Canadian Agency for Drugs and Technology in Health 2008 CADTH Invitational Symposium April 28, 2008

Marguerite Koster, MA, MFTPractice LeaderTechnology Assessment and Guidelines UnitKaiser Permanente Southern California

Packaging Evidence: Integrating Evidence Into the Care Delivery Process

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Presentation Overview

About Kaiser Permanente

About KP Southern California

Knowledge Transfer/Exchange Issues

Example: Pap/HPV Screening

Lessons Learned

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Social Mission

Quality Driven

Shared Accountability for Program Success

Integration along Multiple Dimensions

Prevention & Health Maintenance Focus

A Prepaid Integrated Health Care Delivery System

KaiserFoundationHospitals

PermanenteMedicalGroup

KaiserFoundationHealth Plan

Kaiser Permanente

About Kaiser Permanente

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About Kaiser Permanente

Nation’s largest nonprofit health plan (founded 1945)

Integrated health care delivery system

8.7 million members13,000+ physicians150,000+ employees

8 regions in 9 states and D.C.32 hospitals and med centers430+ medical offices

$37.8 billion annually (2007)

Description:

People:

Facilities:

Revenue:

CO

OR

SCal

GA

OHVA

MDDC

HI

WA

NCal

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KP Southern California

One of KP’s largest regions

3.3 million members• from 140 countries• 90 different languages spoken

6,000 physicians13,000 nurses55,000 employees

12 hospitals and med centers130 medical offices

$9 billion annually (2007)

Description:

People:

Facilities:

Revenue:

CO

OR

SCal

GA

OHVA

MDDC

HI

WA

NCal

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Clinical Practice Guidelines

Medical Technology Assessment

Evidence-Based Implementation

Produce evidence-based technology assessments (evaluate devices, equipment, medical and surgical procedures)

Staff Medical Technology Inquiry Service (respond to 500-600 inquiries per year)

KPSC Technology Assessment & Guidelines Unit

Develop/update 30 evidence-based clinical guidelines to support KPSC clinical strategic goals

Focus on key levers in process of care

Produce evidence reviews on the effectiveness of implementation strategies

Produce evidence reviews to support clinical content for KP electronic health system (“KP HealthConnect”)

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KPSC Technology Assessment & Guidelines Unit (cont.)

Function has been performed within KPSC since the early 1990s

Unit includes 10 research analysts with backgrounds in epidemiology, statistics and research methods

With support from senior leadership, has helped to build a strong evidence-based culture among clinicians and administrators

Knowledge products generally well-received due to involvement of key clinician leaders in all phases:

topic selection

evidence review/synthesis

content development for knowledge products

implementation and knowledge exchange activities

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The Challenge

Integrating evidence-based knowledge into the care delivery process

“Making the right thing easy to do”

Selecting implementation strategies that are effective for a wide range of clinicians, administrators, operations staff and members

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Knowledge Transfer/Exchange Process

Synthesis Transfer Exchange Goals

Identify issues; obtain input from target audience

and analysts

Stakeholder review and approval of

recommendations

Key messages for

clinicians

Key messages for

members

Key messages for champions/

leaders

•Printed booklets•Newsletters•Web content•Outreach•Health risk assessment•“Thrive” media campaign

•Direct mail•Online content•CME presentations•EHS alerts/orders•Proactive encounter

•Detailing toolkit –modified to suit local context

•Module posters/signage•Local presentations

Increase member awareness/

engagement in preventive health

Increase appropriate

ordering Pap/HPV x 3

years

Change operations at

medical center level to support

screening initiatives

Systematic evidence review, documentation

and draft recommendations

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Example: Pap/HPV Screening

Screening practice inconsistent

internal data showed that practitioners not following KPSC guidelines (Pap x3 yrs, after 2 normal tests w/in KP system)

medical specialty societies continued to recommend annual screening despite evidence

members requesting annual screening (influenced by media)

HPV test approved in 2003 for use in conjunction with conventional or liquid-based cytology

Opportunity to standardize practice, increase screening rates, offer reassurance to clinicians and members that 3-year screening interval was effective

“Win-Win”

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Evidence Synthesis

Formed Guideline Development Team of key stakeholder groups

Defined key research topics for evidence review

Conducted formal, systematic review and critical appraisal of available evidence

Involved key stakeholder groups in development, review and approval of recommendations

Physicians on Guideline Team

Medical Directors

Chiefs of Service (Family Medicine, Internal Medicine, Ob/Gyn)

Operations: Regional/local lab managers, department administrators, clinic assistants

Physician champions

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Evidence Synthesis (cont.)

Results of 2004 KPSC systematic evidence review and cost/benefit analysis:

Sensitivity of high-risk HPV tests for CIN II or worse (95%) exceeds that of liquid based cytology (90%) and conventional pap (71%)

Pap + HPV every 3 years – as effective as annual Pap, but at a lower cost– MORE cost-effective than current practice (mix of annual,

biennial and triennial screening)

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Enlisted Guideline Team to develop key messages for:

Champions/Leaders

Clinicians

Operations/support staff

Health Education staff

Members

Initially focused on combination of “passive” and “active” strategies:

Printed materials via direct mail and online

Toolkit developed for detailing by champions at all medical centers

CME presentations by a respected gynecologic oncologist given at all medical centers and selected symposia (“peer to peer”)

Regional implementation manager conducted site visits at all medical centers

Training of physicians, nurses and medical assistants

Knowledge Packaging

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Why use “passive” strategies?

KPSC physician survey conducted in 2004:

Response Rate Information Totals

SCPMG physicians identified (partners & associates) 5,495

SCPMG physicians with a KP e-mail address listed N = 4,418 (80.4%)

Number of SCPMG physicians included in survey pretest 22

Number of e-mails returned as ‘undeliverable’ 184

Number of survey responses (including pretest) 1,409

Response Rate = 1,409/(4,418-184) * 100 = 33.3%

Source: KPSC Clinical Practice Guidelines Physician Survey, May 2004

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Why use “passive” strategies?

5%

7%

9%

12%

26%

42%

0% 10% 20% 30% 40% 50%

Other/Missing

CD-ROM

E-mail

Hard copy

Online web site

Handbook

Sour

ce

Percent of Responding Physicians

Preferred Format For Receiving Guideline Information

Source: KPSC Clinical Practice Guidelines Physician Survey, May 2004

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Clinical Practice Guideline Mailer

• Physicians (family/internal medicine, Ob/Gyn and Pediatrics

• Physician assistants, nurses• Department Administrators• Quality improvement staff• Physician & member

education staff• Executive/operations staff

Direct mailing of 4-page printed booklet to:

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Clinical Practice Guidelines Handbook

• All physicians, physician assistants, nurses

• Department Administrators• Quality improvement staff• Physician & member

education staff• Executive/operations staff

Direct mailing of handbook to:

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Intranet Web Site

Content posted on KPSC intranet web site

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Intranet Web Site (cont.)

• Guideline• Evidence review• Links to member

education• HTML & PDF

formats

Content posted on KPSC intranet web site:

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Clinician Education

Detailing toolkit – modified to suit local context

Training sessions with staff

CME presentations at each medical center

Detailing, training and education sessions:

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Clinician Education (cont.)

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Physician Education (cont.)

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Physician Education (cont.)

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Point-of-Care Posters

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Point-of-Care HPV Instructions

• HPV specimen kits developed, including instructions for sample collection and submission to lab

• Available in exam rooms

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Member Education Materials

• Booklet available to members

• Addressed key messages re screening interval and HPV virus

• Languages: English, Spanish, Chinese, Armenian

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Transition to Electronic Health System

In the past three years, KPSC has implemented an extensive electronic health system – KP HealthConnect™

Offers opportunity to integrate evidence and influence clinician decision making at the point of care

“Making the right thing easy to do”

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Pap/HPV Decision Support Alerts

Designed to support workflow and facilitate actions

Separate alert displays for the provider and is designed to complement the alert for “back office” staff

Alerts focus on the partnership between clinicians, staff and patients in providing quality, evidence- based preventive care while supporting organizational goals

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Best Practice Alert (BPA) Message

This BPA message contains a reminder as to what is due, an action to take and a brief decision support template to use for quick access to relevant codes. It complements a similar BPA for back office staff (e.g., Nurses, Medical Assistants, etc.).

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Progress Notes

Information added from back office staff (e.g., nurses, medical assistants, etc.) can be read in a section for “progress notes”

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Pending Orders

Orders pended for physician review and signature, if appropriate, are marked as “pending”

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Proactive Office Encounter

All processes, tools, and workflow which support the healthcare team in all settings, prior to, during, and after a member-initiated encounter (e.g., face-to-face office visit, telephone message, e-mail, etc.)

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Proactive Office Encounter (cont.)

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Proactive Panel Management

Supports the physician outside of an encounter to reliably and effectively manage the care of their panel of members, especially those not actively seeking care

It is a process for the systematic and periodic review of a target group (“trigger” population) of a physician’s panel of patients

Triages patients and produces decisions and patient-specific, physician orders for actions the health care team can put into effect

The outcome advances the patient along an agreed-upon care path for the purpose of closing care gaps

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Proactive Panel Management (cont.)

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Outreach Efforts

A centrally coordinated system that targets populations through batch mechanisms outside of the patient encounter (e.g. letters, calls, e-mails, etc.)

Supports physician efforts to engage members in actions that improve health outcomes

Targets members who do not come in for regular visits

Process:

Recorded call notifies member of a message from Kaiser Permanente (due for a Pap/HPV test)

Member calls KP Notification System to retrieve message

Member makes appointment

If no response, call followed up by mailed letter, e-mail, etc.

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KP Online – My Health Manager

Reminders for Pap/HPV screening are available online in member’s personal medical record

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KP Branding – “Thrive” Campaign

Television ads

Radio ads

Member feedback: “As a 12-year cancer survivor, I especially like the ‘Saturday’ ad emphasizing that life can go on even when you have cancer. Cancer is a part of your life, but doesn't have to be all- consuming.”

Outdoor billboard ads

Posters

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How are we doing?

Cervical Cancer Screening Rates2004-2007

76.077.078.079.080.081.082.083.084.085.086.087.0

2004 2005 2006 2007

Year

Perc

ent

Source: HEDIS Reports, 2005Source: HEDIS Reports, 2005--2007; KPSC Bimonthly Report, YE 20072007; KPSC Bimonthly Report, YE 2007

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Lessons Learned

Importance of developing an evidence-based culture

Strong support of senior leadership to fund and maintain an infrastructure for evidence-based research and content development

Readiness to change

Evidence-based content development

Involve important stakeholders in all phases (topic selection, evidence review, development of guidance and knowledge exchange)

Manage the scope of the content

Focus on key levers in process of health care, not entire care path

Develop clear summaries with recommendations – concise, plain language

Keep written materials as short as possible, tailor to audience

Larger evidence documents will not be used by clinicians, operations staff or administrators

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Lessons Learned (cont.)*

Impact of electronic health systems on evidence packaging:

Pieces of content that do one thing quickly and well

All-encompassing content not generally well accepted

Actively promoted

Leadership mandates, Resource Stewardship

Modal alerts (can’t avoid seeing it)

Granular content• Very specific recommendations• Codable elements• Operational definitions of disease, drugs, labs• Guidance must be correct and actionable

Define pivot points• Prioritize among the recommendations• Prioritize between guidelines (comorbidities)

*With thanks to Dr. Wiley Chan, KP Northwest

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Lessons Learned (cont.)

Create measures that drive desired performance

Consider Operational Environment• Alert fatigue• Regional priorities• Regional leadership & culture• Local workflows

Guideline writers should help build content• KP National content was little used in NW• Requires knowledge of local operational environment

*With thanks to Dr. Wiley Chan, KP Northwest