How Kaiser Permanente Went PaperlessRachael King
When physician Andrew Wiesenthal needs to work out a problem, he runs around Lake Merritt, across the street from his Oakland (Calif.) office at Kaiser Permanente. As one of the main drivers behind Kaiser's decades-long, multibillion-dollar effort to overhaul the way patient health records are kept, Wiesenthal has had a lot of laps to run.
Doctors and other medical professionals across the country will be working through similar challenges in the coming years. President Barack Obama plans to spend $17.2 billion to induce care providers to maintain patient records electronically, scrapping the current paper-based system. The Obama Administration wants electronic health records for every American by 2014.
Obama's predecessor also made a big push for electronic recordkeeping, and many doctors and hospital administrators see upgrading recordkeeping as a good way to improve care. Yet, fewer than 2% of acute care hospitals have a comprehensive electronic health record system in place, with another 8% to 12% using a basic system, according to a study published by The New England Journal of Medicine in March. Adoption isn't much better among physicians. Only 4% have a comprehensive system in place, with another 13% using basic systems, according to a study published in the journal in July.
Kaiser Permanente is one of the few exceptions. Today, all of its medical clinics and two-thirds of its hospitals operate in a paperless environment and the rest are scheduled to be completely digitized by next year. Across the system, about 14,000 physicians access electronic medical records for 8.7 million patients in nine states and the District of Columbia.
E-Health Records Can Lead to Better Care
As Wiesenthal's lakeside workouts can attest, getting there hasn't been easy. Among those responsible for Kaiser's efforts are CEO George Halvorson, CIO Phil Fasano, and Louise Liang, senior vice-president for quality and clinical systems support. But Wiesenthal has been working on this project longer than just about anyone. A trained pediatrician specializing in infectious diseases, Wiesenthal is associate executive director at the Permanente Federation, an umbrella organization that oversees Kaiser's doctors.
Early efforts began more than 40 years ago and the path to electronic medical records has involved numerous detours, including a $400 million-plus project Kaiser developed with IBM (IBM) that was scrapped in 2003. Along the way, Kaiser has spent $4 billion and encountered disgruntled doctors, system outages, and a temporary decrease in productivity as physicians get accustomed to the new system.
Kaiser officials and patients say the overhaul was worth the headaches and costs, and industry experts say the upgrade has resulted in a higher quality of care in some cases. A 2002 report from a nonprofit organization called the National Committee for Quality Assurance indicated that in Northern California, Kaiser Permanente had reduced death from heart disease so significantly among the region's then-3 million members that it no longer was the leading cause of death in that population, though it remained so in the general population. The report gave partial credit to Kaiser's databases, reports, and tracking and reminder systems.
In 2008, health-care spending in the U.S. reached $2.4 trillion. As much as 30% of that spending goes to ineffective or redundant care, according to studies published between 2002 and 2004 by doctors Elliott Fisher and John E. Wennberg at Dartmouth. Digital health records can improve care by reducing the incidence of medical errors and eliminating duplicative procedures. For instance, electronically stored results of such tests as an MRI or CT scan can be more readily accessible to a wider range of care providers—say, a doctor in an emergency room in a city far from a patient's regular physician—reducing the need for a repeated procedure. As records are integrated with a pharmacy, a doctor or nurse can tell whether a patient hasn't filled a prescription.
Unknown, If Any, Cost Savings Benefit
How much those efforts reduce overall costs is another matter. Sure, electronic medical records reduce waste, such as duplicate office visits and tests, but patients who live longer may ultimately end up consuming greater health-care resources. At Kaiser Permanente, within the first 18 months of installing electronic medical records, the rate of patient visits to doctors' offices and clinics and the emergency department falls by about 7%, Wiesenthal says. Even as Kaiser cuts waste, it adds technology such as software that can perform even more advanced analysis of records, helping doctors make better treatment decisions—and make patients healthier. "We like what we get for the money but we're not going to save any money," Wiesenthal says. "Nobody is going to save any money."
Marc Holland, program director for health-provider research at market research firm Health Industry Insights, concurs. "The bottom line is that a lot of this investment is being made on a combination of faith and a broad interpretation of dozens of reports," Holland says. "There is no hard evidence that if you invest $20 billion, you'll get back $200 billion."
Cost savings or no, Kaiser Permanente patients say they appreciate the convenience and efficiency that electronic health records provide. Christine Neer, a 38-year-old new mother, says she likes being able to make appointments online and having the ability to securely e-mail her doctor or her son's doctor with questions. After receiving the results of some tests recently, Neer had some concerns, so she e-mailed her doctor in the middle of the night. Her doctor replied the next day.
Kaiser's efforts to use computers to track patients' health reach back decades, but gathered steam in the 1980s and 1990s. An early effort was led by Wiesenthal, who joined Kaiser Permanente in 1983 as a clinician in Colorado. "I wanted to make care better," he says. Eventually, he and others realized electronic data about patient care would be vital to understanding the outcome of that care. Wading through paper files was nearly impossible. "So, very naively, because I have no training as an engineer, I decided we needed an electronic medical record," Wiesenthal says.
Private-Practice Doctors Are Slow Adopters
In 1991, Kaiser's operations in Colorado signed a joint development agreement with IBM's Watson Institute for an e-health program called Clinical Information System. By 1998, deployment was completed in Colorado. Kaiser Permanente decided to take that system nationwide and asked Wiesenthal to help lead the project. In 2002, the system was ready and was being piloted in Hawaii. Kaiser's Southern California operations were weeks away from using it when Halvorson, the then-new CEO of Kaiser Permanente, decided to consider commercial alternatives. Ultimately, Kaiser decided to scrap the Clinical Information System and go with an alternative from Epic Systems. Despite the cost and proven effectiveness in certain regions, Kaiser decided that internal development would take longer and be more costly than a commercial system.
As a so-called integrated health system, Kaiser Permanente is different from other providers not only because it owns the hospitals, pharmacies, and labs but also because the physicians in the Permanente Medical Groups only see patients insured by Kaiser. Unlike most physicians, who are paid by the office visit or procedure, Kaiser doctors are paid salaries. This is an important distinction because Kaiser Permanente as an organization bore the costs of implementing the system and has the power to mandate that doctors use it.
At NorthShore University Health System, just north of Chicago, the situation is more typical of hospitals that work with independent doctors. In 2003 and 2004, NorthShore implemented electronic medical records from Epic Systems at three hospitals and 65 medical group offices. Over the past five years, the organization has tried to encourage independent physicians to adopt it, offering 50% discounts on the Epic software. Still, industry experts say it can easily cost $50,000 or more to get a small office up and running. So far, 15 independent offices have installed the software. Today about 60% of the patients who come into the emergency department at NorthShore have a full electronic record, with medications and allergies listed, all of which helps increase patient safety. NorthShore CIO Tom Smith hopes to raise that to 75% or 80% over the next few years as more doctors adopt the technology because of the stimulus funding. Even so, he doesn't expect to get to 100%.
Money is only part of the issue. "A big part of this is the doctor's time to get it set up," Smith says. The installation takes about three months from start to finish. During that period, a doctor needs to be involved about one day a week. Then, while physicians are getting up to speed they typically cut back their patient load by half for at least the first couple of weeks. "It's not a quick process," says Smith, adding that some doctors can get back to a full patient schedule in seven or eight weeks. For some it can take as long as six months. Either way, they lose revenue or work overtime to make up the difference—and learn a new way to work with patients.
Benefits Largely Don't Go to Doctors
The bulk of U.S. health care is a collection of small practices. Wiesenthal estimates that the first-year cost of installing e-health records for a three-doctor practice is somewhere around $70,000 to $80,000 per doctor. The benefits of digitizing health records are largely realized by entities other than the doctor, including the patient, the hospital, the health plan, and the pharmacy. In fact, if waste does come out of the system, physicians can expect fewer patient visits in the near term. "Explain to me again why the doctor down the street wants to spend $80,000 to put in a system so that Walgreens (WAG) can save money," Wiesenthal says.
Svetlana Kogan is asking herself that same question. As a private practitioner of internal medicine on the Upper West Side of Manhattan, Kogan says she thinks electronic medical records wouldn't improve how she practices medicine. She sees the value of e-records in hospitals and she uses the electronic medical records system at Lenox Hill Hospital when she's there. But using a computer in the examining room would be an impediment to how she communicates with patients, she says. When she inquired two years ago about the cost of a system for her office, she received a quote of $90,000. "For a practitioner who gets paid $30 to $40 for a regular visit, how many patients do we need to see to make up for the system?" she says. "It's unrealistic."
CIOs at a number of hospitals say that getting doctors to change how they work is one of the biggest hurdles. When this software is first introduced at a location, Kaiser typically cuts doctor patient loads by 50%. Most people bounce back to full volume in about two weeks, Wiesenthal says. "That doesn't mean they're happy," he says. "In fact they're quite angry two to three months out because they're working hard and things aren't habitual yet."
Inconveniences aside, most doctors don't want to go back to a paper-based system once the new approach is in place, Wiesenthal says. He and other Kaiser officials tell the story of a patient who was visiting an allergist when a nurse, using electronic records, happened to notice that the woman was overdue for a mammogram. The nurse walked the woman over to get a mammogram right then. Turns out the patient had breast cancer but it was caught very early. For Wiesenthal, outcomes like that make e-health records more than worthwhile.