when a problemarises and a decision needs to be made.

Interactions will be more flexible and con-tinuous and less beholden to geographic bar-riers. As the availability and use of clinical in-formation expands, clinicians will interact morerobustly with members’ health care decisionmaking that occurs on a 24/7 basis.Nonprocedural interactions will move beyondthe exam room, since many types of lab test-ing and physiologic monitoring will be done


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Special FeatureKP HealthConnect as a Transformational Tool

T R A N S F O R M AT I O N

at home, and KP members will be commu-nicating with clinicians online. Patients innonmetropolitan areas will have greater abil-ity to interact with their providers, and somesurgeries will even be performed remotely.5

Clinical decisions will be more transparentto members, and navigationthrough the system can occurefficiently. The electronichealth record will be an inter-active tool to be accessedalong with the member. It willprovide in-the-moment infor-mation about continuity ofcare (particularly for chronicconditions) and will incorpo-rate the best available evi-dence relevant to thatmember’s needs. Further pro-cedures and testing can bescheduled before the patientleaves the exam room, and re-sults of previous tests can becalled up and discussed. Medi-cations can be prescribed and transmitted tothe pharmacy online, mitigating medicationerrors and eliciting conversations about pos-sible allergies or contraindications.

Clinician-Clinician InteractionsThis area is likely to change dramatically

over the next few years. The capability of hav-ing a small group of highly specialized consult-ants available to all KP clinicians, no matter whatregion, will be very helpful—particularly in thefield of genetics and in other areas where thereis likely to be a supply shortage. Today, in theNorthwest Region we have electronic chart con-sults, so patients don’t have to physically go tothe consultant’s office. In the future, we couldhave videoconferences to coordinate patientcare, convened by the primary care clinicianand involving multiple caregivers, potentiallyin distant geographic areas. Health care teamswill be both physical (at the care site) and vir-tual (across the care system). No matter wherein the system a member receives care, his/her“care team” will have simultaneous access tohis/her medical information, and when the teamneeds to confer about his/her care, they will belooking at the same updated information.6

Our ability to rapidly assess new technolo-gies and disseminate the results will be en-hanced by common information platforms.Optimizing the use of these tools will take aconcerted effort to create common definitionsof terms, agreement about how information

will be formatted and dis-played, and rules about howwe decide what constitutesgood evidence. Work is go-ing on in all of these areasbut requires a mindset shiftfrom locally autonomous de-cision making to “communitystandard.” The KP communitybecomes all of us, leveragingthe capabilities and values ofour group practice model tolead the next revolution inhealth care.

ConclusionThe wide availability of clini-

cal information systems, linkedseamlessly together, will have an enormous im-pact on the ability to provide high quality, cul-turally sensitive, cost-effective health care. Whilethe locus of much of the care will shift towardthe home; there will be process improvementsacross the entire continuum of care.

Will KP be able to compete and differenti-ate itself in this world? We are uniquely quali-fied to succeed. Our clinicians, working inand supported by our systems, can be world-class information managers and knowledge-transferers. As a national group ofPermanente staff, we can leverage our sizeand our approach to Permanente Medicineto provide value seamlessly. KP is commit-ted to preventive care and chronic care man-agement, both of which are greatly sup-ported by HealthConnect. It will be verydifficult for other, nonintegrated systems ofhealth care to have the same types of infor-mation available at their fingertips.

These changes will be more evolutionary thanrevolutionary, because they all exist now. Ourchallenge will be to identify those technologieswith the most potential, to incorporate theminto practice, and to disseminate them quickly.What a challenge! What an opportunity! ❖

AcknowledgmentMy thanks to Tova Wolking, Institute for Health

Policy, for editorial review and enhancement.

References1. President’s Information Technology Advisory

Committee. Report to the President. Informationtechnology research: investing in our future.Arlington (VA): National Coordination Office forComputing, Information and Communications;1999. Available from: www.itrd.gov/pitac/report/pitac report.pdf (accessed August 18, 2004).

2. Halvorson GC. Epilogue: Prepaid group practiceand computerized caregiver support tools. In:Enthoven AC, Tollen LA, editors. Toward a 21stcentury health system: the contributions andpromise of prepaid group practice. SanFrancisco (CA): Jossey-Bass: 2004. p 249-63.

3. Sokol AJ, Molzen CJ. The changing standard ofcare in medicine. E-health, medical errors, andtechnology add new obstacles. J Leg Med 2002Dec;23(4):449-90.

4. Crosson FJ. Patient safety and the group practiceadvantage. Perm J 2001 Summer;5(3):3-4.

5. Bauer JC. Rural America and the digitaltransformation of health care. New perspectiveson the future. J Leg Med 2002 Mar;23(1):73-83.

6. Wiesenthal AM. Testimony before theSubcommittee on Health of the HouseCommittee on Ways and Means. 2004 Jun 17.Available from: http://waysandmeans.house.gov/hearings.asp?formmode=view&id=1663(accessed August 18, 2004).

Suggested Reading• Breitfeld PP, Dale T, Kohne J, Hui S, Tierney

WM. Accurate case finding using linkedelectronic clinical and administrative data at achildren’s hospital. J Clin Epidemiol 2001 Oct;54(10):1037-45.

• Glaser JP. The strategic application ofinformation technology in health careorganizations. 2nd edition. San Francisco (CA):Jossey-Bass; 2002; See particularly Chapter 4.

• Pollard JK, Fry ME, Rohman S, Santarelli C,Theodorou A, Mohoboob N. Wireless and Web-based medical monitoring in the home. MedInform Internet Med 2002 Sep:27(3):219-27.

• Schlessinger L, Eddy DM. Archimedes: a newmodel for simulating health care systems–themathematical formulation. J Biomed Inform2002 Feb; 35(1):37-50.

• Sittig DF. Potential impact of advanced clinicalinformation technology on health care in 2015.Medinfo 2004;2004:1379-82.

• Landro L. What’s ahead for health care:information technology could revolutionize thepractice of medicine, but not anytime soon.Wall St J 2001 Jun 25;:R14.

The wideavailability of

clinicalinformation

systems, linkedseamlessly

together, willhave an

enormous impacton the ability to

provide highquality, culturally

sensitive, cost-effective health

care.

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