Patient Engagement and Virtual Care, Proceed with Caution

Introduction

Virtual Care has been highlighted by ITAC Health and other Canadian leaders, published via their strategy plans, journal articles, blogs and conference presentations as an emerging digital technology that will have significant impact to reshape Canadian’s health care1. However, VIRTUAL CARE layered on top of current, publicly funded Canadian healthcare processes and associated information and technology platforms will NOT achieve triple AIM desired goals of improving the patient experience of care; improving the health of jurisdictional
populations; and reducing the per capita cost of publicly funded health care.

I will share some of the lessons learned and challenges identified in effort of applying innovative business and solutions model, specifically by Kaiser Permanente (KP) to enable VIRTUAL CARE. KP is a leading U.S. healthcare organization that includes both for- profit (Permanente) and not-for-profit (Kaiser) organizations that support nine regional health divisions in U.S. KP initiated their bundled Virtual Care program for its members over one decade ago in companion to their Healthy Connect clinical provider platform. KP developed evaluation metrics to chart their forward progress and outcomes as they sustained growth of new members participating with Virtual Care as well as the addition of new patient-enabling functionalities e.g. virtual video conferencing,

Kaiser Permanente (KP), Out-Patient Digital Health Engagement and VIRTUAL CARE

KP’s Bernard Tyson, CEO, shared in a 2016 executive panel that KP patients have expanded their use of VIRTUAL CARE interactions with KP providers that surpasses the total number of in person clinic visits, over 50%, including phone, secure email, patient portal and video conferencing. By the following year, 2017, VIRTUAL CARE had grown to 59% of all out- patient
encounters as highlighted in info-graph below.

SIGNIFICANT FACTS CONCERNING KP and Patient Engagement, VIRTUAL CARE

• As of December 31,2018 Kaiser, Permanente has 12.2 million health plan members, 217,415 employees, 22,914 physicians, 59,127 nurses, 39 medical centers, and 690 medical facilities

Revenue
$79.7 billion USD (2018)[1]

Net income
$2.5 billion USD (2018)

kaiser_graph

The following details about Kaiser Permanente were shared over several days of meetings in May of 2014 by a KP International Director with Alberta Health Ministry’s Executive Team:

• KP’s 23,000 physicians are employed by Permanente (for-profit organization joined with not-for-profit Kaiser organization) on salary plus quality incentive bonuses. These physicians are embedded within 3,500 Unit-Based Teams within KP organization that provide collaborative work groups with focus on improved service, quality and care.

• KP’s physicians each have the benefit of continuous quality data comparators with their peers on work performance. New physicians have a three-year probation and only learn at the end of this probation period if they will be retained or released. Each doctor’s history of comparative performance data measurements plays a significant role in this decision milestone.

• Patients qualify for KP service by either private plan enrollment, by Medicare/Medicaid or by employer insurance plan.

• KP has one common digital electronic record for every one of its patients. This electronic record is accessible across all the geographic regional centres that comprise KP. Information for patients’ VIRTUAL CARE interactions with KP providers is captured in the shared electronic health record.

• Almost 70% of all KP patients have signed up to use their KP.ORG Virtual Care

• Kaiser Permanente has 39 hospitals and 701 medical office buildings across eight U.S. states and the District of Colombia. While most of its hospitals include primary care and specialty care clinics, it also has detached medical offices that offer outpatient care only. In several states, including Georgia and Colorado, Kaiser contracts with community hospitals for inpatient care but generally follows its patients in those hospitals with Kaiser Permanente physicians.KP’s providers can access each of their patients’ clinical information online (the right information at the right time and location) and KP’s enrolled patients can elect to access their online electronic patient information.

• By 2014, KP had measured positive results for each of the Triple-Aim outcome metrics for Virtual Care in unison with KP’s Healthy Connect bundled services for their providers and patient members as follows:

Improved Patient Experience (including Quality and Satisfaction) Outcomes:

  • with KP reduced run rate against prior history prior to 2004 implementation of Healthy Connect and bundled Virtual Care.
  • Care are 2.6 times more likely than non-Virtual Care users to remain as KP members.
  • Adoption of Virtual Care by members has expanded beyond 50% of all KP members

Improved Health of Patient Population Outcomes:

  • 57% reduction in medication errors
  • 45% of all KP pharmacy refills are ordered virtually online,
    with higher rate of medication adherence as compared to non- Virtual Care refills.
  • 50% fewer hospitalizations for diabetes cases
  • 73% reduction in cardiac mortality

Reducing the per capita cost of health care Outcomes:

  • 26% reduction in clinic office visits per member
  • 8% reduction in follow-up visits per member
  • 11% reduction in emergency room visits

Patient Advocacy for KP’s VIRTUAL CARE

In 2013, Jamie Ferguson, VP for Health IT Strategy for KP, shared his experiences on a conference call with our Canadian Community of Interest on Information Governance, sponsored by the COACH organization. I told Jamie that Alberta had a standing committee with 20 selected patient advocates to support Alberta’s Personal Health Portal program. Jamie responded that KP had recruited almost 250,000 patients who were providing useful feedback to KP’s governance for their VIRTUAL CARE Engagement.

Lessons Learned for SUCCESSFUL dominant VIRTUAL CARE Patient Engagement

• KP has demonstrated that VIRTUAL CARE is more effective when bundled as a companion to in-person visits, not as replacement for in person clinic visits.

• Sustained Patient Attachment to a Primary Care Medical Clinic is important especially for chronic disease patients

• KP’s providers can access each of their patients’ clinical information online, the right information at the right time and location, and KP’s enrolled patients can access their online electronic clinical information via KP.ORG.

• Patient Engagement, including direct involvement as stakeholders in KP’s governance, is a critical success factor for VIRTUAL CARE adoption and use.

Alberta’s Case Study involving VIRTUAL CARE, applying lessons learned from Kaiser Permanente

Over the course of two significant investigations and formal reports to Government between 2013-2015, Alberta’s Office of Auditor General and their consultants asked Alberta’s Ministry of Health and AHS to consider incorporating innovative elements of KP’s innovative health care model in addressing needed improvements for Alberta’s Primary Care Networks as well as for patients’ chronic disease management4. Their recommendations and suggestions included an emphasis on patient on-line engagement and VIRTUAL CARE patient – provider digital engagements bundled with in-person episodes i.e. telephone, email, patient portal and video conferencing.

Outlined below are several significant action steps for Albera’s VIRTUAL CARE deployment that Alberta initiated subsequent to the OAG reports and in consideration of KP’s innovative approaches:

• The One Patient One Record Strategy and business case concluded in decision by Government to support sustained funding for AHS to proceed. The Connect Care Program includes VIRTUAL CARE components for all of AHS’ patients. The decision in the business case for the Provincial Clinical Information System to proceed was multi-factored and not only because of lessons learned from Kaiser Permanente. An initial pilot with 500 AHS paediatric and adult patients using EPIC ambulatory e-Clinician and MyChart in Edmonton was begun in 2014.

• The Ministry of Health re-launched in 2019 Alberta’s personal health record, My Health Records, to provide on-line access and distribution by patients for their personal and family health information, community pharmacy drug dispenses, immunization data and select clinical laboratory results.

• Implementation by Government of Alberta the Community Data Hub supporting Community Information Integration and Central Patient Attachment Registry, CII/CPAR Program, to support integration of community physician EMR patient data and information with Provincial electronic patient record as well as provide detailed patient data in parallel to administrative billing data. Walk in clinics in both Calgary and Edmonton are widely used once or multiple time by one in four Albertans. CII Program will enable the upload from the walk-in clinic EMR to provincial Netcare EHR for summary clinical information and access by the patient’s medical home team.

• Steps are in progress on the journey to expand physician compensation by blended capitation (ARP agreements by Ministry with doctors), especially for chronic disease management in community episodic care. ‘Through a combination of patient-based capitation payments and volume-based fee for service payments, the Blended Capitation model aims to promote collaborative team-based comprehensive care that encourages health promotion, wellness, continuity of care, and system sustainability.

• Several vendors are promoting Virtual Care solutions as an opportunity for Alberta to reduce expenditures for community-based care. Differing perspectives on how best to fund community Virtual Care were shared by the current and previous Premiers in Alberta in a recent Calgary Herald article.

CONCLUSIONS

Instances of VIRTUAL CARE and online Patient Engagement — popular with the public, are quickly gaining traction in Canada. Some Canadians are being introduced to VIRTUAL CARE by their employer Insurance providers such as ManuLife with emphasis on wellness and preventative care to aid employees to minimize sick days. VIRTUAL CARE will continue to expand.

This article is a cautionary message on Canadian jurisdictions’ expectations of same/similar results as achieved by KP and being considered for Canadian publicly funded health implementation. KP has quantitatively measured and published accomplishments for bundled VIRTUAL CARE, reducing number of in person clinic visits where:

• Permanente Organization encourages each of their doctors in adopting VIRTUAL CARE in their clinical practices and capitation funding model.

• Clinical Information including KP’s VIRTUAL CARE information is captured in one place, in their one electronic patient record accessible online from anywhere.

• Every patient enrolled in KP is attached to a medical home within their Region and Clinic and is offered online access to KP.ORG portal.

• KP has spent significant effort in ‘marketing’ to their patients in order to expand appropriate use of VIRTUAL CARE, including physician prompting patients on advantages to use on-line capabilities.

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