CEO SUMMARY: Proud of a 73% reduction in mortality among patients with coronary artery disease (CAD) at Kaiser Permanente Colorado, clinical care teams there demonstrate how integrated care and more effective use of laboratory test data can lead to remarkable improvements in patient outcomes. Key themes in this achievement are the combined use of an extensive electronic health record (EHR) system and disease registries to give providers instant access to patient information, including real time access to patients’ laboratory test results.
IT’S A POWERFUL DEMONSTRATION of how disease management programs can improve care for patients with chronic conditions. Kaiser Permanente Colorado reports a 73% reduction in cardiac mortality for patients in a comprehensive heart disease management program.
There is good news for clinical laboratories as well. Laboratory test data played a key role in the success of this effort. To achieve these outcomes, Kaiser used team-based care, medical best practices, and computer-generated care registries.
Kaiser Colorado’s clinical care teams are supported by information in an electronic health record (EHR) system, which allows providers to have instant access to patient information. One of the most critical components of the data in the EHR and in the care registries are laboratory test results.
Moreover, the laboratory’s ability to offer both speedy turnaround times and real-time electronic reporting of lab test results in Kaiser’s EHR played a significant role.
Given that Kaiser Permanente is an integrated delivery system, its Collaborative Cardiac Care Services (CCCS) program offers an example of how health systems will use data—including lab test results—to manage patient care in the future and possibly in a reformed health care system. Given the success of Kaiser’s CCCS program to substantially reduce mortality for patients with coronary artery disease (CAD), it is possible that the program could serve as a model for how health reformers may want to redesign the healthcare system in the future.
“Technology itself cannot solve the healthcare crisis,” said George C. Halvorson, Chairman and CEO of Kaiser Permanente. “Our Colorado region achieved quality care results by aligning people and technology in the most efficient care delivery system. It was not newer or more expensive treatments, but an integrated approach to deliver the right care at the right time. Maximizing information for the clinician means optimizing care for the patient. As Congress and the President engage on healthcare reform, we must focus on the need to change the way we deliver care.”
In exclusive interviews with THE DARK REPORT, lab managers and others involved in Kaiser’s CCCS program explained how the disease management system works. At every step, laboratory test results play an important role in helping providers manage cardiac patients with chronic conditions.
LIS Interface To The EHR
Sharon A. Minor, a medical technologist and Senior Manager for Medical Office Laboratories, explained that healthcare providers order lab tests directly in Kaiser’s EHR system, called HealthConnect. “When physicians or clinical pharmacists order lab tests in the medical record, that information goes directly across an interface to our laboratory information system (LIS),” she said.
“These lab test requests are immediately downloaded,” continued Minor, “When the patient comes into a medical office to have his or her blood draw, specimens are collected and sent to our central laboratory.
“Our central lab receives the specimens and performs the tests,” she stated. “These lab results are immediately transmitted through that same interface from our LIS to the patient’s online EHR.
“If that Kaiser member is signed up to have access to portions of his or her EHR— and many of our members are—then that patient can look up the results,” noted Minor. “Many test results are available on the same day. For routine tests, our turnaround times are usually under six hours.”
Kaiser’s EHR, HealthConnect, and HealthTrac, a disease tracking system used by CCCS, both play essential roles. When a patient is due for specific laboratory tests, HealthTrac identifies patients that are due for lab checks and a letter is sent to the patient. Patients normally then visit their Kaiser physician’s office, where the specimens are collected, and then reported into the EHR.
“When the patient presents his/her name and Kaiser card at our physician’s office, the staff checks the LIS to see what lab tests are ordered,” Minor said. “Because those tests are automatically ordered in the lab information system, the staff can print out the labels for the tubes right there. Couriers bring the specimens to our central lab.”
Running Cardiac Lipid Panels
Michael Sheehan, Ph.D, a clinical chemist and Technical Operations Manager of the lab, explained that, “for the CCCS program, we run the usual cardiac tests, such as a standard lipid profile. We recently added a highly sensitive CRP (c-reactive protein) test. Since becoming available about five years ago, it has become an important way to assess for cardiac risk. In the past 24 months, physicians at Kaiser are using it more frequently.
“Like many automated laboratories, our lab is a fully integrated system,” noted Sheehan. “For most routine testing, preaccessioned specimens go right on the automated line. Once lipid specimens reach the chemistry analyzer, results are ready in about 10 minutes. If the laboratory test results are normal, they flow right into the patients’ chart in Kaiser’s Healthconnect EHR.”
“The CCCS program follows more than 12,000 patients,” observed Minor. “This program is a large driver of our lipid screening. In the anticoagulation program, there are about 7,000 patients on warfarin therapy.
“Another branch of the pharmacy department runs the anticoagulation service,” she added. “It monitors warfarin therapy for these patients. In the laboratory, we partner closely with those clinical pharmacists to provide timely and accurate results for INRs (international normalized ratio tests). This permits them to make adjustments to patients’ warfarin doses almost in real time. Our laboratory typically reports these results the same day that the patient had blood drawn.
“In addition, several smaller illness prevention and disease management programs focus on diabetes care, weight management, and colorectal cancer screening,” Minor explained. “Over the past year, we worked with our prevention department to improve colorectal cancer screening rates.
“To do so, we introduced a new laboratory fecal immunochemical test (FIT),” she stated. “The benefit for us is that the test is more sensitive and easier to interpret than the older stool guaiac test, and for the patient, it is much easier to collect.
“Use of the FIT helped us identify a number of cancers that previously would have gone undetected,” added Minor. “A positive lab test result must be confirmed and patient follow-up requires a colonoscopy.”
Integration Plays Key Role
“The fact that Kaiser Permanente is an integrated health system makes it possible to link all aspects of care and each member of the care-delivery team,” explained Brian Sandhoff, Pharm.D., a Clinical Pharmacy Supervisor who manages patients in the CCCS program. “All facets of care are integrated seamlessly. For example, when I order a lab test and the patient goes to provide a specimen, I can be confident that lab results will post in the patient’s EHR in a timely manner.
“The CCCS staff review the lab results and the EHR to identify any confounders that may be contributing to abnormal test results,” he commented. “So integration is key for us. As an integrated health system, Kaiser has invested considerable resources to connect all aspects of care to a sophisticated health information system. Achieving a 73% reduction in mortality of cardiac patients, for example, is an outcome that could not be achieved without connecting each member of the team with this integrated access to information.
“Each of our clinical pharmacy specialists manages the care for about 850 patients,” said Sandhoff. “All individual lab test results automatically post to our in-basket. Currently 15 pharmacists follow more than 12,000 patients in the CCCS program. When a clinical pharmacy specialist enrolls a patient in the cardiac risk program, he or she will review the patient’s profile and assess which lab tests are needed to give us the information useful for us to manage those patients.
“Using HealthConnect—the electronic medical chart—we order those laboratory tests,” he explained. “Thus, when the patient shows up, the laboratory already knows which lab tests to draw. When lab results are ready, they come to us in our in baskets in the EHR, regardless of which clinic the lab tests were drawn.
“Our clinical pharmacy specialists then assess each lab result,” Sandhoff commented. “If needed, the patient will get a telephone call to discuss further interventions. Otherwise, the pharmacist generates a letter saying that the current lab results indicate everything is where it should be and the patient is welcome to call with any questions.
“If a patient needs to come back in six months, a date is entered in the tracking system that tells him/her that patient is due in six months,” Sandhoff continued. “CCCS runs reports every month to iden- tify which patients are due for tests that month. The pharmacy then sends reminder letters via the mail to alert patients who need to come in.
Pharmacy Tracks Lab Tests
“To keep track of all this information, our pharmacy developed a system—called HealthTrac—outside of the electronic medical chart,” he added. “It’s a database that we use to schedule appointments, to generate letters when patients are due for lab tests, and to do queries to let us know which patients have not come in for their tests. HealthTrac ensures that we properly follow up with every patient.
“For the past five years or more, about 97% have had annual cholesterol testing,” Sandhoff said. “When a patient is overdue for his/her next laboratory test, we send a reminder letter. After a third letter goes out, our pharmacy technicians will call these patients to remind them about the services they need. Should a patient fail to respond to these reminders, they will get a letter from us every six months.”
“All of these systems are useful only if the clinical staff is vigilant about reviewing the lab test results and other data in the electronic records,” observed Sheehan. “Once the data gets to where it should be, the system would break down without the vigilance of the people looking at the data.
Sandhoff agreed that having staff who are vigilant about reviewing the results is one key to the program’s success. “CCCS was created to be comprehensive cardiac care service that improved cardiac patient survival and we have achieved that goal,” observed Sandhoff. “When a patient has a heart attack, he or she goes into the hospital, and then gets enrolled in the CCCS program within 90 days of that event.
“Our research shows that if that patient is enrolled in CCCS within 90 days of the event, we can reduce mortality by up to 89% by monitoring each patient and following up over the long term. From a patient care standpoint, this is a very desirable result,” he added.
Clinical pathologists and lab administrators should take note of these achievements. A 73% reduction of mortality among patients with coronary artery disease is a remarkable outcome—and clinician access to real time laboratory test results played an important supporting role in Kaiser Colorado’s CCCS program.
THE DARK REPORT notes that an effective electronic health record, fully interfaced with the laboratory information system (LIS), was a key resource in the success produced by the CCCS effort.
That is a reminder of why it is important for clinical laboratories to have a sophisticated and progressive informatics strategy. Clinicians can be more effective in making diagnoses and selecting the most appropriate therapies when they have ready access to a digital health record that contains all their patients’ laboratory test data.
Real Time Laboratory Test Data Contributes to 73% Reduction in Cardiac Mortality at Kaiser
USING A TEAM-BASED APPROACH TO CARE, Kaiser Permanente Colorado significantly reduced the mortality rate for patients with heart disease. Employing medical best practices and computer-supported care registries, teams of clinical pharmacy specialists and nurses have worked collaboratively with physicians to reduce overall mortality by 76% and cardiac mortality (meaning all deaths from heart events) by 73%!
Called the Collaborative Cardiac Care Services (CCCS) program, it is designed to coordinate the efforts of providers through use of electronic health information, providing instant access to patient information, and giving providers evidence-based clinical guidelines and protocols.
Improving outcomes for patients with coronary artery disease (CAD) was the goal of Kaiser’s care teams. One tool was the creation of an electronic care registry. Recognizing the importance of early treatment and intervention, every patient who presented with CAD was enrolled in the CCCS program for both short-and long-term care. Using proven CAD risk-reduction strategies, clinical pharmacy specialists and nurses work collaboratively with CAD patients and their physicians to coordinate care. Activities such as lifestyle modification, medication management, patient education, laboratory results monitoring, and management of adverse events are all coordinated across a multifunctional team.
The program is driven by agreed-upon, consistent clinical care guidelines and protocols that are integrated into Kaiser Permanente HealthConnect, a decision-support tool that guides the care teams, at the point of care, as they follow more than 12,000 CAD patients in the program. Immediate access to reliable, evidence-based information at all points of care enables each care team member to support a given patient’s care plan, encourage treatment adherence, and allow disparate care teams to coordinate care, regardless of setting.
Research shows that fewer than 20% of CAD patients are expected to survive 10 years after their first heart attack. The coordinated, evidence-based care, enabled by KP HealthConnect and an electronic care registry, increased that survival rate dramatically. It is estimated that more than 135 deaths and 260 costly emergency interventions were prevented annually, as a result of improved care.
In addition, Kaiser said the program achieved the following results:
- Patients have an 88% reduced risk of dying of a cardiac-related cause when enrolled within 90 days of a heart attack, compared to those not in the program.
- The number of patients meeting their cholesterol goal went from 26% to 73%.
- The number of patients screened for cholesterol went from 55% to 97%.
Kaiser also reports that 10% of all patients account for 80% of healthcare costs—and 75% of those costs are related to chronic conditions. CAD affects 80 million Americans and is one of the five top chronic conditions that drive most health care costs, Kaiser said. It is the leading cause of death in the United States. Poorly managed, CAD often results in hospitalization and early death.
Kaiser Uses Lab Data to Improve Efficiency, And Boost Its National HEDIS Rankings
WHEN IT COMES TO HEALTH PLANS that are effective at moving laboratory test data into patients’ electronic health records (EHRs), Kaiser Permanente is at the leading edge, so declares John Moor, a consultant with Chilmark Research in Boston, Massachusetts.
Having real time laboratory test data in a patient health record can make a significant difference. Consultant Moore observed that, when a patient with an EHR that contains recent lab test results shows up in an emergency room (ER), the physician can proceed with treatment. By contrast, the patient who does not have an EHR may need a battery of tests before the ER physician can treat.
And here’s the downside for the patient who does not have an EHR: That patient may have had those same tests done recently but the ER may lack access to those results at the point of care. Therefore, the patient waits while the doctor orders new tests, wasting time and raising costs needlessly.
Improved Patient Outcomes
While Kaiser Permanente recognizes that using EHR data in this way empowers patients and providers while improving patient outcomes, there is another important reason why Kaiser created a real time flow of laboratory test data in its EHR and also stores that lab data in its HealthTrac system. As an HMO, each year Kaiser submits health data to HEDIS (Healthcare Effectiveness Data and Information Set). HEDIS is a set of standardized performance measures designed by the National Committee on Quality Assurance (NCQAO) to help purchasers and consumers compare the performance of HMOs and PPOs.
Every year, U.S. News and World Report publishes its rankings of the nation’s top health plans. HEDIS scores are a key component of those rankings. Kaiser Permanente Colorado currently is ranked as the top health plan in Colorado. It is ranked number 42 in the United States. The next closest Colorado plan was ranked number 72 in the United States.
For Medicare members, Kaiser Permanente Colorado ranked number 8 in the United States, and was first in Colorado. The next closest Colorado plan was number 58 in the United States, according to data from U.S. News and World Report.
Top Clinical Care Rankings
Furthermore, Kaiser Permanente Colorado consistently ranks among the top health plans in the nation in the specific areas of cholesterol screening, advising smokers to quit, and prescribing beta-blockers to cardiac patients.
Real time flow of laboratory test data directly into patients’ EHRs is recognized as one reason Kaiser Permanente Colorado achieves improved patient outcomes, relative to peer health plans. “We’ve worked hard in our laboratory organization to improve turnaround times and support a variety of clinical initiatives,” stated Sharon Minor, Senior Manager for Medical Office Laboratories at KP Colorado.
“What gives our laboratory test data extra leverage with physicians is that our health systems IT systems are tightly integrated and talk to each other,” she continued. “Having an EHR with a bi-directional interface to our LIS is recognized as essential in helping our care teams achieve improved outcomes. When providers have access to the medical record and complete, up-to-the-minute laboratory test data on their patients, it makes a positive difference in patient care.”