It’s Not About The Box Improving Care at Group Health with People, Process and Technology

November 27, 2009

AHRQ’s Transforming Healthcare Quality through Information Technology (THQIT) Grants

Filed under: Research — Matt Handley @ 1:24 pm

Next Tuesday I will be in Washington DC participating in a Technical Expert Panel for AHRQ to help synthesize  the available evidence (gathered through AHRQ implementation grants) to accelerate the adoption of HIT.  I see it as a great opportunity to work with a small group of committed people who each have each learned by doing and who are committed to move past their own anecdotes to develop a generalizable body of knowledge that helps others implement patient centered health information technology.  For me the focus will be on the patient – largely because of the incredible work made possible by the clinical community and investments at Group Health.

In 2004, AHRQ launched a health IT program that funds a variety of grants and cooperative agreements aimed at filling gaps in knowledge about health IT and stimulating health IT implementation. Transforming Healthcare Quality through Information Technology (THQIT), a series of funding opportunities resulting from AHRQ’s health IT program, represented an early, major federal investment in health IT to improve health care quality. Because of the groundbreaking nature of the grants, AHRQ has often referred to this portfolio as its “real-world laboratory” for examining health IT.

The THQIT grants aim to:

(1)   help clinicians develop higher-quality, safer health care;

(2)   put the patient more squarely at the center of health care;

(3)   stimulate planning and implementation of health IT, especially in rural and underserved areas;

(4)   identify the most successful approaches, as well as barriers, to implementation; and

(5)   make the business case for health IT by evaluating costs and benefits.

I would appreciate perspectives on how to approach the work, and where to focus future evaluative efforts.  Would love to bring additional ideas to the party

November 24, 2009

Epic Article on

Filed under: Epic — David Kauff @ 1:34 pm

Here is a nice little article about Epic and their place in the EMR community. Some very clear and interesting insights about the culture and growth stratagy.

Wired Medicine’s Silent Giant by Robert Langreth
The hottest company in the electronic medical records industry is a secretive Wisconsin outfit called Epic Systems.

Big name companies like General Electric, Siemens, McKesson and Cerner are rushing to profit from the push to install electronic patient records.

But the hottest company in the electronic medical records industry is a secretive Wisconsin outfit called Epic Systems. It does little marketing or advertising, shuns acquisitions, never issues press releases and tries to stay out of the headlines. The privately owned company admits it once put up a billboard that said “Marketing Sucks … Epic Systems.”

Yet with a reputation for customer service and software that is more user-friendly than most, Epic has snagged contracts with famous places like the Cleveland Clinic and University of Chicago Medical Center, the big HMO Kaiser Permanente and Group Health Cooperative in Seattle.

EPIC has recently been winning about 40% of the new contracts for electronic records systems at major hospitals–far ahead of its competitors, says health care research firm Klas Enterprises in Utah. In 2008, Epic won 24 big-hospital contracts, versus 12 for McKesson ( MCK – news – people ) and 10 for Siemens ( SI – news – people ), according to Klas. “They continue to win a lion’s share of the new business,” says Klas chairman Kent Gale. A contract to install medical records software at a 400-bed hospital might be worth $20 to $30 million over several years.

Based in 500-acre campus in Verona, Wis., Epic had $600 million in revenue last year, up from $500 million in 2007. It does not disclose its profits. The company focuses exclusively on larger hospitals and health systems–it has just 180 customers–allowing it to get business by word of mouth without much marketing. Obama’s stimulus package, which provides $36 billion in incentives for doctors and hospitals to add electronic patient records, could turbocharge the entire industry.

Computer programmer Judith Faulkner founded Epic in 1979 with three part-time employees and is still chief executive. By all accounts, she remains the dominant force, but rarely does interviews. A call to the company was returned by an outside public relations agency, which said Faulkner was traveling and unavailable for interviews. It couldn’t even verify her age. But she is known for her liberal politics and buying quirky artwork for headquarters, according to local newspaper reports.

Health care is a weird software market. You have hospitals who are flush and spend money like drunken sailors and then you have long term care, home care, clinics, doctors offices that have little mo….

Read All Comments (4)Post a CommentInstalling a medical records system at a hospital is a bit like doing a massive house renovation while the house is still occupied. All sorts of things can go wrong. The process is so complicated that IBM ( IBM – news – people ) is making money by advising hospitals how to combine dozens of disparate software systems, while Microsoft ( MSFT – news – people ) is selling software to rapidly extract data from multiple systems. Some installations of commercial drug ordering systems from other companies have gone awry and caused new types of prescription medication errors, according to published studies (see “The Dark Side of Wired Medicine”)–or even higher death rates, according to one controversial study (see “The Devil Inside Wired Medicine”).

Epic has a reputation for relatively high prices and high levels of service to ensure software is installed on time with as few snafus as possible. “They deliver what they promise,” says Dr. David S. Mendelson, chief of medical informatics at Mount Sinai Medical Center in New York. Mount Sinai uses Epic in its outpatient clinics and plans to install the company’s software in its 1,200-bed hospital as well. The fact that Epic is private is also viewed as an advantage by some hospitals, says Gale. Installing medical records can take a year or more, and hospitals don’t want a vendor that will be distracted every three months with earnings reports.

Drexel University medical computing expert Scot Silverstein is a harsh critic of most medical records systems, which he says are confusing, glitch-prone and hard to use. But he gives Epic some grudging respect. “It is not terrible. Epic has the advantage of having been around for a long time, and they have been steadily improving the quality of their product. It is much simpler in its appearance to end users than some of the competing products. The user is not presented with a massively complex set of screens.” However, he criticizes Epic’s reputation for hiring people fresh out of college who have no health care information technology experience.

What really put Epic on the map was when it won a massive contract in 2003 to install electronic patient records at Kaiser Permanente, the giant HMO in California and several other states. Kaiser gave Epic the job after abandoning a years-long effort to design its own electronic patient records system.

The Kaiser project was bigger and more complex than anything Epic had done. (Kaiser has more than 8 million members.) “Most competitors thought it would bring Epic to its knees,” says Gale. But today, despite some controversy along the way, all 435 of Kaiser’s outpatient clinics and 30 of its 36 hospitals are fully wired. One study of Kaiser clinics in Hawaii found that patient office visits dropped 26.2% after the electronic system was installed, as many simpler problems were now able to be resolved by telephone appointments or secure e-mail.

The Kaiser project will cost $4.2 billion by the time the final updates are completed in 2013. Two billion dollars of this is going to hardware and software, and much of the rest is for training, but exactly how much of this Epic gets is unclear. “They excel at helping clients deploy the software,” says Kaiser pediatric infectious disease specialist Andrew Wiesenthal, who is associate executive director at the Permanente Federation, Kaiser’s doctor group. “Their service level has been at the top,” agrees Cleveland Clinic Chief Information Officer Martin Harris. Compared to other vendors, he says, he rarely has had to call Epic to replace a software consultant that isn’t working out.

Not everyone picks Epic. Intermountain Healthcare in Utah, known for its medical computing expertise and cited for its top-quality care by President Obama, decided a few years ago that none of the existing medical records systems had the advanced capabilities it wanted. So it is collaborating with General Electric ( GE – news – people ) to design a new system from scratch. Epic, of course, was unavailable for comment.

November 18, 2009

The Mammography Controversy

Filed under: Uncategorized — Matt Handley @ 10:30 am
All over the papers, and on the minds of many of our patients, the USPSTF released their new recommendations for breast cancer screening.   Group Health has a nice summary for patients available (nice job getting that up semi-instantly, team).

The major changes are available everywhere – routine screening is no longer recommended for women in their 40s, a recommendation to move from annual to every other year mammography, and self breast exam is no longer recommended.

For me the missing part of the mammography story is that all of the protagonists (the medical groups) generally agree on how effective mammography is at reducing breast cancer deaths (about 1,900 women age 40 would need to be screened regularly for 10 years to save one woman’s life from breast cancer – ages 50 – 59:  1,313  – ages 60 – 69:  377). They also generally agree on the harms of screening. The difference that leads to the controversy is the way difference groups value those differences, and how they think about harms. The evidence of effectiveness has generally been hidden from view, with advocates for screening worried that transparency on the issue would lead more women to choose not to be screened.

After decades of professional groups’ promoting a simplistic message about screening – that more is always better, and that it is always a good thing – it is not surprising that advancing a more balanced and nuanced message generates friction. I am hopeful that this controversy helps us move to a model of shared decision making around screening issues based not on fear and advocacy, but instead on accurate, balanced and complete information that lets patients decide whether or not to be screened based on their own values.

The best summary of the real issues (e.g., complexities/challenges) in screening is a book by Gil Welsh MD, called “Should I be Tested for Cancer”.  Highly recommend it.

And – here is my new smartphrase for responding to patients’ concerns abou the change in mammography recommendations:

The United States Preventive Services Task Force (USPSTF), the major scientific group that make recommendations for preventive care in the US, has changed their recommendations for breast cancer screening.

The major changes include:
Mammography is no longer recommended for most woman in their 40s, and
Mammograms are only recommended every other year, instead of every year.

It is hard for many women to hear conflicting recommendations from national groups.  I think it is important to recognize that all of the professional groups agree about how effective mammograms are – what they disagree on is the balance between benefits and harms.

How effective are mammograms?
Because of differences in how well mammograms work in different age groups, and how likely a woman is to get cancer at different ages, you need to screen different numbers of women at different ages to save a life from breast cancer.
Ages 40 – 50:  1,909 women would need to be screened for 10 years to save one life.
Ages 50 – 59:  1,313 women would need to be screened for 10 years to save one life.
Ages 60 – 69:  377 women would need to be screened for 10 years to save one life.
These are averages – within each age group the higher a woman’s individual risk of cancer is, the more likely mammography is to help.  Analyses also showed that you get almost all of the benefits of screening with every two year mammograms, at lower risk.

Groups like the USPSTF worry about the increased harms of mammography in younger women (before menopause breast tissue is denser, leading to more false positives in younger women), and some groups like the American Cancer Society believe that if any life might be saved we should do more mammograms.

I would be glad to talk with you about how you could use this information to think through your decision about breast cancer screening.

November 14, 2009

“Its Great to be Us” – NBCH award for the Health Profile

Filed under: Uncategorized — Matt Handley @ 7:24 am

My Favorite quote from our colleague Ted Eytan will always be “It’s great to be us!”. I had a chance to have a walking meeting with Ted yesterday and talk about the work that led to Group Health’s recent award from the National Business Coalition on Health (NBCH).  We could never have won the award without Ted’s part in the larger team.  And now Ted is poised to help KP take their HRA to the next level with true integration into HealthConnect, KP’s build of Epic.

Maureena Moran was at the NBCH meeting representing Group Health and sent out this message to the team:

To all who helped create our award-winning Health Profile/EpicCare integration:

On Monday, I had the honor of accepting an award, really on your behalf, for your innovative work on the Health Profile/EpicCare integration.  I wish you all could have been there to accept the award, and I hope to share with you some of the pride I felt when accepting it and talking about the innovation.

The National Business Coalition on Health is a national organization of local coalitions focused on improving healthcare quality and affordability.  Puget Sound Health Alliance is one of the coalitions.  Purchasers drive the agenda for NBCH, and since we want GH to grow, getting an award from NBCH is great visibility.  How did the award come about?  Well, as part of our eValue8 submission (an annual RFI process to which GH responds) to NBCH, we were allowed to submit up to three innovations.  There were 100 innovation entries from health plans around the country.  9 finalists were chosen, of which we were one.  This gave us the opportunity to present our innovation in a poster session, which I did on Sunday afternoon as the NBCH annual conference was getting underway.  On Monday, two winners were announced.  Group Health and United Healthcare.  Some of our other local competitors (Regence, Premera) were nominated but did not win.

I use the Health Profile every day I am in practice – in ways that I could do no where else.  Because only at Group Health is there a robust two way interface that brings discrete data into the EMR from the HRA.  So my patients help me write their medical record.  As it should be.  Another demonstration of Group Health innovating in support of true patient centered care.

November 13, 2009

KP National Primary Care Conference

Filed under: Uncategorized — Matt Handley @ 12:34 pm

I am sitting in a conference room in Anaheim (under the shadow of the Mouse) at the KP National Primary Care conference – which deserves capitalization.     This year the Care Management Institute, KP’s national resource for sharing content and implementation strategies is having their annual meeting at the same time, bringing together the pragmatism of front line primary care clinicians with one of the innovation dissemination teams for KP.

Jeff Weisz MD, Executive Medical Director from KPSC, is starting things off with his perspectives on challenges in primary care medicine, and the changes over the course of his career, starting with a personal reluctance to give up the rotary phone.  he is talking about the importance of prevention, and a lot about primary care.  His objectives:

  1. Review changes taking place in Primary Care across the country
  2. What KP needs to do to make KP the best place to practice primary care medicine
  3. Appeal to the group to help lead KP to be the premier care delivery system in the country

You can listen along (back of the room flip video audio track):

Jeff Weisz MD at KP PC Conf

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