Tuesday, March 10, 2009

Kaiser's Electronic Messaging System and the Implications for Disease Management (and KP's own disease management programs)

The Disease Management Care Blog has been slowly navigating through the latest issue of Health Affairs and wanted to draw readers' attention to the lead article that examines Kaiser's electronic health record (EHR). It's by Catherine Chen, Terhilda Garrido, Don Chock, Grant Okawa and Louise Lian and optimistically titled 'The Kaiser Permanente electronic health record: transforming and streamlining modalities of care.' It describes how office visits dropped at Kaiser Hawaii by 26.2% between 2004 and 2007, coincident with the implementation of an EHR-based messaging system. As office visits declined, telephonic and email visits went up, HEDIS measures didn't appear to decline and an in-house patient satisfaction survey held steady. The total number of encounters, i.e., visits, phone and messaging increased by 8%.

Is the DMCB impressed? It isn't sure. First off, this isn't the first time that Kaiser has claimed that its technology has reduced patient visit numbers. What would be impressive is if the shift from face-to-face visits was accompanied by a decreased in the number of health care providers and/or fixed costs. What probably happened was that the same numbers of doctors and nurses were spending more time on the phone and less time in clinic rooms. So what?

Secondly, this may be a classic demonstration of regression to the mean. In other words, it could be that remote messaging the EHR was implemented during a time of comparatively high clinic utilization prior to 2004 with a predestined decline in the years that followed. Alternatively, there may have been other reasons for the decrease in visits, some of which the authors recognize (including an increase in co-payments and changes in clinic work flows) and some of which may be going unsaid (like some organizational turmoil). But maybe not, since the DMCB found these data which indicated another group of clinics in Hawaii had an parallel increase in patient visits in the 2004-5 time period. Curious that Health Affairs would pick this flawed article has the lead off in an important issue.

That being said however, the total number of encounters increased. If this occurred absent any change in clinic personnel then it would imply that practice efficiency increased.

The implications for disease management (DM)? The DMCB still thinks that when it comes to inbound and outbound electronic and telephonic messaging, the DM organizations are just as and maybe more efficiently able to contribute to a decrease office visits with even lower overhead compared to healthcare settings. The trick is to find the right combination of remote and local clinic nurse support, all designed to keep physicians 'hassles' (i.e., using an expensive resource to manage picayune issues) to a minimum.

What makes the DMCB think that? Well, even Kaiser Permanente would seem to agree that 24/7 nurse availability is a good idea and is making it separately available without having to buy their mainsteam health insurance or clinical services. Interestingly, the service doesn't appear to rely on the clinic based EHR-based messaging system described by Chen et al. They've come up with a better alternative.

Ironic, hm?

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