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HEALTH PLANS/TECH: Full text of Andrew Wiesenthal (Permanente Federation) interview

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Here’s the full text of my interview from last week with Andrew Wiesenthal of the Permanente Federation–mostly about the HealthConnect project and attendant controversies!

Matthew Holt: This is Matthew Holt at The Health Care Blog and tonight at rather short notice I am lucky to have an interview with Andrew Wiesenthal who is an executive director in the Permanent Federation which is the umbrella group that oversees the entire Permanente Medical Group in the different regions of Kaiser Permanente. Andrew contacted me this afternoon as he had seen a number of the postings on various blogs on some of the issues that have been going on with Kaiser. And I thought it would be a good chance to have a discussion with him about many of the issues, some of which have been raised in the last week about Health Connect and some others. So, Andrew, thanks a lot for agreeing to take the call. I know you are in the back of a cab there and hopefully we can have a decent conversation. So could you just give me a very brief thumbnail sketch of your role at Permanente and a little bit on how the Permanent Federation is organized.

Andrew Wiesenthal: Sure, I am a pediatrics infectious disease physician and I began my career as a member of Kaiser Permanente as a member of the Colorado Permanente Medical Group something over 20 years ago. I took care of patients and also had responsibility for quality improvement and other things in my medical group in Denver, Colorado. And, as part of that, almost 20 years ago I began to clearly see the need for an electronic health record in order to gather the kinds of information we want them to have so we could measure our quality and improve it. Ultimately I was the Physician leader for the development of what we called the CIS or Clinical Information Systems in Colorado. We finished that development and deployment work in 1998. Kaiser Permanente in Colorado does not own and operate Hospitals so the record was in the ambulatory setting. But this did serve at that time about 600 physicians and approximately 400,000 members of the Colorado regions. That was what it was doing at that particular point. Basically the physicians, nurses and staff of Kaiser Permanent in Colorado were essentially paperless from that point forward.

Continue reading…

BLOGS/HEALTH PLANS: Why we love Roy Poses!

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Over at Health Care Renewal Roy Poses notes that the Annals of Internal Medicine has an article by a little known Columbia University public health professor (well, actually not one, but you’d never know) with the name J. Rowe which appears to promote pay for performance. Roy notices that a certain major national health plan until recently had a CEO with a very similar name which might possible benefit from P4P.

Roy wonders if they are, perchance, related?

HOPSITALS/HEALTH PLANS: You’d think Kaiser’s had enough bad publicity lately, but then again

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The city of  Los Angeles. is filing patient `dumping’ charges against Kaiser Permanente. Obviously there are plenty of hospitals dumping patients onto LA’s Skid Row, and obviously the way our society deals with elderly people with dementia, (and younger ones with other problems too)—by leaving them out on the streets—is a disaster. We clearly need a national health and social services system to deal with these issues,a nd Kaiser (and the rest of the health care system) should throw its weight behind us getting one. But given that we don’t the city is just picking the best example, which happens to be from an organization with deep pockets. 

And I’m sure that the Kaiser staff meant for the elderly patient still wearing a hospital gown to make it from the taxi into the Union Rescue Mission (rather than as the video shows literally wonder the wrong way down a busy road, not even on the sidewalk). But for KP, this is just a damning indictment:

The Los Angeles city attorney’s office filed false-imprisonment and dependent-care-endangerment charges against hospital giant Kaiser Permanente on Wednesday, the first criminal prosecution of a medical center accused of “dumping” patients on skid row. The charges stem from an incident earlier this year when a 63-year-old patient from Kaiser Permanente’s Bellflower hospital was videotaped as she left a taxi in gown and socks, and then wandered skid row streets.

<SNIP>

The day she was discharged, March 20, hospital staff members wrote on her chart that she was “non-talkative,” “forgetful” and “disoriented,” according to court documents.”Despite these findings,” prosecutors said, “the Kaiser Bellflower staff made no other efforts to assess or treat her medical condition.” Instead, the documents say, hospital staff “summoned a taxicab and directed the taxi driver to transport Ms. Reyes to skid row, approximately 16 miles away…. [She] was literally rushed out of the hospital and into the taxi even though the hospital staff could not locate her clothes…. [T]hey escorted her to the taxi without any pants, even though Ms. Reyes expressed concern about her clothes.” Court documents allege that Reyes was not told that she was being taken to skid row.After Reyes arrived at skid row, Union Rescue Mission staff members worked out a special arrangement so that she could remain in the facility during the day rather than check out the next morning and re-apply for a bed later in the day. But three days after her discharge from Bellflower, according to the documents, Reyes “lost consciousness in the bathroom of URM, falling and suffering head trauma.”Jeff Isaacs, head of the city attorney’s criminal division, said Reyes was subsequently hospitalized at Los Angeles County-USC Medical Center, where she was diagnosed with pneumonia, anemia and dementia, a progressive brain dysfunction, and remained in the hospital for at least 45 days. A guardian has been appointed to protect her interests, Isaacs said.

And the cynics would point out that if the patient had spent those 45 days at Kaiser rather than LA County, then they, not the taxpayer, would have paid for it.

TECH/HEALTH PLANS: Perhaps the last word on KP (for now at least)

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Here’s a stack more comments on Kaiser HealthConnect at HISTalk (go down) and then Mr HISTalk’s conclusions, (again read down) which are very sensible and basically mirror mine! (surprise surprise!).

As I said in comments over there and here—openness for KP would be good. But regarding HealthConnect, the real question is how will it operate when it’s deployed and all the power problems have been sorted out. And what does Health Care have to learn from Google, Ebay et al which manage to have millions of users bang on them without going down. I’m not a techie, so I don’t know, but I suspect that the answer lies there.

TECH/HEALTH PLAN: HISTalk nabs Justen Deal

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HISTalk has an interview with Justen Deal (of Kaiser Permanente although probably not for long, my guess)! It seems to me that we’re now coming down to degrees as to how to interpret the same facts. There isn’t too much that he says that directly contradicts my interview with Permanente Federation Exec, Andrew Wiesenthal on Friday. The basic “he said, he said” conflict is over how deep the agreement to go with Epic + Citrix was at the time and whether Dodd was in charge of HealthConnect or a peripheral figure. A time, it’s worth noting when Deal didn’t yet work for KP! Otherwise they agree that power outages have been a big problem, that the Citrix installation is bigger than Citrix can handle so far, and that Epic is written in a 30 year old programming language. Although Deal continually suggests that they shouldn’t use Epic alone, none of the complaints in the internal documents in the ComputerWorld article seems to relate to Epic’s software not working as far as I can tell. And let’s face it, it’s not as if any alternative vendor strategy would have had no issues (Pain free Cerner installations, anyone?).

This is a bit like Kremlin-watchers in the 1960s trying to figure out which warring internal camp who had control over who the Soviets would invade next. It really smacks of the HealthConnect people not trusting the KP-IT staff and vice versa. Frankly, it almost makes little difference. The question is whether HealthConnect genuinely can be scaled to the whole KP organization and made reliable. We’re just not going to know until it gets rolled out, and that won’t either be stopped now (as it’s too far in and not working badly enough to be junked) nor will we know how well it works will the whole thing is rolled out in 2007–8.

That’s not to say that there isn’t some good to come out of all this and from Justen Deal’s email heard around the health IT world. Kaiser has failed to be as open as it should be about a range of issues—especially as a non-profit it has responsibilities to more than just its executives and members. This is a brave new world for it and many other HC organizations to deal with (pun not exactly not intended). Getting the truth and the facts out there is something that they all need to do. Dimitriy is right about that. Prodded by Deal, Kaiser appears to be slowly doing so.

BTW: For some reason I got a lot of hits Monday from Madison, Wisconsin. Can’t imagine why!

HEALTH PLANS/POLICY: Would you buy a used health care policy solution from this association?

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Here it is. AHIP’s Proposal — because they didn’t obviously didn’t get enough at the MMA trough in the last go around, they figure another $30 Billion a year for ten years will get us all the way to 95% coverage in 10 years.

Um, how about getting to 100% coverage for no more money than we’re spending now? I could do that. Of course that might piss some people off along the way, including those AHIP members with their snouts deepest in the trough. But fear not, that’ll come too because no way that this coalition can seriously hold together given the discrepancy of interests and moral values amongst their membership—even with its leader’s skill in believing her own prevariactions. Because eventually the shysters and those who genuinely believe that they add value to the care process will not be able to hang together.

TECH/HEALTH PLANS: Chris Rauber pokes more into KP

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For those of you who can’t get enough, Chris Rauber, health care reporter from the SF Business Times has discovered that the investigations into the KP Kidney transplant fiasco are getting wider. And if anyone from KP wants to go on the record about that, as did Andrew Wiesenthal about the HealthConnect issues, I’ll be happy to give a full and fair interview.

Meanwhile I’d missed this, but he also caught this one from July—Kaiser was trimming costs in its outsourcing for IT staff  by asking vendors to cut their rates. If you looked at HotJobs for tech jobs in San Francisco this year, you’d have noticed that KP was on a hiring binge for HealthConnect, so this all fits with the desire to cut costs.

Meanwhile even more gossip about Epic and whether running the future of health care on a 30 year old obscure programming language is a good idea or not here.

Oh, and at DiabetesMine, Amy Tenderich finally has her interview with KP’s PR guy in charge of promoting their HealthySolutions DM outsourcing group, who explains a little more about how their internal DM processes work. You get the impression Amy wishes that she’s done this interview a little later!

I’m sure there’ll be more, whether or not Epic employees think this is newsworthy!

 

TECH/HEALTH PLANS: more on KP

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Well it’s coming thick and fast. First the podcast with Andrew Wiesenthal (previous post here). Then Gadlfy in her anti Kaiser site has some more about her take, including her commenters thinking that I’m just an apolgist being paid off by KP (and I’m still waiting for the check!).Finally MrHISTalk has much more on his site including this list of questions, which using what little I know and was told, I’ve tried to answer below (Questions have bullets; my answers are below)

  • On George Halvorson’s first day, he cancelled KP’s existing $442 million KP-CIS project to implement electronic health records.
According to Wiesenthal, Halvorson asked a big team to take a look at what the right solution was–postponing the CIS project at that time. Separately a senior KP doc who’s a tech expert, who I know and respect and has not been in the news, told me that the IBM code was the worst he’s ever seen, but that Epic’s was good (He also said Soarian might be better if it ever got into production!). CIS was considered as a potential option going forward.
  • Mr. Halvorson had also pushed through the selection of Epic at the health plan he previously had led, in Minnesota.
  • George Halvorson’s previous employer, HealthPartners of Minnesota, has faced significant problems with its Epic project, and, so far, the Epic software has only been able to completely cover about half of HealthPartners members. 
HealthPartners definitley selected Epic while Halvorson was CEO and it seems to be working OK there—according only to a patient that I know! Not clear who lead that selection or how badly things have gone there compared to what they hoped to achieve.
  • KP’s CEO and CIO ignored internal engineering reports which said Epic software would be unreliable for KP’s size and difficult to adapt to KP’s scope.
Unclear as to whether this is more than rumor. Wiesenthal said a large team looked at Epic, CIS and Cener (on Halverson’s request) and decided that Epic was the best option for what they were trying to do. He says the current problems are to do with Citrix (some thing to do with too big a server installation in one place) and power and UPS problems in their S. Cal data center. His quote "Epic is rock solid"
  • Mr. Dodd brought in a company called Tanning Technology to give an opinion on the viability of Epic within an organization as large as Kaiser Permanente. Mr. Dodd, while serving as an officer of Health Plan, also simultaneously served as a director for Tanning. Ignoring this significant conflict of interest, Mr. Dodd paid nearly $1 million dollars for Tanning Technology to give a favorable report on his and Mr. Halvorson’s predetermined plan to shift KP’s business to Epic.
Tanning apparently was brought in for a different task not related to HealthConnect, who’s selection Dodd was NOT part of. Wiesenthal claims not to know why Dodd resigned but claims it had nothing to do with the Deal email
  • A decision was made to replace almost all of the KP home grown systems … with one "integrated" system and do it in three years. Those making the decision had no concept of the real scope this project or the expertise required to do it. Epic is a good product whose average client was no bigger that 2,500 users running on one instance. Kaiser retooled it to scale to 150,000 users and 20 instances using the same building and configuring techniques as the average client, which is manually building and configuring again and again.
This is basically true. But only because no one had done anything this big before in health care and certainly not in the US (outside of the VA), so it’s likely that they didn’t know what they were getting into. The proof though will be in the pudding when it’s all up and running system wide in a year or so, and seeing whether it works as advertised. They’re clearly not turning back
  • KP-CIS (the homegrown system that Epic replaced) was not a $400 million loss for KP, it was much more. Somewhere around $4-5 billion. In 2000-2001, KP-CIS was spending between $500,000 and $750,000 a day.
Highly unlikely. In this period KP went from losing money in 1998ish to making big profits in the early part of this decade. How they would have hid a $4bn loss/write-off in 2002 is unlikely. If CIS was spending $500,000 a day from 1998 to 2002 that still way less than $1 billion ($500K x 365 = $182m. $182m x 5 <$1bn. So the $400m write off sounds much closer to the truth given back of the envelope math.  And according to one interview I read (I think with Halvorson) some of the money they paid IBM in that $400m, they got to transfer over for use of hardware, etc.
  • One of the major problems with KP-IT stems from the continuous turmoil in the organization.
And this makes them different to other large American corporate entities, how? In addition apparently HealthConnect and the KP-IT stack are not the same people (which of course may be part of the problem!!)
  • J. Clifford Dodd was soon discovered to be on the board of directors of one of the companies he was outsourcing to. He first resigned from Kaiser (in an e-mail) and then said that he really meant to resign from his outsourcing company.
Second part is rumor (unless someone kept that email). First part appears to be confirmed by Tanning’s SEC statements referenced elsewhere on HISTalk–he seems to have selected Tanning for work while he was both a director there and was their hirer at KP. I assume that this is why he resigned–on the presumtion that either this was kept from the board/management or ignored by them between April 2002 and last week.
  • Epic outages called "Code White" have increased from just over 9,000 user hours per month in June to over 59,000 last month. When the system is down, no paper or locally stored data is available, so treatment decisions are made without any previously recorded information.
Wiesenthal suggests that this is to do with the power and Citrix issues mentioned earlier and that the major problems were earlier this year. (More details in my interview with him). He claims more than 98–9% uptime since. Someone smart than me can work out how many user hours there are, and how many a single half hour failure adds to that total (as happened this week) and how much that relates to the 99% claimed uptime.
  • The 26,500 concurrent KP users figure isn’t anywhere near accurate – it’s more like 9,000 to 13,000, on average. Saying 24 hospitals are live on "several apps" means they’re live on check in and registration, and maybe a few people are echarting. Those two hospitals that are "completely rolled out" regularly (at least every few days) drop to Code White (back to paper).
More details are in the interview, but Wiesenthal says that the outpatient side of HealthConnect is up everywhere outside Calif and up for 30-40% of both California regions. (That’s were most of the users are of course). Only 2 hospitals in Cal are fully up on Inpatient Epic plus other apps in the suite, but others are coming on board over time. The concept that both hospitals are using paper seems unlikely as Wiesenthal stressed that outpatient clinics on Epic use no paper. Rationally, paper copies of everything for an EMR doesnt make sense. As with the Parkland experience discussed in HISTalk, a strong unbreakable contemporary electronic back up is what’s needed and what Yahoo, Ebay et al do for their businesses.
  • Bruce Turkstra is interim: as soon as they can find someone outside who will take the job, Bruce is gone, too.
Who knows. Certainly doesn’t seem that Dodd’s departure was planned. Wiesenthal stressed that HealthConnect is his baby on the Permanente side and Louise Liang’s on the plan side and Dodd had nothing much to do with it.

TECH/HEALTH PLANS: A Permanente Group Executive speaks

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There continues to be much flack in about the “email heard around the health care IT world” about Kaiser Permanente’s HealthConnect program and its success or lack or it, and its contribution or lack of it to a potential massive shortfall or profit  in the organization’s finances. If you want to know what lots of insiders and outsiders think, go read these comments on KP in this HISTalk post. Suffice it to say that there’s a wide, wide divergence of views on whether Epic is scalable or not, or if anything else would or could work. Given that this is America’s largest health care EMR deployment, it’s not a trivial issue.

But in addition there are wider rumblings that something is going awry at Kaiser Permanente. Given that it’s just coming out the other side (bar the lawsuits) of a scandal where something went very badly wrong in its new kidney transplant program in Northern California, this latest brou-ha-ha is more grist for the mill for the anti-KP folks. I am not one of those, and in fact have been criticized for being too supportive of pre-paid medicine in the past. But I call things the way I see them, and I don’t get any money from Kaiser. So I’m trying to remain “neutral” in what is a highly emotional issue.

Today Andy Wiesenthal, an Executive Director with the Permanente Federation, the umbrella group for the regional PMGs emailed me offering to go on the record. I told him that I would ask about HealthConnect, the kidney transplant fiasco and how TPMG works with the health plan. This podcast is what he had to say when we spoke late Friday evening. It was via cell phone so the sound quality isn’t the greatest.

He was unable to comment on the kidney transplant story, claiming to only know what he read in the papers. But about everything else he had strong and I think relatively balanced opinions–especially as he was the physician executive in Colorado who was in charge of the CIS project that was being implemented system-wide when it was scrapped in favor of the Epic/HealthConnect software system–which he strongly defends.

Whatever your views, it’s very interesting stuff. I hope I asked him the tough questions and in general I think he gave very thoughtful answers. And it’s to his credit that he decided to get his and Permanente’s side of the story out, as they’ve been far too reticent to talk openly in the past. Here’s the interview. There’ll be a transcript as soon as it’s available.

HEALTH PLANS: Legal cons abound in health insurance

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(Hat tip to Don McCanne). Apparently being a scummy insurance company and selling not-quite-fraudulent policies to dumb consumers is all fine and dandy—or at least legal. This is not the first or last we’ve head of this type of thing—a company called Mega Life and Health selling a cut rate policy via commission salesmen to unsuspecting punters. When something really bad happens the punter discovers that the policy is worth basically squat, and they owe $200K plus. The judge says this is America and you should have read the fine print. We all know that the best cons are the legal ones.

There’s a related category of insurers who pay out on small claims but dissapear completely when enough big ones come in. Jon Cohn’s soon to be published book will blow the lid of that bunch (I hope) so I won’t say much about them. But essentially these are all on a sliding scale from California Blue Cross cancelling coverage after the fact, to Golden Rule selling their underwritten products, to the con artists and outright fraudsters. And given the collapsing state of the employer insurance market, and the growth in desperation from people like the couple in this article, I guess it’s only a matter of time before these insurers become a bigger and bigger piece of the market and someone like United HealthGroup buys them.

And if Active Health Management is over on the Yin side of the health insurance world, these shysters are out there on the Yang end. There is a possible solution to the whole thing, but if the responsible heads in the insurer world won’t push for serious reform of their own industry, these kinds of stories will make a government run system much more likely. I suspect I’ll be saying “I told you so” in 2016 or thereabouts

CODA: I missed this at the time, but the (now fortunately dead) Shadegg bill would have aloowed the shysters at Mega and their ilk to do this everywhere, as PBS NOW reported. See the excellent transcript.

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