OPMGUPDATE
The Ohio Permanente Medical Group Newsletter
Ohio Permanente Medical Group, Inc.
IN THIS Winter 2008
ISSUE
Plenty to be proud of,
but we must press on . . . . . . . . . . . . . 1
Advanced care management for
care delivery transformation. . . . . . . 4
21st Century Care Collaborative
aids effort to improve
member health . . . . . . . . . . . . . . . . .6
Fishing: 21st Century care’s
key to creating capacity . . . . . . . . . . 7
Advanced care panel: using the
“house call” to improve
management of chronic disease . . .8
Members embrace
health coaching . . . . . . . . . . . . . . .10
Ball is rolling for physician
work life committee . . . . . . . . . . . . 11
Be on the alert for
CMS “welcome” letters . . . . . . . . . .11
Patient safety programs strengthen
communication skills . . . . . . . . . . . 12
Patient safety and quality care . . . . .14
Abramson’s anecdotes:
What makes a good doctor? . . . . . . 15
Encryption effort protects
health information. . . . . . . . . . . . . .16
Kaiser Permanente encryption:
A five-phase program . . . . . . . . . . . 17
Medical Library services update . .18
Referrals management and
clinical review updates . . . . . . . . . .18
Performance improvement
efforts moving forward . . . . . . . . . .19
Plenty to be proud of,
but we must press on
Ronald L. Copeland, MD, President and Executive Medical Director, OPMG
I have two simple objectives for this advanced care management effort,
column: 1) invite you to read up on as well as the companion pieces
the efforts that will help KP Ohio that explain the 21st Century Care
transform our delivery system, and Collaborative and the advanced care
2) to say thank you for all the hard panel (formerly the “mini panel).
work that has occurred these past few And now, let us review some of our
years and particularly during 2007. key accomplishments over the past 12
I’ll do that by listing just some of the to 18 months.
many incredible accomplishments that
could not have occurred without the In the whirlwind that is the Kaiser
help of many dedicated individuals. Permanente Ohio turnaround, it’s
easy to overlook the fact that we
But first, a good portion of this
have made significant strides and
issue focuses on the advanced
that we have much about which
care management for care delivery
we can be proud. As I have said on
transformation effort, with special
more than one occasion, progress is
focus on some of its key features.
not an accident. It occurs because
Many of you may have heard mention
people agree to make it happen. The
of the advanced care management
examples below underscore that
effort, and it is a critical component
commitment as well as the progress
of our turnaround and sustainability
that flows from it.
strategies, so the goal of this issue is
to provide a helpful overview of the This is a partial list, of course, but an
endeavor and its implications. important one; in fact, the first four
items are updates on key turnaround
Advanced care management is
projects. But beyond showcasing
being largely shepherded by
notable achievements, the list also
Charles DeShazer, MD, who joined
serves as reminder that none of our
KP Ohio last spring as associate
accomplishments occur without the
medical director for quality, clinical
hard work of many individuals who
performance improvement and
are dedicated to, and believe in,
research. Dr. DeShazer is helping lead
OPMG and KP Ohio’s shared mission
the effort to harness our technological
of providing the best health care
resources to aid and strengthen
at the best price. Nor could OPMG
proactive panel management,
exist without the dedication and
particularly among members with
loyalty of its physicians—veterans and
significant disease burden, and to
newcomers alike—who despite all of
precipitate outreach efforts that build
the challenges, believe that what we
trust with membership and help them
have is unique and worth preserving
collaborate on disease management
and advancing.
challenges. I encourage you to
delve into his article explaining the
continued on page 2
WINTER 2008
Plenty to be proud of,
but we must press on
continued from page 1
Diabetes complete care
One of the objectives of advanced
care management is developing
proactive population-based
initiatives to improve the health
of the KP Ohio membership. The
diabetes complete care program
is one such project and involves
the efforts of dedicated staff from
pharmacy, primary care medicine,
health care teams (i.e., medical
office nurses) and population care
management. Among members
diagnosed with diabetes, the goal
of the program is to maximize
the number of those who use the
aspirin, lovastatin, lisinopril (ALL)
regimen. Launched in September
2007, the program is fueled
in part by electronic medical
record analysis and subsequent
telephone outreach, which is used
to encourage members to begin
adhering to the ALL regimen, or to
get them scheduled for overdue
blood testing, office appointments
or both. As of November 30, 2007,
2,835 members (among panels from
10 facilities) have been identified
and contacted. (Contacting a
member invariably requires multiple
attempts, and as of December
2007, the total number of “touches”
currently exceeded 5,400.) Among
those contacted, more than 1,220
members had agreed to begin
the ALL regimen. The diabetes
complete care effort is a sterling
example of how our integrated
model can be leveraged to enhance
coordination of care to achieve
stronger outcomes. Such efforts
require sustained collaboration by
an array of teams and departments,
not to mention relentless attention
to detail, but these are exactly the
types of endeavors our model is
tailor-made for.
2
Redirecting referrals
In 2006, one of the “close the gap”
efforts involved reducing costs
through proactive management
of utilization and optimization
of appropriate use of medical
resources. A key component of the
effort involves redirecting, whenever
possible and appropriate, referral
cases back into the OPMG realm
of expertise. Thus far, the redirect
program has been quite successful,
particularly since the process now
occurs inside KP HealthConnect. As
of October 2007, more than 4,200
referrals were redirected to OPMG
specialties. The redirect effort
focused particularly on areas that
historically see high rates of referral:
cardiology, neurology, urology and
orthopedics. Referrals also are
common when special services are
needed for members. These include
GI related services, sleep studies,
liver biopsy, physical therapy,
dermatologic services and nuclear
medicine services. As of October
2007, more than 11,800 service
referrals were redirected back
into OPMG. Without the redirect
effort, OPMG would have incurred
significant costs for those specialty
services referred to non-OPMG or
non-contracted providers. Without
KP HealthConnect, no ready-to-use
options exist for automating the
referral process, nor would we have
the ability to track referral activity
and outcomes as they occur.
Case management hub
The emergency case management
hub, launched in January 2007, is
a centralized “command” center
designed to manage hospital
and ambulance utilization that
arise from emergent scenarios. In
addition to providing members
24/7 telephone access to
physicians who can dispense
advice and assistance, the hub
helps keep members in—or
brings members back to—the
OPMG care network. It also helps
them avoid unnecessary ED visits
(and attendant co-pays). Hub
physicians provide consultation
for non-KP practitioners who
have KP members in their care,
field priority calls from KP advice
nurses, and work with emergency
department staff to select the
appropriate hospitals for members.
Also, any member who calls can
speak directly with a hub physician.
As of October 2007, the hub
orchestrated 3,001 repatriations
(directing a member to contracted
care) and 5,708 prepatriations
(determining the most appropriate
level of care for members before
they present at an emergency
department or hospital).
Coding and
documentation
Another key thrust of the
turnaround effort—and vital to
substantiating the true health status
of our membership—is the quest to
improve coding and documentation
accuracy and improve the diagnosis
refresh performance for the
Medicare population. Stepped
up training, education and
awareness efforts, complemented
by quarterly reporting, has helped
make a significant impact in
coding/documentation accuracy.
For instance, in first quarter
2005, OPMG was at a 45 percent
accuracy level. For the same period
in 2006, the accuracy level was
73 percent. For the third quarter
2007, coding/documentation
accuracy reached 80 percent. This
is great progress and we are on
our way to the 90th percentile. The
diagnosis refresh effort is proving
a bit more challenging, although
we are making definite headway.
Physicians now receive diagnosis
refresh reports (i.e., a running tally
continued on page 3

Plenty to be proud of,
but we must press on
continued from page 2
of diagnosis refresh “opportunities”)
daily to aid the effort. With the
diagnosis refresh, we have two
key goals: refresh diagnoses that
are still relevant and resolve “old”
diagnoses that are no longer
pertinent. (Note: In Medicare’s eyes,
credit is only given for a diagnosis
refresh when it results from a
face-to-face visit.) To help make
diagnosis refresh a proactive rather
than passive pursuit, an outreach
pilot was established to identify and
contact KP Ohio Medicare members
due for diagnosis refreshes, office
visits, or both. Thus far, the outreach
pilot, which focuses on KP Medicare
members with a comparatively
high chronic disease load, has
helped boost diagnosis refresh
performance. Overall, we have
made commendable progress in
boosting our refresh numbers, but,
given the higher disease burden
among our Medicare members,
we still have plenty of room for
improvement.
CME accreditation
In 2007, KP Ohio earned
provisional accreditation to present
continuing medical education
(CME) programs. In addition
to making it more convenient
for OPMG physicians to meet
mandatory CME requirements,
an internal CME program helps
showcase our multispecialty
clinical expertise in the northeast
Ohio medical community. And
because our clinical care is driven
by evidence-based medicine,
CME programs can be used to
strengthen our delivery efforts.
The accreditation effort also
accommodates our ongoing need
as practitioners to acquire new
clinical knowledge and continually
hone clinical skills.
Laboratory re-accreditation
KP Ohio’s laboratories at the
Chapel Hill, Cleveland Heights,
Parma, and Willoughby medical
centers earned accreditation from
the Intersocietal Commission
for the Accreditation of Vascular
Laboratories through January 2010.
By participating in the accreditation
process, the facilities demonstrate
a commitment to the performance
of quality vascular testing and strive
to meet nationally recognized
standards. During the accreditation
process, vascular laboratories must
submit documentation on every
aspect of their daily operations.
KP HealthConnect Online
If we want members to actively
participate in their care, then
we need to give them access to
information that can help make that
happen. And that’s exactly what
we did with KP HealthConnect
Online, the component of our
new electronic medical record
that gives member’s access to key
health information. In addition to
reviewing lab results, immunization
history, office visit history, and
office visit summaries, members
can view, request or cancel
appointments, request updates to
the medical record and email any
OPMG provider they have had
face-to-face contact with or with
whom they have had a telephone
encounters within the last three
years. This empowering tool will
aid our quest to optimize disease
prevention and management.
KPO physicians help
solve medical mystery
This spring, OPMG physicians
Ronald Adams, MD and Lawrence
Scott, MD appeared in an episode
of Mystery Diagnosis, a program
produced by Discovery Health. Ed
Leigh’s cancer symptoms surfaced
in 1997, but it wasn’t until August
1999, after having become a KP
OPMGUPDATE
Ohio member and a patient of Dr.
Adams, that Leigh was diagnosed
with stage III colon cancer. The
Mystery Diagnosis episode tells
Leigh’s story and recounts how Drs.
Adams and Scott helped save his
life. The episode is still airing.
Sustaining the
momentum
This impressive sampling
underscores in part the Herculean
effort under way to prepare us
for the critical challenges ahead.
The efforts also underscore the
momentum we have developed in
just a short period of time.
I, and all of my colleagues on the
OPMG board of directors, extend
a genuine thanks to all of you for
persevering, for pressing forward
with the effort to transform OMPG’s
care delivery capacity and capability
from “good to great” for 2008 and
beyond. In short, 2008 will be a
defining “moment,” because how
well we fare in 2008 will largely
inform our existence and outlook for
the years that follow.
The test now is to sustain the
momentum so that we achieve
our objective of providing optimal,
coordinated care for our members.
That means parlaying the strengths
of our integrated model, but more
important, continuing to pursue
market leading excellence in
quality, service and affordability,
for that is how we distinguish
ourselves as a medical group and
in the marketplace. For all of us
within OPMG, the quality of our
professional life and career security
we seek is directly proportional to
our commitment to excellence—
excellence in preserving health,
managing disease, communicating
with our patients, achieving effective
stewardship and inspiring each other
to be the best we can be for our
patients, each other and ourselves.
3
WINTER 2008
Advanced care management for care
delivery transformation
A special message from:
Charles DeShazer, MD
Associate medical director, quality, OPMG
It’s no secret that the KP Ohio
region faces significant economic
and market challenges over the
next several years. Those challenges
include coping effectively with
northeast Ohio’s stagnant
population, the imminent change in
the way we’ll be reimbursed for our
Medicare members, ever-evolving
member expectations regarding
health insurance offerings, increased
focus by employers on health care
delivery “report cards” (such as
those produced by NCQA), rising
health care costs, attaining coding
and documentation proficiency,
optimizing the tracking of service
delivery and ensuring accurate
payment of it, and optimizing use
of the clinical expertise within the
OPMG network.
These are challenges that will test
the creativity, ingenuity, and resolve
of everyone in the medical group
and the health plan. For the past
year, however, key leads from the
medical group and health plan
have collaborated to develop a
compelling strategy to help lock
in KP Ohio’s long-term future. The
clinical portion of this effort is called
advanced care management (ACM),
and it will meld the strengths of
KP’s integrated model of health
care delivery with its burgeoning
strengths in information technology
and parlay those not just to meet
the aforementioned challenges,
but to allow KP Ohio to leapfrog its
competition.
Parts of the ACM effort have been
underway for months in piloting
projects at the Bedford facility.
4
Overall, the ACM program has four
main components and they will be
briefly discussed here.
1) Member engagement
The overall focus of this effort is
on improving relationships with
our members and facilitating or
improving their access to health
information and health care. A main
driver of this effort will be proactive
member outreach. We’ll use a few
key tools to identify members who
can benefit from more vigilant
care and then we’ll use some new
resources and different approaches
to contact those members and
deliver their care. For instance,
physicians and members will not
have to rely solely on the office visit
to communicate with one another.
The new KP HealthConnect Online
feature (launched in November
2007) offers members the option
of communicating with their
physicians via e-mail. We’ll also
use “telephone visits” as part
of the care delivery effort. For
members who are interested in
it, KP Healthy Solutions offers the
opportunity to collaborate with a
health coach on achieving goals
set by the primary care physician.
Health coaches also are trained
to help educate members about
health and medical issues, offer
guidance about treatment options
for certain conditions, and provide
encouragement and guidance to
members challenged by disease
management goals.
2) Care management support
Care management support involves
identifying care gaps and using
(or developing) the expertise,
tools, and resources to address
those care gaps. We know, for
instance, that a comparatively small
portion of the population uses a
disproportionate percentage of
health care resources. By refocusing
our attention on KP Ohio members
who have single or multiple
chronic disease, by using proactive
outreach to contact them, and by
redoubling our efforts to ensure
evidence-based management of
their care, we can make a significant
impact on their health statuses.
Improving their health, in turn,
reduces use of resources. We’ve
already set our sights on members
with diabetes and heart failure;
that undertaking will be followed
by similar efforts directed toward
coronary artery disease, chronic
obstructive pulmonary disease,
asthma and depression.
3) Advanced practice
management
Perhaps what most distinguishes
the KP model from its competitors
is its ability to make rapid and
sweeping changes with regard
to care delivery. Unfortunately,
this capability has not been used
effectively nor aggressively enough.
But that is quickly changing in Ohio.
Advanced practice management
(APM) involves redesign of the
health care team with the objectives
of achieving benchmark level
performance in cost, quality, service
and workforce satisfaction. It will
rely on harnessing data-driven panel
management systems, leveraging
technology and connectivity for
new workflows and processes,
and creating improved flexibility,
control, and support for the health
care team to adapt its expertise
continued on page 5

Advanced care management for care
delivery transformation
continued from page 4
and efforts to the needs of their
patient panel.
For the past several months,
KP Ohio’s Bedford facility has
been piloting a project called
21st Century Collaborative Care,
a key component of the APM.
The 21st Century Collaborative
exemplifies the potential KP has
to use unconventional approaches
to improve disease management.
This is a highly proactive approach
to managing chronic disease and
preventing events precipitated by
or associated with them. Members
at high risk for chronic disease
and members diagnosed with
chronic disease are targeted for
proactive, vigilant care. They are
literally mustered into the KP Ohio
system to ensure they receive
optimal, timely care and that they
get guidance about managing
their condition. Another feature of
advanced practice management
is the advanced care panel. (See
pages 6-8 for more details on 21st
Century care and the advanced care
panel.)
4) Infrastructure
The infrastructure component
refers to the resources, tools,
and processes that will support
implementation and maintenance
of member engagement, care
management support and
advanced practice management.
These efforts depend on our
access to accurate and timely
data as well as our ability to fine
tune or overhaul structures and
workflows when necessary. Data
capture and reporting tools include
KP HealthConnect and POINT
(Permanente Online Interactive
Network Tools). POINT already
is helping us identify and more
effectively manage members with
chronic disease. POINT and other
data reporting tools will allow us
to identify and resolve care gaps,
improve panel management,
and optimize use of office visit
time. Putting data to work for
us proactively will enable clinical
teams to improve overall member
care, optimize care for members
with chronic disease, minimize the
likelihood of undertreatment and
aid the coding, documentation and
diagnosis refresh efforts.
Ambitious effort
To be sure, this is an ambitious
effort with an equally ambitious
timeline. Advanced care
management has to be up and
running with wrinkles resolved
in time to accommodate the
transition we’ll undergo regarding
reimbursement for our Medicare
members. Under the new plan,
we become the primary payer for
100 percent of the care we deliver
to KP Ohio members eligible for
Medicare. The program, Medicare
Advantage, will be funded
prospectively by the Center for
Medicare & Medicaid Services
based on member data we provide.
If that data is incomplete or
inaccurate, the costs for treating
our Medicare members will exceed
what CMS has allotted us for that
care. Essentially, we will be giving
away care for which we are entitled
to reimbursement. That’s why
accurate coding and documentation
and annual diagnosis refreshes are
imperative; without them, CMS
gets an inaccurate reading on the
true health status of our members.
(Inaccurate member data also
constitutes Medicare fraud.) On
the other hand, the combination of
highly accurate member data and
proactive disease management that
results in more effective prevention
and control of chronic disease and
of adverse events associated with
them, greatly improves our ability
to preserve cost-of-care dollars.
OPMGUPDATE
The other point to keep in mind is
that success of the ACM program
depends on effective execution of
all the program components and
their respective elements. Each
part of the effort supports another.
And though clearly a key to our
sustainability mission, preservation
of cost-of-care dollars is just one
of several payoffs the ACM effort
will yield. It also will allow us to
practice better medicine and
improve the health statuses of our
patients. Quality of care will be
enhanced. We will become experts
at managing chronic disease
and comorbidity proactively. The
member experience will improve.
Member trust in us will build. Our
expertise will attract the attention
of employers grappling with
health plan costs and interested in
proactive rather than reactive health
care. All of that means securing our
future in the region.
Success of the ACM program also
depends on support and embrace
of it by everyone in OPMG and
the health plan. To be sure, there
will be wrinkles and recalibrations,
but the overall plan is sound,
and the early indications are that
the program offers tremendous
potential for us to take our care
delivery to a new level and make it
one that others will emulate.
The ACM program sponsors
include Ruth Langstraat, MD,
vice president, health systems
design and performance, Kaiser
Foundation health plan (KFHP);
Belva Denmark Tibbs, vice
president, medical operations,
KFHP; and Walid Sidani, MD,
vice president and associate
medical director, medical affairs,
OPMG. All of them deeply
believe in this endeavor and have
worked tirelessly to help lay the
groundwork for it.
continued on page 20
5
WINTER 2008
21st Century Care Collaborative aids
effort to improve member health
One of the key features of the
advanced care management
effort is the 21st Century Care
Collaborative. At its core, 21st
Century care is an effort to improve
the health of the KP membership
and to give the care teams more
control over the means and
methods they use to deliver care
and manage daily schedules.
Achieving those two goals will
have a ripple effect of improving
member satisfaction and improving
the work life of the clinical teams.
In the 21st Century Care model,
technology, teamwork, member
outreach, creative care delivery,
and proactive disease management
merge to create a more patient
centered system. This approach
involves not just reviewing the
care needs of members, but
understanding what works best for
them in terms of communicating
and interacting with the care team.
It also takes account of patients’
interpretations of their health.
And where possible, the patient is
enlisted to become a more active
participant in the care plan.
The 21st Century Care
Collaborative grew from a
desire inside Kaiser Permanente
to improve care delivery (as
reflected in internal and external
measures) and to develop new
approaches for managing the
health of KP members. In part, it
was the acknowledgement that
the traditional model for disease
management—the office visit—is
valuable and necessary, but, by
itself, is not an adequate means
of achieving the goals of offering
the most effective and affordable
care, particularly in a changing
and increasingly complex health
care world, and particularly one in
which technology will be a staple.
For instance, in addition to the
6
electronic medical record, Kaiser
Permanente now has at its disposal
several powerful electronic tools
that can aid the task of proactive
disease management.
A second impetus is improving
member satisfaction. Data show
that most members feel better
about their health care experience
when they are proactively and
positively engaged in the task of
care management.
Another catalyst for 21st Century
Care is the desire to improve
the work life of the care teams.
In addition to the day-to-day
challenges they face—in particular,
a member population that presents
with multiple diseases—a recurring
issue is the feeling of loss of control
over the work day. In the 21st
Century model, however, clinical
teams have the opportunity to
recapture some of that control.
For instance, the traditional office
visit model is passive rather than
proactive—the care team waits
for patients. The model also is
temperamental and imperfect.
Patients can’t always get to
appointments on time; some show
up late or not at all, some show
up unannounced. Moreover, the
face-to-face visit often involves the
exchange of fairly basic information.
Yet between the member and
provider staff, a significant
amount of time and energy must
be expended to make that visit
happen—appointment scheduling,
negotiating time off from work,
making travel arrangements (then
traveling), handling the copay,
waiting for the appointment to
begin (or waiting for the member
to arrive), getting the patient
“roomed,” etc. But what if an
alternative existed that could
eliminate much of that expenditure?
With 21st Century care, there are
alternatives, and several of these
are outlined below.
The 21st Century Care
Collaborative will be rolled out in
a way similar to the launch of KP
HealthConnect, in phases and with
thorough training and guidance.
Bedford got underway in April 2007
and thus far is having great success.
Two key components of the
21st Century program are the
change package and the rapid
improvement model, or RIM. The
latter consists of pilot-like studies
that test elements of the change
package or variations of them. The
goal is to allow each facility to use
the change package partly as a
starting point; team members then
collaborate on developing pilots to
test strategies and ideas informed
by member demographics as well
as the attributes, strengths and
weaknesses of the care team and
facility.
The change package
elements are as follows:
1) Build the care team
The goal is to create a patient-
centered focus, where the care
team and work flows are organized
to meet the needs of the team’s
member population. One key is
that care team members agree to
share accountability for managing
the health of all members of the
panel; another is using information
resources to proactively analyze
the needs of the panel.
2) Develop relationship based care
Successful disease management
in part depends on an awareness
continued on page 7

21st Century Care Collaborative aids
effort to improve member health
continued from page 6
of who is in the panel and then
building relationships with those
members using an array of
strategies. In relationship based
care, the care team really knows
its members; the electronic
medical record is used not just to
document and store nuts and bolts
health information, but also to
record information that improves
the task of providing individualized
care. The medical record can
then be reviewed in advance
of appointments to improve
the office- or telephone-visit
experience and make them more
productive. Another objective of
relationship based care is ensuring
that members have signed up
Fishing: 21st Century care’s key to creating capacity
A key component of panel
management is “fishing,”
a strategy that involves
surveying the appointment
schedule hours or days into
the future and determining
whether some of the
appointments can be managed
with a phone call. Many
appointments involve routine
follow-up or the exchange of
basic information and plenty
of members would prefer to
get that information without
having to take precious hours
from their day to show up
for an office visit. Fishing
takes advantage of those
opportunities.
Fishing occurs at pre-
established times during the
work day, and can be done
by a physician alone, or by
a physician and nurse. The
first step is to review medical
records for select members
scheduled for office visits.
with or are assigned to a primary
care physician.
3) Use alternatives to the
traditional office visit
Offering alternatives to the one-
on-one, or face-to-face office
visit accomplishes several goals
simultaneously: it gives members
and care team staff options for
communicating; it allows the care
team to have member “touches”
where none existed; and where
appropriate, an alternative visit
can replace the office visit. This
relieves the member of the
attendant burdens and stresses
associated with an office visit.
Offering alternatives to the
traditional office visit also allows
the care team to achieve more
control over panel management
using a tactic called “fishing.” This
Once identified, the physician
places a call to the member
and the conversation goes like
this: “Mrs. Quentin, this Dr.
Kaiser, your physician. I see
that you’re coming in on Friday
and I’m calling to prepare
for your visit.” That sets the
stage for a discussion that
can determine whether the
appointment is still necessary.
The goal is not to convince
the member to cancel, rather
it is to establish contact,
relay helpful information, and
then let the member decide
whether the appointment is
warranted. Experience has
shown that if both member
and physician feel comfortable
that the phone call resolved
any outstanding issues,
the member will cancel
the visit. Of course, if the
member prefers to keep the
appointment, that is fine. The
phone contact is still valuable
for both parties because both
OPMGUPDATE
in turn “creates capacity” in the
work days; that capacity, and the
ability to create it, is one of the
keys to care teams gaining more
control over, and deriving more
satisfaction from, work life. Fishing
is integral to the 21st Century
effort and is explained in more
detail in the sidebar below.
Alternative visits include telephone
calls and emails between physicians
and members; group visits and other
options are under consideration.
4) Achieve total panel ownership
The essence of total panel
ownership is providing the best
possible care to the highest
percentage patients in a given
panel—in short, optimal panel and
population care management. The
continued on page 9
exchange valuable information.
And from the health care
team’s vantage, the call
represents an important touch
point that would not have
occurred otherwise.
When a member does cancel,
a physician hold is placed on
the now open appointment
slot. The physician and health
care team can then decide
how best to use that newly
acquired capacity. That
could mean more fishing,
mammogram outreach, or
care planning with an RN, for
instance for diabetes complete
care. Or the time could be
used to see a member who
has complex disease, maintain
medical records or perform
administrative tasks. In short,
fishing allows the medical
team to create capacity that
is used to fulfill the goals of
21st Century Care and regional
performance measures.
7
WINTER 2008
Advanced care panel: using the “house call”
to improve management of chronic disease
The advanced care panel
represents one of several
initiatives underway in Ohio to
help significantly improve the
health of Kaiser Permanente
members. And like the the 21st
Century Care Collaborative, it
presents an alternative to the
traditional approach to disease
management. Because what is
becoming increasingly apparent
is that the traditional model of
care—regularly scheduled office
visits—works well for healthy
patients, but not so well for
those sick from one or more
chronic diseases.
The advanced care panel,
or ACP, initiative occurs in
collaboration with Kaiser
Permanente’s Care Management
Institute, created in 1997 to
help Kaiser Permanente improve
the quality of care and health
outcomes for members. ACP
also is a pilot project for all
of Kaiser Permanente. Wayne
Opalk is project manager for
the effort, and Ann L. Scott,
director of primary care, and
Nicholas Dreher, MD, assistant
medical director, primary care,
are the clinical leads.
Modern house call
The essence of the advanced
care panel is proactive, vigilant,
individualized care that is
brought to the patient. In
short, it’s a house call, but a
much more modern version
of it, because in this case the
physician is part of a team
responsible for the member’s
health. The team includes an
RN, social worker, PharmD,
and scheduler, who manages
8
the appointment schedule (the
physician and RN positions are
full time, the others part time).
The team approach is key because
members of the advanced care
panel are complex patients, that
is, individuals with multiple chronic
diseases and at high risk for
emergent events or hospitalization
because of their conditions.
These also are patients whose
conditions, for a host of
reasons, are not well controlled.
Ineffective management of
chronic disease is not so much a
function of lack of effort or lack
of good intentions on behalf of
physician or patient. Rather it’s
a function of forces that both
may be up against: poor health
literacy, lack of transportation to
and from an appointment, not
feeling well enough to make an
appointment, inability to leave
work for an appointment. For
some patients, the responsibility
of managing a chronic disease
can be overwhelming and
immobilizing. Depression also
is a common companion to
chronic disease. Both variables
can squelch the will or sap
the energy required to follow
through with self-management
responsibilities, including
making it to office visits. And
face-to-face visits are crucial
for effective management of
chronic disease.
Recruiting members, creating
the panel
The initial effort seeks to
create an advanced care panel
of 150 members. Inclusion
criteria for this first panel are:
age 55 to 64, diagnoses of
diabetes and congestive heart
failure, and high likelihood of
hospitalization.
Members were identified for
participation in the ACM panel
using a predictive modeling
tool created by DxCG, Inc., a
software company based in
Boston, MA. DxCG specializes
in tools that aid management
of health care and utilization
costs and Kaiser Permanente
has used their tools for several
years. The ACM project
uses DxCG’s Likelihood of
Hospitalization Model, which
can assess risk among defined
populations. Churning through
multiple variables including
diagnoses, medication use,
health care costs, and utilization
history, the tool can predict
which members are most
likely to need hospitalization
within a given time frame, for
instance 6 or 12 months. It has
a 35 percent accuracy rate.
Kaiser Permanente’s northern
Californian department of
management information and
analysis runs the LOH model for
Ohio.
Once identified, members are
mailed a “welcome” letter
explaining the ACP program
and inviting their participation.
The letter is followed within
a week by telephone contact
from one of the ACP team
members. KP members who
express interest in the program
are scheduled for an “office
visit,” but in the 21st Century
model, that visit occurs at
continued on page 9

21st Century Care Collaborative aids
effort to improve member health
continued from page 7
goals include earlier intervention in
or prevention of disease, greater
oversight and stepped up care of
members at high risk of medical
events associated with chronic
disease, and proactive outreach to
members who are not connected
with, or have been out of touch
with, their primary care physicians
and care teams. These tasks will be
aided by information technology
resources like POINT, the panel
management tool that makes it
easy to stratify panel members
according to one, several or many
Advanced care panel: improving
management of chronic disease
continued from page 8
the member’s home and is
performed by a physician, RN,
or both, depending on the
patient’s health status. The
house call makes moot the
issue of transportation, which
can be a significant barrier
to care, particularly among
older persons. In the wake of
the house call, which is the
equivalent of a first office visit,
the ACP team convenes to map
out a care plan for the member.
Communication also occurs
between the ACP physician
and the primary care physicians
of members being recruited
to the panel: once at the time
a welcome letter is sent to a
patient and again if the patient
agrees to join the new panel. In
both cases, the ACP physician
uses KP HealthConnect
messaging. In the first case,
the message notifies the
primary care physician that a
filtering criteria. One example of a
total panel ownership effort is the
diabetes complete care program,
which involves using POINT to
identify members whose medical
status warrants commencement of
the aspirin, lovastatin, lisinopril, or
ALL, regimen.
5) Collaborative care planning
This objective recognizes that
1) the medical office can be a launch
pad for disease management,
but sustaining the effort means
tapping an array of tools to help
keep members and care teams
connected and communicating
and 2) collaborating with members
about their care can significantly
welcome letter has been sent
to a patient about joining the
ACP; in the second case, the
message informs the physician
of the patient’s decision to join
or not join the new panel.
The ACP physician, in turn,
becomes the member’s new
full time primary care doctor.
If patients have a change of
heart, they are free to return
to their original primary care
physicians. Otherwise, it is
expected that member’s
will stay on the ACM panel
indefinitely. The panel also will
collaborate with behavioral
health, in the event their
expertise is warranted.
Nuts and bolts
For the time being, the
ACM team will be based at
Willoughby. Team members
include Bill Schwab, MD; Willa
Pugh, RN; Kathleen Skerl,
MSW; and Jill Arnold, PharmD.
The team will meet on a regular
basis to discuss the health
OPMGUPDATE
aid the disease management effort.
In fact, the goal is to empower
members to become their own
primary care providers and to
use Kaiser Permanente’s delivery
system to supply the expertise
and resources to help make that
happen. Rather than being passive
participants, members are engaged
in management of their health care
and collaborate with the care team.
They are cognizant of their care
goals and take the necessary steps
to help ensure a healthy future.
If you have questions about the 21st
Century Care Collaborative, contact Kris
Pilarski, project manager, at 98-330-4483 or
216-635-4483.
status of patients, to fine tune
care plans and to troubleshoot.
Batches of 10 letters have
been sent out weekly since the
middle of September 2007 and
this will continue until the team
contacts the 150 members
identified by POINT. If
achieving the target enrollment
of 150 proves elusive because
of member disinterest, the
inclusion criteria may be
broadened.
The physician, RN, and social
worker are outfitted with
laptops that have wireless
capabilities; they also get
Blackerrys (a brand of personal
digital assistant). Both
tools will have access to KP
HealthConnect. Clinicians also
carry blood pressure kits and
otoscopes for house calls.
Documentation is a key part
of the effort, so there’s close
collaboration with information
technology to ensure that
all of the care efforts can be
captured accurately through
KP HealthConnect.
9
WINTER 2008
Members embrace health coaching
KP Healthy Solutions is the health
coaching service launched in
July 2007 to complement the
disease management efforts of
OPMG physicians. The goal of
the coaching is to encourage
commercial (non-Medicare)
members to become active
participants in the management
of their health and to spur
meaningful discussions between
members and their physicians.
According to a recent activity
report for the period July 16–
September 15, 2007, KP Healthy
Solutions coaches have made
more than 1,900 telephone
connections with members and
netted more than 2,000 key
impacts. A key impact refers to
a coach helping a member at a
key decision making point, for
instance, making an appointment
for an overdue office visit,
pledging to take up exercise, or
committing to be more vigilant
about taking medications.
Thus far, the opt out rate (i.e.,
the percentage of members
declining the health coaching) is
comparatively low at less than 1
percent of those contacted.
“The results tell us that members
have responded positively to the
KP Healthy Solutions offerings,”
says Ronald Adams, chief, primary
care and primary care lead, KP
Healthy Solutions. “I encourage
my colleagues to continue
assisting in building awareness
among members of this resource.”
Physicians play a key role in the
coaching effort by activating a
service request through
KP HealthConnect: they identify
patients likely to benefit from use
of the service and fax a request for
patient contact to the KP Healthy
Solutions health coach center.
There are many ways to activate a
service request, says JoAnn Kahl,
RN, MBA, project manager, KP
Healthy Solutions. Service requests
10
can originate from an array of
settings where patients have
contact with KP Ohio medical team
members (primary care physicians,
specialists, hospitalists, in-patient
care coordinators), including
medical facilities, emergency
rooms, contracted hospitals, and
contracted skilled nursing facilities.
Kahl also says that clinicians
filing service requests through
KP HealthConnect can increase
the likelihood of successful
contact between a member
and health coach by verifying
the member’s phone number,
asking when the best time to
call is (and documenting it), and
providing the member with the
Healthy Solutions “800” number
(1-800-574-8460), for instance
by including it in the after visit
summary. (For members interested
in the coaching but uncomfortable
with phone contact, coaching can
occur via email; members should
register at the secure Web site:
kp.org/healthysolutions.)
The KP Healthy Solutions health
coach communications system
is set up such that members are
never far from their KP roots, so to
speak. The coaches, for instance,
have the technical capability to
transfer members to KP Ohio’s
member service center (e.g., to
relay messages to physicians,
make appointments, or obtain
information on KP Ohio health
education and wellness classes),
customer relations (e.g., to get
benefits information), or to nurse
advice (e.g., to have clinical
questions/concerns addressed).
“We’re closing the circle, in a sense,
with the coaching,” says Dr. Adams.
“And we’re increasing the likelihood
that our members become more
informed and educated about
their conditions and appropriate
management of them.”
One important point to keep in
mind about KP Healthy Solutions,
says Kahl, is that it is just one
of many resources available to
KP members. For instance, she
encourages KP clinicians to remind
members to seek out the array
of valuable tools and resources
that are available online, via the
KP.org Web site. These include
a health encyclopedia, condition
and disease encyclopedia, drug
encyclopedia, natural medicines
database, “live healthy” guide
(which includes health videos and
audio files), and the HealthMedia®
healthy lifestyle programs.
In addition to Dr. Adams and JoAnn
Kahl, KP Healthy Solutions also is
championed by Mike Nowak, MD,
surgeon, specialties lead.
Healthy Solutions by
the numbers:
(July 16 launch through
September 15, 2007)
• Nearly 2,000 members have
had phone conversations with
KPHS health coaches.
• More than 3,800 telephone
contacts were attempted by
health coaches, including 582
outreach calls and 214 follow-
up calls.
• Kaiser Permanente Ohio
providers made 281 service
requests for health coaching.
• KP Healthy Solutions sent more
than 150,000 mailings (i.e.,
introductory, chronic condition
outreach and health education
materials) to KPO commercial
members. Materials included
flu vaccine reminders and
outreach letters for preventive
care to members with chronic
conditions.
 OPMGUPDATE

Ball is rolling for physician work life committee

It’s a simple equation: work life
satisfaction=high productivity, high
morale, low turnover and high
customer satisfaction. Making that
simple equation work, however,
is no easy task, particularly in an
arena as complex as health care
delivery and particularly at a time
when health care providers face so
many challenges.
Nevertheless, improvement of work
life satisfaction continues to be a
priority for the Ohio Permanente
Medical Group. To that end, early
in the summer of 2007 the OPMG
Work Life Committee was formed.
The committee was created to
help minimize the possible impact
on work life satisfaction by various
OPMG initiatives—for instance
KP HealthConnect—and to study,
address, and resolve work life
issues raised in People Pulse
Opinion Surveys, which began to
be administered annually in 2005.
Gabriel Obi, MD, internist and
OPMG board member, chairs
the steering committee, which
develops the work life agenda.
Eddie Wills, Jr., MD, associate
medical director, is executive
sponsor. A focus group aids the
effort by providing feedback from
staff on work life issues.
The Work Life Committee’s mission
is to help identify areas of work
life that are not optimally balanced
and report on those to the OPMG
Board, which serves in part as a
bridge between OPMG physicians
and KP operations. “Sometimes
there’s a disconnect between the
two groups and that can lead to
resentment and frustration, when
in fact, our goals and objectives
are really the same,” says Dr.
Obi. He also says that physicians
and management sometimes
have different perspectives when
they’re looking at work life issues.
In fact, after becoming a board
member in 2005, Dr. Obi says
he has a new perspective on
the limitations and challenges of
addressing such issues, particularly
given that Kaiser Permanente’s
business model is distinctly
different from those used by its
competitors who have significant
footholds locally and regionally.
continued on page 12

Be on the alert for CMS “welcome” letters

OPMG’s regional coding compliance department
asks that physicians be on the lookout for provider
“welcome” letters generated by the Centers for
Medicare and Medicaid Services and sent to “new”
providers. The letters open with a statement
similar to, “We are pleased to have you on board
as a Medicare provider.” The letter goes on to
request a sampling of copies of medical records
for which claims have been submitted to CMS for
reimbursement.
All physicians who receive such letters should,
as soon as possible, forward copies of them to
the regional coding compliance department. The
address is:
Kaiser Permanente
Regional coding compliance
North Point Tower, Suite 1200
1001 Lakeside Ave.
Cleveland, OH 44114-1153
Please direct the correspondence to the attention
of the coding compliance specialist. OPMG
physicians are not responsible for submitting, nor
should they attempt to submit, claims to CMS
for care provided to Kaiser Permanente Medicare
patients. Documentation and submission of
CMS claims are the responsibility of the coding
compliance specialist. If you have questions,
contact Lynn Brady, RHIT, coding compliance
specialist, at 98-328-5938 or 216-479-5938.

11
WINTER 2008

Ball is rolling for physician work life
committee
continued from page 11
Once up and running, preliminary
querying of OPMG staff by the
Work Life Committee revealed
a spectrum of concerns—work-
day duration, clinical efforts
going unrecognized, opinions not
counting, too little control over
support staff hiring. Dr. Obi and his
Work Life colleagues decided that
rather than trying to address many
discrete issues individually, some of
which are uncontrollable and would
be encountered no matter where
or for whom a physician practiced,
the committee would take a more
strategic approach.
“We wanted the greatest impact
possible on work life improvement,
and we concluded that would
occur by taking a broader view
of the situation,” says Dr. Obi.
“The question was, ‘what can we
do systematically to bring about
changes that resolve or address
many of the issues raised? How do
we have the greatest impact in the
shortest amount of time and make
work life better for everyone?’”
The answer lay in two of the People
Pulse indexes. The committee
concluded that by focusing efforts
on addressing these two issues,
they would in turn be addressing
multiple work life areas ripe for
improvement. The two indexes are:
1) When clinicians have good
ideas about improving the quality
of care delivered to members,
management usually makes use of
them.
2) I would recommend KP to a
close friend as a good place to get
health care.
Results from People Pulse 2006
showed that just 60 percent of
OPMG docs would recommend
KP to a close friend. A separate
internal survey, commissioned by
Charles DeShazer, MD, associate
medical director, quality, showed
that just 54 percent would
recommend KP. The 2006 People
Pulse findings represent a drop of
3 points from 2005. As for ideas for
improving quality of care, just 24
percent of OPMG docs feel their
ideas are used. That is also down
from 30 percent in 2005.
“Two-thirds of our physicians feel
we don’t listen to their ideas,”
says Dr. Obi. “When you feel no
one is listening, you stop offering
suggestions, possibly even stop
caring about the organization. So it
is crucial that we address this.”
“One of the challenges for
OPMG leadership is that we do
not always communicate in a
consistent and empowering way,
and that hurts us,” says Dr. Wills.
“When we don’t do a good job
providing context and rationale for
a business decision or explaining
how we arrived there, when a
decision may seem to arise out
of the blue, that objective can
come off looking disconnected or
unrealistic.” Moreover, problems
can also arise when messages get
delivered to the “front lines” by
chiefs and leads as edicts. “There’s
an opportunity there to have
an informed discussion, to say,
‘here’s the challenge, and I need
input from everyone as to how we
might address the challenge, and
if there are barriers, we need to
communicate those to leadership.’”
Those conversations, says Dr.
continued on page 13

Patient safety programs

strengthen communication skills
Last year, Performance Improvement and Patient
Safety (PIPS) launched two separate efforts to help
improve patient safety. One, the highly reliable
surgical team (or HRST) project, is an instructional
course designed to strengthen communication
skills among surgical team members. Data
show that when surgical team members feel
free to communicate and voice their expertise,
perioperative error rates decline. Another effort,
the perinatal safety project, is designed to build
communication and troubleshooting skills among
OB/GYN birthing team members. In this innovative
program, sophisticated mannequins stand in for
mother and baby, and participants have clinical
scenarios “thrown” at them. The perinatal safety
project offers training on a monthly basis at
Fairview and Marymount Hospitals. The PPSP’s
15-member implementation team included KPO’s
Kerry Dease, RN, BSN, Sharon Zahtilla, RN, and
Charles Zonfa, MD. Last March, the program was
recognized at the Cleveland Clinic’s Patient Safety
Forum with a People’s Choice Award.

12
 OPMGUPDATE

Ball is rolling for physician work life
committee
continued from page 12
Wills, need to be the rule rather
than exception when chiefs and
leads address their staffs. “That
empowers people and gives them
a greater sense of ownership and
stake in the enterprise”
With regard to addressing the
low score on the “recommending
KP to a close friend” index, some
efforts already are underway.
These include a service initiative
launched in June 2007 at Cleveland
Heights and the piloting in spring
2007 of the 21st Century Care
Collaborative. (For examples of
initiatives designed to respond to
ideas offered to improve quality
of care delivery, see table 1. In
addition to addressing People
Pulse indexes, the Work Life
Committee has also assembled
ideas for improving physician
performance; see table 2.)
Initiatives like the 21st Care
Collaborative will be key to helping
care teams develop a better
sense of ownership and control
over the work day, says Dr. Wills.
“The 21st century model allows
the physicians and care teams to
organize their expertise as they
see fit and distribute work loads
creatively across team members.
It allows the team to run a much
more proactive medical practice so
that they can better serve members
and better manage their patients
with chronic disease.” That also
supports OPMG’s and KP’s mission
to improve performance on NCQA
metrics like CAHPS and HEDIS.1
1 In pursuing its mission to measure and
improve health care quality, the National
Committee for Quality Assurance, or
NCQA, uses two tools: the Healthcare
Effectiveness Data and Information Set
(HEDIS) is used to monitor the quality of
care in health plans; Consumer Assessment
of Healthcare Providers and Systems
(CAHPS) surveys are used to accurately
and reliably capture information from
consumers about their experiences with
care in health and Medicaid plans.

Table 1
Work Life Committee initiatives,
recommendations
The Work Life Committee’s mission is to help
identify areas of work life that are not optimally
balanced and report on those to the OPMG Board.
The committee has an array of recommendations
and initiatives on the drawing board or in the works.
Shown here are examples of ideas generated to
help improve quality of care delivered to members.
• Allow practitioners to finance purchase of
tools or resources that can aide clinical duties
with study leave funds. For instance, speech
recognition software, which would be used
inside KP HealthConnect, could aid physicians
with limited typing skills. (In fact, the request for
speech recognition software was approved at the
October 2007 board meeting.)
• Broaden the selection of training and educational
programs that are “practitioner friendly” (e.g.,
programs that are Web-based, CME accredited,
doable on study leave time).

Table 2
Work Life Committee: Ideas for improving
physician performance and cultivating
ownership
• Broaden the scope of productivity metrics to
include non-office visit encounters; for instance
include telephone contact and e-mails. Also,
focus on outcomes rather than the number of
patients seen in a given time frame.
• Make more aggressive use of clinical coaching
to help physicians and support staff identify
opportunities to increase efficiencies,
productivity.
• Increase opportunities for health care team
members to build relationships with one another
outside the workplace, for instance by creating a
sports league.
• Address staffing and coverage issues in the
hospitals with which KP holds contracts. For
instance, use a ratio formula to arrive at a staffing
level that more appropriately aligns with the
number of hospital contracts, so that work loads
and travel time allow for optimal care.

13
WINTER 2008
Patient safety and quality care
Verbal consent caution
added to policy on blood
product administration
Nursing administration, the blood
bank, and laboratory services
recently revised Kaiser Permanente
Ohio’s regional policy on “Blood
and Blood Product Administration,
and Management of Transfusion
Reactions.” The revised policy was
endorsed by the clinical operations
leadership team (COLT) and the
nurse practice council. The result is
a precaution regarding “obtaining
verbal consent” from a patient who
needs blood or blood products.
Ideally, administration of blood or
blood products should only occur
after a physician has carefully
discussed with the patient—face-
to-face—the risks and benefits
associated with the procedure
and the patient has provided, with
the physician observing, written
consent for the procedure.
14
Because it is difficult to reliably
document, verbal consent is
discouraged; however, there are
situations that arise that may
warrant obtaining verbal consent.
For example, a physician might
receive a critically relevant lab
result after the patient has left
the medical office and must
then arrange for the patient to
receive a blood transfusion while
the patient is off-site/away from/
outside the Kaiser medical facility.
In this case, the physician must
relay the findings to the member
via telephone and discuss the
need for blood or blood product
administration. The physician can
then obtain verbal consent, so long
as the requirements outlined below
are met:
The physician must have a licensed
staff member (RN, NP, LPN, PA,
etc.) listen to the explanation
of risks and benefits associated
with receiving a transfusion of
blood or blood products. Then,
both parties must document the
interaction with the member in KP
HealthConnect. This confirms that
a two-party process has occurred:
the physician and a licensed staff
member listened to the consent via
telephone, and the physician and a
licensed staff member documented
that the patient understood the
explanation. (Note: The patient
should be made aware that a staff
member has been asked to listen in
on the conversation.)
If you have questions about the
verbal consent precaution , please
contact Lynn Shesser, RN, MSN,
lead, nursing quality and systems
management, at 98-332-4616 or
440-975-4616.
To view the revised policy online, from
the Ohio Intranet homepage, click on
the following links: Policies, Ohio Joint
Regional Policies, Patient Care.

Abramson’s anecdotes
What makes a good doctor?
Scott Abramson, MD
Clinician patient communication
consultant
If we were to ask ourselves
that great clinical question—
what makes a “good”
doctor?—I bet that some of
our answers would include
words like “knowledgeable,”
“conscientious,” “hard-
working,” and “compassionate.”
But what if we posed the same
question to our patients? What
are the qualities that they
believe make a “good” doctor?
Recently, I attended a
community focus group meeting
and had the extraordinary
opportunity to hear lay people
weigh in about what makes
a good doctor and other
important clinical questions.
This particular group was
made up of Indians who
had immigrated from that
subcontinent.
All agreed that the most
important factor in choosing a
health plan was ensuring that
they would have access to a
“good” doctor. When asked
to elaborate on what makes a
doctor good, here is what some
of them said:
“When you first see him, he
smiles.”
“As he walks into the room, he
makes you feel good.”
“Hospitality,” was another of
the descriptors used that night
by the focus group.
Well, mea culpa. I’m guilty of
doing exactly the opposite of
what these individuals say they
want from a physician. I can’t
begin to count all the times
I have walked into an exam
room, chart in hand, serious
look on my face, ready to get
down to business. On the
other hand, we are physicians.
We’re driven, focused, task
oriented. We don’t much like
anything—distraction, diversion,
pleasantries—that get in the
way of office visit momentum.
Surely our patients understand
these basic facts of our clinical
lives. Surely they comprehend
the incredible pressures
physicians and their staffs face
on not just a daily basis, but
an hourly basis. Surely they
understand that we’re in their
corner, that despite our matter-
of-fact, down-to-business
demeanors, foremost on our
agenda is providing the care
they seek. Right?
Well, not to downplay the
diagnostic expertise nor the
desire to always move forward,
but perhaps we need to think
about the answers that came
out of this humble focus group.
Perhaps before walking into
that exam room, we need to
pause just for a second or two,
and remind ourselves what
brings patients to us in the first
place. I’m not talking about
the obvious forces that bring
them to our offices—the aches,
pains, or coughs, or the myriad
symptoms that they believe
OPMGUPDATE
must be this, that, or another
disease. Sure, they want these
issues addressed. But what
most patients want initially is
1) to feel safe (in other words,
they trust us) and 2) to be
reassured.
If you think about it, that’s not
a lot to ask, particularly given
that the office visit is a very
personal interaction and one
during which many patients feel
vulnerable or exposed.
So, when we walk into that
exam room, before anything
else, perhaps we need to
welcome our patients first with
a genuine smile and even a few
kind words or some gesture that
relays a message of hospitality.
Because with those actions, we
are saying to patients, “You
are welcome here. You are safe
here. We’ll do our best to sort
out what’s bothering you.”
Our reputation as a “good”
doctor may depend on it.
(This column first appeared in April
2007 in CPC Consultant’s Corner,
a publication of The Permanente
Federation Clinician/Patient
Communication effort, online at
http://kpnet.kp.org/cpc.)
Dr. Abramson is a neurologist at the
Hayward Medical Center in Northern
California and is celebrating his 27th
year with The Permanente Medical
Group. He has spent all of his 27 years
of service at the Hayward Medical
Center, where he continues to learn
about the art of communication from
patients and colleagues.
15
WINTER 2008
Encryption effort protects health information
During the past year, Kaiser
Permanente of Ohio has been
engaged in an encryption effort
to ensure that patient medical
data (also known as health
information) is protected from
unauthorized viewing or use.
This is a joint effort between
the Information Technology and
National Compliance, Ethics and
Integrity offices.
Protecting health information
is mandated by the Health
Insurance Portability and
Accountability Act of 1996,
better known as HIPAA.
Unprotected health information
puts KP at risk for punitive
action and could jeopardize
its ability to participate in the
Medicare program, which is
administered by the Centers for
Medicare and Medicaid Services
(CMS). Also, because theft or
loss of electronic devices are
inevitable, an active encryption
program minimizes the risk
of health information getting
into the wrong hands and then
being used maliciously or to
commit fraud, behavior that also
could result in punitive action
against Kaiser Permanente.
In fact, Kaiser Permanente
policy prohibits storage of
health information on laptops,
desktops and other electronic
media, but in the event that
protected health information is
inadvertently placed on storage
devices, encryption protects
unwarranted access to it.
Health information means
any information, whether oral
or recorded in any form or
medium, that a) is created
or received by a health care
provider, health plan, public
health authority, employer, life
insurer, school or university,
or health care clearinghouse;
and b) relates to the past,
16
present, or future physical or
mental health or condition of
an individual, the provision of
health care to an individual,
or the past, present, or future
payment for the provision of
health care to an individual.1
The encryption effort plays out
in five phases, two of which are
explored in detail here. (For an
overview of the effort, see the
sidebar, “Kaiser Permanente
encryption: A five-phase
program,” on page 17.)
Protection of e-mail that
contains health information
Any Kaiser employee, including
those on contract, who sends
an e-mail outside the KP e-mail
network (i.e., to a non-kp.org
address) that includes any
patient health information is
responsible for ensuring that the
e-mail is encrypted. Encrypting
an e-mail is simple and involves
typing one of three keywords—
“phi,” “encrypt” or “mpii”—into
the subject field of an e-mail.
The keyword must be flanked
by parentheses or brackets, for
example: (phi) or [phi] or {phi}.
The keyword can be used alone
or it can accompany a regular
text subject, for instance:
Subject: Blood test results
(encrypt)
The external recipient of an
encrypted e-mail will receive
“decryption” instructions,
that is, guidance on how to
open the encrypted e-mail.
This process includes the
recipient registering at a secure,
KP-managed Web site. To
avoid confusion, KP’s office
of information technology
recommends contacting the
intended recipient before
sending an encrypted e-mail
and explaining the procedure.
No special software is needed
by the sender or the recipient
to send or receive encrypted
correspondence. Encryption
does not work, nor is it required
for, e-mails sent within the
kp.org network. The e-mail
encryption procedure also
is outlined on KP’s National
Compliance, Ethics and Integrity
Web site, accessible via the KP
intranet. From their homepage
(kpnet.kp.org/national/
compliance), click through this
pathway: Our Program, Privacy
& Security, Secure E-mail.
Secure electronic storage of
health information.
This component of the
encryption effort involves
protection of KP workstations,
that is, lap- and desktop hard
drives and other computing or
information storage devices.
The program to encrypt
workstations was completed
during summer 2007; it also
occurs proactively any time a
new workstation is issued. Once
a lap or desktop is encrypted,
the information stored on it
can only be accessed with a
legitimate Kaiser Permanente
user ID and password,
according to Paul Graca, lead
project manager, KP information
technology—enterprise
engineering. Even if thieves
extract the hard drive from a
unit and reinstall it elsewhere,
they’re not getting any
information from it, says Graca.
“Unless you can log in with the
authorized password, you’re not
going anywhere.”
Again, Kaiser Permanente
prohibits storage—even
temporary—of any health
information on the hard
continued on page 17

Encryption effort protects health
information
continued from page 16
drive of a workstation. “That
information should always be
stored or saved within KP’s
computing network and data
centers, on KP network servers,
shared drives, or servers that
otherwise meet KP-IT security
standards,” says Barbara J.
Martin, privacy/security officer,
KP Ohio Regional Compliance,
Privacy and Security Office.
“However, if such information
Kaiser Permanente encryption: A five-phase program
The program to protect member/
patient identifiable information,
or MPII, is a joint effort between
the Kaiser Permanente Information
Technology and National
Compliance, Ethics and Integrity
offices. The goal is to prevent
unwarranted access to protected
health information should a
storage device, such as a desktop,
laptop, or personal digital
assistant, be lost or stolen.
Once outfitted with encryption
software, data on a hard drive or
other storage device can only be
“seen” when a user logs in with
the proper access credentials.
Encryption protects the data
regardless of the tactic used to
get at it, says Justin W. DiGrazia,
lead project manager, Enterprise
Engineering, Engagement
Services, Kaiser Permanente
Information Technology.
“Regardless of the ploy used—
hacking into the computer, using
“brute force” (repeated log-in
attempts), removing a hard drive
and reinstalling it on a different
device—encryption protects the
data,” says DiGrazia.
The five-phase effort was launched
in 2006 and primarily occurs
remotely: that is, the AES-256 bit
is inadvertently saved to a hard
drive, encryption minimizes the
risk of it getting into the wrong
hands should the workstation
be lost or stolen.” Users can
verify that a device has been
encrypted by locating the
“Pointsec for PC” icon that
displays on the Windows tool
bar (or task bar). It’s a “P” that
slants to the left, set against a
circular, green background.
A related initiative involves
protecting health information
that gets stored on personal
encryption software is “pushed” to
devices via the local area network
from information technology
servers in California. Phases 1 and
2 are complete; phases 3 and 4
are in progress; phase five is in the
developmental stages. The phases
are outlined below.
Phase 1: Completed in
early October 2006, phase 1
focused on protecting laptops
used by KP home health care
staff based in the California,
Colorado and Northwest regions.
These individuals—nurses and
occupational, physical and speech
therapists, and other licensed
medical professionals—provide
home-based care to older persons
and those who are disabled.
Collectively, this effort involved
encrypting more than 850
laptops to meet state and federal
requirements.
Phase 2: Completed October 31,
2007, phase 2 protected Kaiser
owned and managed desktop and
laptop PCs. Preliminary efforts
got under way in October 2006,
though the actual encryption of
devices kicked off in June 2007.
Nationwide, more than 170,000
laptops and desktops received the
OPMGUPDATE
digital assistants, or PDAs,
such as Blackberrys and Palms.
Details of this effort are still
being finalized by the IT and
compliance offices.
1 From “Health Insurance Portability
and Accountability Act of 1996”; public
law 104-191, Aug. 21, 1996; via the
United States Department of Health and
Human Services Web site, http://aspe.
hhs.gov/admnsimp/pl104191.htm#1177.
For more information about the Secure
Electronic Storage (SES) Program, go to
http://kpnet.kp.org:81/security/ses/.
encryption software; roughly 2,900
of those were in Ohio.
Phase 3 focuses on safeguarding
personal digital assistants, for
instance Blackberries or Palms.
Following a pilot to test strategies,
phase 3 is slated for completion
sometime in 2008.
Phase 4 focuses on safeguarding
removable media, for instance
flash or “thumb” drives, as well as
CDs, DVDs, and floppies. Phase 4
is slated for completion sometime
in 2008.
Phase 5 focuses on providing a
protected computing environment
for KP staff, affiliates, and alliance
partners who work from their
homes on their on devices. One
solution under investigation is
a kind of virtual desktop, which
would involve logging in remotely
to a protected system. Once
inside, a user could tap into
commonly used applications as
well as stored (and protected)
health information.
To learn more about Kaiser
Permanente’s secure electronic
storage program, go to http://
kpnet.kp.org:81/security/ses/.
17
WINTER 2008
Referrals management and clinical
review updates
Michael Nowak , M. D.
Medical director
Maureen Kane R.N., Manager
The Kaiser Permanente Referrals
Management and Clinical Review
(RMCR) office is a division of
Medical Management, the
department whose mission is to
collaborate with practitioners to
ensure that services rendered are
medically necessary, covered by
the health care plan and rendered
in the most appropriate setting
and in a timely fashion.
One of RMCR’s goals is to
maintain regular communication
with practitioners by relaying
Medical Library services update
Online technology has changed
the way that organizations,
including Kaiser Permanente,
conduct business and deliver
services. The most recent entity
at KP Ohio to respond to online
opportunities is the Medical
Library. For the last several years,
the trend has been toward KPO
medical professionals doing
information searches online rather
than requesting searches to be
conducted through our Medical
Library. After reviewing the usage
of the Medical Library, in relation
to the cost associated with
continuing to provide this service
internally, the decision was made
to cease offering internal Medical
Library services as of January 1,
2008. However, Kaiser Permanente
staff have access to a wealth of
free clinical resources via two
internal urls:
18
up-to-date information about
the referral process (also known
as utilization review), as well as
information about any procedural
changes that might impact
those processes (e.g., federal/
state mandates or accreditation
requirements relating to
information required on a referral
request).
Referral fundamentals
Referral decisions are based
in part on nationally accepted,
evidence-based clinical criteria
delineating appropriate levels of
care for a given clinical scenario.
Thus, utilization management
decisions reflect whether a service
kpLibraries
http://cl.kp.org/pkc/kplibraries/
This is your connection to all
of Kaiser Permanente’s health
sciences libraries, giving you
access to the Kaiser Permanente
Libraries online catalog as well
as access to books, journals,
audiovisuals, and electronic
resources.
Clinical Library (Permanente
Knowledge Connection)
http://cl.kp.org/portal/site/
national/
This is KP’s online resource for
clinical guidelines, member
education handouts, drug and lab
information, online CME, and full-
text journals and textbooks. (You
can also access this from Kaiser
or treatment is deemed medically
appropriate or whether the
member’s coverage allows it. (To
view the appropriateness criteria,
see OPMG, March/April 2006,
page 9.)
All referral decisions based on
medical necessity (i.e., member
has appropriate coverage, but the
service is medically unwarranted
based on clinical review criteria) are
made by a board-certified physician
advisor. No monetary incentives
are associated with the utilization
review process. Physicians are
continued on page 20
Permanente’s portal site—
http://insidekp.kp.org. Click on
“Deliver Health Care”—left-hand
index area-and then on “Clinical
Library.”)
If you have not visited these sites,
please log on and give them a try.
Because some medical information
searches need to be conducted
off-line, other avenues for
requesting and conducting such
searches are being explored
and updates on this effort will
be provided accordingly. If you
have questions regarding the
cessation of internal Medical
Library Services, contact Ronald
Copeland, MD, president and
executive medical director, OPMG,
at 98-328-8781, 216-623-8781 or
via Lotus Notes at
ronald.copeland@nsmtp.kp.org.

Performance improvement efforts
moving forward
Communication skills are an
integral component of good
doctoring and just like medical
skills, they have to be learned,
developed and honed. Because of
that, OPMG is moving ahead with
two efforts to support physicians
interested in guidance and
training designed to help improve
communication skills. Both
support programs are elements
of the performance improvement
endeavor that is part of the
OPMG turnaround plan, which
among other objectives, seeks
to boost Art of Medicine and
CAHPS (Consumer Assessment of
Healthcare Providers and Systems)
scores. Select practitioners whose
AOM scoring falls below the
expected level of performance
are invited, on a volunteer basis,
to participate in the support
programs.
The first program is designed
as the foundation for
improving AOM scores. The
Communications Skills Intensive,
or CSI, is a thorough training
program of communications skills
building developed by Terry Stein,
MD, director, clinician-patient
communication, Permanente
Medical group, regional offices,
Oakland, CA. Since its piloting
in 1996 in northern California,
several other KP regions have
developed CSI training efforts,
including Colorado and the Mid-
Atlantic states. The program
teaches relationship-centered
communication strategies that
can be used in the real world but
that are particularly valuable in
clinical settings. CSI was created
in response to communications
issues identified through patient
satisfaction surveys.
The second program involves
offering a diagnostic reliability
assessment of practitioners by
a representative from KP Ohio’s
Performance Improvement and
Patient Safety (PIPS) office.
The “diagnostic” assessment
involves observation of patient
interactions, interactions with
staff and office work flows. The
goal is to first identify and resolve
communication and other issues
that can negatively impact the
member experience and then
consult with the physician and
staff about resolving them.
Introduction of the CSI program
into KP accomplished several
goals. First, it addressed a
longstanding need to help
clinicians who are technically
competent although less adept
at relating to patients. Second,
the credibility and visibility of
clinician-patient communication
education was enhanced when
colleagues and chiefs observed
the often dramatic transformation
of some of the participants’
skills and attitudes after the
course. Third, and perhaps most
important, each year since CSI
was launched, patient satisfaction
scores of the cohort of clinicians
attending the course have
showed significant improvement.
In short, CSI training works.
Soon, the CSI program will
be available in Ohio through
OPMG’s human resources and
organizational development
department. They plan to offer
the first course in February
2008. The intensive is presented
offsite, over 3.5 days and takes
attendees through a spectrum of
interactive instructional exercises.
OPMGUPDATE
A good chunk of the intensive
involves practitioners interacting
with actors posing as patients.
Videotaping of the interactions
allows clinicians to see themselves
in action and to observe and
discuss communication strengths
and weaknesses with course
facilitators and clinical peers. At a
later date, participants are invited
to a one-day follow up to review
skills objectives.
In preparation of the launch of
CSI training in Ohio, this past
fall, several OPMG staff members
attended a CSI session hosted
by Dr. Stein and her staff in
Northern California. Attendees
included Eddie Wills, Jr., MD,
associate medical director for
human resources, professional
and organizational development;
Iris Hale, SPHR, director,
OPMG human resources and
credentialing; and Roger Lightner,
RCC, senior human resources
and organizational development
consultant.
CSI is built around the “four
habits model” of effective
clinician-patient communication
(invest in the beginning, elicit
the patient's perspective,
demonstrate empathy, and invest
in the end). “It’s a big investment
by the organization and of
yourself, but there’s a big return
for that investment” says Lightner,
“and Kaiser has the data to back
that up.”
If you have questions about these
programs, contact Roger Lightner
at roger.c.lightner@kp.org.
19
WINTER 2008
Advanced care management for care
delivery transformation
continued from page 5
We look forward to working with you
on this very important endeavor.
During his 16
years with Kaiser
Permanente, Dr,
DeShazer has
focused much
of his energy on
using information
Referrals management and clinical
review updates
continued from page 18
not rewarded for referring or not
referring, and utilization reviewers
are not rewarded for approving or
denying referral requests; any of
these scenarios can result in over-
or under-utilization of services.
Incomplete forms mean
processing delays
Submitting an incomplete referral
request delays the review process,
because a request cannot undergo
review or be approved without
the required referral information.
Valuable time can be lost for
practitioners, review staff and
members when review staff have
to contact practitioners to retrieve
information that should have been
included in the referral request.
To help minimize turnaround time,
please fax, rather than mail, all
referral requests to: 216-529-5533
or 98-326-5533.
Suite 1200
1001 Lakeside Ave
Cleveland, Ohio 44114-1153
technology to help improve the
way KP delivers care and manages
its operations. At the Southeast
Permanente Medical Group in Atlanta,
GA, where he was director of clinical
information systems, Dr. DeShazer
developed an automated medical
record abstract application that
produced one-page summaries of
patient records. The effort, used to
expedite more than 500,000 annual
patient visits over a 10-year period,
helped improve provider and member
satisfaction scores, lowered the
cost of medical record maintenance
and lowered malpractice costs. Dr.
Requesting a
reconsideration
OPMG physicians can request a
reconsideration for denials based
on medical necessity, that is, a
member has appropriate health
plan coverage, but the service
is medically unwarranted based
on clinical review criteria. Also, a
request for reconsideration can
only be made with the member's
written permission and can only
be made for initial or concurrent
determinations (not post service).
To request a reconsideration,
please call the RMCR at
216-529-5588 or 98-326-5588;
please also have available any
new information that supports the
rationale for the reconsideration
request. A decision will be made
within three business days of
receipt of the reconsideration
request. Practitioners requesting
the reconsideration can also speak
directly about the case with the
physician reviewer.
DeShazer also co-led KP Atlanta’s
primary care redesign project, one of
the first models in the country that
emphasized team-based primary care.
In 1997, he became vice president
and national director of the KP mid-
Atlantic business processes and
computing division, directing the
installation of a $42 million claims
processing system that yielded a
40% reduction in per claim costs.
He also co-led care management
and community provider integration
improvement initiatives.
Pre certification
documentation and KP
HealthConnect
Please be sure to use the
precertifcation, or “precert,”
service if members require
hospitalization or need to be
scheduled for a surgical procedure.
If a specialty consult is required
urgently, please contact the chief
of the relevant specialty prior to
calling RMCR. The precert phone
number is: 216-529-5588 or 98-
326-5588. (Beginning in January
2008, authorizations provided via
the RMCR precert phone line will
be documented and available for
viewing in KP HealthConnect, via
the “Letters” tab.)
Provider satisfaction
surveys
Many thanks for a very robust
response to the request for
survey completion. A summary of
results and any actions/changes
as a result of your comments will
be forthcoming.