Addressing Autism – Understanding a Complex Condition

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Autism spectrum disorder (ASD) is a developmental disorder that the CDC estimates affects one in 68 children.

The symptoms are different for each child, but may include difficulties with social interaction or communication or repetitive behaviors. As with the disorder, the causes are also complex, and it is generally accepted that both genetic and environmental factors play a role.

Researchers at Kaiser Permanente are studying autism with the belief that their findings could lead to development of better prevention and treatment strategies.

See more of this story: Kaiser Permanente’s Institute for Health Policy

Community-Based Organizations Remain Integral to Reduce HIV/AIDS Disparities

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For World AIDS Day (Dec. 1, 2015), we offer this following post written by community practitioners, advocates, activists and researchers with the Kaiser Permanente Community-Based HIV Test and Treat Initiative. Through the initiative they have found that community-based organizations play a critical role in serving people living with HIV when they are able to link their medical care with social, economic and behavioral support services – the total health of an individual. 

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In July 2015, the White House updated its National HIV/AIDS Strategy for the United States, with a vision to ensure that new infections are rare and all people living with HIV (PLWH) have equal and unfettered access to HIV clinical care. Central to achieving this vision for the country’s 1.2 million PLWH are recommendations for widespread linkage to and retention in comprehensive HIV care, support for HIV medical adherence, and achievement of viral suppression. Unfortunately, racial/ethnic disparities persist in linkage to care, retention in care, and viral suppression. Community-based organizations (CBOs), and particularly AIDS Service Organizations, may be better able to provide more tailored approaches to reach and support socially vulnerable and minority PLWH, but there is little guidance in the national strategy regarding how CBOs can support these goals.

For World AIDS Day 2015, we offer our recommendations for CBOs to achieve these National Strategy goals, as a collective of community practitioners, advocates, activists and researchers with the Kaiser Permanente (KP) Community Based HIV Test and Treat Initiative. The Kaiser Permanente HIV initiative began in 2013 and involves implementation and evaluation of innovative community-based and CBO-led interventions to increase linkage to and retention in HIV care among Black and Hispanic men who have sex with men (MSM) in Los Angeles, CA; African American women and transgender women in Oakland, CA; African Americans in the rural and suburban southeast; and people who use drugs and those recently released from prison in the New York metropolitan area. While outcome evaluation findings are not yet available, our collective experience over the past three years demonstrates the following findings to support more effective CBO interventions:

 

  1. Community-based organizations (CBOs) can play an instrumental role in reaching PLWH, but require strong relationships with clinics to support linkage to and retention in care.

CBOs connected to racial/ethnic minority or socially vulnerable groups (e.g., prison releases, MSM of color, transgender women) and holistic AIDS services may have better reach to PLWH within these communities, than may non-community-based HIV clinics. Through partnership with CBOs, clinics may extend their reach for linkage and retention in care. CBOs with in-house clinical services and those effectively partnered with clinics appear to be most successful in recruiting and retaining patients who have fallen out of care. Culturally and linguistically tailored services were uniformly identified as central to meeting the needs of these clients.

 

  1. CBOs can support more effective HIV care by helping clients understand and recall medications and information on clinical indicators, such as CD4 and viral load.

While clinical care and initiation of and adherence to antiretroviral therapy (ART) can improve quality and longevity of life, meaningful engagement in HIV care and treatment requires understanding and recall of medication regimens and clinical indicators of health. Many participants reached through this initiative reported recent receipt of CD4 counts and viral load but could not recall the numbers, impeding their use of this information as a means of tracking their health. Low health literacy was also a concern, with participants reporting difficulties reading their medication bottle labels or understanding when to take their medications. CBOs can support patients’ health literacy related to medications and reinforce strategies for recall and interpretation of health indicators following clinical care appointments.

  1. CBOs’ promotion of effective engagement in HIV care for socially vulnerable populations requires support for clients’ linkage to care for key comorbidities, as well.

Vulnerable PLWH commonly present with multiple comorbidities, including substance use and mental health issues, as well as chronic diseases increasingly faced by the nation’s aging HIV-positive population. Linking clients to clinical care broadly, not just HIV care, is critical and may better support more cost-effective funding streams to help sustain CBOs working with PLWH by extending these health support services to vulnerable populations regardless of HIV status.

  1. Life-stabilizing wraparound services and trauma-informed care are needed to support HIV care utilization and medical adherence given the social vulnerabilities faced by PLWH.

HIV care utilization can only be prioritized when their clients’ diverse range of non-medical social needs are simultaneously supported through wrap-around services, including transportation assistance, housing, food security, and group support. A disproportionate burden of abuse histories across the lifespan is also reported among populations served through this initiative, and trauma-informed care and social services have been identified as requirements to support broader HIV and other health care utilization.

  1. Social support as part of palliative care remains an important CBO service for PLWH.

Life-enhancing benefits of ART are not reflected in the health status of our most socially and medically vulnerable PLWH, some of whom learn of their HIV status when they are already at Stage 3 disease progression, rendering a need for complementary palliative care support well into the 3rd decade of the epidemic. Too often social support networks are inadequate for PLWH, and end of life social support from CBO representatives may offer the only non-clinical social support available to these clients. Training and support for CBO staff providing these services is vitally important to help sustain CBO continuity of care.

We offer these recommendations for CBOs to support their capacities to extend the reach of clinical care and link and retain racial/ethnic minority and socially vulnerable PLWH in care, as we believe that elimination of health disparities in care utilization, medical adherence and HIV-related life expectancy requires a community-centered approach best achieved via CBOs. We believe that engagement of CBOs in partnership with HIV clinical care can accelerate the progress of the National HIV Strategy and achieve the Strategy’s vision with regard to “unfettered access to high quality, life-extending care, free from stigma and discrimination.”

Authors:

Kaiser Permanente, National Community Benefit, Oakland CA

Alexandra Caraballo, National Manager, Philanthropy

John Edmiston, National Manager, Community Engagement

Pamela Schwartz, MPH, Director Program Evaluation

Melissa Ramos, Evaluation Consultant

 

UC San Diego Center on Gender Equity and Health- UCSD GEH, San Diego CA

Anita Raj, PhD, Professor of Medicine and Global Public Health

Lianne Urada, PhD, Assistant Professor of Medicine and Global Public Health

Laramie Smith, PhD, Assistant Professor of Medicine and Global Public Health

Sankari Ayyaluru, Research Coordinator

 

John Wesley Community Health (JWCH) Institute, Los Angeles CA

Sergio Avina, Division Director

Christopher Hucks-Ortiz, MPH, Evaluation Specialist

 

Institute for Public Health Innovation (IPHI), Prince Georges County MD

Bradley Boekeloo, PhD, Evaluator, University of Maryland

Abby Charles, MPH, Senior Program Manager

 

Public Health Institute (PHI), Oakland CA

Tooru Nemoto, PhD, Research Program Director

Mariko Iwamoto, Project Director

 

The Fortune Society, Long Island City NY

Nilda Ricard, Director Drop in Center-Health Services, Fortune Society

Brendan O’Connell, MSW, Senior Program Analyst

Jahad Robinson, Transitional Specialist

 

North Jersey Community Research Initiative (NJCRI), Newark NJ

Corey Rosmarin-DeStefano, Director of Clinical Services

Sharif Hall, Data Coordinator

Liliane Windsor, PhD, MSW, Assistant Professor, The University of Illinois at Urbana-Champaign

 

ASK4Care/Duke University, North Carolina

Beth Stringfield, Project Coordinator

Sara LeGrand, PhD, Assistant Research Professor of Global Health

 

Women Organized to Respond to Life Threatening Diseases (WORLD), Oakland CA

Cynthia Carey-Grant, Executive Director

Stephanie Cornwell, MA, Program Services Director

Samantha Feld, MPH, Evaluation Data Manager, Cardea Services, Oakland CA

 

 

 

Delving into the Data of Diabetes – A Research Roundup

By Muriel LaMois and Natalie Kish

The Centers for Disease Control and Prevention recognizes November as National Diabetes Month. It represents a time to increase awareness for and understanding of living with diabetes. Nationwide, nearly one out of 11 people has diabetes, and more than one-third of adults are pre-diabetic. Kaiser Permanente treats many of its members with these conditions, and researchers across the organization study diabetes-related health issues to determine how to better serve these individuals.

Stabilizing Trends in New Cases of Diabetes

Several Kaiser Permanente regions participated in a study published in January 2015 aimed at determining trends in new diabetes cases in 11 integrated health systems from 2006 through 2011. After analyzing the health records of approximately seven million newly diagnosed diabetic patients aged 20 and older, researchers found no statistically significant increase in the number of diabetes cases between 2006 and 2010 – with the exception of a small rise in cases in 2011. However, they found significant increases in diabetes cases for certain groups, including racial and ethnic minorities, older adults, males, and people with higher body mass indices. Despite the relatively stable overall rate of new cases, these results suggest that new cases of diabetes are appearing more often in certain populations than in others. Gregory Nichols, PhD, Senior Investigator with Kaiser Permanente’s Center for Health Research, led the study.

Regional Trends in Existing Cases of Diabetes: In Northern California Ethnic Disparities Reduced

Andrew Karter, PhD, and researchers from the Division of Research, conducted a study to evaluate ethnic differences in the severity of existing diabetes-related complications. Study participants included Kaiser Permanente Northern California members with diabetes who were at least 60 years old in 2010. The complications included: myocardial infarction, stroke, heart failure, amputation, end-stage renal disease, advanced diabetic eye disease, and hypoglycemic events. Among those who were studied, 32 percent of patients had at least one complication in the past two years, with eye disease and heart failure occurring most often. Karter and his team also found that certain ethnic groups were more likely to have diabetes-related complications. According to the research, Whites have the highest prevalence for most diabetes-related complications and Asians and Filipinos have the lowest prevalence. The differences in the prevalence of complications between ethnic minorities were modest. These results suggest Northern California is making progress toward reducing health disparities of diabetes-related complications among existing patients who already have diabetes.

Kaiser Permanente Southern California Improves Detection of Diabetes-Related Eye Disease

Diabetic retinopathy is the leading cause of blindness among adults in the United States. A project conducted in Kaiser Permanente’s Southern California medical centers sought to improve diagnostic accuracy of this condition by implementing a centralized reading center that assigned a single team of technicians to assess images for diabetic retinopathy for all of the region’s facilities. The center allowed for physicians to have more time for patients who needed to see them; specially trained technicians to provide more consistent and accurate readings; and photographers to get feedback that improved their images. Most importantly, it allowed more patients with diabetes to learn whether they have potentially sight-threatening retinopathy, and receive appropriate education and treatment. Recently the retinopathy center initiative received the David M. Lawrence Patient Safety Award in recognition of the project’s impact on improving the safety of care for patients and accelerating the rate and scope of patient-safety improvements at Kaiser Permanente.

 

The Quest for Quality Care: Informing Clinical Decisions in an Integrated Health Care System

horbergEver-expanding health care costs have led to increased scrutiny of treatments and a new emphasis on value. In response, providers are seeking to improve clinical decision making by considering various factors, such as the effectiveness of different interventions, side effects, and how patients want to live their lives. Bringing these variables together is an example of the intersection of comparative effectiveness research and shared decision making between clinicians and patients.

Comparative effectiveness research allows healthcare professionals to compare different drugs, technologies, and care processes to ensure that they are best serving patients. Kaiser Permanente’s integrated health system, serving 10.1 million people across the nation, is uniquely suited for this kind of research. Michael Horberg, MD, MAS, one of the organization’s leaders in this space, discussed why this is true.

Michael Horberg, MD, MAS is the Executive Director of Research for Kaiser Permanente’s Mid-Atlantic Permanente Medical Group and Mid-Atlantic Permanente Research Institute

What role does an integrated health system with shared decision making like KP play in comparative effectiveness research?

Our goal is to conduct comparative effectiveness research on established processes or technologies to improve patient care.

The key aspects of clinical decision making are the patients’ wants, needs, aspirations, and their life stage. Research can always be very biological—for example, Drug A lowered blood pressure more than Drug B, so Drug A is superior—that doesn’t consider other factors, such as how often Drug A has to be taken. Drug A may be successful under ideal circumstances, but it may not produce the same effect in real-life situations, and FDA’s approval of a drug and patients’ willingness to take the drug don’t always align.

What’s important is synthesizing information for patients. In a non-integrated system, there isn’t a systematic way to make the decision between Drug A and Drug B. There is also not a method to weigh this data. In small fee-for-service practices, the doctors’ decisions may be based on a small sample of patients or lobbying by drug companies. At KP, we can collect information from a large sample of patients without industry influence and make more well-informed decisions.

Many stakeholders believe that comparative effectiveness research will have a moderate to substantial impact on healthcare decision making in the next five years. Where do you see it by 2020?

Comparative effectiveness is going to be critical, especially as patients become more engaged in care and more drugs, technology, and care processes become available.

Because patients are the center of care, we will see more talk about how to bring them into the decision making process and into research. A lot of the questions research scientists think are very clear in our minds can be broadened by incorporating patients’ perspectives.

We will also start to see a lot of people and organizations talking about the effectiveness of different technologies and practices. For example, in pharmaceuticals, we will see more studies comparing generic medications and branded prescriptions, as well as comparing different branded drugs. As we observe just minor gradations of improvement of one product over a previous product, people will start asking about the significance and magnitude of the added benefit or if there is any extra value at all.

To learn more about comparative effectiveness research at KP, please see the pages for the Mid-Atlantic Permanente Research Institute and the Center for Effectiveness and Safety Research.

Preventive Screening is Gleaning for Good Health

ClinicalGuidelines-300x200Kaiser Permanente promotes wellness, delivers high quality care, and manages chronic disease in order to improve total health. Screening for health conditions is fundamental to this goal. This month, the Institute for Health Policy highlights Kaiser Permanente’s efforts to increase access to and quality of screenings as a way to better manage the health of our members.

Alcohol as a Vital Sign

The Kaiser Permanente Northern California Division of Research measured the results of Alcohol as a Vital Sign, a screening program in which medical assistants ask patients about their drinking behavior. The purpose of this program is to identify unhealthy levels of alcohol consumption and risk of alcohol dependency. Patient responses inform physician conversations — if patients report having unhealthy drinking levels, physicians can discuss the risks of overconsumption and the benefits of reducing consumption. Kaiser Permanente rolled out Alcohol as a Vital Sign across Northern California in 2013. Thus far, the program has shown positive results: 85 percent of the Northern California region’s patients have been screened for alcohol consumption, equal to the screening levels for smoking and exercise.

Higher Quality Colonoscopies, Lower Risk of Death from Colorectal Cancer

A recent study by Douglas A. Corley, MD, PhD, MPH, from the Kaiser Permanente Northern California Division of Research and Reinier G. S. Meester, MsC, from Erasmus University showed that improving colonoscopy adenoma detection rates (ADRs) may have long-term health benefits. Compared to unscreened patients, patients screened with low ADR colonoscopies had a 22 percent reduction in lifetime colorectal cancer incidence and a 57 percent reduction in colorectal cancer mortality. As ADRs increased, patients’ risks decreased further, the authors found. Patients screened with the highest ADR colonoscopies had much larger total reductions of incidence and death, compared to no screening, of 63 percent and 83 percent, respectively – additional relative reductions of 53 percent and 60 percent beyond those achieved with the lowest ADR tests. Although higher ADR colonoscopies are more expensive, researchers project these costs are almost completely offset by reductions in cancer treatment costs.

Expanded Blood Pressure Screenings for Hypertension Detection

Joel Handler, MD, and researchers from Kaiser Permanente Southern California’s Department of Research & Evaluation, were recently covered for their publication in The Journal of Clinical Hypertension. The team studied the benefits of screening for high blood pressure in non-primary care settings. To do so, they analyzed health records of Kaiser Permanente Southern California patients with hypertension to see if the condition was diagnosed during a primary care or specialty care visit. The study yielded two main findings. First, of hypertensive patients, 17 percent were diagnosed in specialty settings. Second, both primary care and non-primary care settings had comparable percentages of false positives, i.e. patients diagnosed with hypertension who did not have high blood pressure during follow-up. These results suggest that extending blood pressure screenings to non-primary care settings may be an effective way to detect hypertension, particularly for patients who do not regularly use primary care.

Kaiser Permanente is taking strides to improve members’ health by advancing quality of and access to screenings. These measures may help providers deliver more informed care and patients better manage their health. Next month’s research roundup will feature studies on the relationship between research and policy. For more information on this month’s research, Please contact Al Martinez at Albert.Martinez@kp.org.

Kaiser Permanente Encourages Mental Health Awareness for National Depression Screening Day

After his wife died, Tom found himself in a very dark place and he didn’t know how to get out.

He knew he needed to do two things: Get a mental health evaluation, and if it confirmed what he already suspected was the case, he needed to get care.

“I was having some trouble with depression and anxiety,” said Tom, a Kaiser Permanente member whose real name is not being used to protect his privacy. “I was distraught after my wife passed away. I really needed someone to say, ‘Hey man, do this because you are screwing up.’ I wanted to get a handle on myself. I wanted to be less depressed. I just wanted to get a grip again.” 

October 8 is a day dedicated to helping people like Tom get the help they need. This year marks the 25th observance of National Depression Screening Day, dedicated to raising awareness about the importance of screenings for depression and related mood and anxiety disorders.

blue background with circular green that makes a tree. The blue inside the green makes a person with arms raised which is the trunk of the tree with leaves. National Depression Screening Day logo.

According to Screening for Mental Health, the non-profit organization that established this annual screening day, depression screening is effective in linking at-risk individuals with treatment options. A 2009 independent research study by the University of Connecticut and commissioned by Screening for Mental Health showed that 55 percent of participants who completed an online depression screening and who agreed to participate in a follow-up survey sought depression treatment within three months of the screening.

Kaiser Permanente’s offers an online self-assessment tool that can be used by members and non-members to help identify signs of depression and learn more about it.

Committed to total health

Kaiser Permanente members like Tom can be assured that providing high-quality mental health care is a key priority for the largest integrated non-profit health care system in the nation. With its mental health therapists, psychiatrists, primary care physicians, and pharmacists coordinating care for its patients, the organization is well-positioned to meet the needs of the growing population of Americans in need of mental health care, and ultimately provide a model for the delivery of such care in the community.

“We are committed to the total health of our members, and that means caring for the mind, body and spirit,” said Patrick Courneya, MD, executive vice president and chief medical officer at Kaiser Permanente. “The goals of National Depression Screening Day are the same ones our primary care physicians and behavioral health specialists pursue every day. We strive to eliminate any stigma associated with depression, anxiety and any other similar conditions and to provide the tools and care our members need for emotional and mental well-being.”

Learn more about Kaiser Permanente’s integrated approach to health care by reading the rest of the article here.

 

Another rung on the ladder towards achieving a high-performing health care system – to be or not to be?

Does the word learning associated with a health care system cause concern? Most people want to be assured that their care providers already understand all there is to know. In fact, a learning health care system is synonymous with care that is constantly evolving and improving based on new evidence. The concept of creating a voluntary certification for health care organizations to achieve designation as a learning health care system was fodder for an exploratory discussion among a small group of health care thought leaders at a September convening of the National Academy of Medicine in Washington, DC.

As a representative of the nation’s largest, private, not-for-profit health plan, serving more than 10 million people, the Kaiser Permanente Institute for Health Policy was invited to join the discussion. Also present were experts from academia; government agencies such as the Centers for Disease Control and Prevention, the Food and Drug Administration, and the Agency for Healthcare Research and Quality; The Joint Commission; Association of American Medical College; American Medical Group Association, and others.

Best-care-Lower-Cost-300x225In its 2012 publication, Best Care At Lower Cost: The path to continuously learning health care in America, The Institute of Medicine laid out a definition of a learning health care system, which is a key component to achieving higher quality care at lower cost. “A learning health care system is one in which science, informatics, incentives, and culture are aligned for continuous improvement and innovation, with best practices seamlessly embedded in the care process, patients and families active participants in all elements, and new knowledge captured as an integral by-product of the care experience.”

With this goal in mind, the group spent time debating the nomenclature – learning health care system. To me the word “learning” denotes humility, but more so suggests to consumers and those of us on the inside that health care is dynamic, self-aware, and willing to change to make good use of new information. But other attendees suggested that the word might possibly have the counter-effect, raising anxiety in consumers who believe that the health care system is fully informed.

The primary goal of creating this certification would be to accelerate progress toward continuous learning in health care to improve health outcomes. One might logically ask: has anyone seen a learning health care system before, and how would we know when we’ve come in contact with one? Well, a number of health care organizations deem themselves as such, and are also acknowledged by others in the field, accordingly. Not surprisingly, these organizations are kindred spirits – they resemble one another in more ways than one. Some household names are: Kaiser Permanente, Geisinger, Intermountain Health Care, Mayo Clinic, and the Cleveland clinic. On the public side, the Veterans’ Administration is also considered a learning health care system by many. When we examine these organizations, we find common characteristics that exist among them that are in concert with the idea of learning. Included are visionary leadership, data-enabled care, complete transparency (or a goal thereof), incorporation of new knowledge (through research activities) into care processes, promotion of patient engagement activities, and seeding of innovative ideas for scale and spread. Several in the room encouraged the group to think about implementing a tiered certification program in consideration of the needs of the smaller, and in some instances, rural health systems that may not have the resources/capital and full complements of the larger systems named above, or the means to get there.

In contemplating next steps, this certification could offer other potential values. On one hand, it could be something that distinguishes a hospital system and serve as a differentiator in the marketplace, or a “feather in their hat,” that allows them capitalize on the designation of a learning health care system as marketing tool. Likewise, the value of the designation might benefit consumers who are, increasingly, faced with decisions about their health care – plan choices, provider choices, and care sites. One might argue that it’s not hugely different from the mom who seeks out and chooses to deliver her baby at a hospital that has achieved “mother-friendly/baby-friendly” designation for its maternity program.

If we agree that this certification would yield a cadre of high-performing health care institutions and the by-products would include continuous learning, improvements in care delivery, organizational goals matched with patient goals, increased transparency, improved health outcomes – what is the barrier to forging ahead? Or is this just too disruptive to the status quo? While many will need to take a multitude of steps to become a learning system, the good news is that this is not uncharted territory; so existing models such as Kaiser Permanente, and others, can lead the way.

 

Rx2Move Graphic

A Prescription to Move (#Rx2Move): How Health Care Providers Can Encourage Physical Activity for Patients and Communities

Only about half of Americans meet the recommended 150 minutes a week of moderate aerobic activity. To help get people moving, health care providers need to become better health advocates. The first step is spreading the word, which is why the Kaiser Permanente Institute for Health Policy and American College of Sports Medicine are offering three strategies for health care leaders to promote physical activity and to shape environments to support active living. These include: encouraging physical activity in conversations with patients, redesigning health care environments, and investing in community health.

“Health care providers are under pressure to find new and more effective ways to help patients address obesity and other chronic diseases that are influenced by inactivity,” said Brian Raymond, MPH, senior health policy consultant at Kaiser Permanente. “This campaign is about changing how health care providers perceive their role in improving physical activity and ultimately encouraging innovative action.”

Titled, A Prescription to Move (hashtag #Rx2Move), the campaign includes three webinars, a policy brief, and a series of infographics that highlight the various ways that providers can promote active living and make environments more suitable for physical activity. Here’s a little more on the three core principles.

  1. Having Conversations with Patients – Making Exercise a Vital Sign: Conversations between primary care providers and patients about physical activity and more active lifestyles can improve health.
  2. Designing Active Health Care Environments: Design innovations adopted by hospitals and health systems can encourage physical activity and give patients, visitors, and staff opportunities to engage in “active transportation” (walking, biking, and using public transit).
  3. Investing in Community Health: By advocating for and investing in active transportation, public recreational spaces, and school-based health initiatives, health care providers can promote more active, healthier communities.

There are three ways you can support #Rx2Move:

  1. Join the #Rx2Move Webinar Series and Pass along the Invite

The first of a three-part Rx2Move webinar series, Making Physical Activity a Vital Sign, is scheduled on Tuesday, October 13, 12:30-1:30 PM Pacific/ 3:30-4:30 PM Eastern. Registration and additional information is available at: http://www.kpihp.org/rx2move-webinar-series/

  1. Spread the Word about the #Rx2Move Online Issue Brief

Our new online issue brief, How Health Care Providers Can Encourage Physical Activity for Patients and Communities, highlights emerging strategies health care providers are using to encourage exercise amongst their patients and the communities they serve. The issue brief is available at: http://www.kpihp.org/rx2move/

  1. Participate in the #Rx2Move Social Media Campaign

Join us in using Twitter, Facebook and Linkedin to raise awareness about the #Rx2Move key messages. Infographic banners and sample messages supporting the social media campaign are available at: http://www.kpihp.org/rx2move/.   ‎We encourage you to use the #Rx2Move hashtag in your digital conversations.

Empowering Patients to Drive Their Own Care: A Conversation with Kaiser Permanente’s Terhilda Garrido

Health information technology (IT) is revolutionizing how patients and physicians interact. Electronic health records (EHRs), such as Kaiser Permanente’s KP HealthConnect, allow physicians to have a more complete view of patient health information. EHRs also enable patients to have more access to their physicians through secure emails, phone calls, and video visits. To learn more about the ways KP HealthConnect impacts members and providers across Kaiser Permanente, the Institute for Health Policy spoke with Terhilda Garrido, vce president for health information technology transformation & analytics at Kaiser Permanente.

Health information technology is changing the practice of medicine across the nation. What are the most profound changes KP HealthConnect has brought to Kaiser Permanente?

Terhilda Garrido, Kaiser Permanente

Terhilda Garrido, Kaiser Permanente

Physicians now go to the computer as opposed to paper records for checking medical history, taking notes, and ordering prescriptions. Providers are alerted about patient issues and in some locations can bring in added expertise through a function called eConsult. Increasingly, our patients drive care. Patients have the ability to access their health information through kp.org. They have extremely high satisfaction with the patient portal, and those who use kp.org are 2.6 times more likely to remain Kaiser Permanente members than are non-users. Once people experience the convenience of accessing care online, they tend to stay with Kaiser Permanente.

As a result of these capabilities, outpatient primary care has changed. Half of primary care visits are now virtual. Secure emails and phone calls represent about 30 percent and 20 percent, respectively, of primary care contacts. In absolute terms, face-to-face visits per member per year are slightly decreasing, but our secure email visits per member are substantially increasing. Primary care access has improved because technology allows more contact with patients. Virtual visits replace some face-to-face visits, but primarily virtual visits occur after a face-to-face encounter has already taken place.

Have clinicians in Kaiser Permanente embraced KP HealthConnect and the changes that have come with it?

The organization has embraced the changes, but the impact on physicians is mixed. Some physicians embrace the technology because they feel it improves care for their patients, while some are still reconciling this new workflow with their already busy calendars. We are such a huge organization, so it’s not out of the ordinary to have such varying reactions. We are still trying to understand and support the best use of our providers’ time.

You have been involved with research exploring the unintentional health care disparities that can emerge with Health IT. Can you explain why these disparities occur?

We’ve conducted a few studies on eHealth disparities. After controlling for various factors, including age, sex, comorbidities, distance to a medical center, income, and education levels, researchers found that Asians, African Americans, and Latinos have lower levels of use of the patient portal. This finding shows us that there are underlying biases between non-Hispanic whites and other ethnic groups.

Recently, we’ve done focus groups with African Americans and Latinos to explore the reasons for their lower levels of enrollment. One reason for not using MyChart is the belief that the site is not secure. Other explanations include login difficulties and language issues, which Southern California has attempted to address by turning on Spanish MyChart. Fewer people cite lack of access to the technology as their reason for not using MyChart.

Are there any policies that could be implemented to help reduce eHealth disparities?

General education campaigns showing that virtual care augments rather than substitutes for in-person care would be beneficial. There are people who think virtual care is cheaper care used to keep patients out of physicians’ offices. There should be broader understanding that many of people are benefiting from virtual care, and it is still high quality care.

Also, the Centers for Medicare and Medicaid Services (CMS) could help to support appropriate funding for virtual care to help it become more mainstream. Despite the fact that the Office of the National Coordinator for Health IT (ONC) is encouraging organizations to adopt virtual care, CMS still only pays for face-to-face visits. This is contrary to the direction in which ONC is pushing healthcare. Acknowledging that virtual care is beneficial and reimbursing for it could make it more widely available and help reduce eHealth disparities.

What is the next frontier in health IT and care transformation, and how are we preparing for it?

The next improvements will encourage self-service for patients and help them be more engaged in their care. Social networking and apps, such as glucose measurers, weight monitors, and fitness trackers, will help patients be more involved. Apple’s Health Kit is an app that combines health information from various health apps. Video visits will also become more common as we move forward. Finally, we will see more machine learning in healthcare. Technology like IBM’s Watson – a machine that can observe, interpret, evaluate, and decide – may be used to help support clinical care.

Research Roundup: Considering the Mind, Body and Spirit in Health Care

Health care is not just about diagnosing and treating patients in the exam room and helping them avoid illnesses. It is also about considering the “mind, body, and spirit” together in order to encourage both physical and mental wellness. At Kaiser Permanente, our focus is the total health of patients. In this month’s research roundup, the Institute for Health Policy highlights KP research on ways to improve the well-being of our members.

Service Dogs for Veterans

Dr. Carla Green testified to an Oregon legislative subcommittee about the benefits of providing service dogs to veterans. Initial findings from the Pairing Assistance-Dogs with Soldiers (PAWS) Study showed that veterans with service dogs had fewer symptoms of post-traumatic stress disorder (PTSD), lower levels of depression, better personal relationships, and lower rates of substance abuse. In her testimony, Dr. Green described one veteran’s experience with a dog that would regularly wake him from nightmares of past traumatic events. Each dog has a one-time cost of $10,000 to breed and train. However, that may be small compared to the $5,635 to $31,695 spent on care for a veteran with PTSD, major depression, or co-occurring PTSD and major depression in the first two years after returning from combat. In order to support this kind of intervention, lawmakers need more data that service dogs are beneficial. Dr. Green’s research shows promise, and the U.S. Department of Veterans Affairs has also resumed its own research on service dogs and PTSD. With additional evidence, the government may decide to provide services dogs to veterans in the future.

Reducing the Risk of Depression Among Pregnant Women

Women with a history of depression are at greater risk of encountering the illness in the weeks before and after childbirth. Researchers in Colorado, including Dr. Arne Beck, recently published a study about using mindfulness-based cognitive theory (MBCT) for pregnant women at risk of a depressive relapse. MBCT combines mindfulness, meditation, and cognitive behavioral strategies. It also helps individuals become more aware of negative thoughts and feelings and respond to these states before they lead to depression. The intervention includes brief exercises that women can use even while handling the demands of caring for a newborn. Women who went through the intervention had a lower risk (18% compared to 30%) of developing depressive symptoms during pregnancy and six months postpartum. A larger study needs to be conducted to ensure the efficacy of this approach and to see if it is helpful for other pregnant women at risk of depression.

Mindfulness Training for Cancer Patients

In Northern California, Dr. Ai Kubo is building on the work of other Kaiser Permanente researchers who found that mindfulness-based stress reduction (MBSR) training improved the mood and quality of life of cancer patients. Standard MBSR requires over 30 hours of in-person training over 8 weeks, making it nearly impossible for busy and highly stressed caregivers or patients actively undergoing chemotherapy. Therefore the Kaiser Permanente study provided trainings through audio recordings on CDs, so that patients could listen during treatment and at home. Due to the success of this pilot study, Dr. Kubo is currently conducting a follow-up study. She is collaborating with a popular mindfulness app company, Headspace, to test if mindfulness training provided on a mobile app is accepted and helpful among cancer patients and caregivers. Dr. Kubo hopes to examine whether an 8-week regimen of mobile mindfulness exercises result in better quality of life and sleep, as well as lower levels of stress and fewer side effects from treatment.

Strategies to improve the well-being of patients can be provided alongside traditional office-based care to maintain the total health of patients. Look for next month’s research roundup on improving screenings. For more information about the research studies, please contact Al Martinez at Albert.Martinez@kp.org.