The Feasibility of Automating Assessment of Concordance Between Advance Care Preferences and Care Received Near the End of Life.

BACKGROUND: End-of-life care is patient centered when it is concordant with patient preferences. Concordance has been frequently assessed by interview, chart review, or both. These time-consuming methods can constrain sample sizes, precluding population-level quality assessment. Concordance between preferences and care as measured by automated methods is described. METHODS: Automated processes extracted and analyzed electronic health record (EHR) data to assess concordance between 15 advance care planning preference domains and 232 related end-of-life care events for 388 patients aged 65 years or older with an inpatient encounter at Kaiser Permanente Southern California who died during or after the encounter. Patient preferences were recorded in advance directives or physician orders or reflected in hospital code status. Concordance, assessed in relation to the most recent documents, orders, or code status, occurred when patients received care they preferred or did not receive nonpreferred care. Discordance occurred when patients received care they did not prefer or did not receive care they preferred. RESULTS: Overall concordance for 12,592 observed end-of-life care events was 97.7%. A total of 55 of 4,154 (1.3%) received care events were nonpreferred, according to patient preferences in the EHR. Automated methods could not distinguish between medically nonbeneficial treatments, those that were not medically indicated, and potential undertreatment. CONCLUSION: Automating assessment of concordance between care near the end of life and preferences is feasible but requires model refinement and discrete care preference data. Automated methods may be most valuable as a screening tool to identify potential overtreatment and undertreatment, with chart review to verify discordance.

"I Want to Keep the Personal Relationship With My Doctor": Understanding Barriers to Portal Use among African Americans and Latinos.

BACKGROUND: Despite the widespread implementation of electronic health records (EHRs), there is growing evidence that racial/ethnic minority patients do not use portals as frequently as non-Hispanic whites to access their EHR information online. This differential portal use could be problematic for health care disparities since early evidence links portal use to better outcomes. OBJECTIVE: We sought to understand specific barriers to portal use among African American and Latino patients at Kaiser Permanente, which has had a portal in place for over a decade, and broad uptake among the patient population at large. METHODS: We conducted 10 focus groups with 87 participants in 2012 and 2013 among African American and Latino Kaiser Permanente members in the mid-Atlantic, Georgia, and Southern California regions. Members were eligible to participate if they were not registered for portal access. Focus groups were conducted within each racial/ethnic group, and each included individuals who were older, had a chronic disease, or were parents (as these are the three biggest users of the portal at Kaiser Permanente overall). We videotaped each focus group and transcribed the discussion for analysis. We used general inductive coding to develop themes for major barriers to portal use, overall and separately by racial/ethnic group. RESULTS: We found that lack of support was a key barrier to initiating portal use in our sample-both in terms of technical assistance as well as the fear of the portal eroding existing personal relationships with health care providers. This held true across a range of focus groups representing a mix of age, income, health conditions, and geographic regions. CONCLUSIONS: Our study was among the first qualitative explorations of barriers to portal use among racial/ethnic subgroups. Our findings suggest that uniform adoption of portal use across diverse patient groups requires more usable and personalized websites, which may be particularly important for reducing health care disparities. This work is particularly important as all health care systems continue to offer and promote more health care features online via portals.

Impact of a Care Directives Activity Tab in the Electronic Health Record on Documentation of Advance Care Planning.

CONTEXT: To ensure patient-centered end-of-life care, advance care planning (ACP) must be documented in the medical record and readily retrieved across care settings. OBJECTIVE: To describe use of the Care Directives Activity tab (CDA), a single-location feature in the electronic health record for collecting and viewing ACP documentation in inpatient and ambulatory care settings, and to assess its association with ACP documentation rates. DESIGN: Retrospective pre- and postimplementation analysis in 2012 and 2013 at Kaiser Permanente Southern California among 113,309 patients aged 65 years and older with ACP opportunities during outpatient or inpatient encounters. MAIN OUTCOME MEASURES: Providers' CDA use rates and documentation rates of advance directives and physician orders for life-sustaining treatments stratified by CDA use. RESULTS: Documentation rates of advance directives and physician orders for life-sustaining treatments among patients with outpatient and inpatient encounters were 3.5 to 9.6 percentage points higher for patients with CDA use vs those without it. The greatest differences were for orders for life-sustaining treatments among patients with inpatient encounters and for advance directives among patients with outpatient encounters; both were 9.6 percentage points higher among those with CDA use than those without it. All differences were significant after controlling for yearly variation (p < 0.001). CONCLUSION: Statistically significant differences in documentation rates between patients with and without CDA use suggest the potential of a standardized location in the electronic health record to improve ACP documentation. Further research is required to understand effects of CDA use on retrieval of preferences and end-of-life care.

An information model for automated assessment of concordance between advance care preferences and care delivered near the end of life.

OBJECTIVE: To develop an information model for automating evaluation of concordance between patient preferences and end-of-life care. METHODS: We modeled and validated 15 end-of-life care preference option domains, to which we mapped preferences recorded in standardized advance care planning documents and 232 end-of-life care events defined by procedure and medication codes. Patient preferences and end-of-life care events were available in electronic health records. Data from Kaiser Permanente Southern California modeling and testing populations were evaluated for concordance between patients' preferences and the end-of-life care events they experienced. RESULTS: The information model successfully assessed concordance between patient preferences and end-of-life care events. Among 388 expired patients in the modeling population, 4164 care events occurred, 4100 (98%) of which were preference-concordant, and 64 (2%) of which were preference-discordant. Including end-of-life care events that did not occur increased the number of observations to 6029; 99% were preference-concordant. At the level of individuals, 72% (278) of patients experienced only preference-concordant care events, 13% (50) experienced at least one preference-discordant care event, and 15% (60) experienced no preference-related care events. DISCUSSION: Model limitations pertain to assumptions that are required to match advance care planning documents with patient preference options and exclusion of preferred care that did not occur. Further research is required to apply the model to larger populations and to investigate the need for additional preference options. CONCLUSION: An information model for automating the assessment of the concordance between patients' advance care planning preferences and the end-of-life care they received was effective in a small population and has the potential to assess population-level preference-concordance on an ongoing basis.

Association between secure patient-clinician email and clinical services utilisation in a US integrated health system: a retrospective cohort study.

OBJECTIVE: To assess associations between secure patient-clinician email use and clinical services utilisation over time. DESIGN: Retrospective cohort study between July 2010 and December 2013. Controlling for a utilisation surge around first secure email use, we analysed difference of differences between propensity score-matched groups of secure patient-clinician email users and non-users for utilisation 1-12 months before and 7-18 months after first email (users) or a randomly assigned index date (non-users). SETTING: US integrated healthcare delivery system. PARTICIPANTS: 9345 adults with first secure email use between July 2011 and July 2012 and continuous enrolment for ≥30 months and 9345 adults without secure email use between July 2010 and July 2012 matched to users on demographics, health status, and baseline utilisation. PRIMARY OUTCOME MEASURES: Rates of office visits, patient-initiated phone calls, scheduled telephone visits, after-hours clinic visits, emergency department visits, and hospitalisations. RESULTS: After controlling for multiple factors, no statistically significant differences in utilisation between secure email users and non-users occurred. Utilisation transiently increased by 88-237% around first email use. Annual rates of patient-initiated phone calls decreased among secure email users, 0.2 fewer calls per person (95% CI -0.3 to -0.1), from a mean of 4.1 calls per person 1-12 months before first use to a mean of 3.8 calls per person 7-18 months after first use. Rates of patient-initiated phone calls also decreased among non-users, 0.1 fewer calls per person (95% CI -0.2 to 0.0), from a mean of 4.2 calls per person 1-12 months before the index date to mean of 4.1 calls per person 7-18 months after the index date. CONCLUSIONS: Compared with non-users, patient use of secure email with clinicians was not associated with statistically significant differences in clinical services utilisation 7-18 months after first use.

Access to Radiology Reports via an Online Patient Portal: Experiences of Referring Physicians and Patients.

PURPOSE: Few organizations have reported providing radiology reports to patients via an electronic health record patient portal. The authors describe the process of manual release of reports made by referring physicians, and patients' and referring physicians' experiences during the first year that release through the portal was available. METHODS: A survey of 508 patients assessed perceived accessibility and importance of portal-released radiology reports, and communications with referring physicians before and after the release. A survey of 48 referring physicians and a group interview assessed the utility of releasing reports, preferences regarding automatic release, and workload impact. Data were analyzed using descriptive statistics and qualitative methods. RESULTS: A total of 74% (377) of patients found reports easy to access, and 88% (446) reported that the ability to do so was important. In all, 49% (250) of patients were contacted by their referring physician before report release, and 25% (156) contacted their physician for more information after viewing a report. Of the referring physicians, 88% (42) found that releasing reports to patients was useful. Auto-release of x-ray reports, with a 1-week delay, was preferred by 58% (28), but they were more reluctant to auto-release CT and MRI reports. A total of 86% (41) of referring physicians reported that follow-up emails, telephone calls, and office visits were unchanged or had decreased. CONCLUSIONS: Referring-physician release of radiology reports via the online portal is important to patients, useful to referring physicians, and does not affect referring-physician workloads. A delay between reporting results to referring physicians and releasing them to patients allows time for needed physician-patient communication.

Race/ethnicity, personal health record access, and quality of care.

OBJECTIVES: To estimate the impact of race/ethnicity and written language preference on registration for a personal health record (PHR) that included emailing providers, viewing lab results, refilling prescriptions, and other functionalities, and the impact of PHR use on quality across racial/ethnic groups with comparable access. STUDY DESIGN AND METHODS: Retrospective observational design among 3,173,774 adults. Factors affecting registration were assessed using logistic regression, and propensity score matching techniques assessed the impact of language preference on registration and PHR use on quality of care. Difference-in-differences methods assessed the significance of between-group changes in Healthcare Effectiveness Data and Information Set (HEDIS) scores, such as glycated hemoglobin and lipid screening and control. RESULTS: Race/ethnicity most strongly predicted PHR registration. After adjusting for multiple factors, Asian American, Latino American, and African American members remained 23%, 55%, and 62% less likely to register, respectively, than non-Hispanic white members. Preference for Spanish as a written language predicted poor PHR adoption. The probability of registration was 0.451 (95% CI, 0.449-0.453) for English language-preferring Latinos and 0.174 (95% CI, 0.173-0.176) for Spanish language-preferring Latinos. For non- Hispanic whites, Latinos, and African Americans using the PHR, HEDIS scores increased after PHR use by 1.3 to 12.7 percentage points, compared with differences of -1.1 to 8.1 percentage points among nonusers. All but 2 difference-in-differences between PHR users and nonusers were statistically significant. CONCLUSIONS: Nonwhite race/ethnicity and Spanish language preference independently predict poor PHR adoption. PHR use is associated with higher quality healthcare, and when PHR use is equivalent across racial/ethnic groups, so is quality of care.

Nurses' use of an integrated electronic health record: results of a case site analysis.

PURPOSE: To explore how nurses use an integrated Electronic Health Record (EHR) in practice. METHODS: A multi-site case study across two hospitals in Kaiser Permanente Northern California. Non-participant observation was used to explore nurses' use of the EHR, while semi-structured interviews with nurses and managers explored their perceptions of the EHR and how it affected their practice. Data were analyzed thematically using codes derived deductively from the literature and inductively from the data. RESULTS: Key themes arising from the analysis suggest that the EHR changed various elements of the way nurses practiced. Introducing the EHR was thought to have improved communication, ease of access to information and the safety of medication administration processes. At an organizational level, there was variability in how the EHR was used to support care documentation and initiatives to improve the quality of care provided by nurses. CONCLUSION: The EHR was perceived to improve efficiency, safety and communication by the majority of nurses who were interviewed. However, it is likely that a number of other factors such as individual nurse's characteristics and organizational culture influence how an EHR can be used effectively to improve outcomes for patients.

Successful practices in the use of secure e-mail.

Physician use of secure e-mail with patients is anticipated to increase under Stage 2 Meaningful Use requirements, but little is known about how physicians can successfully incorporate it into daily work. We interviewed 27 "super user" physicians at Kaiser Permanente and Group Health who were identified by leaders as being technologically, operationally, and clinically adept and as having high levels of secure e-mail use with patients. They highly valued the use of secure e-mail with patients, despite concerns about a lack of adequate time to respond, and provided tips for using it successfully. They identified benefits that included better care and improved relationships with their patients.

Secure e-mailing between physicians and patients: transformational change in ambulatory care.

Secure e-mailing between Kaiser Permanente physicians and patients is widespread; primary care providers receive an average of 5 e-mails from patients each workday. However, on average, secure e-mailing with patients has not substantially impacted primary care provider workloads. Secure e-mail has been associated with increased member retention and improved quality of care. Separate studies associated patient portal and secure e-mail use with both decreased and increased use of other health care services, such as office visits, telephone encounters, emergency department visits, and hospitalizations. Directions for future research include more granular analysis of associations between patient-physician secure e-mail and health care utilization.

e-Measures: insight into the challenges and opportunities of automating publicly reported quality measures.

Using electronic health records (EHR) to automate publicly reported quality measures is receiving increasing attention and is one of the promises of EHR implementation. Kaiser Permanente has fully or partly automated six of 13 the joint commission measure sets. We describe our experience with automation and the resulting time savings: a reduction by approximately 50% of abstractor time required for one measure set alone (surgical care improvement project). However, our experience illustrates the gap between the current and desired states of automated public quality reporting, which has important implications for measure developers, accrediting entities, EHR vendors, public/private payers, and government.

Effects of proactive population-based nephrologist oversight on progression of chronic kidney disease: a retrospective control analysis.

BACKGROUND: Benefits of early nephrology care are well-established, but as many as 40% of U.S. patients with end-stage renal disease (ESRD) do not see a nephrologist before its onset. Our objective was to evaluate the effect of proactive, population-based nephrologist oversight (PPNO) on chronic kidney disease (CKD) progression. METHODS: Retrospective control analysis of Kaiser Permanente Hawaii members with CKD using propensity score matching methods. We matched 2,938 control and case pairs of individuals with stage 3a CKD for the pre-PPNO period (2001-2004) and post-PPNO period (2005-2008) that were similar in other characteristics: age, gender, and the presence of diabetes and hypertension. After three years, we classified the stage outcomes for all individuals. We assessed the PPNO effect across all stages of progression with a χ2-test. We used the z-score test to assess the proportional differences in progression within a stage. RESULTS: The progression within the post-PPNO period was less severe and significantly different from the pre-PPNO period (p = 0.027). Within the stages, there were 2.6% more individuals remaining in 3a in the post-period (95% confidence interval [CI], 1.5% to 3.8%; P value < 0.00001). Progression from 3a to 3b was 2.2% less in the post-period (95% [CI], 0.7% to 3.6%; P value = 0.0017), 3a to 4/5 was 0.2% less (95% CI, 0.0% to 0.87%; P value = 0.26), and 3a to ESRD was 0.24% less (95% CI, 0.0% to 0.66%, P value = 0.10). CONCLUSIONS: Proactive, population-based nephrologist oversight was associated with a statistically significant decrease in progression. With enabling health information technology, risk stratification and targeted intervention by collaborative primary and specialty care achieves population-level care improvements. This model may be applicable to other chronic conditions.

Association between personal health record enrollment and patient loyalty.

OBJECTIVES: To examine the association between patient loyalty, as measured by member retention in the health plan, and access to My Health Manager (MHM), Kaiser Permanente's PHR, which is linked to its electronic health record, KP HealthConnect. DESIGN: We conducted a retrospective cohort observational quality improvement project from the third quarter of 2005 to the fourth quarter of 2008 for approximately 394,000 Kaiser Permanente Northwest members. METHODS: To control for self-selection bias, we used propensity scores to perform exact 1-to-1 matching without replacement between MHM users and nonusers. We estimated retention rates of the matched data and assessed the association between MHM use and retention versus voluntary termination. We also estimated odds ratios of significant variables impacting member retention. RESULTS: The probability of remaining a member or being involuntarily terminated versus voluntary termination was 96.7% for users (95% confidence interval [CI], 96.6%-96.7%) and 92.2% for nonusers (95% CI, 92.1%-92.4%; P <.001). In the logistic model, MHM use was a significant predictor; only tenure and illness burden were stronger predictors. Users were 2.578 (95% CI, 2.487%-2.671%) times more likely to choose to remain members than were nonusers. The impact was more substantial among newer members. CONCLUSIONS: MHM use was significantly associated with voluntary membership retention. An indicator of patient loyalty, retention is critical to healthcare organizations.

The impact of an electronic health record on nurse sensitive patient outcomes: an interrupted time series analysis.

OBJECTIVES: To evaluate the impact of electronic health record (EHR) implementation on nursing care processes and outcomes. DESIGN: Interrupted time series analysis, 2003-2009. SETTING: A large US not-for-profit integrated health care organization. PARTICIPANTS: 29 hospitals in Northern and Southern California. INTERVENTION: An integrated EHR including computerized physician order entry, nursing documentation, risk assessment tools, and documentation tools. MAIN OUTCOME MEASURES: Percentage of patients with completed risk assessments for hospital acquired pressure ulcers (HAPUs) and falls (process measures) and rates of HAPU and falls (outcome measures). RESULTS: EHR implementation was significantly associated with an increase in documentation rates for HAPU risk (coefficient 2.21, 95% CI 0.67 to 3.75); the increase for fall risk was not statistically significant (0.36; -3.58 to 4.30). EHR implementation was associated with a 13% decrease in HAPU rates (coefficient -0.76, 95% CI -1.37 to -0.16) but no decrease in fall rates (-0.091; -0.29 to 0.11). Irrespective of EHR implementation, HAPU rates decreased significantly over time (-0.16; -0.20 to -0.13), while fall rates did not (0.0052; -0.01 to 0.02). Hospital region was a significant predictor of variation for both HAPU (0.72; 0.30 to 1.14) and fall rates (0.57; 0.41 to 0.72). CONCLUSIONS: The introduction of an integrated EHR was associated with a reduction in the number of HAPUs but not in patient fall rates. Other factors, such as changes over time and hospital region, were also associated with variation in outcomes. The findings suggest that EHR impact on nursing care processes and outcomes is dependent on a number of factors that should be further explored.

Use of electronic health records can improve the health care industry's environmental footprint.

Electronic health records have the potential to improve the environmental footprint of the health care industry. We estimate that Kaiser Permanente's electronic health record system, which covers 8.7 million beneficiaries, eliminated 1,000 tons of paper records and 68 tons of x-ray film, and that it has lowered gasoline consumption among patients who otherwise would have made trips to the doctor by at least three million gallons per year. However, the use of personal computers resulted in higher energy consumption and generated an additional 250 tons of waste. We conclude that electronic health records have a positive net effect on the environment, and that our model for evaluating their impact can be used to determine whether their use can improve communities' health.

Improving population care with an integrated electronic panel support tool.

This study measured the impact of an electronic Panel Support Tool (PST) on primary care teams' performance on preventive, monitoring, and therapeutic evidence-based recommendations. The PST, tightly integrated with a comprehensive electronic health record, is a dynamic report that identifies gaps in 32 evidence-based care recommendations for individual patients, groups of patients selected by a provider, or all patients on a primary care provider's panel. It combines point-of-care recommendations, disease registry capabilities, and continuous performance feedback for providers. A serial cross-sectional study of the PST's impact on care performance was conducted, retrospectively using monthly summary data for 207 teams caring for 263,509 adult members in Kaiser Permanente's Northwest region. Baseline care performance was assessed 3 months before first PST use and at 4-month intervals over 20 months of follow-up. The main outcome measure was a monthly care performance percentage for each provider, calculated as the number of selected care recommendations that were completed for all patients divided by the number of clinical indications for care recommendations among them. Statistical analysis was performed using the t test and multiple regression. Average baseline care performance on the 13 measures was 72.9% (95% confidence interval [CI], 71.8%-74.0%). During the first 12 months of tool use, performance improved to a statistically significant degree every 4 months. After 20 months of follow-up, it increased to an average of 80.0% (95% CI, 79.3%-80.7%).

The northern california perinatal research unit: a hybrid model bridging research, quality improvement and clinical practice.

Kaiser Permanente (KP) has a long-standing commitment to conduct research and report publicly. Simultaneously, it faces a different imperative: harnessing information systems to leverage internal improvements in outcomes, efficiency, and costs. Now that KP HealthConnect, the KP electronic health record, is fully implemented, research challenges at KP are moving away from issues of data access and toward the mechanisms through which raw data create meaningful clinical knowledge that is based on rigorous research. In this report we describe a model for research-the Northern California Division of Research Perinatal Research Unit-that leverages internal and external resources to fulfill these twin missions.

Improved quality at Kaiser Permanente through e-mail between physicians and patients.

The American Recovery and Reinvestment Act identified secure patient-physician e-mail messaging as an objective of the meaningful use of electronic health records. In our study of 35,423 people with diabetes, hypertension, or both, the use of secure patient-physician e-mail within a two-month period was associated with a statistically significant improvement in effectiveness of care as measured by the Healthcare Effectiveness Data and Information Set (HEDIS). In addition, the use of e-mail was associated with an improvement of 2.0-6.5 percentage points in performance on other HEDIS measures such as glycemic (HbA1c), cholesterol, and blood pressure screening and control.

The Kaiser Permanente Electronic Health Record: transforming and streamlining modalities of care.

We examined the impact of implementing a comprehensive electronic health record (EHR) system on ambulatory care use in an integrated health care delivery system with more than 225,000 members. Between 2004 and 2007, the annual age/sex-adjusted total office visit rate decreased 26.2 percent, the adjusted primary care office visit rate decreased 25.3 percent, and the adjusted specialty care office visit rate decreased 21.5 percent. Scheduled telephone visits increased more than eightfold, and secure e-mail messaging, which began in late 2005, increased nearly sixfold by 2007. Introducing an EHR creates operational efficiencies by offering nontraditional, patient-centered ways of providing care.

Patient access to an electronic health record with secure messaging: impact on primary care utilization.

OBJECTIVE: To determine whether patient access to secure patient-physician messaging affects annual adult primary care office visit and documented telephone contact rates. STUDY DESIGN: Retrospective cohort and matched-control studies with pre-post analysis. METHODS: The cohort study sample included 4686 adult members of Kaiser Permanente Northwest (KPNW) who had been registered KP HealthConnect Online users longer than 13 months and had used at least 1 feature. The matched-control study sample included 3201 randomly selected controls matched by age/sex, selected chronic conditions, and primary care physician to 3201 registered users. We calculated the difference in primary care office visit and documented telephone contact rates in the pre- and post-periods (defined, respectively, as 3-14 months before and 2-13 months after registration for KP HealthConnect Online). Paired t tests were used to assess significance. RESULTS: Annual office visit rates decreased by 0.23 (-9.7%) visits per member in the cohort study. Annual office visit rates for users in the matched-control study decreased by 0.25 (-10.3%); the corresponding decrease for the controls was 0.08 (-3.7%). This 0.17 (-6.7%) reduction was significant (P < .003). Annual documented telephone contact rates for users in the matched-control design increased by 0.32 (16.2%) contacts per member; the corresponding rate for the control group was 0.52 (29.9%). This 0.20 (13.7%) difference was significant (P < .01). CONCLUSION: Patient access to the secure messaging feature of KP HealthConnect Online was associated with decreased rates of primary care office visits and telephone contacts.