Kaiser Permanente takes on patient safety initiatives in the outpatient setting

While Michael Kanter, MD, is optimistic about patient safety efforts gaining traction around the country, one area that’s been overlooked is outpatient care, he says. As medical director of quality and clinical analysis for the Southern California Permanente Medical Group, Kanter has helped launch a safety net program that electronically tracks outpatient care, looking for such problems as a patient not returning for follow-up care after an abnormal laboratory test result. That’s not so dramatic as fixing life-threatening mistakes made in the hospital, but it is important because of the sheer volume of outpatient visits, he says.

“One of our passions is preventive care, and our program allows us to monitor patients over time and attempt to intervene before anything bad happens.” Kanter shared information on the program at the National Patient Safety Foundation’s Patient Safety Congress in late May.

Addressing patient safety issues from different vantage points is common for Kanter, who over the years has championed the effort to improve health care with computers in exam rooms, with e-mail communication with patients, and by matching physicians and patients who speak the same language.

The NCQA has recognized Kaiser Permanente Southern California several times for its work in the latter area, including in May, when it awarded the group the NCQA’s first Multicultural Health Care Distinction certification.

A pathologist, Kanter joined Kaiser Permanente in 1984. He was assistant to the area medical director for the Woodland Hills Medical Center, chair of the patient safety committee, and secretary of the medical executive committee. From 1994 to 2008, he was also an assistant clinical professor at the University of California–Los Angeles. Kanter has written more than 30 articles published in peer-reviewed journals, and he serves on many national committees in the Kaiser Permanente organization, including the national diversity council and national quality committee. He earned his medical degree at the University of California–San Francisco School of Medicine and completed a residency and an internship in pathology at Harbor-UCLA Medical Center. He spoke recently with MANAGED CARE Editor John Marcille.

MANAGED CARE: What was the impetus for an outpatient safety net program?

MICHAEL KANTER, MD: We are doing something different from other folks. When you look at patient safety literature, you find that most of it deals with inpatient safety, hospital safety. We realized that we have many more contacts with patients in the outpatient setting. In our system, between 1 and 2 percent of patient contacts are on the inpatient side, and the rest are outpatient. There has been surprisingly little work on the outpatient side, so we wanted to create some kind of safety program for outpatient work.

MC: Why has that balance been skewed toward inpatient care?

KANTER: One of the big differences is that inpatient care happens incredibly fast. That has helped cultivate patient safety programs on the inpatient side, because when someone makes a mistake or there is an unsafe condition, you notice it right away. In the outpatient setting, you might make a mistake — say, fail to diagnose a cancer — and it takes five years before that mistake comes to light. That longer time frame makes it harder to study, but easier to intervene.

MC: Patients have to cooperate, though.

KANTER: Yes. Another difference in the outpatient setting is that patients play a more active role in the care. In an inpatient setting, you sit in your hospital bed and people do stuff to you all day long, and hopefully they do the right stuff, and you get better. In the outpatient setting, the patient is an equal partner with the doctor. Patients are the ones who have to go to their appointments, get their labs done, and take their medication. And they don’t always do it.

MC: Tell us about the program you’ve created.

KANTER: We follow care electronically, and as we see things that should be happening not happening, we intervene. Certain things should happen by a certain date, and if they don’t, somebody needs to do something.

MC: Is this similar to the checklist initiatives that are going on around the country?

KANTER: This is like a checklist, but different because it is not happening at the exact time that the care is provided.

MC: So all of this is a collection of rules and algorithms in a program somewhere?

KANTER: It’s actually a series of programs. This began way back when where we started tracking our positive Pap smear results. When someone has a Pap smear and is screened for cervical cancer, there are all kinds of mild abnormalities that require follow up, whether it is a biopsy or some other procedure. We have known for decades that if we didn’t have a follow-up system in place, patients would fall through the cracks and get into trouble years down the road. So we set up a system to track abnormal Pap smears, and that system is still in place. We then got the idea to do the same thing for abnormal PSA tests for prostate cancer.

MC: What does that program look like?

KANTER: When someone has a high PSA level, the follow up usually involves that patient seeing a urologist and getting a biopsy, but not always. Our system allows us to make sure that every high PSA level gets followed up appropriately. We order around 250,000 PSAs a year, so even if our doctors follow up appropriately 99.9 percent of the time, with volume that high, things are still going to get missed. This tracks all of our prostate cancer patients to completion.

MC: Other ideas followed?

KANTER: We realized that we could do this with a lot of different diseases and entities. We are following more than 10 right now. We can create new safety nets fairly quickly, on the order of a couple of months.

MC: How do you decide which diseases or tests to tackle?

KANTER: I can’t tell you that we have it down to a science, but we look at a few sources of information. One is that we ask our doctors where they feel there is potential for things getting lost. We also look at our medical legal claims and at reports on unusual occurrences and other patient safety issues. We put all of that together and then try to determine whether the area is amenable to this kind of approach. Can we track it in our systems electronically? HEDIS and other publicly reported safety measures are also low-hanging fruit that we have created systems around. We have a program on digoxin monitoring. This drug is used for heart failure, and patients who are taking it need certain lab tests once a year. That is publicly reported. We were doing reasonably well on it, yet we now use our safety net to bring in patients who have not come in for annual testing.

MC: So you get a double hit there — you can provide better care and get higher HEDIS scores?

KANTER: That is correct.

MC: Are there some areas where this approach won’t work?

KANTER: I am very interested in diagnostic errors. There are a lot of reasons why a diagnosis may be wrong, but many of them, if you read the literature, are based on subtle perceptual, cognitive errors. So a radiologist reads an X-ray and doesn’t see something on the film because he’s either distracted or has a preconceived notion of what should be there. The same is true about how all doctors make decisions. Do they come in with a bias? Do they get stuck in their initial impression and not revise their thinking? These things are common errors talked about in the literature, yet they are not amenable to an easy fix.

MC: So what did you do?

KANTER: We decided to focus on diagnostic errors that are more amenable to electronic fixes. Failure to follow up on abnormal tests is a lot easier to address than trying to figure out whether the physician’s reasoning was right or wrong at the time.

MC: It sounds like your program is a great advertisement for the electronic medical record.

KANTER: That’s true, but we get some of our data from our laboratory and other systems, so this could be done without an electronic medical record. Our Pap smear tracking system was done manually long before we had an electronic medical record. Doing this without computers would be a lot less elegant, but that doesn’t mean it wouldn’t work, particularly in a smaller practice.

MC: Possible but unlikely, considering what compensation is like for primary care doctors.

KANTER: You raise an interesting issue. What is in this for providers, other than doing the right thing? There’s no financial incentive as yet, other than maybe some malpractice avoidance, but that’s probably not going to make the thing pay for itself. So there are some interesting public policy issues.

MC: You are using this for your entire population. Have you been measuring its success?

KANTER: We measure how many people get caught in the safety net and then get into the right care. We don’t have a control group — I am not going to randomize our population — so we are only looking at how many folks we capture. At some point, I will publish some of the data on our outcomes. It’s not a controlled study, though, and that is going to be the downside from a scientific point of view.

MC: Have you had to build a business case for making the investment in the program?

KANTER: We do this with very minimal resources, so it’s not something that I have had to have a big business case on. We have a handful of people working on this: a pharmacist, an RN, and some clerical staff. Fewer than six people for our whole membership base. It is incredibly cost-effective. Even if you just find a couple of patients, it’s worthwhile.

MC: What’s in this for the non-Kaiser world? What can other insurers learn?

KANTER: Awareness is a big deal, and this raises awareness about the medications, the lab tests, and the diagnoses, which may actually help decrease the need for a safety net, although it will never go to zero no matter how good you are. In surveys, many physicians will admit that they are not so comfortable with their system for following up labs. That’s the first place a health plan should look — encouraging its network providers to put a system in place that they are more comfortable with. Integrated health systems could do this, but even if you are not in one, you could get creative in your thinking about how to track follow-up care. I also think that accountable care organizations could aggregate systems and get all of the information in one place. That is where the future is going, and this is a good reason that ACOs need to form.

MC: Would the ACO notify the physician that a negative laboratory result needed to be followed up?

KANTER: There would presumably be a part of the ACO that was responsible for quality — that’s essentially what I am — and they could take on this role. If you didn’t have an ACO, insurance companies might have a data problem, although if they got the laboratory results rather than just claims, they could look for subsequent claims that would confirm whether the patient got follow up care. They could then remind the physician that a patient didn’t get a follow-up lab test.

MC: At Kaiser, are physicians notified at the time a letter is going out to a patient?

KANTER: They have to sign off on ordering the laboratory study, so they know the patient is getting a letter. Once they sign the order, we take care regionally of contacting the patient and getting him into the lab. Physicians then get the results in their inboxes. Each program is set up a little differently. In some programs, pharmacists are intervening on some of the medications under a protocol. The doctors know this is happening but may not know about each and every patient when it happens.

MC: So it’s not completely automated?

KANTER: At some point you do end up with a manual system. With the PSA tests, for example, we sometimes have to talk to somebody or look in records. The patient might be 90 years old with Alzheimer’s disease, and a clinician may have made a clinically appropriate decision not to follow up on an abnormal lab test. That wouldn’t be reflected in our administrative data. You just filter out as much as you can electronically before you go to a manual system.

MC: Have you identified other health plans or health systems that have programs analogous to yours?

KANTER: We didn’t copy anyone’s system. It’s common to track Pap smear results, and physicians have been tracking things for a long time manually in one- and two-person offices. Every physician is trained that when you order a laboratory test, you should have a system for following it up. We are not doing rocket science; we are just making it scalable to 3.5 million members and partially computerizing it.

MC: How do you think things stand regarding patient safety in general?

KANTER: The outpatient effort could be a big part of reducing medical errors. People have just overlooked it because the findings are less dramatic than on the inpatient side, where you give the wrong drug and somebody has a terrible allergic reaction right away. For me, the outpatient side is an untapped, unexplored area in general.

MC: Have you, like many others, been disappointed with the progress on the inpatient side?

KANTER: I am an optimistic person, so I’m looking at the glass as being half full rather than half empty. We are starting to see some traction. Look at the work on bloodstream infection reductions and ventilator-associated pneumonia reductions, which you covered recently [“A Conversation With Peter J. Pronovost, MD, PhD,” April 2011; http://bit.ly/jX7zFV]. There is a lot of complexity to this. It is very difficult to take into account all of the human-factors engineering that needs to go into making things safer. Providing medical care is different from flying an airplane, which is often the analogy we hear.

MC: You’ve been an advocate of communicating with patients by way of e-mail. Do you see that as having a patient safety component?

KANTER: It’s a great way to communicate with patients. You have 24/7 contact. From a safety point of view, you leave a very clear written record. A lot of our e-mail is replacing phones. If you tell someone over the phone to take two pills, three times a day, they may take three pills, two times a day because they misheard you. When you use e-mail, it is all written down very precisely. So it is an inherently safer way to communicate with patients when conveying information that doesn’t require a back-and-forth exchange. It can be limiting if you need to have the back-and-forth exchange and make sure the patient truly understands what you are trying to convey.

MC: Do people read all of the e-mail you send?

KANTER: We do find that some patients get e-mails and they don’t look at them. That’s a problem. We did a study looking at hypertensive and diabetic patients, and after controlling for a lot of variables, we found that patients who used e-mail more had better outcomes for control rates for diabetes and hypertension. That was evaluated using HEDIS measures. So we saw big quality improvement there, but it was related to how many e-mails they actually did receive. I like e-mail because when I go to the doctor, I get an after-visit summary. Everything that happened during the appointment is written down.

MC: How complex is it to get around HIPAA restrictions when you are communicating with e-mail?

KANTER: It’s complicated, actually. Because of HIPAA regulations, patients have to go into the system, log in with security codes, and look at what we’ve sent them. Some people just don’t do that. So whenever we do an outreach electronically, we lose a certain percentage of patients because of that. We need the HIPAA rules; we need some kind of privacy protection, but it does present some challenges in terms of patient communication, which then creates a safety issue.

MC: Another one of the areas you work in is exploiting the benefits of physicians and patients speaking the same language. What are the implications for patient safety and good quality care?

KANTER: When the physician and the patient speak different languages, there is some evidence that miscommunication can happen, even if they use an interpreter. Sometimes the interpreter gets it wrong. Sometimes a physician thinks he is fluent in a language, but he is not, so he may misspeak. There is also some good research showing that if the physician speaks the same language as the patient, they can make better decisions. The history is really a key component of the diagnostic workup. We all focus on the gadgets and gizmos, but the old-fashioned Marcus Welby talking-to-the-patient approach is often what makes the difference. If you are hindered by language, you just can’t do that as well, no matter how good your interpreter is.

MC: Do you have recruitment programs for physicians who speak a second language?

KANTER: Yes. We have programs in place with a lot of surrounding medical schools to establish relationships with Latino medical students — not all of them speak Spanish, but a lot of them do — and we advertise often that we prefer a second language. We have programs to attract people who are interested in having a practice where they can speak a non-English language to their patients. We are also trying to get a lot of moderately fluent physicians up to the fluent level. We send some of them to an immersion program. You can’t go from no language to fluent in two months, but if you are moderately fluent, these immersion programs can help. We are actively studying how quickly physicians can improve their language skills, and we have a standardized exam that we give physicians who are interested.

MC: What other efforts are in place to help?

KANTER: We make a conscious effort to assign new patients to physicians who are bilingual when the patient needs or requests it. If we didn’t do that, we would have our valuable bilingual physicians with all English-speaking patients, who don’t benefit from their language skills. We also measure our language concordance by visit.

MC: You’ve measured the benefits?

KANTER: We look at disparities in HEDIS scores by language, rather than by race. We have found that the disparities we identify for Spanish-speaking members, for example, are mitigated by whether they have a Spanish-speaking doctor or not.

MC: Thank you.

We decided to focus on diagnostic errors that are more amenable to electronic fixes.

E-mail is a great way to communicate with patients. You have 24/7 contact.

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