Kaiser Permanente: Medical Devices and Health IT Improving Quality of Care

1. Kaiser Permanente: Medical Devices and Health IT ImprovingQuality of Care • Tom Judd, MS, CCE, CPHQ, CPHIMS • National Project Director, Clinical Technology • Kaiser Permanente • WHO-PAHO Health Technology Consultant

2. Presentación • HealthcareContext • US & Colombia • Medical DeviceIndustry, Quality, and Health IT • Health IT =healthcarecomponent of Information & Communication Technologies (ICTs) in US • Health IT also = Medical DevicesIntegratedwith EMR/EHRs, aka “DeviceInteroperability” • Kaiser Permanente (KP) & Medical Devices • QualityDefined & CareDelivery • Devices: TheirRequirements, Integrated Management, & Testing • KP Technology-Related Case Studies & Outcomes • ForAcute & ChronicDisease, Costs, PatientEngagement • Conclusions & Appendices

3. Context: An interesting time in Healthcare! US: Affordable Care Act (ACA) reimbursement … meaningful use of EHRs (Electronic Health Records) & HIEs (Health Info. Exchanges) • The use of Health IT improves quality of care • Note improvements in Heart Failure & Pneumonia to Sepsis & Stroke, from 7/14 study Columbia: • One Health Leader: “Our law required that by 2013 everybody should have a EHR, but that law has not been implemented; the most serious risk is that nothing has been written about standards of HIE. This is where the proposal of IHE profiles can become a real advantage to Latin American countries.” • From MinSalud: http://www.minsalud.gov.co/English/Paginas/Because-we-colombians-are-entitled-to-timely-and-quality-health-services.aspx The Business Case for Medical Device Quality: McKinsey • Quality issues rightly concern every stakeholder in the medical device industry value chain • Optimum Quality … reliably meets/exceeds expectations of customers/regulators while maximizing value

4. Context: An interesting time in Healthcare! • US: Chronic Disease Management (CDM) – medical devices needed! • Centers for Disease Control: 75% of healthcare expenses devoted to CDM • Need for the Affordable Care Act to align incentives between providers, payers, patients • Colombia: • Colombia also deals with high prevalence & cost for CDM • Maternal mortality surveillance another national focus, eg, one of several Maternal Child Health (MCH) issues • Can technology better address CDM Google’s Moonshot: Human Bodies • Baseline pilot: find biomarkers from diagnostic devices so CDM detected and treated earlier • Stanford/Duke University medical teams to analyze genomes, metabolism, data from wearable devices

5. Explosion of Devices … at what Cost? In context of tremendous device growth last 20 years

6. Device Industry Quality Business Case Factors in rising complexity of device/user environment • Interoperability • Wireless • Mobile Health (mHealth) • Device Security • Human Factors All Increasing the likelihood of significant Q issues • Device consumers claim quality (Q) is a key consideration in purchasing • Q typically means efficacy, durability, and ease of use • Device Quality Systems need to catch up with industry demands • Through its value chain: including manufacturers and regulators as well as payors, doctors, and patients for risk areas

7. Device Business Case – How To Respond? • Baxter Infusion Device Recall in 2010 • Numerous design flaws • FDA Total Product Life Cycle created Industry Quality example, 2013 • Challenges • quality costs • problem prevention • low-quality supplier performance • Transformation • reduce quality-related costs while increasing capacity • reorganization of the quality function • Introduce proactive quality, system for tracking, dialogues around key indicators, and root-cause problem solving • Results • Reduction in cost of Q by 35% • improved profit by 2.5% revenues • → FDA notes 7 opportunities, 2011 Design & reliability Monitoring & feedback Supplier management Quality metrics & systems Quality organization Performance management Quality culture • → • Pew Charitable Trust to FDA, 2014 • New approach to device development • ensure timely pre-market studies • robust post-market surveillance infrastructure • unique device identifier (UDI) capture in EHRs • and use of clinical registries • →

8. US FDA, Health IT and Medical Devices • FDA Safety and Innovation Act (FDASIA) • A nationwide health IT (HIT) infrastructure • Risk-based framework for HIT • FDA to focus its attention/oversight on device health IT functionality • How devices used in EMR/EHR workflows* *Each of 12 EHR workflow device uses defined in Appendices

9. Kaiser Permanente – Who We Are

10. KP and Quality

11. Our Technology Journey Over the past decade Kaiser Permanente transitioned to a truly technology-enabled company; our next decade will ensure that health IT becomes one of our enduring competitive advantages. • Strategic Priorities • KP HealthConnect (EHR = Electronic Health Record) • Health Plan • Digital Health • Big Data & Analytics • Clinical Technology • Corporate Infrastructure • Risk Management • Digital Health • Mobile • Internet • Intranet • Social • New Platforms • Claims • Lab • National Pricing • OneLink • Pharmacy • Revenue Cycle • Data Centers • Continuous Availability • Analytics • Archimedes • Point • Panel Support Tool • EMR/EHR • Inpatient • Oncology • Outpatient • Registration • Scheduling • Communication Tools • Contact Center • Wireless • Voice 2015 + • Online • My Health Manager • E-visits • Rx Refill • Lab Review • Regulatory • 5010 • HIPAA • ICD-10 • Medicare Modernization Act • Meaningful Use 2004 - 2014 Real-time, personalized Delighting our Consumers and Care Team Paper-based Paperless

12. Using the EHR for Better Outcomes How KP Uses Technology Improves Outcomes, Cost, & Patient Engagement Overview then Case Studies • Meeting US EHR Meaningful Use requirements • CPOE (Computerized Practitioner Order Entry), best practice alerts/alarms on EHR drive evidence-based care • Social media interfaces driving Patient Engagement • Interactive patient care at Point of Care • Data mining for Clinical Decision Support (CDS) tools • Medical device integration in hospitals and clinics • Patient data from mobile applications for CDMs (chronic disease) • Wireless infrastructure/RTLS (real time location systems) improve clinical workflows • Emerging Genomic patient evaluation • Facilitates telehealth for improved access & e-consult

13. US EHR “Meaningful Use” Regulations CDM mmmmmmmmmmmmmmmmm

14. Patient Facing Clinician Facing Shared Evidence-Based, Personalized Care • Location and proximity • Virtual Care / Videoconferencing • Hourly Rounding • New roles –Transition Coordinator • ‘Ready Room’ • Interactive Patient Care • Patient Schedule • Device integration • EMR optimization • Hand hygiene • RFID tags • Falls Prevention • Medication Administration • Integrated Communications • Mobility / mobile devices • Workflow Automation • Predictive Analytics • Real Time Dashboards Patient Empowerment Interactive Patient Care: IPC Systems return control to the patient in their hospital room by providing increased autonomy, capability, and comfort

15. Patient Engagement Focus Social Media Tools Care Where You Are

16. Integrated mobile apps for patients & clinicians • Mobile electronic health record • Android and Apple iOS • View part of your health record • See your lab results • Send a secure message to your physician • Refill your prescriptions • Book an appointment with your physician • KP Locator • iPhone platform • Find any KP facility using iPhone GPS • Every Body Walk • App to encourage fitness and walking • Professional Applications for access to EMR/EHR by clinicians KP, George Panagiotopoulos, June 2013

17. Inpatient Room of the Future: Nurses Moving to an Integrated Environment A Nurse’s Day - Inpatient • Practice work environment is challenging • Patients and families often feel un-empowered • Technology is often not integrated • Data and information needed for clinical practice decisions is not always easy to locate • The environment does not support efficiency • Communication often requires multiple devices “Time and Motion” Study Findings 7% of a nurse’s time is spent on patient assessment 17%of a day shift nurse’s time (median) is spent onmedication administration 35% of a nurse’s time is spent on documentation Day shift nurses spend about 30.8% of their time in patient roomswith all of their patients Care Coordination 20.6% Convergence of: voice secure messaging alerts presence EMR integration workflow automation usability Hendrich, A., et al, A 36- Hospital Time and Motion Study: How do Medical-Surgical Nurses Spend their Time? The Permanente Journal Summer 2008 v12. No 3

18. Smart CARE Strategy with Health IT Clinical Transformation Design * Reference Appendix A: SmartCARE Components * *Source: Kaiser Permanente Annual Report 2010 Bedside Devices Infrastructure Device-EHR Middleware Design Interactive Patient Care Location & Proximity Communication Computing Technology

19. Benefits of Medical Device Integration • Benefits of Integration • Time saved (primarily Nursing; up to 35% of time) • FTE efficiency gains (ECG and Anesthesia) • Revenue capture and reduction in supplies (ECG billing and Anesthesia) • Reduced Adverse Events • Incremental Overtime reduction (Nursing and other clinical staff) • Focus on critical devices • Provide real-time patient information • Require most documentation time from clinicians • Potentially the most medical errors ($17B/year in US) due to manual EHR entry (25% of manual entry vital signs have 1 or more errors) • Create revenue capture opportunities

20. Case Studies • Health 360 / Interactive Patient Care (slides 21-28) • Multi-Vendor Collaboration • Inpatient & Care Anywhere • Clinical Decision Support-CDS & Dashboard (29-31) • Sepsis identification • Community acquired Pneumonia • Mobile Vital Signs (32-39) • Mobile devices capturing vital signs directly to EHR • Telehealth(40-44) • Value of Health IT and mHealth(45-49)

21. Case Study 1: Transforming Care Delivery Care anytime, anywhere Convenient & affordable Personalized PATIENT Perspective Real-time access Immersive user experience Automated & coordinated Clinician Perspective

22. Coalition of Leading Companies Delivering the next generation of total health solutions

23. Health360 Overview Health360 brings together clinicians, IT and operations to scale new technologies to create market-leading differentiation and accelerate the transformation to a personalized member-driven model of care Objectives • Seamless patient experience • More efficient clinical workflows • Accelerate virtual care and enhanced access strategies Scope & Approach • Defines an enterprise strategy for new technologies (e.g. mobile, video, analytics, social, etc.) • Focuses on a 3-year time frame to keep pace with technology, market forces and consumer expectations • Establishes “platforms of innovation” to ensure critical capabilities implemented quickly Phase One: Building the Foundation • Secure Text Messaging Platform • Enterprise Video Teleconsulting Platform • Event Management Platform • Rapid Sign-On to KP HealthConnect • Real-time Resource Location (care teams, patients, bed status, ClinEngr.) • Mobile Facility Wayfinding Application • Interactive Patient Education • Remote Diabetic Monitoring

24. Scope in 2013 Description Based on stakeholder feedback, Health360 has launched four efforts to streamline communications, re-engineer clinical workflow, and empower our members and their care circles Converges voice, messaging, video, and clinical alerts onto a flexible mobile platform and improve accessibility to our EMR Clinical Mobility & Communications Enables care anywhere with any device through a secure video teleconsult platform Real Time Location Awareness Enhances the clinical environment by enabling real time access to contextual clinical information at the point of care Video Teleconsults Provides interactive devices for patient and family engagement, education, and communications Interactive Patient Care

25. Interactive Patient Care: Use Case Example Core IPC Scope Extended Function IPC Scope Core Functionality • Competitive Advantage • Patient Self-Service • Patient Experience (Satisfaction& Quality) Room ControlsLights Blinds SurveysReal Time Service Recovery Metrics EducationPatient Education Videos Medication Teaching Library EntertainmentInternet TV/Movies Dietary Pain Management Care Team Efficiency Staff Satisfaction eCareboard Nurse/Doctor Communication Staff Responsiveness Service Recovery 2-Way Integration w/Health Connect (Patient Education, Pain Mgmt.) Connection To Family And Friends Patient Engagement Remote Consult My Team Clinical Communication Integration (IPC Event Management – Text, Email About Me 2-Way Video Edu. & Discharge Instruction @Home IPC Via Nurse/Clinician Tablet My Day Video Interpreter Services Patient to Family Video Conferencing Patient Education Clinician to Clinician Video Conf. IPC MobilityClinician Tablet (IOS, Win8) Smart Device IPC Remote ControlHome Portal (Pat. Edu, Discharge Info) Alarm Interaction(Event Triggered Look-In) • Increased Patient Satisfaction • Patient Self-Service • Increased Nurse Face-time • Increased Staff Satisfaction Tele-Sitting “Health360” IPC Track • Remote Care and Consultation • Care Team Collaboration • Patient-family member interaction

26. The Roadmap This roadmap illustrates how we will evolve from having multiple point solutions to delivering seamless communication tools that enable and transform the care experience Phase 1 Secured Messaging & EMR Access Phase 2Alarm & Workflow Integration Phase 3 Access Anywhere End State Today • Secure messaging • Voice • Physician EMR Access • Clinical alarms & alerts • Nurse call management • Off-campus communication • Real-time presence location integration • Nurse EMR Access • Single device supporting multiple functions • Quiet and unnecessary interruptions • Intelligent routing and escalation of messages • Standardized platform • Multiple devices with disparate integration • Noisy and plenty of interruptions • Wasted time searching for people • No standard for mobile integration with EMR

27. Future Activities In collaboration with regional stakeholders, Health360 has identified the following mobile and virtualization capability initiatives to focus in on the next six months. Description Proposal Desired Outcome Video Teleconsulting Use Cases Enabling real-time consultation between remote healthcare providers, patients and care teams through video-conferencing Pilot a Specialists-to-Emergency Department (ED) video teleconsultation ‘turnkey’ solution Decreased wait times, reduce costs, improve flexibility for on call specialists Conduct pilot to acquire, analyze, visually present, and take action on patient biometric data collected from 50 KP members within diabetic population Reduce emergency department and hospital readmits, improve A1C levels, reduce time on data collection during consultations Integrate personal generatedhealth-related data including biometric devices, fitness data Member-generated Data Proactively identify patients at risk; reduce hospitalization and length of stay; ability to predict adverse events Implement predictive models to improve identification, care protocols, and outcomes for high risk patients Optimize predictive algorithms to identify patients at risk for clinical deterioration in real-time by conducting a pilot Advanced Alert Monitoring Improve member experience, satisfaction, and safety; increase in member appointment on-time arrivals Utilize wayfinding to improve a member’s ability to find KP facilities and appointment location Conduct wayfinding pilot to evaluate technology and low fidelity solutions Mobile Wayfinding

28. 2014 KP Diabetes mHealth Pilot

29. Case Study 2: Clinical Decision Support ‘Predict’ Tools The general idea is that Predict allows us to implement patient scoring and risk algorithms, from simple ones like CURB-65 that generate a score of 0,1,2,3,4 or 5 to more complex ones like a risk of Severe Sepsis score at ED Triage that generates a percentage of risk, from 0 to 100%. SIRS = Systemic Inflammatory Response Syndrome (”Shock”) Tool The Predict framework holds many calculations that can be viewed by an end user in Print Groups, Patient List Columns or Smartlinks. The algorithms are stored in a smarttext record and the functions run when a user accesses the information or on a timed cycle with a batch job. Severe Sepsis (Infection) Tool CURB =Community Acquired Pneumonia Tool

30. View of ‘Predict’ Smartlinks in KP EHR

31. Clinical Care Dashboard

32. Case Study 3 • Describe the current Med/SurgenviroMobile Vital Signs National Proof of Concept, KP NW Pilot • Review the current state of vital signs accuracy and latency • Describe the Mobile Vital Signs Pilot • Review pilot data • Provide recommendations & next steps

33. Nursing workflow on Med/Surg

34. Research data on Med/Surg Vital Signs KPNW

35. Goals for Data Integration in Med/Surg

36. Pre-Pilot Metrics Mobile Vital Signs (VS) Summary • Documentation error rate: • 1.48 min latency between VS taken and documented in EHR • 213.1 mins to take 68 sets of VS • 3.3 min/set of VS

37. Instant Wins Challenges Pilot: 6 month pilot began mid-June 2013 • Log on process • Battery life • Charge capture rows can not be integrated. • No warning to end user if server is down • Defaults • Patient ID • Immediate transmission of VS • KPHC downtime transmission • MORE rows • Data easily entered • Time savings EHR View of Integrated Values KPNW

38. Success Metrics: Feedback Metrics Post Pilot Metrics • Vital Sign (VS) Accuracy • VS Latency • Total time VS collection • End user satisfaction • Workflow efficiency • 100% Accuracy if used correctly. • Immediate transmission of VS. • 1. 4 minute time savings per VS transmission. • Mixed Satisfaction • Rate it a 5 if taking multiple VS • Rate it a 1 if taking single set of VS • Log on process is tedious at first • Workflow change Costs KPNW

39. Recommendations Value: • Most value when vital signs are taken on a series of patients in one care interaction i.e., all 7am vitals taken in a row. • Improved value when nurses can sign on to the Neuron (med device middleware) with a barcode to identify themselves rather than manual log on. IT Considerations: • Requires a robust wireless infrastructure • Requires the latest Capsule DataCapture(middleware) version Training and Go-live: • Develop a robust Super User team • Test the system one last time before go-live KPN

40. Case Study 4: Telehealth Leverage technology and process to support the Imagine Care Anywhere strategy demonstrating a positive impact to the following key aspects of the traditional care delivery model: • Cost - minimize unnecessary ED visits; maximize utilization of in-network and specialty resources; reduce travel for both patients and providers • Quality – leverage optimal resources regardless of location; encourage cross-training and collaboration between providers through real-time consults; improve consistency in care delivery • Access – expedite access to care; provide access to specialists for remote locations; expand internal provider to provider consults • Continuity of Care – remote monitoring allows for targeted intervention; reduce point-in-time evaluations; improve medication compliance

41. Developing a Telehealth IT Strategy The Telehealth IT program will support the regional business needs, market expectations and the Care Anywhere strategy. Transforming Care • Business Needs • Consistent, predictable member experience through KP.org • Seamless provider workflow • Appropriate integration to existing systems • Use Cases • Develop member access to on-demand video teleconsults as a natural part of daily clinical workflow • Leverage clinical peripheral device data to enhance care delivery outside KP facilities • Internal Business Drivers • Care Anywhere Strategy • Cost Pressures • Limited Specialty Resources • Rapidly Expanding Membership • Aging Population • Market Influences • Competition • Health Reform • Technology Evolution • Member Expectations Telehealth Solution Engaging Members Expanding Provider Capacity • Technology • Demonstrated, scalable applications & architecture that are device independent (ie, mobile support) • High availability with 24X7 support • Flexible to regional needs • IT Operations • Streamlined and centralized support • Published SLAs • Flexible training program Leveraging Technology

42. The Telehealth Platform Evolution The KP Telehealth SaaS platform is the foundation for flexible regional implementations of comprehensive Telehealth programs including video, remote monitoring and on-demand access to clinical care. 2015 24X7 On-Demand Video Consults w/ full KPHC and Analytics Integration 2014-2015 • Remote Monitoring • (Support for Peripherals) • Collecting clinical data to support timely interventions • Improving adherence to medication and care plans • Improved outcomes with reduced readmissions • Support post discharge members in the home environment 2014-2015 2013-2015 2011-2014 • Intelligent Routing • (For Video & UCC) • Provider staffing efficiencies • Expanded coverage • Expedited access to care • Drive to the right communication tool • Internal Teleconsults • Care collaboration • Improve timely access to specialists • Member & Provider satisfaction • (Expanding to scale) • External Teleconsults • Reduced transports and transportation time • Support patient education programs • Improve timely access to care • Provide triage to appropriate level of care • Member & Provider satisfaction Green – currently available Blue – in design

43. Video Visits @ KP Currently in production across all regions: • Cisco Movifor use on the KP network where there is a dependency of Avizia Clinical Carts (ieTelestroke) • Vidyo for use on/off the KP network across any device. Working to seamlessly integrate with Epic (KPHC), KP.org and KP Flagship App. • Over 5,000 clinician accounts • Over 5,000 video visits in 2014 YTD

44. Medical Devices • A variety of medical devices can be attached to the Avizia or Cisco carts to support clinical needs • Stethoscope, dermatoscope, otoscope, ultrasound, etc • Two video sources and one audio source are supported concurrently

45. Case Study 5: Realized Value of Health IT

46. Transforming Care with Health IT Vilardi, O’Brien, KP, HIMSS, March,2013

47. HIMSS Davies EHR Health IT Award • How health systems use the EHR in innovative ways, once fully deployed, eg, Stage 6 or 7 - demonstrate via case studies Deploy CPOE, CDS, & measure ROI; see http://apps.himss.org/davies/ 1. Clinical Value (Core Case Study) 2. Return on Investment (Core Case Study)- hard & soft ROI Hawai‘i Pacific Health, Hawai‘i’s largest health system and largest private employer, has demonstrated an annual return on investment from an integrated EHR of 9.0% over ten years. Success was achieved through the integration of all revenue cycle functions and by driving financial and clinical performance through transparency, collaboration, and accountability. • Reduce support costs by consolidating 32 major systems. These systems included RIS, pharmacy systems,patientscheduling systems, 7 patient accounting systems, 3 charge masters, 7 patient management systems, 4 medical records /coding systems, a standalone EMR, and a clinical messaging system. • Improve net revenue through the reduction of avoidable write-offs. Prior to the implementation, approximately 2.6% of annual hospital gross revenue ($16 million) was being written off to bad debt and avoidable administrative adjustments. A reduction to 2.0% could produce improvements of more than $1 million in net revenue annually. • Reduced transcription costs. Movement toward online clinical documentation and integrated voice recognition would mean less dependence on Transcription. • Improved Cost-to-Collect. Operating on a single platform allowed savings through improved efficiency, better charge capture, and consolidation of 3 hospital billing groups and 3 physician billing/coding groups. Hawai‘i Pacific Health’s EHR has been critical to improvements in overall safety, quality, and effectiveness of care. Significant measureable improvements have been achieved in reducing or eliminating ventilator associated pneumonia, catheter associated urinary tract infections, and central line associated bloodstream infections. Similar improvements have been accomplished in core measures, including very good performance in children’s asthma and recently adopted perinatal core measures. Outpatient clinical care improvements in diabetes, hypertension and cancer screening have benchmarked HPH Clinics to the 90th percentile of the country on many measures. The EHR, and Health IT as a whole, has served as the cornerstone of this success. KP won in 2011!

48. KP mHealth in the Near Future

49. Future: Care Delivery All User Environments

50. Gracias Tom Judd Tom.judd@kp.org