Hard-Learned Lessons About e-Medical Records from Kaiser Permanente

Loraine Lawson

IT Business Edge reader and consultant Frank Millar suggested that if the U.S. government wants to succeed with a national electronic medical records (EMR) system, it should study Kaiser Permanente's work in this field:


"Their internally-built healthcare systems seem to be advanced and impressively successful. I attribute at least part of this success to Kaiser's effective use of architecture practices."


Millar was responding to last week's post, "Is IT Capable of Building a National Electronic Health Records System?," which summarized Burton Group analyst Joe Bugajski's concerns about the data integration barriers to President Obama's national EMR system.


Certainly, if any EMR project can serve as a starting point for a national model, it would be Kaiser Permanente. Earlier this month, the Healthcare Information and Management Systems Society recognized 12 of Kaiser's hospitals with its Stage 7 award, which is "the highest level of recognition for hospital-based EMR implementation." And the health care system's EMR-with its to-date $4 billion price tag - was even recently profiled by Business Week.


Unfortunately, the Business Week article does not specifically address the integration challenges of Kaiser's EMR system. However, there are still plenty of relevant takeaways from this special report on Kaiser Permanente's efforts:


  1. It seems the integrated system did lead to better, more efficient health care. The article offers statistical and anecdotal evidence, including the results of a nonprofit report crediting, in part, Kaiser's databases, reports, tracking and reminder system with reducing heart disease in Northern California, "so significantly among the region's then-3 million members that it no longer was the leading cause of death in that population, though it remained so in the general population." EMR translated into 7 percent fewer patient visits to Kaiser's doctors' offices, clinics and ER.
  2. Better health care - yes, but cost savings? No. EMR didn't save Kaiser money. The article quotes one Kaiser Permanente doctor who has been involved in the project from the beginning as saying "We like what we get for the money but we're not going to save any money. Nobody is going to save any money." Within 18 months, patient visits fell by 7 percent in doctors' offices, clinics and ER departments.
  3. That said, it seems to me the article paints a more favorable financial picture for a closed health care system, such as the U.S. military. EMR did make the health care system more efficient and effective on a macro level. It also may bode well for the government and individual patients, both of whom gain if overall health care costs are reduced and are-theoretically - less concerned with the impact on health care revenue. One Dartmouth study calculated that as much as 30 percent of health care costs are spent on ineffective or redundant care. Consider the savings if you could recoup even 30 percent of what the U.S. spent on health care in 2008 -- $2.4 trillion.
  4. Assuming we can solve the technology challenges, there are definitely cultural and financial barriers to adoption. Kaiser Permanente's story is riddled with situations that made its doctors very unhappy. And while the article notes that "most doctors don't want to go back to a paper-based system once the new approach is in place," you still have to convince them to devote their time to installing and learning the system.
  5. Adoption is particularly a problem when you look at small, private-practice doctors, where the costs of EMR and the resulting reduced office visits may actually create a financial disincentive for adoption. Ultimately, a national system would have to find a way to bring those individual practitioners on board.
  6. Even Kaiser didn't get it right the first time around. They've been working on it for 40 years and in 2003, they scrapped a more than $400 million project Kaiser developed with IBM, opting to buy a solution rather than build.


Millar said he saw Bugajski's experience as proof that we needed a national EMR system. I don't think Bugajski would disagree, considering he wrote this in response:


"A national HIT network is feasible if we take time to conceive, design, build, and test it starting with smallish steps. ... As IT professionals, we have an obligation to sound the alarm and provide meaningful solutions."


Bugajski even recently expanded his thoughts on a national EMR project to include a post about lessons we can learn from a similar project in the UK, called the National Health Service program.


Clearly, a national EMR system could be a wonderful technology contribution to the nation's health care. But it could also be a disaster if we ignore the potential pitfalls. I agree with Bugajski: Let's discuss the problems now, in the hopes of solving them in the planning stages, before these missteps can cost lives.

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Add Comment      Leave a comment on this blog post
Apr 22, 2009 11:22 AM EMR update EMR update  says: in response to Bill_S

The biggest roadblock to implementation of EMR is the clunky time consuming EMR itself.

A doctor's opinion

Apr 22, 2009 5:19 PM Bill_S Bill_S  says:

Initially in an EMR implementation due to workflow changes and the issue of rolling out a new system, patient visits will drop initially in clinics. The staff and providers need to get used to the system before they may speed up their documentation process and improve their workflows.

That is the cost of new systems. Having said that, practices that I work with have increased their billing accuracy. (Less rejections of claims, better support and documentation of services performed, higher accuracy in reporting).

You have to look at the ROI. Kaiser is still a new implementation. When you look at the short term, no you will not see cost savings, but over the long term they will.

The biggest roadblock to implementation of EMR is the providers themselves. Older physicians are not computer friendly but as the older providers retire and younger doctors (who have used EMR in their residences and internships) replace them, the transition is much smoother. I don't know how many times projects I worked on were scuttled by older physicians who were rejecting the change.

Kaiser also had the unenviable task of starting something new without a template. So there was quite a bit of trial and error involved. As more and more clinics and physician groups come on board the lessons previously learned will enable faster and more efficient implementations.

When we work with smaller phyisician practices we can train and implement in a few short months with the practice being fully operable within a year. (There is always some tweaking to the workflow).

Many of the practices admit they never want to go through it again but they never want to go back to what they had been doing previously either.

Apr 24, 2009 9:15 AM Roger Appleby Roger Appleby  says:

Being a systems developer and working with medical records systems, one of the biggest issues to adopting new technology is the over eager technologists.  Incremental introduction and simple interfaces can chage the perception and adoption dramtically.  Too much automation and too many options are barriers - not enablers.

Months of training indicate a system not designed for the end user - which should be the ultimate goal of any system.  Having followed the development of the Kaiser system - the goal became the system not the development of a service.

Cost alone causes me to wonder - 400 mil. would allow for 166 developers earning 120K per year for ten years.

All too often self interests and dictating to the user community as to what they need becomes the norm - it is important to listen and deliver what they want and how they want it.  Specialist panels and user community representatives take on self importance and stop listening to the communities they serve.

Technology should simplify our experiences and enable us to do greater things - failure to deliver this - is a failure of IT service providers - and the reason we have lost the faith of so many.

May 24, 2009 3:29 PM Jay Andrews Jay Andrews  says:

Electronic Medical Records have the potential to streamline patient care in areas such as ordering care, ordering medications, running reports about one patient or the entire clinic

Oct 21, 2009 1:31 PM Allscripts Online Training Allscripts Online Training  says:

Electronic Health Sytem have the potential to improve patient's Health care and maintain reports of patient.EMR System provides the best way to handle the Patient Secure.


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