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The Ohio Permanente Medical Group Newsletter

Ohio Permanente Medical Group, Inc.

Plenty to be proud of,

IN THIS Winter 2008
but we must press on
ISSUE Ronald L. Copeland, MD, President and Executive Medical Director, OPMG
I have two simple objectives for this advanced care management effort,
column: 1) invite you to read up on as well as the companion pieces
the efforts that will help KP Ohio that explain the 21st Century Care
Plenty to be proud of, transform our delivery system, and Collaborative and the advanced care
but we must press on . . . . . . . . . . . . . 1 2) to say thank you for all the hard panel (formerly the “mini panel).
Advanced care management for work that has occurred these past few And now, let us review some of our
care delivery transformation. . . . . . . 4 years and particularly during 2007. key accomplishments over the past 12
21st Century Care Collaborative I’ll do that by listing just some of the to 18 months.
aids effort to improve many incredible accomplishments that
member health . . . . . . . . . . . . . . . . .6 could not have occurred without the In the whirlwind that is the Kaiser
help of many dedicated individuals. Permanente Ohio turnaround, it’s
Fishing: 21st Century care’s
easy to overlook the fact that we
key to creating capacity . . . . . . . . . . 7 But first, a good portion of this
have made significant strides and
Advanced care panel: using the issue focuses on the advanced
that we have much about which
“house call” to improve care management for care delivery
we can be proud. As I have said on
management of chronic disease . . .8 transformation effort, with special
more than one occasion, progress is
Members embrace focus on some of its key features.
not an accident. It occurs because
health coaching . . . . . . . . . . . . . . .10 Many of you may have heard mention
people agree to make it happen. The
of the advanced care management
Ball is rolling for physician examples below underscore that
effort, and it is a critical component
work life committee . . . . . . . . . . . . 11 commitment as well as the progress
of our turnaround and sustainability
Be on the alert for that flows from it.
strategies, so the goal of this issue is
CMS “welcome” letters . . . . . . . . . .11 to provide a helpful overview of the This is a partial list, of course, but an
Patient safety programs strengthen endeavor and its implications. important one; in fact, the first four
communication skills . . . . . . . . . . . 12 items are updates on key turnaround
Advanced care management is
projects. But beyond showcasing
Patient safety and quality care . . . . .14 being largely shepherded by
notable achievements, the list also
Charles DeShazer, MD, who joined
Abramson’s anecdotes: serves as reminder that none of our
KP Ohio last spring as associate
What makes a good doctor? . . . . . . 15 accomplishments occur without the
medical director for quality, clinical
Encryption effort protects hard work of many individuals who
performance improvement and
health information. . . . . . . . . . . . . .16 are dedicated to, and believe in,
research. Dr. DeShazer is helping lead
OPMG and KP Ohio’s shared mission
Kaiser Permanente encryption: the effort to harness our technological
of providing the best health care
A five-phase program . . . . . . . . . . . 17 resources to aid and strengthen
at the best price. Nor could OPMG
Medical Library services update . .18 proactive panel management,
exist without the dedication and
particularly among members with
Referrals management and loyalty of its physicians—veterans and
significant disease burden, and to
clinical review updates . . . . . . . . . .18 newcomers alike—who despite all of
precipitate outreach efforts that build
Performance improvement the challenges, believe that what we
trust with membership and help them
efforts moving forward . . . . . . . . . .19 have is unique and worth preserving
collaborate on disease management
and advancing.
challenges. I encourage you to
delve into his article explaining the
continued on page 2

Plenty to be proud of, Redirecting referrals brings members back to—the

but we must press on OPMG care network. It also helps
In 2006, one of the “close the gap”
continued from page 1 them avoid unnecessary ED visits
efforts involved reducing costs
(and attendant co-pays). Hub
through proactive management
Diabetes complete care physicians provide consultation
of utilization and optimization
One of the objectives of advanced for non-KP practitioners who
of appropriate use of medical
care management is developing have KP members in their care,
resources. A key component of the
proactive population-based field priority calls from KP advice
effort involves redirecting, whenever
initiatives to improve the health nurses, and work with emergency
possible and appropriate, referral
of the KP Ohio membership. The department staff to select the
cases back into the OPMG realm
diabetes complete care program appropriate hospitals for members.
of expertise. Thus far, the redirect
is one such project and involves Also, any member who calls can
program has been quite successful,
the efforts of dedicated staff from speak directly with a hub physician.
particularly since the process now
pharmacy, primary care medicine, As of October 2007, the hub
occurs inside KP HealthConnect. As
health care teams (i.e., medical orchestrated 3,001 repatriations
of October 2007, more than 4,200
office nurses) and population care (directing a member to contracted
referrals were redirected to OPMG
management. Among members care) and 5,708 prepatriations
specialties. The redirect effort
diagnosed with diabetes, the goal (determining the most appropriate
focused particularly on areas that level of care for members before
of the program is to maximize historically see high rates of referral:
the number of those who use the they present at an emergency
cardiology, neurology, urology and department or hospital).
aspirin, lovastatin, lisinopril (ALL) orthopedics. Referrals also are
regimen. Launched in September common when special services are Coding and
2007, the program is fueled needed for members. These include documentation
in part by electronic medical GI related services, sleep studies, Another key thrust of the
record analysis and subsequent liver biopsy, physical therapy, turnaround effort—and vital to
telephone outreach, which is used dermatologic services and nuclear substantiating the true health status
to encourage members to begin medicine services. As of October of our membership—is the quest to
adhering to the ALL regimen, or to 2007, more than 11,800 service improve coding and documentation
get them scheduled for overdue referrals were redirected back accuracy and improve the diagnosis
blood testing, office appointments into OPMG. Without the redirect refresh performance for the
or both. As of November 30, 2007, effort, OPMG would have incurred Medicare population. Stepped
2,835 members (among panels from significant costs for those specialty up training, education and
10 facilities) have been identified services referred to non-OPMG or awareness efforts, complemented
and contacted. (Contacting a non-contracted providers. Without by quarterly reporting, has helped
member invariably requires multiple KP HealthConnect, no ready-to-use make a significant impact in
attempts, and as of December options exist for automating the coding/documentation accuracy.
2007, the total number of “touches” referral process, nor would we have For instance, in first quarter
currently exceeded 5,400.) Among the ability to track referral activity 2005, OPMG was at a 45 percent
those contacted, more than 1,220 and outcomes as they occur. accuracy level. For the same period
members had agreed to begin in 2006, the accuracy level was
the ALL regimen. The diabetes Case management hub 73 percent. For the third quarter
complete care effort is a sterling The emergency case management 2007, coding/documentation
example of how our integrated hub, launched in January 2007, is accuracy reached 80 percent. This
model can be leveraged to enhance a centralized “command” center is great progress and we are on
coordination of care to achieve designed to manage hospital our way to the 90th percentile. The
stronger outcomes. Such efforts and ambulance utilization that diagnosis refresh effort is proving
require sustained collaboration by arise from emergent scenarios. In a bit more challenging, although
an array of teams and departments, addition to providing members we are making definite headway.
not to mention relentless attention 24/7 telephone access to Physicians now receive diagnosis
to detail, but these are exactly the physicians who can dispense refresh reports (i.e., a running tally
types of endeavors our model is advice and assistance, the hub
tailor-made for. helps keep members in—or continued on page 3


Plenty to be proud of, Laboratory re-accreditation Ohio member and a patient of Dr.
but we must press on KP Ohio’s laboratories at the
Adams, that Leigh was diagnosed
continued from page 2 with stage III colon cancer. The
Chapel Hill, Cleveland Heights,
of diagnosis refresh “opportunities”) Parma, and Willoughby medical Mystery Diagnosis episode tells
daily to aid the effort. With the centers earned accreditation from Leigh’s story and recounts how Drs.
diagnosis refresh, we have two the Intersocietal Commission Adams and Scott helped save his
key goals: refresh diagnoses that for the Accreditation of Vascular life. The episode is still airing.
are still relevant and resolve “old” Laboratories through January 2010.
diagnoses that are no longer
Sustaining the
By participating in the accreditation momentum
pertinent. (Note: In Medicare’s eyes, process, the facilities demonstrate
credit is only given for a diagnosis a commitment to the performance This impressive sampling
refresh when it results from a of quality vascular testing and strive underscores in part the Herculean
face-to-face visit.) To help make to meet nationally recognized effort under way to prepare us
diagnosis refresh a proactive rather standards. During the accreditation for the critical challenges ahead.
than passive pursuit, an outreach process, vascular laboratories must The efforts also underscore the
pilot was established to identify and submit documentation on every momentum we have developed in
contact KP Ohio Medicare members aspect of their daily operations. just a short period of time.
due for diagnosis refreshes, office I, and all of my colleagues on the
visits, or both. Thus far, the outreach
KP HealthConnect Online
OPMG board of directors, extend
pilot, which focuses on KP Medicare If we want members to actively
a genuine thanks to all of you for
members with a comparatively participate in their care, then
persevering, for pressing forward
high chronic disease load, has we need to give them access to
with the effort to transform OMPG’s
helped boost diagnosis refresh information that can help make that
care delivery capacity and capability
performance. Overall, we have happen. And that’s exactly what
from “good to great” for 2008 and
made commendable progress in we did with KP HealthConnect
Online, the component of our beyond. In short, 2008 will be a
boosting our refresh numbers, but, defining “moment,” because how
new electronic medical record
given the higher disease burden well we fare in 2008 will largely
that gives member’s access to key
among our Medicare members, inform our existence and outlook for
health information. In addition to
we still have plenty of room for the years that follow.
reviewing lab results, immunization
history, office visit history, and The test now is to sustain the
CME accreditation office visit summaries, members momentum so that we achieve
can view, request or cancel our objective of providing optimal,
In 2007, KP Ohio earned
appointments, request updates to coordinated care for our members.
provisional accreditation to present
the medical record and email any That means parlaying the strengths
continuing medical education
OPMG provider they have had of our integrated model, but more
(CME) programs. In addition
face-to-face contact with or with important, continuing to pursue
to making it more convenient
whom they have had a telephone market leading excellence in
for OPMG physicians to meet
encounters within the last three
mandatory CME requirements, quality, service and affordability,
years. This empowering tool will
an internal CME program helps for that is how we distinguish
aid our quest to optimize disease
showcase our multispecialty ourselves as a medical group and
prevention and management.
clinical expertise in the northeast in the marketplace. For all of us
Ohio medical community. And KPO physicians help within OPMG, the quality of our
because our clinical care is driven solve medical mystery professional life and career security
by evidence-based medicine, This spring, OPMG physicians we seek is directly proportional to
CME programs can be used to Ronald Adams, MD and Lawrence our commitment to excellence—
strengthen our delivery efforts. Scott, MD appeared in an episode excellence in preserving health,
The accreditation effort also of Mystery Diagnosis, a program managing disease, communicating
accommodates our ongoing need produced by Discovery Health. Ed with our patients, achieving effective
as practitioners to acquire new Leigh’s cancer symptoms surfaced stewardship and inspiring each other
clinical knowledge and continually in 1997, but it wasn’t until August to be the best we can be for our
hone clinical skills. 1999, after having become a KP patients, each other and ourselves.


Advanced care management for care

delivery transformation
A special message from: Overall, the ACM program has four those care gaps. We know, for
main components and they will be instance, that a comparatively small
Charles DeShazer, MD briefly discussed here. portion of the population uses a
Associate medical director, quality, OPMG disproportionate percentage of
1) Member engagement health care resources. By refocusing
It’s no secret that the KP Ohio our attention on KP Ohio members
region faces significant economic The overall focus of this effort is
who have single or multiple
and market challenges over the on improving relationships with
chronic disease, by using proactive
next several years. Those challenges our members and facilitating or
outreach to contact them, and by
include coping effectively with improving their access to health
redoubling our efforts to ensure
northeast Ohio’s stagnant information and health care. A main
evidence-based management of
population, the imminent change in driver of this effort will be proactive
their care, we can make a significant
the way we’ll be reimbursed for our member outreach. We’ll use a few
impact on their health statuses.
Medicare members, ever-evolving key tools to identify members who
Improving their health, in turn,
member expectations regarding can benefit from more vigilant
reduces use of resources. We’ve
health insurance offerings, increased care and then we’ll use some new
already set our sights on members
focus by employers on health care resources and different approaches
with diabetes and heart failure;
delivery “report cards” (such as to contact those members and that undertaking will be followed
those produced by NCQA), rising deliver their care. For instance, by similar efforts directed toward
health care costs, attaining coding physicians and members will not coronary artery disease, chronic
and documentation proficiency, have to rely solely on the office visit obstructive pulmonary disease,
optimizing the tracking of service to communicate with one another. asthma and depression.
delivery and ensuring accurate The new KP HealthConnect Online
payment of it, and optimizing use feature (launched in November 3) Advanced practice
of the clinical expertise within the 2007) offers members the option management
OPMG network. of communicating with their
These are challenges that will test physicians via e-mail. We’ll also Perhaps what most distinguishes
the creativity, ingenuity, and resolve use “telephone visits” as part the KP model from its competitors
of everyone in the medical group of the care delivery effort. For is its ability to make rapid and
and the health plan. For the past members who are interested in sweeping changes with regard
year, however, key leads from the it, KP Healthy Solutions offers the to care delivery. Unfortunately,
medical group and health plan this capability has not been used
opportunity to collaborate with a
have collaborated to develop a effectively nor aggressively enough.
health coach on achieving goals
compelling strategy to help lock But that is quickly changing in Ohio.
set by the primary care physician.
in KP Ohio’s long-term future. The Advanced practice management
Health coaches also are trained
clinical portion of this effort is called (APM) involves redesign of the
to help educate members about
advanced care management (ACM), health care team with the objectives
health and medical issues, offer
and it will meld the strengths of of achieving benchmark level
guidance about treatment options
KP’s integrated model of health performance in cost, quality, service
for certain conditions, and provide
care delivery with its burgeoning and workforce satisfaction. It will
encouragement and guidance to
strengths in information technology rely on harnessing data-driven panel
members challenged by disease
and parlay those not just to meet management systems, leveraging
management goals.
the aforementioned challenges, technology and connectivity for
but to allow KP Ohio to leapfrog its new workflows and processes,
2) Care management support and creating improved flexibility,
Care management support involves control, and support for the health
Parts of the ACM effort have been identifying care gaps and using care team to adapt its expertise
underway for months in piloting (or developing) the expertise,
projects at the Bedford facility. tools, and resources to address continued on page 5


Advanced care management for care data reporting tools will allow us The other point to keep in mind is
delivery transformation to identify and resolve care gaps, that success of the ACM program
continued from page 4 improve panel management, depends on effective execution of
and efforts to the needs of their and optimize use of office visit all the program components and
patient panel. time. Putting data to work for their respective elements. Each
us proactively will enable clinical part of the effort supports another.
For the past several months, teams to improve overall member And though clearly a key to our
KP Ohio’s Bedford facility has care, optimize care for members sustainability mission, preservation
been piloting a project called with chronic disease, minimize the of cost-of-care dollars is just one
21st Century Collaborative Care, likelihood of undertreatment and of several payoffs the ACM effort
a key component of the APM. aid the coding, documentation and will yield. It also will allow us to
The 21st Century Collaborative diagnosis refresh efforts. practice better medicine and
exemplifies the potential KP has improve the health statuses of our
to use unconventional approaches Ambitious effort patients. Quality of care will be
to improve disease management. enhanced. We will become experts
This is a highly proactive approach To be sure, this is an ambitious
effort with an equally ambitious at managing chronic disease
to managing chronic disease and and comorbidity proactively. The
preventing events precipitated by timeline. Advanced care
management has to be up and member experience will improve.
or associated with them. Members
running with wrinkles resolved Member trust in us will build. Our
at high risk for chronic disease
in time to accommodate the expertise will attract the attention
and members diagnosed with
transition we’ll undergo regarding of employers grappling with
chronic disease are targeted for
reimbursement for our Medicare health plan costs and interested in
proactive, vigilant care. They are
literally mustered into the KP Ohio members. Under the new plan, proactive rather than reactive health
system to ensure they receive we become the primary payer for care. All of that means securing our
optimal, timely care and that they 100 percent of the care we deliver future in the region.
get guidance about managing to KP Ohio members eligible for Success of the ACM program also
their condition. Another feature of Medicare. The program, Medicare depends on support and embrace
advanced practice management Advantage, will be funded of it by everyone in OPMG and
is the advanced care panel. (See prospectively by the Center for
pages 6-8 for more details on 21st the health plan. To be sure, there
Medicare & Medicaid Services will be wrinkles and recalibrations,
Century care and the advanced care based on member data we provide.
panel.) but the overall plan is sound,
If that data is incomplete or and the early indications are that
inaccurate, the costs for treating the program offers tremendous
4) Infrastructure our Medicare members will exceed potential for us to take our care
The infrastructure component what CMS has allotted us for that delivery to a new level and make it
refers to the resources, tools, care. Essentially, we will be giving one that others will emulate.
and processes that will support away care for which we are entitled
implementation and maintenance to reimbursement. That’s why The ACM program sponsors
of member engagement, care accurate coding and documentation include Ruth Langstraat, MD,
management support and and annual diagnosis refreshes are vice president, health systems
advanced practice management. imperative; without them, CMS design and performance, Kaiser
These efforts depend on our gets an inaccurate reading on the Foundation health plan (KFHP);
access to accurate and timely
true health status of our members. Belva Denmark Tibbs, vice
data as well as our ability to fine
(Inaccurate member data also president, medical operations,
tune or overhaul structures and
constitutes Medicare fraud.) On KFHP; and Walid Sidani, MD,
workflows when necessary. Data
the other hand, the combination of vice president and associate
capture and reporting tools include
KP HealthConnect and POINT highly accurate member data and medical director, medical affairs,
(Permanente Online Interactive proactive disease management that OPMG. All of them deeply
Network Tools). POINT already results in more effective prevention believe in this endeavor and have
is helping us identify and more and control of chronic disease and worked tirelessly to help lay the
effectively manage members with of adverse events associated with groundwork for it.
chronic disease. POINT and other them, greatly improves our ability
to preserve cost-of-care dollars. continued on page 20


21st Century Care Collaborative aids

effort to improve member health
One of the key features of the electronic medical record, Kaiser With 21st Century care, there are
advanced care management Permanente now has at its disposal alternatives, and several of these
effort is the 21st Century Care several powerful electronic tools are outlined below.
Collaborative. At its core, 21st that can aid the task of proactive
Century care is an effort to improve disease management. The 21st Century Care
the health of the KP membership Collaborative will be rolled out in
and to give the care teams more A second impetus is improving a way similar to the launch of KP
control over the means and member satisfaction. Data show HealthConnect, in phases and with
methods they use to deliver care that most members feel better thorough training and guidance.
and manage daily schedules. about their health care experience Bedford got underway in April 2007
Achieving those two goals will when they are proactively and and thus far is having great success.
have a ripple effect of improving positively engaged in the task of
member satisfaction and improving care management. Two key components of the
the work life of the clinical teams. 21st Century program are the
Another catalyst for 21st Century change package and the rapid
In the 21st Century Care model, Care is the desire to improve improvement model, or RIM. The
technology, teamwork, member the work life of the care teams. latter consists of pilot-like studies
outreach, creative care delivery, In addition to the day-to-day that test elements of the change
and proactive disease management challenges they face—in particular, package or variations of them. The
merge to create a more patient a member population that presents goal is to allow each facility to use
centered system. This approach with multiple diseases—a recurring the change package partly as a
involves not just reviewing the issue is the feeling of loss of control starting point; team members then
care needs of members, but over the work day. In the 21st collaborate on developing pilots to
understanding what works best for Century model, however, clinical test strategies and ideas informed
them in terms of communicating teams have the opportunity to by member demographics as well
and interacting with the care team. recapture some of that control. as the attributes, strengths and
It also takes account of patients’ weaknesses of the care team and
interpretations of their health. For instance, the traditional office facility.
And where possible, the patient is visit model is passive rather than
enlisted to become a more active proactive—the care team waits
participant in the care plan. for patients. The model also is The change package
temperamental and imperfect. elements are as follows:
The 21st Century Care Patients can’t always get to
Collaborative grew from a appointments on time; some show 1) Build the care team
desire inside Kaiser Permanente up late or not at all, some show The goal is to create a patient-
to improve care delivery (as up unannounced. Moreover, the centered focus, where the care
reflected in internal and external face-to-face visit often involves the team and work flows are organized
measures) and to develop new exchange of fairly basic information. to meet the needs of the team’s
approaches for managing the Yet between the member and member population. One key is
health of KP members. In part, it provider staff, a significant that care team members agree to
was the acknowledgement that amount of time and energy must share accountability for managing
the traditional model for disease be expended to make that visit the health of all members of the
management—the office visit—is happen—appointment scheduling, panel; another is using information
valuable and necessary, but, by negotiating time off from work, resources to proactively analyze
itself, is not an adequate means making travel arrangements (then the needs of the panel.
of achieving the goals of offering traveling), handling the copay,
the most effective and affordable waiting for the appointment to 2) Develop relationship based care
care, particularly in a changing begin (or waiting for the member
and increasingly complex health to arrive), getting the patient Successful disease management
care world, and particularly one in “roomed,” etc. But what if an in part depends on an awareness
which technology will be a staple. alternative existed that could
For instance, in addition to the eliminate much of that expenditure? continued on page 7


21st Century Care Collaborative aids with or are assigned to a primary in turn “creates capacity” in the
effort to improve member health care physician. work days; that capacity, and the
continued from page 6 ability to create it, is one of the
3) Use alternatives to the keys to care teams gaining more
of who is in the panel and then control over, and deriving more
building relationships with those traditional office visit
satisfaction from, work life. Fishing
members using an array of Offering alternatives to the one- is integral to the 21st Century
strategies. In relationship based on-one, or face-to-face office effort and is explained in more
care, the care team really knows visit accomplishes several goals detail in the sidebar below.
its members; the electronic simultaneously: it gives members
medical record is used not just to and care team staff options for Alternative visits include telephone
communicating; it allows the care calls and emails between physicians
document and store nuts and bolts
team to have member “touches” and members; group visits and other
health information, but also to options are under consideration.
where none existed; and where
record information that improves
appropriate, an alternative visit
the task of providing individualized 4) Achieve total panel ownership
can replace the office visit. This
care. The medical record can relieves the member of the The essence of total panel
then be reviewed in advance attendant burdens and stresses ownership is providing the best
of appointments to improve associated with an office visit. possible care to the highest
the office- or telephone-visit Offering alternatives to the percentage patients in a given
experience and make them more traditional office visit also allows panel—in short, optimal panel and
productive. Another objective of the care team to achieve more population care management. The
relationship based care is ensuring control over panel management
that members have signed up using a tactic called “fishing.” This continued on page 9

Fishing: 21st Century care’s key to creating capacity

A key component of panel Once identified, the physician exchange valuable information.
management is “fishing,” places a call to the member And from the health care
a strategy that involves and the conversation goes like team’s vantage, the call
surveying the appointment this: “Mrs. Quentin, this Dr. represents an important touch
schedule hours or days into Kaiser, your physician. I see point that would not have
the future and determining that you’re coming in on Friday occurred otherwise.
whether some of the and I’m calling to prepare
appointments can be managed for your visit.” That sets the When a member does cancel,
with a phone call. Many stage for a discussion that a physician hold is placed on
appointments involve routine can determine whether the the now open appointment
follow-up or the exchange of appointment is still necessary. slot. The physician and health
basic information and plenty The goal is not to convince care team can then decide
of members would prefer to the member to cancel, rather how best to use that newly
get that information without it is to establish contact, acquired capacity. That
having to take precious hours relay helpful information, and could mean more fishing,
from their day to show up then let the member decide mammogram outreach, or
for an office visit. Fishing whether the appointment is care planning with an RN, for
takes advantage of those warranted. Experience has instance for diabetes complete
opportunities. shown that if both member care. Or the time could be
and physician feel comfortable used to see a member who
Fishing occurs at pre- that the phone call resolved has complex disease, maintain
established times during the any outstanding issues, medical records or perform
work day, and can be done the member will cancel administrative tasks. In short,
by a physician alone, or by the visit. Of course, if the fishing allows the medical
a physician and nurse. The member prefers to keep the team to create capacity that
first step is to review medical appointment, that is fine. The is used to fulfill the goals of
records for select members phone contact is still valuable 21st Century Care and regional
scheduled for office visits. for both parties because both performance measures.


Advanced care panel: using the “house call”

to improve management of chronic disease
The advanced care panel the appointment schedule (the age 55 to 64, diagnoses of
represents one of several physician and RN positions are diabetes and congestive heart
initiatives underway in Ohio to full time, the others part time). failure, and high likelihood of
help significantly improve the hospitalization.
health of Kaiser Permanente The team approach is key because
members. And like the the 21st members of the advanced care Members were identified for
Century Care Collaborative, it panel are complex patients, that participation in the ACM panel
presents an alternative to the is, individuals with multiple chronic using a predictive modeling
traditional approach to disease diseases and at high risk for tool created by DxCG, Inc., a
management. Because what is emergent events or hospitalization software company based in
becoming increasingly apparent because of their conditions. Boston, MA. DxCG specializes
is that the traditional model of in tools that aid management
care—regularly scheduled office These also are patients whose of health care and utilization
visits—works well for healthy conditions, for a host of costs and Kaiser Permanente
patients, but not so well for reasons, are not well controlled. has used their tools for several
those sick from one or more Ineffective management of years. The ACM project
chronic diseases. chronic disease is not so much a uses DxCG’s Likelihood of
function of lack of effort or lack Hospitalization Model, which
The advanced care panel, of good intentions on behalf of can assess risk among defined
or ACP, initiative occurs in physician or patient. Rather it’s populations. Churning through
collaboration with Kaiser a function of forces that both multiple variables including
Permanente’s Care Management may be up against: poor health diagnoses, medication use,
Institute, created in 1997 to literacy, lack of transportation to health care costs, and utilization
help Kaiser Permanente improve and from an appointment, not history, the tool can predict
the quality of care and health feeling well enough to make an which members are most
outcomes for members. ACP appointment, inability to leave likely to need hospitalization
also is a pilot project for all work for an appointment. For within a given time frame, for
of Kaiser Permanente. Wayne some patients, the responsibility instance 6 or 12 months. It has
Opalk is project manager for of managing a chronic disease a 35 percent accuracy rate.
the effort, and Ann L. Scott, can be overwhelming and Kaiser Permanente’s northern
director of primary care, and immobilizing. Depression also Californian department of
Nicholas Dreher, MD, assistant is a common companion to management information and
medical director, primary care, chronic disease. Both variables analysis runs the LOH model for
are the clinical leads. can squelch the will or sap Ohio.
the energy required to follow
Modern house call through with self-management Once identified, members are
responsibilities, including mailed a “welcome” letter
The essence of the advanced explaining the ACP program
making it to office visits. And
care panel is proactive, vigilant, and inviting their participation.
face-to-face visits are crucial
individualized care that is The letter is followed within
for effective management of
brought to the patient. In a week by telephone contact
chronic disease.
short, it’s a house call, but a from one of the ACP team
much more modern version members. KP members who
of it, because in this case the Recruiting members, creating
the panel express interest in the program
physician is part of a team are scheduled for an “office
responsible for the member’s The initial effort seeks to visit,” but in the 21st Century
health. The team includes an create an advanced care panel model, that visit occurs at
RN, social worker, PharmD, of 150 members. Inclusion
and scheduler, who manages criteria for this first panel are: continued on page 9


21st Century Care Collaborative aids filtering criteria. One example of a aid the disease management effort.
effort to improve member health total panel ownership effort is the In fact, the goal is to empower
continued from page 7 diabetes complete care program, members to become their own
which involves using POINT to primary care providers and to
goals include earlier intervention in identify members whose medical
or prevention of disease, greater use Kaiser Permanente’s delivery
status warrants commencement of
oversight and stepped up care of system to supply the expertise
the aspirin, lovastatin, lisinopril, or
members at high risk of medical ALL, regimen. and resources to help make that
events associated with chronic happen. Rather than being passive
disease, and proactive outreach to 5) Collaborative care planning participants, members are engaged
members who are not connected in management of their health care
This objective recognizes that
with, or have been out of touch and collaborate with the care team.
1) the medical office can be a launch
with, their primary care physicians They are cognizant of their care
pad for disease management,
and care teams. These tasks will be goals and take the necessary steps
but sustaining the effort means
aided by information technology tapping an array of tools to help to help ensure a healthy future.
resources like POINT, the panel keep members and care teams
management tool that makes it connected and communicating
If you have questions about the 21st
easy to stratify panel members Century Care Collaborative, contact Kris
and 2) collaborating with members Pilarski, project manager, at 98-330-4483 or
according to one, several or many about their care can significantly 216-635-4483.

Advanced care panel: improving welcome letter has been sent status of patients, to fine tune
management of chronic disease to a patient about joining the care plans and to troubleshoot.
continued from page 8 ACP; in the second case, the
message informs the physician Batches of 10 letters have
the member’s home and is of the patient’s decision to join been sent out weekly since the
performed by a physician, RN, middle of September 2007 and
or not join the new panel.
or both, depending on the this will continue until the team
patient’s health status. The The ACP physician, in turn, contacts the 150 members
house call makes moot the becomes the member’s new identified by POINT. If
full time primary care doctor. achieving the target enrollment
issue of transportation, which
of 150 proves elusive because
can be a significant barrier If patients have a change of
of member disinterest, the
to care, particularly among heart, they are free to return
inclusion criteria may be
older persons. In the wake of to their original primary care
the house call, which is the physicians. Otherwise, it is
equivalent of a first office visit, expected that member’s The physician, RN, and social
the ACP team convenes to map will stay on the ACM panel worker are outfitted with
out a care plan for the member. indefinitely. The panel also will laptops that have wireless
collaborate with behavioral capabilities; they also get
Communication also occurs health, in the event their Blackerrys (a brand of personal
between the ACP physician expertise is warranted. digital assistant). Both
and the primary care physicians tools will have access to KP
of members being recruited Nuts and bolts HealthConnect. Clinicians also
to the panel: once at the time carry blood pressure kits and
For the time being, the otoscopes for house calls.
a welcome letter is sent to a
ACM team will be based at
patient and again if the patient
Willoughby. Team members Documentation is a key part
agrees to join the new panel. In
include Bill Schwab, MD; Willa of the effort, so there’s close
both cases, the ACP physician
Pugh, RN; Kathleen Skerl, collaboration with information
uses KP HealthConnect technology to ensure that
MSW; and Jill Arnold, PharmD.
messaging. In the first case, all of the care efforts can be
the message notifies the The team will meet on a regular captured accurately through
primary care physician that a basis to discuss the health KP HealthConnect.


Members embrace health coaching

KP Healthy Solutions is the health can originate from an array of One important point to keep in
coaching service launched in settings where patients have mind about KP Healthy Solutions,
July 2007 to complement the contact with KP Ohio medical team says Kahl, is that it is just one
disease management efforts of members (primary care physicians, of many resources available to
OPMG physicians. The goal of specialists, hospitalists, in-patient KP members. For instance, she
the coaching is to encourage care coordinators), including encourages KP clinicians to remind
commercial (non-Medicare) medical facilities, emergency members to seek out the array
members to become active rooms, contracted hospitals, and of valuable tools and resources
participants in the management contracted skilled nursing facilities.
of their health and to spur that are available online, via the
meaningful discussions between KP.org Web site. These include
Kahl also says that clinicians
members and their physicians. a health encyclopedia, condition
filing service requests through
and disease encyclopedia, drug
KP HealthConnect can increase
According to a recent activity encyclopedia, natural medicines
the likelihood of successful
report for the period July 16– database, “live healthy” guide
contact between a member
September 15, 2007, KP Healthy (which includes health videos and
Solutions coaches have made and health coach by verifying
the member’s phone number, audio files), and the HealthMedia®
more than 1,900 telephone healthy lifestyle programs.
connections with members and asking when the best time to
netted more than 2,000 key call is (and documenting it), and
In addition to Dr. Adams and JoAnn
impacts. A key impact refers to providing the member with the
Kahl, KP Healthy Solutions also is
a coach helping a member at a Healthy Solutions “800” number
(1-800-574-8460), for instance championed by Mike Nowak, MD,
key decision making point, for surgeon, specialties lead.
instance, making an appointment by including it in the after visit
for an overdue office visit, summary. (For members interested
pledging to take up exercise, or in the coaching but uncomfortable Healthy Solutions by
committing to be more vigilant
about taking medications.
with phone contact, coaching can
occur via email; members should
the numbers:
Thus far, the opt out rate (i.e., register at the secure Web site: (July 16 launch through
the percentage of members kp.org/healthysolutions.) September 15, 2007)
declining the health coaching) is
comparatively low at less than 1 The KP Healthy Solutions health • Nearly 2,000 members have
percent of those contacted. coach communications system had phone conversations with
is set up such that members are KPHS health coaches.
“The results tell us that members never far from their KP roots, so to
have responded positively to the speak. The coaches, for instance, • More than 3,800 telephone
KP Healthy Solutions offerings,” have the technical capability to contacts were attempted by
says Ronald Adams, chief, primary transfer members to KP Ohio’s health coaches, including 582
care and primary care lead, KP member service center (e.g., to outreach calls and 214 follow-
Healthy Solutions. “I encourage relay messages to physicians, up calls.
my colleagues to continue
make appointments, or obtain
assisting in building awareness • Kaiser Permanente Ohio
information on KP Ohio health
among members of this resource.” providers made 281 service
education and wellness classes),
customer relations (e.g., to get requests for health coaching.
Physicians play a key role in the
coaching effort by activating a benefits information), or to nurse
• KP Healthy Solutions sent more
service request through advice (e.g., to have clinical
than 150,000 mailings (i.e.,
KP HealthConnect: they identify questions/concerns addressed).
introductory, chronic condition
patients likely to benefit from use
“We’re closing the circle, in a sense, outreach and health education
of the service and fax a request for
patient contact to the KP Healthy with the coaching,” says Dr. Adams. materials) to KPO commercial
Solutions health coach center. “And we’re increasing the likelihood members. Materials included
There are many ways to activate a that our members become more flu vaccine reminders and
service request, says JoAnn Kahl, informed and educated about outreach letters for preventive
RN, MBA, project manager, KP their conditions and appropriate care to members with chronic
Healthy Solutions. Service requests management of them.” conditions.


Ball is rolling for physician work life committee

It’s a simple equation: work life
satisfaction=high productivity, high
morale, low turnover and high
customer satisfaction. Making that
simple equation work, however,
is no easy task, particularly in an
arena as complex as health care
delivery and particularly at a time
when health care providers face so Gabriel Obi, MD, internist and resentment and frustration, when
many challenges. OPMG board member, chairs in fact, our goals and objectives
the steering committee, which are really the same,” says Dr.
Nevertheless, improvement of work develops the work life agenda. Obi. He also says that physicians
life satisfaction continues to be a Eddie Wills, Jr., MD, associate and management sometimes
priority for the Ohio Permanente medical director, is executive have different perspectives when
Medical Group. To that end, early sponsor. A focus group aids the they’re looking at work life issues.
in the summer of 2007 the OPMG effort by providing feedback from In fact, after becoming a board
Work Life Committee was formed. staff on work life issues. member in 2005, Dr. Obi says
The committee was created to he has a new perspective on
The Work Life Committee’s mission the limitations and challenges of
help minimize the possible impact is to help identify areas of work
on work life satisfaction by various addressing such issues, particularly
life that are not optimally balanced
given that Kaiser Permanente’s
OPMG initiatives—for instance and report on those to the OPMG
business model is distinctly
KP HealthConnect—and to study, Board, which serves in part as a
different from those used by its
address, and resolve work life bridge between OPMG physicians
competitors who have significant
issues raised in People Pulse and KP operations. “Sometimes
footholds locally and regionally.
Opinion Surveys, which began to there’s a disconnect between the
be administered annually in 2005. two groups and that can lead to
continued on page 12

Be on the alert for CMS “welcome” letters

OPMG’s regional coding compliance department Kaiser Permanente
asks that physicians be on the lookout for provider Regional coding compliance
“welcome” letters generated by the Centers for North Point Tower, Suite 1200
Medicare and Medicaid Services and sent to “new” 1001 Lakeside Ave.
providers. The letters open with a statement Cleveland, OH 44114-1153
similar to, “We are pleased to have you on board
Please direct the correspondence to the attention
as a Medicare provider.” The letter goes on to
of the coding compliance specialist. OPMG
request a sampling of copies of medical records
physicians are not responsible for submitting, nor
for which claims have been submitted to CMS for
should they attempt to submit, claims to CMS
reimbursement. for care provided to Kaiser Permanente Medicare
patients. Documentation and submission of
All physicians who receive such letters should, CMS claims are the responsibility of the coding
as soon as possible, forward copies of them to compliance specialist. If you have questions,
the regional coding compliance department. The contact Lynn Brady, RHIT, coding compliance
address is: specialist, at 98-328-5938 or 216-479-5938.


Ball is rolling for physician work life The answer lay in two of the People “Two-thirds of our physicians feel
committee Pulse indexes. The committee we don’t listen to their ideas,”
continued from page 11 concluded that by focusing efforts says Dr. Obi. “When you feel no
on addressing these two issues, one is listening, you stop offering
Once up and running, preliminary suggestions, possibly even stop
they would in turn be addressing
querying of OPMG staff by the caring about the organization. So it
multiple work life areas ripe for
Work Life Committee revealed is crucial that we address this.”
improvement. The two indexes are:
a spectrum of concerns—work-
day duration, clinical efforts “One of the challenges for
1) When clinicians have good
going unrecognized, opinions not OPMG leadership is that we do
ideas about improving the quality not always communicate in a
counting, too little control over of care delivered to members,
support staff hiring. Dr. Obi and his consistent and empowering way,
management usually makes use of and that hurts us,” says Dr. Wills.
Work Life colleagues decided that
them. “When we don’t do a good job
rather than trying to address many
providing context and rationale for
discrete issues individually, some of 2) I would recommend KP to a a business decision or explaining
which are uncontrollable and would close friend as a good place to get how we arrived there, when a
be encountered no matter where health care. decision may seem to arise out
or for whom a physician practiced, of the blue, that objective can
the committee would take a more Results from People Pulse 2006 come off looking disconnected or
strategic approach. showed that just 60 percent of unrealistic.” Moreover, problems
OPMG docs would recommend can also arise when messages get
“We wanted the greatest impact
KP to a close friend. A separate delivered to the “front lines” by
possible on work life improvement,
internal survey, commissioned by chiefs and leads as edicts. “There’s
and we concluded that would an opportunity there to have
Charles DeShazer, MD, associate
occur by taking a broader view an informed discussion, to say,
medical director, quality, showed
of the situation,” says Dr. Obi. ‘here’s the challenge, and I need
that just 54 percent would
“The question was, ‘what can we input from everyone as to how we
recommend KP. The 2006 People
do systematically to bring about might address the challenge, and
changes that resolve or address Pulse findings represent a drop of
if there are barriers, we need to
many of the issues raised? How do 3 points from 2005. As for ideas for
communicate those to leadership.’”
we have the greatest impact in the improving quality of care, just 24 Those conversations, says Dr.
shortest amount of time and make percent of OPMG docs feel their
work life better for everyone?’” ideas are used. That is also down
from 30 percent in 2005. continued on page 13

Patient safety programs

strengthen communication skills
Last year, Performance Improvement and Patient OB/GYN birthing team members. In this innovative
Safety (PIPS) launched two separate efforts to help program, sophisticated mannequins stand in for
improve patient safety. One, the highly reliable mother and baby, and participants have clinical
surgical team (or HRST) project, is an instructional scenarios “thrown” at them. The perinatal safety
course designed to strengthen communication project offers training on a monthly basis at
skills among surgical team members. Data Fairview and Marymount Hospitals. The PPSP’s
show that when surgical team members feel 15-member implementation team included KPO’s
free to communicate and voice their expertise, Kerry Dease, RN, BSN, Sharon Zahtilla, RN, and
perioperative error rates decline. Another effort, Charles Zonfa, MD. Last March, the program was
the perinatal safety project, is designed to build recognized at the Cleveland Clinic’s Patient Safety
communication and troubleshooting skills among Forum with a People’s Choice Award.


Ball is rolling for physician work life initiatives designed to respond to more proactive medical practice so
committee ideas offered to improve quality that they can better serve members
continued from page 12 of care delivery, see table 1. In and better manage their patients
addition to addressing People with chronic disease.” That also
Wills, need to be the rule rather
Pulse indexes, the Work Life
than exception when chiefs and supports OPMG’s and KP’s mission
Committee has also assembled
leads address their staffs. “That to improve performance on NCQA
empowers people and gives them ideas for improving physician
performance; see table 2.) metrics like CAHPS and HEDIS.1
a greater sense of ownership and
stake in the enterprise” Initiatives like the 21st Care
1 In pursuing its mission to measure and
improve health care quality, the National
Collaborative will be key to helping
With regard to addressing the Committee for Quality Assurance, or
care teams develop a better
low score on the “recommending NCQA, uses two tools: the Healthcare
sense of ownership and control Effectiveness Data and Information Set
KP to a close friend” index, some
over the work day, says Dr. Wills. (HEDIS) is used to monitor the quality of
efforts already are underway. “The 21st century model allows care in health plans; Consumer Assessment
These include a service initiative the physicians and care teams to of Healthcare Providers and Systems
launched in June 2007 at Cleveland organize their expertise as they (CAHPS) surveys are used to accurately
Heights and the piloting in spring see fit and distribute work loads and reliably capture information from
2007 of the 21st Century Care creatively across team members. consumers about their experiences with
Collaborative. (For examples of It allows the team to run a much care in health and Medicaid plans.

Table 1
Work Life Committee initiatives, • Allow practitioners to finance purchase of
recommendations tools or resources that can aide clinical duties
with study leave funds. For instance, speech
The Work Life Committee’s mission is to help recognition software, which would be used
identify areas of work life that are not optimally inside KP HealthConnect, could aid physicians
balanced and report on those to the OPMG Board. with limited typing skills. (In fact, the request for
The committee has an array of recommendations speech recognition software was approved at the
and initiatives on the drawing board or in the works. October 2007 board meeting.)
Shown here are examples of ideas generated to
help improve quality of care delivered to members. • Broaden the selection of training and educational
programs that are “practitioner friendly” (e.g.,
programs that are Web-based, CME accredited,
doable on study leave time).

Table 2
Work Life Committee: Ideas for improving • Increase opportunities for health care team
physician performance and cultivating members to build relationships with one another
ownership outside the workplace, for instance by creating a
sports league.
• Broaden the scope of productivity metrics to
include non-office visit encounters; for instance • Address staffing and coverage issues in the
include telephone contact and e-mails. Also, hospitals with which KP holds contracts. For
focus on outcomes rather than the number of instance, use a ratio formula to arrive at a staffing
patients seen in a given time frame. level that more appropriately aligns with the
number of hospital contracts, so that work loads
• Make more aggressive use of clinical coaching and travel time allow for optimal care.
to help physicians and support staff identify
opportunities to increase efficiencies,


Patient safety and quality care

Verbal consent caution Because it is difficult to reliably blood or blood products. Then,
added to policy on blood document, verbal consent is both parties must document the
discouraged; however, there are interaction with the member in KP
product administration
situations that arise that may HealthConnect. This confirms that
Nursing administration, the blood warrant obtaining verbal consent. a two-party process has occurred:
bank, and laboratory services For example, a physician might the physician and a licensed staff
recently revised Kaiser Permanente receive a critically relevant lab member listened to the consent via
Ohio’s regional policy on “Blood result after the patient has left telephone, and the physician and a
and Blood Product Administration, the medical office and must
licensed staff member documented
and Management of Transfusion then arrange for the patient to
that the patient understood the
Reactions.” The revised policy was receive a blood transfusion while
explanation. (Note: The patient
endorsed by the clinical operations the patient is off-site/away from/
should be made aware that a staff
leadership team (COLT) and the outside the Kaiser medical facility.
In this case, the physician must member has been asked to listen in
nurse practice council. The result is
a precaution regarding “obtaining relay the findings to the member on the conversation.)
verbal consent” from a patient who via telephone and discuss the
If you have questions about the
needs blood or blood products. need for blood or blood product
verbal consent precaution , please
administration. The physician can
Ideally, administration of blood or then obtain verbal consent, so long contact Lynn Shesser, RN, MSN,
blood products should only occur as the requirements outlined below lead, nursing quality and systems
after a physician has carefully are met: management, at 98-332-4616 or
discussed with the patient—face- 440-975-4616.
to-face—the risks and benefits The physician must have a licensed
associated with the procedure staff member (RN, NP, LPN, PA, To view the revised policy online, from
and the patient has provided, with etc.) listen to the explanation the Ohio Intranet homepage, click on
the physician observing, written of risks and benefits associated the following links: Policies, Ohio Joint
consent for the procedure. with receiving a transfusion of Regional Policies, Patient Care.


Abramson’s anecdotes
What makes a good doctor?
Scott Abramson, MD Well, mea culpa. I’m guilty of must be this, that, or another
Clinician patient communication doing exactly the opposite of disease. Sure, they want these
consultant what these individuals say they issues addressed. But what
want from a physician. I can’t most patients want initially is
If we were to ask ourselves begin to count all the times 1) to feel safe (in other words,
that great clinical question— I have walked into an exam they trust us) and 2) to be
what makes a “good” room, chart in hand, serious reassured.
doctor?—I bet that some of look on my face, ready to get
our answers would include down to business. On the If you think about it, that’s not
words like “knowledgeable,” other hand, we are physicians. a lot to ask, particularly given
“conscientious,” “hard- We’re driven, focused, task that the office visit is a very
working,” and “compassionate.” oriented. We don’t much like personal interaction and one
But what if we posed the same anything—distraction, diversion, during which many patients feel
question to our patients? What pleasantries—that get in the vulnerable or exposed.
are the qualities that they way of office visit momentum.
Surely our patients understand So, when we walk into that
believe make a “good” doctor?
these basic facts of our clinical exam room, before anything
Recently, I attended a lives. Surely they comprehend else, perhaps we need to
community focus group meeting the incredible pressures welcome our patients first with
and had the extraordinary physicians and their staffs face a genuine smile and even a few
opportunity to hear lay people on not just a daily basis, but kind words or some gesture that
weigh in about what makes an hourly basis. Surely they relays a message of hospitality.
a good doctor and other understand that we’re in their Because with those actions, we
important clinical questions. corner, that despite our matter- are saying to patients, “You
This particular group was of-fact, down-to-business are welcome here. You are safe
made up of Indians who demeanors, foremost on our here. We’ll do our best to sort
had immigrated from that agenda is providing the care out what’s bothering you.”
subcontinent. they seek. Right?
Our reputation as a “good”
All agreed that the most Well, not to downplay the doctor may depend on it.
important factor in choosing a diagnostic expertise nor the
health plan was ensuring that (This column first appeared in April
desire to always move forward,
they would have access to a 2007 in CPC Consultant’s Corner,
but perhaps we need to think
“good” doctor. When asked a publication of The Permanente
about the answers that came
to elaborate on what makes a out of this humble focus group.
Federation Clinician/Patient
doctor good, here is what some Communication effort, online at
of them said: Perhaps before walking into http://kpnet.kp.org/cpc.)
that exam room, we need to
“When you first see him, he Dr. Abramson is a neurologist at the
pause just for a second or two,
smiles.” Hayward Medical Center in Northern
and remind ourselves what
California and is celebrating his 27th
“As he walks into the room, he brings patients to us in the first year with The Permanente Medical
makes you feel good.” place. I’m not talking about Group. He has spent all of his 27 years
the obvious forces that bring of service at the Hayward Medical
“Hospitality,” was another of them to our offices—the aches, Center, where he continues to learn
the descriptors used that night pains, or coughs, or the myriad about the art of communication from
by the focus group. symptoms that they believe patients and colleagues.


Encryption effort protects health information

During the past year, Kaiser present, or future physical or No special software is needed
Permanente of Ohio has been mental health or condition of by the sender or the recipient
engaged in an encryption effort an individual, the provision of to send or receive encrypted
to ensure that patient medical health care to an individual, correspondence. Encryption
data (also known as health or the past, present, or future does not work, nor is it required
information) is protected from payment for the provision of for, e-mails sent within the
unauthorized viewing or use. health care to an individual.1 kp.org network. The e-mail
This is a joint effort between encryption procedure also
the Information Technology and The encryption effort plays out is outlined on KP’s National
National Compliance, Ethics and in five phases, two of which are Compliance, Ethics and Integrity
Integrity offices. explored in detail here. (For an Web site, accessible via the KP
overview of the effort, see the intranet. From their homepage
Protecting health information sidebar, “Kaiser Permanente (kpnet.kp.org/national/
is mandated by the Health encryption: A five-phase compliance), click through this
Insurance Portability and program,” on page 17.) pathway: Our Program, Privacy
Accountability Act of 1996, & Security, Secure E-mail.
better known as HIPAA. Protection of e-mail that
Unprotected health information contains health information Secure electronic storage of
puts KP at risk for punitive
Any Kaiser employee, including health information.
action and could jeopardize
its ability to participate in the those on contract, who sends This component of the
Medicare program, which is an e-mail outside the KP e-mail encryption effort involves
administered by the Centers for network (i.e., to a non-kp.org protection of KP workstations,
Medicare and Medicaid Services address) that includes any that is, lap- and desktop hard
(CMS). Also, because theft or patient health information is drives and other computing or
loss of electronic devices are responsible for ensuring that the information storage devices.
inevitable, an active encryption e-mail is encrypted. Encrypting The program to encrypt
program minimizes the risk an e-mail is simple and involves workstations was completed
of health information getting typing one of three keywords— during summer 2007; it also
into the wrong hands and then “phi,” “encrypt” or “mpii”—into occurs proactively any time a
being used maliciously or to the subject field of an e-mail. new workstation is issued. Once
The keyword must be flanked a lap or desktop is encrypted,
commit fraud, behavior that also
by parentheses or brackets, for the information stored on it
could result in punitive action
example: (phi) or [phi] or {phi}. can only be accessed with a
against Kaiser Permanente.
The keyword can be used alone legitimate Kaiser Permanente
In fact, Kaiser Permanente
or it can accompany a regular user ID and password,
policy prohibits storage of
text subject, for instance: according to Paul Graca, lead
health information on laptops,
desktops and other electronic Subject: Blood test results project manager, KP information
media, but in the event that (encrypt) technology—enterprise
protected health information is engineering. Even if thieves
inadvertently placed on storage The external recipient of an extract the hard drive from a
devices, encryption protects encrypted e-mail will receive unit and reinstall it elsewhere,
unwarranted access to it. “decryption” instructions, they’re not getting any
that is, guidance on how to information from it, says Graca.
Health information means open the encrypted e-mail. “Unless you can log in with the
any information, whether oral This process includes the authorized password, you’re not
or recorded in any form or recipient registering at a secure, going anywhere.”
medium, that a) is created KP-managed Web site. To
or received by a health care avoid confusion, KP’s office Again, Kaiser Permanente
provider, health plan, public of information technology prohibits storage—even
health authority, employer, life recommends contacting the temporary—of any health
insurer, school or university, intended recipient before information on the hard
or health care clearinghouse; sending an encrypted e-mail
and b) relates to the past, and explaining the procedure. continued on page 17


Encryption effort protects health is inadvertently saved to a hard digital assistants, or PDAs,
information drive, encryption minimizes the such as Blackberrys and Palms.
continued from page 16 risk of it getting into the wrong Details of this effort are still
hands should the workstation being finalized by the IT and
drive of a workstation. “That be lost or stolen.” Users can
information should always be verify that a device has been compliance offices.
stored or saved within KP’s encrypted by locating the 1 From “Health Insurance Portability
computing network and data “Pointsec for PC” icon that
centers, on KP network servers, and Accountability Act of 1996”; public
displays on the Windows tool law 104-191, Aug. 21, 1996; via the
shared drives, or servers that bar (or task bar). It’s a “P” that
otherwise meet KP-IT security United States Department of Health and
slants to the left, set against a Human Services Web site, http://aspe.
standards,” says Barbara J. circular, green background. hhs.gov/admnsimp/pl104191.htm#1177.
Martin, privacy/security officer,
KP Ohio Regional Compliance, A related initiative involves For more information about the Secure
Privacy and Security Office. protecting health information Electronic Storage (SES) Program, go to
“However, if such information that gets stored on personal http://kpnet.kp.org:81/security/ses/.

Kaiser Permanente encryption: A five-phase program

The program to protect member/ encryption software is “pushed” to encryption software; roughly 2,900
patient identifiable information, devices via the local area network of those were in Ohio.
or MPII, is a joint effort between from information technology
the Kaiser Permanente Information servers in California. Phases 1 and Phase 3 focuses on safeguarding
Technology and National 2 are complete; phases 3 and 4 personal digital assistants, for
Compliance, Ethics and Integrity are in progress; phase five is in the instance Blackberries or Palms.
offices. The goal is to prevent developmental stages. The phases Following a pilot to test strategies,
unwarranted access to protected are outlined below. phase 3 is slated for completion
health information should a sometime in 2008.
storage device, such as a desktop, Phase 1: Completed in
laptop, or personal digital early October 2006, phase 1 Phase 4 focuses on safeguarding
assistant, be lost or stolen. focused on protecting laptops removable media, for instance
used by KP home health care flash or “thumb” drives, as well as
Once outfitted with encryption staff based in the California, CDs, DVDs, and floppies. Phase 4
software, data on a hard drive or Colorado and Northwest regions. is slated for completion sometime
other storage device can only be These individuals—nurses and in 2008.
“seen” when a user logs in with
occupational, physical and speech
the proper access credentials. Phase 5 focuses on providing a
therapists, and other licensed
Encryption protects the data protected computing environment
medical professionals—provide
regardless of the tactic used to for KP staff, affiliates, and alliance
get at it, says Justin W. DiGrazia, home-based care to older persons
and those who are disabled. partners who work from their
lead project manager, Enterprise homes on their on devices. One
Engineering, Engagement Collectively, this effort involved
encrypting more than 850 solution under investigation is
Services, Kaiser Permanente
laptops to meet state and federal a kind of virtual desktop, which
Information Technology.
requirements. would involve logging in remotely
“Regardless of the ploy used—
hacking into the computer, using to a protected system. Once
“brute force” (repeated log-in Phase 2: Completed October 31, inside, a user could tap into
attempts), removing a hard drive 2007, phase 2 protected Kaiser commonly used applications as
and reinstalling it on a different owned and managed desktop and well as stored (and protected)
device—encryption protects the laptop PCs. Preliminary efforts health information.
data,” says DiGrazia. got under way in October 2006,
though the actual encryption of To learn more about Kaiser
The five-phase effort was launched devices kicked off in June 2007. Permanente’s secure electronic
in 2006 and primarily occurs Nationwide, more than 170,000 storage program, go to http://
remotely: that is, the AES-256 bit laptops and desktops received the kpnet.kp.org:81/security/ses/.


Referrals management and clinical

review updates
Michael Nowak , M. D. up-to-date information about or treatment is deemed medically
Medical director the referral process (also known appropriate or whether the
as utilization review), as well as member’s coverage allows it. (To
Maureen Kane R.N., Manager
information about any procedural view the appropriateness criteria,
The Kaiser Permanente Referrals changes that might impact see OPMG, March/April 2006,
Management and Clinical Review those processes (e.g., federal/ page 9.)
(RMCR) office is a division of state mandates or accreditation
Medical Management, the requirements relating to All referral decisions based on
department whose mission is to information required on a referral medical necessity (i.e., member
collaborate with practitioners to request).
has appropriate coverage, but the
ensure that services rendered are service is medically unwarranted
medically necessary, covered by Referral fundamentals
based on clinical review criteria) are
the health care plan and rendered Referral decisions are based
made by a board-certified physician
in the most appropriate setting in part on nationally accepted,
evidence-based clinical criteria advisor. No monetary incentives
and in a timely fashion.
delineating appropriate levels of are associated with the utilization
One of RMCR’s goals is to care for a given clinical scenario. review process. Physicians are
maintain regular communication Thus, utilization management
with practitioners by relaying decisions reflect whether a service continued on page 20

Medical Library services update

Online technology has changed kpLibraries Permanente’s portal site—
the way that organizations, http://insidekp.kp.org. Click on
including Kaiser Permanente, “Deliver Health Care”—left-hand
conduct business and deliver This is your connection to all index area-and then on “Clinical
services. The most recent entity of Kaiser Permanente’s health Library.”)
at KP Ohio to respond to online sciences libraries, giving you
opportunities is the Medical If you have not visited these sites,
access to the Kaiser Permanente
Library. For the last several years, please log on and give them a try.
Libraries online catalog as well
the trend has been toward KPO
as access to books, journals, Because some medical information
medical professionals doing
audiovisuals, and electronic searches need to be conducted
information searches online rather
resources. off-line, other avenues for
than requesting searches to be
conducted through our Medical requesting and conducting such
Clinical Library (Permanente searches are being explored
Library. After reviewing the usage
of the Medical Library, in relation Knowledge Connection) and updates on this effort will
to the cost associated with http://cl.kp.org/portal/site/ be provided accordingly. If you
continuing to provide this service national/ have questions regarding the
internally, the decision was made cessation of internal Medical
to cease offering internal Medical This is KP’s online resource for Library Services, contact Ronald
Library services as of January 1, clinical guidelines, member Copeland, MD, president and
2008. However, Kaiser Permanente education handouts, drug and lab executive medical director, OPMG,
staff have access to a wealth of information, online CME, and full- at 98-328-8781, 216-623-8781 or
free clinical resources via two text journals and textbooks. (You via Lotus Notes at
internal urls: can also access this from Kaiser ronald.copeland@nsmtp.kp.org.


Performance improvement efforts

moving forward
Communication skills are an The second program involves A good chunk of the intensive
integral component of good offering a diagnostic reliability involves practitioners interacting
doctoring and just like medical assessment of practitioners by with actors posing as patients.
skills, they have to be learned, a representative from KP Ohio’s Videotaping of the interactions
developed and honed. Because of Performance Improvement and allows clinicians to see themselves
that, OPMG is moving ahead with Patient Safety (PIPS) office. in action and to observe and
two efforts to support physicians The “diagnostic” assessment
discuss communication strengths
interested in guidance and involves observation of patient
and weaknesses with course
training designed to help improve interactions, interactions with
communication skills. Both staff and office work flows. The facilitators and clinical peers. At a
support programs are elements goal is to first identify and resolve later date, participants are invited
of the performance improvement communication and other issues to a one-day follow up to review
endeavor that is part of the that can negatively impact the skills objectives.
OPMG turnaround plan, which member experience and then
among other objectives, seeks consult with the physician and In preparation of the launch of
to boost Art of Medicine and staff about resolving them. CSI training in Ohio, this past
CAHPS (Consumer Assessment of fall, several OPMG staff members
Healthcare Providers and Systems) Introduction of the CSI program attended a CSI session hosted
scores. Select practitioners whose into KP accomplished several by Dr. Stein and her staff in
AOM scoring falls below the goals. First, it addressed a Northern California. Attendees
expected level of performance longstanding need to help included Eddie Wills, Jr., MD,
are invited, on a volunteer basis, clinicians who are technically
associate medical director for
to participate in the support competent although less adept
human resources, professional
programs. at relating to patients. Second,
the credibility and visibility of and organizational development;
The first program is designed clinician-patient communication Iris Hale, SPHR, director,
as the foundation for education was enhanced when OPMG human resources and
improving AOM scores. The colleagues and chiefs observed credentialing; and Roger Lightner,
Communications Skills Intensive, the often dramatic transformation RCC, senior human resources
or CSI, is a thorough training of some of the participants’ and organizational development
program of communications skills skills and attitudes after the consultant.
building developed by Terry Stein, course. Third, and perhaps most
MD, director, clinician-patient important, each year since CSI CSI is built around the “four
communication, Permanente was launched, patient satisfaction habits model” of effective
Medical group, regional offices, scores of the cohort of clinicians clinician-patient communication
Oakland, CA. Since its piloting attending the course have (invest in the beginning, elicit
in 1996 in northern California, showed significant improvement. the patient's perspective,
several other KP regions have In short, CSI training works. demonstrate empathy, and invest
developed CSI training efforts,
Soon, the CSI program will in the end). “It’s a big investment
including Colorado and the Mid-
Atlantic states. The program be available in Ohio through by the organization and of
teaches relationship-centered OPMG’s human resources and yourself, but there’s a big return
communication strategies that organizational development for that investment” says Lightner,
can be used in the real world but department. They plan to offer “and Kaiser has the data to back
that are particularly valuable in the first course in February that up.”
clinical settings. CSI was created 2008. The intensive is presented
in response to communications offsite, over 3.5 days and takes If you have questions about these
issues identified through patient attendees through a spectrum of programs, contact Roger Lightner
satisfaction surveys. interactive instructional exercises. at roger.c.lightner@kp.org.


Advanced care management for care technology to help improve the DeShazer also co-led KP Atlanta’s
way KP delivers care and manages primary care redesign project, one of
delivery transformation its operations. At the Southeast
continued from page 5 the first models in the country that
Permanente Medical Group in Atlanta,
emphasized team-based primary care.
GA, where he was director of clinical
We look forward to working with you information systems, Dr. DeShazer In 1997, he became vice president
on this very important endeavor. developed an automated medical and national director of the KP mid-
record abstract application that Atlantic business processes and
produced one-page summaries of computing division, directing the
During his 16 patient records. The effort, used to installation of a $42 million claims
years with Kaiser expedite more than 500,000 annual processing system that yielded a
Permanente, Dr, patient visits over a 10-year period,
DeShazer has helped improve provider and member 40% reduction in per claim costs.
focused much satisfaction scores, lowered the He also co-led care management
of his energy on cost of medical record maintenance and community provider integration
using information and lowered malpractice costs. Dr. improvement initiatives.

Referrals management and clinical Requesting a Pre certification

review updates reconsideration documentation and KP
continued from page 18 HealthConnect
OPMG physicians can request a
not rewarded for referring or not reconsideration for denials based Please be sure to use the
referring, and utilization reviewers on medical necessity, that is, a precertifcation, or “precert,”
are not rewarded for approving or member has appropriate health service if members require
denying referral requests; any of plan coverage, but the service hospitalization or need to be
these scenarios can result in over- is medically unwarranted based scheduled for a surgical procedure.
or under-utilization of services. on clinical review criteria. Also, a If a specialty consult is required
request for reconsideration can urgently, please contact the chief
Incomplete forms mean only be made with the member's of the relevant specialty prior to
processing delays written permission and can only calling RMCR. The precert phone
be made for initial or concurrent number is: 216-529-5588 or 98-
Submitting an incomplete referral 326-5588. (Beginning in January
determinations (not post service).
request delays the review process, 2008, authorizations provided via
because a request cannot undergo To request a reconsideration, the RMCR precert phone line will
review or be approved without please call the RMCR at be documented and available for
the required referral information. 216-529-5588 or 98-326-5588; viewing in KP HealthConnect, via
Valuable time can be lost for please also have available any the “Letters” tab.)
practitioners, review staff and new information that supports the
members when review staff have Provider satisfaction
rationale for the reconsideration
to contact practitioners to retrieve surveys
request. A decision will be made
information that should have been within three business days of Many thanks for a very robust
included in the referral request. receipt of the reconsideration response to the request for
To help minimize turnaround time, request. Practitioners requesting survey completion. A summary of
please fax, rather than mail, all the reconsideration can also speak results and any actions/changes
referral requests to: 216-529-5533 directly about the case with the as a result of your comments will
or 98-326-5533. physician reviewer. be forthcoming.

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1001 Lakeside Ave
Cleveland, Ohio 44114-1153