Phil Fasano, EVP/CIO, Kaiser Permanente
Earlier this month, five organizations launched the Care Connectivity Consortium to facilitate the secure exchange of electronic data in real-time at facilities across the country. The vision, according to Kaiser Permanente EVP and CIO Phil Fasano, is for providers to have all of a patient’s information at his or her fingertips during the encounter. But before that vision can be realized, there are a few key questions that need to be answered, primarily in terms of reimbursement and standardization. In this interview, Fasano talks about how the nation’s largest non-for-profit health plan and care provider plans to deal with the reimbursement issue, how it is preparing for Meaningful Use, how it handles budgeting and project prioritization, and why data sharing is so important.
Chapter 2
- Staying in sync with government
- Thoughts on PCAST — “We do not believe that putting health data in a cloud is in the best interests of our patients from a security and privacy standpoint”
- Thinking through the new ACO regs
- Meshing ACO/MU — “We believe we’re directionally correct and fundamentally aligned”
- An update on the Epic project
- Life post-implementation
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Bold Statements
We’d also hope that the government agencies would look at what we’re doing, and from a practical perspective, determine that there’s value here and potentially leverage some of the real world outcomes that we’ll achieve in the near term to help them as they consider the standards that are appropriate for this industry.
We do not believe that putting health data in a cloud is in the best interest of our patients from a security and privacy standpoint. We do believe that making medical information interoperable and sharing it in real-time with other organizations that are going to treat patients is in the best interest of patients.
But the secret sauce from our perspective is the integration of care; having all elements of care, from primary care to specialty care, accessing that medical record and seamlessly taking advantage of the knowledge that we have on an individual patient’s basis to treat patients across our entire system.
When you layer additional analytics and decision support tools on top of the medical record that are particularly focused on chronic condition management, you really start to multiply the impact of having an electronic medical record system implemented in your organization.
Guerra: How much do you watch with government is doing—ONC, the Standards Committee, and the Policy Committee. Do you really communicate with them in the real time? Do you not want to get out too far ahead, and then have them come out with something in Meaningful Use Stage 2 or 3 that moves away from some of the standards you were moving toward? How do you say in step with what’s going on there, because that could really upset your projects if things take a different direction.
Fasano: Well, we certainly are very cognizant of what the government, both federal and state, are doing relative to regulations in this area. And some of those regulations, as your question would indicate, are quite formative. As we develop our approach, our hope would be that the standards and the technologies that we deploy to satisfy our interoperability needs will be well-aligned with government standards, both at the federal and state level. And also, we’ll have the ability to evolve as those standards emerge and become more complete. We’d also hope—and we would certainly expect—that the government agencies would look at what we’re doing, and from a practical perspective, determine that there’s value here and potentially leverage some of the real world outcomes that we’ll achieve in the near term to help them as they consider the standards that are appropriate for this industry.
Guerra: Have you taken much of a look at the PCAST report—the report from the presidential group of advisors on science and technology that suggested a more atomic level of day-to-day exchange and the different exchange mechanisms? There is some controversy around privacy and security. Have you taken much of a look at that?
Fasano: Our organization certainly has looked at the PCAST report and I’ve read through it at least once. And I certainly understand the intent and the direction that that report is hopefully indicating for the nation.
Guerra: What are your thoughts on it? Do you feel like it’s the right direction and is something worth going for?
Fasano: Well, I think when you consider the PCAST report in the larger context of sharing medical information for the benefit of patients, the report itself does outline certain approaches, and we believe that there are numerous approaches that could get you to the same outcome. And at the same time, there are elements of the PCAST report that are quite specific and would indicate that potentially putting information in the cloud for purposes other than treatment could be a potential outcome as well.
We, and I speak specifically for Kaiser Permanente, do not believe that putting health data in a cloud is in the best interest of our patients from a security and privacy standpoint. We do believe that making medical information interoperable and sharing it in real-time with other organizations that are going to treat patients is in the best interest of patients. So in that area, we may differ. That said, we do believe that there’s quite a number of important goals around medical research that when you consider the information that’s contained even within the five organizations that have decided to collaborate, that there are high degrees of potential for advanced medical research. But there’s one caveat, and the caveat is that the patient has to explicitly indicate that they’re willing to have their medical information used for that purpose.
Guerra: And I think that’s probably what has made some people uncomfortable about the report. It seems like everything gets put out there and people feel like there’s a loss of control of the data on some level. Would you say that might be one of the things that concern people?
Fasano: I’m sure it concerns a number of people, especially privacy advocates in this country. At the same time, I understand the purpose and the intent of the report. There are a lot of noble goals that are out there, and I think PCAST as a report, and some of the content to that report, attempts to work toward those noble goals for the entire country with the desired outcome that we have better health in this country. And I certainly support the country focusing on better health.
Guerra: Right. We recently saw some ACO guidance come out. Kaiser essentially is an ACO, correct? I mean, from the definitional point of view of working together under one roof—all the different entities that provide care.
Fasano: We’re a fully integrated system, and a lot of people would look at us as potentially a leading organization under the definition of ACOs that’s been put forward recently.
Guerra: So, you still have to apply, but you don’t have to sort of reconstitute yourself if you’re already an ACO?
Fasano: I don’t believe we’re going to have to reconstitute our organization. Our integrated model is, in my opinion, quite world class. And it achieved results that are so substantially high quality for our patients that we were quite proud of many of the outcomes that we achieved within our current model; although we’re always striving to be better. We’re very proud of where we are as an organization.
Guerra: I’m going to ask you probably a very silly elemental question. Do you have the payer mix to be eligible for Meaningful Use funds?
Fasano: Yes, we will be eligible, I believe, for Meaningful Use funds.
Guerra: I didn’t know if you had the Medicare or Medicaid population.
Fasano: We absolutely do.
Guerra: Okay, so you’re eligible. One of the things in the ACO requirements over the proposal, it’s an MPRM, was that 50 percent of the primary care physicians in the ACO be Meaningful Users by the start of the second ACO year, I believe. You’re up for the Meaningful Use funds anyway, so that’s something you’re working toward. Does this all work together for you? Does this will make sense? Do you have any problems with the way this is evolving?
Fasano: I believe it all makes sense. We certainly have a number of people who are working quite diligently toward the goals of Meaningful Use, you know. Like many other organizations, it’s not an easy effort for us; at the same time we’re quite focused as an organization because of our integration and our model. We believe that we’re generally directionally correct in those areas and fundamentally aligned with both the intent of Meaningful Use, and frankly, the goal of being a Meaningful User of electronic medical information. As you may know, we’ve had 35 of our 36 hospitals win HIMSS Stage 7 awards, which means they’re already paperless. You know, in a straight phrase. And so we’re highly competent in our use of electronic medical records. They’re pervasive around our entire organization. Every one of our providers uses our electronic medical record and everyone of our patient is contained within it.
Guerra: It’s interesting if people were just looking at the financial incentives in Meaningful Use and making decisions based on that. Well now, if you don’t have enough Meaningful Users, you get cut out of the ACO game too. So they are further putting in different leverage carrots and sticks to get people to use electronic records.
Fasano: And frankly, from our experience, appropriately so. Electronic medical records from our experience in the evidence that we have over the past number of years—and we’ve been using electronic records for many years; even before we were noted for our use, we’ve been using them at Kaiser Permanente—we find they improved care, improve quality, and allow us to practice preventive medicine, which enables us to keep our patients healthier.
Guerra: Let’s talk at the high level about the Epic project. Where are you with that? Do you ever actually finish that? Or maybe you can give us some idea of what you’re currently working on in that project.
Fasano: Sure. We are entirely implemented across our whole health system; all of our medical facilities, all of our medical operations—both hospitals and clinical have been implemented, so inpatient and outpatient. We are completely an electronic medical record system on an end-to-end basis. So our patients have access to their medical records through our website (www.kp.org), and they also have access to their electronic lab results. They’re doing e-visits with their physicians and exchanging e-mails with their physicians at the pace of about 10 million emails a year in a secure fashion. They’re avoiding coming in for, in many cases, office visits to the consequence of many of these capabilities, and we’re achieving higher and higher quality scores as a consequence of these systems being implemented.
But the secret sauce from our perspective is the integration of care; having all elements of care, from primary care to specialty care, accessing that medical record and seamlessly taking advantage of the knowledge that we have on an individual patient’s basis to treat patients across our entire system.
Guerra: Is it now a question of do you have 100 percent use or is it now a question of increasing use or getting to more depth in the system—more clinical decision support rules. What is the evolution of the project? Where do you go from here?
Fasano: Well, we are entirely implemented with our electronic medical record system. We have then subsequently—and in tandem, in many instances over the past couple of years—implemented population care tools that are focused on chronic conditions and chronic condition management. We’re using those tools aligned with our electronic medical record system to even go further in terms of our ability to provide preventive care for patients who have chronic conditions.
So as I said earlier, many of the outcomes we’re achieving are just dramatic. You know, an individual who has a first heart attack or heart situation, within our system ultimately has about an 80 plus percent chance of survival above the other organizations outside of our system—over the first three months of care following that event. Diabetics are finding that they’re seeing a 50 percent reduction in their hospitalizations across our system because of these tools.
We’ve now coupled our electronic medical record with additional analytic tools that are assessing chronic conditions against our evidence, and we are now focused truly on the founding principle of the organization, leveraging that knowledge and information with respect to preventive care and outreach. And our programs are oriented around doing that. Everything from our call centers to the patients themselves are accessing their information in a way that allows us to collaborate with patients to keep them healthier and improve their ultimate health outcomes.
Guerra: So would you say there’s a stages effect that goes with implementing electronic records? I’m thinking about the organizations out there that are at the beginning or maybe a little bit down the road on their journey and have to get buy-in, go out and get a system, select the system, implement the system. But then the real value comes when you add on these layering analytics tools. Do you see it almost as a layered effect?
Fasano: You go through phases with these implementations. There’s the initial decision to implement the medical record system, and, you can implement the medical record system and not get the outcomes we’ve achieved. So you have to not only be committed to implementing the medical record system and documenting electronically as you used to do on paper—the patients’ conditions and your notes on their conditions as a physician, but it’s also the sharing of that information with other departments who are also treating that patient that then enhance the value of the medical record itself. So when we talk about connecting our five organizations in the Care Connectivity Consortium, it’s being able to share that medical record with other physicians who are treating the patient that really becomes the most powerful element of this.
Then when you layer additional analytics and decision support tools on top of the medical record that are particularly focused on chronic condition management, you really start to multiply the impact of having an electronic medical record system implemented in your organization and focused on improving the health of your patient. Frankly, for us, that’s been the ultimate journey and goal for this work.
And as you said, the work continues, because we continue to learn as we evolve our use of our medical record system and the adjacent systems; we integrate other systems like laboratory and pharmacy and all of our other care systems that are revolving around our medical record into the medical record. So it becomes a comprehensive tool for both the physician and any other clinical person involved in the care of that patient. It becomes quite powerful because it’s completely, comprehensively, and accessibly a tool that they use to enhance the health of that patient.
It’s amazing the simple examples that we find. You could be visiting our optical center and having your eyes tested, and the person behind the counter has complete access to your medical records. And in our system, we’ve had this experience where a woman is showing up who hasn’t had a mammogram, but the mammogram is indicated. So the person that’s having them basically officed for their visit with the optometrist notices that and makes the recommendation that the woman go upstairs after the optometry session for a mammogram. And they ultimately find cancer in many cases, which ends up saving that person’s life.
So that’s quite a dramatic, but it’s certainly a real-life example within our organization that happens quite frequently, and there are numerous examples across many specialties of that. And one of the measures of success in electronic medical record implementation, in my opinion, is life saved.
Guerra: Is that something that people are able to capture, do you think? How many lives have been saved as a result of the electronic record—is that something they can start capturing?
Fasano: They absolutely can. And in our organization, there is a statistic that my IT organization has captured because it’s motivating to the organization. We’ve extrapolated that since our medical record system was implemented, in our consistent use of medical record systems and the adjacent technologies that we’ve aligned with them and integrated with them, that over 12,000 lives have been saved in our organization just over the past five to six years.
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