# Presentation: 155436

## The Benefits of Standards in Healthcare

- NCVHS:  Workgroup on Computer-based Patient Records
- Washington, DC
- December 8 & 9, 1998

**Homer L. Chin, MD, MS****Medical Director for Clinical Information Systems****Kaiser Permanente Northwest**

## Outline

**Kaiser Permanente Northwest**
**Organizational structure**
**Strategic advantages:  Integrated comprehensive healthcare**
**Information Systems**
**Defacto standards**
**Results of our information systems development**
**Data Standards in Healthcare**
**Prioritization of various standards**

## 18 states and D.C.
31 hospitals
337 medical offices
15,000 group-practice physicians 
100,000 non-physician employees
9.1 million capitated lives (members)
America's largest not-for-profit group practice health maintenance organization 
An integrated health care system:  Insurance, administration and healthcare “under the same roof”

- 31 hospitals
- 337 medical offices
- 15,000 group-practice physicians
- 100,000 non-physician employees
- 9.1 million capitated lives (members)
- America's largest not-for-profit group practice health maintenance organization
- An integrated health care system:  Insurance, administration and healthcare “under the same roof”

**Kaiser Permanente**

## OR and WA
Own + 6 affiliated hospitals
24 medical offices
600 physicians
4000 non-physician employees
430,000 members -- 2 million visits / year
*Integrated healthcare system

**OR and WA**
**Own + 6 affiliated hospitals**
**24 medical offices**
**600 physicians**
**4000 non-physician employees**
**430,000 members -- 2 million visits / year**
***Integrated healthcare system**

## Integrated Nature ofKaiser Permanente

**Integrated Nature of****Kaiser Permanente**

- An integrated health delivery system with a close partnership between Health Plan and Medical Groups
- Full responsibility for providing medical care is assumed by the Permanente Medical Groups.

## Kaiser Permanente Northwest:Integrated Information Systems

**Single member identifier**
**Single organization delivering comprehensive healthcare**
**Single organizational ownership of systems**
**Defacto “standards” **
**Single systems**
**Comprehensive healthcare = Complete clinical information on members**

## KPNW Clinical Systems(Circa 1992)

**TOPS**
**(Pharmacy)**

**LIS**
**(Lab)**

** ****STAR**
**(Transcription)**

**MIPS**
**(Membership)**

**RIM**
**(Radiology)**

**ADT and**
**Appointment**

**Pathology/**
**Cytology**

**Tumor**
**Registry**

## KPNW Results Reporting: Leveraging information in existing systems(1993)

**TOPS**
**(Pharmacy)**

**LIS**
**(Lab)**

** ****STAR**
**(Transcription)**

**MIPS**
**(Membership)**

**Results**
**Reporting**

**RIM**
**(Radiology)**

**ADT and**
**Appointment**

**Pathology/**
**Cytology**

**Tumor**
**Registry**

## KPNW Results Reporting: Leveraging information in existing systems(1993)

**(Pharmacy)**

**LIS**
**(Lab)**

** ****STAR**
**(Transcription)**

**MIPS**
**(Membership)**

**Results**
**Reporting**

**RIM**
**(Radiology)**

**CLINICIAN**

**ADT and**
**Appointment**

**Outside **
**Reports**

**Pathology/**
**Cytology**

**Tumor**
**Registry**

**KPNW Results Reporting: ****Leveraging information in existing systems****(1993)**

## Summary Printouts from RRS

**Summary Printouts from RRS**

## RRS:  Summary View (1)Health Prevention Section - With Guidelines

-   **HEALTH SCREENING:**
-  Mammogram: 03/14/96
-  Pap Test:  04/02/92
-  Flex Sig:  02/02/98
-  * Mammogram recommended every 1-2 years in average/low risk women ages 50-70.
-  * In average risk women Pap smears are recommended annually for 3 years after
-    onset sexual activity, then every 2 years if smears have been negative.
-    Pap smears not needed after age 69 if previous screening negative or after
-    total hysterectomy for benign disease.
-  * Screening for colon cancer with a single flex sig after age 50 is
-    recommended when there is a family history of colon cancer.
-   **IMMUNIZATIONS:**
-  Pneumovax:               Flu: 10/13/97  Tetanus: 04/02/92
-        MMR:           Rubella:           Rubeola:
-  * Revaccinate for Pneumonia every 6 years for HIGHEST risk groups (e.g.
-    asplenics, nephrotic syndrome, renal failure, transplants, CSF leaks, etc.)
-    For HIGH risk groups (e.g. age > 65, chronic illnesses) revaccinate once
-    only in > 6 years from first dose.
-  * Screen for Rubella (blood test) and vaccinate susceptible adolescents and
-    adults, particularly women of childbearing age who are not pregnant.

## RRS:  Summary View (2)Cholesterol and Diabetes Section

-                   07/17/97    06/09/95    04/05/95
-  Cholesterol           202         182         224
-  HDL Cholesterol        39          44
-  LDL Cholesterol       106
-  Triglyceride          184
-  * Cholesterol screening recommended every 5 years between ages 20-70.
-    Screening after age 70 is controversial in otherwise healthy persons.
-   **DIABETES TREND:**
-                   10/06/97    07/17/97    06/05/97    01/17/97    11/15/96
-  HbA1c
-  Fructosamine          343 H       303 H       370 H       319 H       290 H
-  Random Glucose        235 H                               160
-  Fasting Glucose                   157 H       224 H
-  Creatinine                01/17/97  0.7
-  Urine Microalbumin Screen 01/17/97  4.3
-  Eye Care Visit:   02/09/98  BOYER,JOHN
-  * Annual screening recommended for diabetic retinopathy.

**RRS:  Summary View (2)****Cholesterol and Diabetes Section**

## RRS:  Summary View (3)Lab Summary Section

-   **CONDENSED LAB SUMMARY:**
-  10/16/97 Stool Occult Blood
-  10/06/97 Diabetes Studies
-  10/06/97 CBC
-  01/17/97 Quant Urine Chemistry Studies
-  01/17/97 Liver Function Tests
-  01/17/97 Ca,(PO4)
-  01/17/97 (Na,K,Cl,BUN),Creat
-  01/17/97 ESR
-  02/23/96 UA
-  09/18/95 Thyroid Function Tests
-  06/09/95 Lipid Studies
-  04/05/95 FSH
-  11/16/92 Group A Strep Screen
-   **ANY OF LAST 3 RESULTS ABNORMAL (EXCLUDES CULTURES AND TEXT REPORTS):**
-                  02/23/96         09/18/95         04/05/95
-  Glucose         > 1000 *         100 *            NEGATIVE
-  WBC/HPF         0 - 4
-  RBC/HPF         0 - 4

## RRS:  Summary View (4)Reports and Visit Section

-  **LAST REPORTS BY TYPE AND PROVIDER:**
-  CHEST XRAY - 2                             12/17/97 OPD  SANDBERG,SCOTT
-  Outpatient Consult                         02/27/97 OPD  YOUNG,ROBERT
-  MAMMOGRAPHY,SCREENING,BILAT,4              03/14/96 OPD  KOSTINER,ANTHONY
-  ABDOMEN ULTRASOUND, COMPLETE               11/02/95 OPD  SANDBERG,C,JOAN
-  Path-Lipoma, right shoulder                06/09/95 OPD  CHAN,GEORGE
-  Mammography, diagnostic,bilat <MORE EXAMS> 12/23/94 OPD  KOSTINER,ANTHONY
-  Abdomen ultrasound;complete(incl:abdomen,a 09/16/92 OPD  WILSON,JAMES,L
-  Chest ; 2                                  08/27/92 OPD  WILSON,JAMES,L
-  Industrial Med Clinic                      04/15/92 OPD  USHMAN,DAVID,P
-  Screening mammography, bilateral, 4        04/13/92 OPD  WILSON,JAMES,L
-  CYTOLOGY - VAGINA                          04/02/92 OPD  UNKNOWN DOCTOR
-  Ultrasound                                 08/26/91 OPD  WAWRUKIEWICZ,ANTH
-  X-Ray                                      03/12/91 OPD  WILSON,JAMES,L
-   **HOSPITAL/CLINIC ENCOUNTERS:**
-       Hospital Discharges:
-            Emergency Dept:  09/10/91
-                 PCP Visit:  11/10/97  CHIN,HOMER
-  Recent/Future Encounters:  04/09/98  APPT FUTURE BVN  IM    CHIN,HOMER
-                             02/09/98  APPT KEPT   BVN  OPTO  BOYER,JOHN
-                             02/02/98  APPT KEPT   WIN  SURG  PRIMIANO,PETER
-                             12/29/97  APPT NOSHOW BVN  IM    CHIN,HOMER
-                             12/17/97  APPT CANCEL BVN  FP    GERGYES,JOSEPH
-                             12/17/97  APPT KEPT   BVN  IM    BVT MED ADVICE RN

## Population Management of our Diabetic Members

## Diabetic Glucose Control

## Disease Prevention: Pap Smear Rates

## Components to the Computer-Based Patient Record in KPNW

**Results Reporting (RRS): 1993**
**Prevention and Disease Registries**
**Diabetes**
**Pap Smears and Mammograms**
**Lipid control of high risk members**
**EpicCare (Comprehensive Computer-Based Outpatient Record): 1995 - 1997**

## EpicCare: CPR and Outpatient Processes

**Standard coding of all diagnoses, procedures, LOS ==> automatic bill generation**
**Problem list maintenance**
**Order communication (guidelines embedded)**
**Pharmacy**
**Lab, radiology**
**Referrals**
**Messaging**
**Progress note**
**Patient instructions**
**Integrates decision support into the process of care**

## Embedding Guidelines: Imaging

## Embedding  Pharmacy Guidelines

## Results:Laboratory Test Utilization

## Outpatient Visits

## Defacto Standards at KPNW

**Single Patient Identifier**
**Single Systems**
**Complete Information on Our Members**
**Results of Defacto Standards:**
**Ability to consolidate information**
**Improved quality and appropriateness of care**
**Decreased unnecessary variation in treatment **
**Decreased outpatient office visits**
**Population-based prevention and disease management**
**Improve overall quality with less cost**

## Prioritization of Healthcare Data Standards

**Unique Patient Identifier**
**Consolidation of patient information from different systems**
**Test and Procedure Naming Standards**
**Allows labeling of information for summary displays **
**Results Standards**
**Allows consolidation of results on a particular test -- enables population-based prevention and disease management**
**Diagnosis Code Standards**
**Consolidation of Problem Lists, Diagnoses from different systems**
**Other**
**Data elements with known benefit in decision support, outcomes analysis**

## Kaiser Permanente Northwest:A Glimpse into the Benefits of Data Standardization in Healthcare

**Kaiser Permanente Northwest:****A Glimpse into the Benefits of ****Data Standardization in Healthcare**