Re: Kaiser-ized

[Guest guest]

,

I was wondering how you may be adjusting to the whole Kaiser thing especially since you have been so proactive in the solo micropractice concept. Thanks for the update!

To: IMPCore ; Sent: Thursday, October 30, 2008 1:05:37 AMSubject: Kaiser-ized

OK gang, it has been a week and a half at Kaiser and I am in complete culture shock. Here are a few tidbits that stand out as thought provoking coming from a 500 pt solo solo micropractice.

1. I was just handed a panel of 700 patients. I'll get 700 more in January. I start with seeing one patient an hour and slowly ramp up to three an hour by March. Total adjusted panel is to be about 2150 eventually. My schedule includes four scheduled phone encounters set up by the nursing pool for isues that need a phone call and about 4-5 office slots held for open access. The first hour of the day is reserved for "desktop medicine" where I sit in my office going over my inbox and log into the phone system so in case any of my personal patients happen to call, they are automatically routed to my phone for direct access.

2. The clinic building I work at has two family medicine practices with about 6 docs each, an internal med practice, a peds practice, and an OB practice. There is an on site pharmacy, lab, x-ray, and minor trauma center staffed by PAs. The building services 50,000 people (members)

3. Across from my office is the nursing pool for my FM practice. Three of them sit in a dark room and do telephone medicine all day long including refilling many prescriptions by protocols. Any questions get shuttled to MD's via the EMR.

4. At my disposal is a Diabetes Care manager, an Asthma Care manager, a Senior Care Manager, a Chronic Care manager, a Weight loss manager. All DM patients on insulin are automatically followed by he DM care manager. The manager can order labs, arranges education, does sit down meetings with members, and even titrates some DM medications per protocols. I just get little notices in my inbox when something changes. There is a similar program for secondary prevention CAD patients that have their lipids, Bp's tracked and medications adjusted without me doing a thing. Disease registries drive all of the data tracking and this info is available to anyone in the system.

5. Referrals to other specialties are done with a simple order in the patient's chart. Referrals go to departments, not specific physicians. Internal secure email and instant messaging systems are available for official and non official questions to just about any specialty you want. Everything is in the same system, and easily trackable in the EMR.

6. During my orientation, I saw a ton of practice metrics. They measure everything. They just instituted a new "Advanced Access" system last september. Many apts are reserved for same day access. Metric measured is number of days to the third available apt. My practice averages about 2.4 days. HEIDIS quality measures are quoted everywhere you go. Monthly reports of all of the measures are circulated per department with little Green, Yellow, and Red markers to see how you are doing in each category.

7. On my first day. One of my newly assigned patients died with an appointment to see me scheduled for the following day. One of my first tasks was to fill out his death certificate. ......omen?

8. This Saturday morning I will be participating in the second flu clinic of the season. Traffic gets routed into the parking lot in single file lines and vaccines are given in "drive through" efficiency.. Pull up, put it in park, roll up your sleeve, and presto you're done. They did 75,000 of these two weeks ago throughout the Denver area.

So after a week and a half, I am full of mixed emotions. On one hand, I am mourning the independence of my IMP practice and incredible satisfaction I had in building it and doing it by myself (with all of your help of course). On the other hand, I am completely blown away at the sheer complexity of this system and have been very impressed at the resources given to preventative and chronic care managment. This is going to be a very interesting experience in any case. Sorry for the long email, but I thought some of you might enjoy it. Re: [iMPCore] AAFP proprosal want feed back just thoguht of this

I submitted two prposals( access stuff , taking care of people in pain) butI have been toying with something for a while just to make my own office work Suddenly occurs to me that i can write up as a proposal Want help. will also ask Lou. Hope SCOTT is listening This may have been actually a Larry Lyon thing from imp camp 1 butI need a cool title and any feedback to tune it upsoThe topic is a kind of efficiency /information flow thing Information comes in to the office in certain finite numbers of ways Fax mail Phone Email and then lets say dialogue- from patietns and maybe form staff( messages /info) Info must go out of office in finite ways fax to consultants results to patietns etc How do i get them to flow back and forth or match

up? example Pulmonary fucntion testsMany offices have a stack of forms( where do you keep them? one place or some in each room and a stash in a closet or one master with occaisional replenishment ?Replenishment is kept trackof by who? stocking is done by who? then doc fill sit out an d it goes into? a fax? paper to chart? or to hosipital mail and we must write down the form was sent?The form gets lost by someone How to reconstruct the data in it?)hence emr but how do i do that task ?the form is kept where?If i scan it in I cannot "take it out" and write on itI can write on it if i receive it as a fax Then I must know where it is int he fax folder to find it in a jiffy next time I need it Or, easier in the long run but harder to get it goign, have it in the emr with info

preloaded into it by the templating an emr can do BUt hospitla wants their form- theri own excactly ; do i type in a facsimile( the residecny here spent a fortune having someone reconstruct the states' Bright Future well child forms) Can't I make that a talk and teach people how to think about it? I envision a matching column as a teachig tool on the left are the ways info comes inon the right a colum of how info goes out If i get soeinthing in one of theways onthe left say email how tdo i get it into emr If i get info as a fax how do i email that results or info to someoneMost of this is about software but it is about thinking about how you do your owrk and about eficiencyHelp /volunteers /criticisms / a cool title pleae?I

have today to do this PS SHARON YOU DID do good by giving out 4 flu shots at home You are always coolJean

On Tue, Oct 28, 2008 at 5:37 PM, Dr. Gordon <gmoore@idealhealthn etwork.com> wrote:

OK, so who wants to go but has no proposal in the hopper and would like to do one with me?I'm presuming that I'll do the same ones I did with Sharon this past year (if that's cool with you Sharon).

This past year I did an IMP overview and can put someone else up there with me.

I can do others too….

G-- If you are a patient please allow up to 12 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD ph fax

-- If you are a patient please allow up to 12 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD ph fax

[Guest guest]

,As someone who has come from the other direction (from Kaiser to IMP) 4 years ago, I understand and recollect a lot of what you are describing. Granted, Kaiser Southern California is a slightly different beast that Kaiser Colorado but I always had the impression that Kaiser Colorado was more progressive and willing to experiment with new things. It is very complex, bureaucratic and has thrown itself 100% into going electronic with an EMR they had promised us since 1992. I think it does a lot of things right with a major focus on preventive care and registries to track performance. Because the main decision-makers are physicians and because it is a non-profit, I felt like it had its heart in the right place and was as ideal as corporate medicine could get. I trust Kaiser enough that we still have it as our family's insurance plan through my wife's job.I left Kaiser mainly because of the lack of time available to do what I considered a good job. When I used to moonlight at Kaiser, I would have to shift back into "Kaiser mode" and be very direct in my questions and zoom in to the most likely diagnosis as soon as I could. If there was time leftover, I would do some preventive care stuff like check when the last mammogram or cholesterol test was done. Some doctors do very well at Kaiser, even thrive (to borrow their current slogan). It pays very well with lots of benefits. If I ever had to close my practice, I would probably go back to Kaiser despite the lack of patient contact time.Where I was, many doctors were content to go with the flow and just do their jobs and go home. A go-getter like you, , with new ideas and enthusiasm to make things better can move quickly up the Kaiser ranks, if you are so inclined. Maybe you can figure out a way to start an "IMP within KP". But beware the "Kaiser Reward": the more efficient you are in seeing patients, the more patients you get to see. Here on the listserve, it is better known as the Hamster Wheel. Take care! SetoSouth Pasadena, CAOK gang, it has been a week and a half at Kaiser and I am in complete culture shock. Here are a few tidbits that stand out as thought provoking coming from a 500 pt solo solo micropractice.1. I was just handed a panel of 700 patients. I'll get 700 more in January. I start with seeing one patient an hour and slowly ramp up to three an hour by March. Total adjusted panel is to be about 2150 eventually. My schedule includes four scheduled phone encounters set up by the nursing pool for isues that need a phone call and about 4-5 office slots held for open access. The first hour of the day is reserved for "desktop medicine" where I sit in my office going over my inbox and log into the phone system so in case any of my personal patients happen to call, they are automatically routed to my phone for direct access. 2. The clinic building I work at has two family medicine practices with about 6 docs each, an internal med practice, a peds practice, and an OB practice. There is an on site pharmacy, lab, x-ray, and minor trauma center staffed by PAs. The building services 50,000 people (members)3. Across from my office is the nursing pool for my FM practice. Three of them sit in a dark room and do telephone medicine all day long including refilling many prescriptions by protocols. Any questions get shuttled to MD's via the EMR. 4. At my disposal is a Diabetes Care manager, an Asthma Care manager, a Senior Care Manager, a Chronic Care manager, a Weight loss manager. All DM patients on insulin are automatically followed by he DM care manager. The manager can order labs, arranges education, does sit down meetings with members, and even titrates some DM medications per protocols. I just get little notices in my inbox when something changes. There is a similar program for secondary prevention CAD patients that have their lipids, Bp's tracked and medications adjusted without me doing a thing. Disease registries drive all of the data tracking and this info is available to anyone in the system.5. Referrals to other specialties are done with a simple order in the patient's chart. Referrals go to departments, not specific physicians. Internal secure email and instant messaging systems are available for official and non official questions to just about any specialty you want. Everything is in the same system, and easily trackable in the EMR.6. During my orientation, I saw a ton of practice metrics. They measure everything. They just instituted a new "Advanced Access" system last september. Many apts are reserved for same day access. Metric measured is number of days to the third available apt. My practice averages about 2.4 days. HEIDIS quality measures are quoted everywhere you go. Monthly reports of all of the measures are circulated per department with little Green, Yellow, and Red markers to see how you are doing in each category.7. On my first day. One of my newly assigned patients died with an appointment to see me scheduled for the following day. One of my first tasks was to fill out his death certificate.......omen?8. This Saturday morning I will be participating in the second flu clinic of the season. Traffic gets routed into the parking lot in single file lines and vaccines are given in "drive through" efficiency.. Pull up, put it in park, roll up your sleeve, and presto you're done. They did 75,000 of these two weeks ago throughout the Denver area. So after a week and a half, I am full of mixed emotions. On one hand, I am mourning the independence of my IMP practice and incredible satisfaction I had in building it and doing it by myself (with all of your help of course). On the other hand, I am completely blown away at the sheer complexity of this system and have been very impressed at the resources given to preventative and chronic care managment. This is going to be a very interesting experience in any case. Sorry for the long email, but I thought some of you might enjoy it. Re: [iMPCore] AAFP proprosal want feed back just thoguht of this I submitted two prposals( access stuff , taking care of people in pain) butI have been toying with something for a while just to make my own office work Suddenly occurs to me that i can write up as a proposal Want help. will also ask Lou. Hope SCOTT is listening This may have been actually a Larry Lyon thing from imp camp 1 butI need a cool title and any feedback to tune it upsoThe topic is a kind of efficiency /information flow thing Information comes in to the office in certain finite numbers of ways Fax mail Phone Email and then lets say dialogue- from patietns and maybe form staff( messages /info) Info must go out of office in finite ways fax to consultants results to patietns etc How do i get them to flow back and forth or match up? example Pulmonary fucntion testsMany offices have a stack of forms( where do you keep them? one place or some in each room and a stash in a closet or one master with occaisional replenishment ?Replenishment is kept trackof by who? stocking is done by who? then doc fill sit out an d it goes into? a fax? paper to chart? or to hosipital mail and we must write down the form was sent?The form gets lost by someone How to reconstruct the data in it?)hence emr but how do i do that task ?the form is kept where?If i scan it in I cannot "take it out" and write on itI can write on it if i receive it as a fax Then I must know where it is int he fax folder to find it in a jiffy next time I need it Or, easier in the long run but harder to get it goign, have it in the emr with info preloaded into it by the templating an emr can do BUt hospitla wants their form- theri own excactly ; do i type in a facsimile( the residecny here spent a fortune having someone reconstruct the states' Bright Future well child forms) Can't I make that a talk and teach people how to think about it? I envision a matching column as a teachig tool on the left are the ways info comes inon the right a colum of how info goes out If i get soeinthing in one of theways onthe left say email how tdo i get it into emr If i get info as a fax how do i email that results or info to someoneMost of this is about software but it is about thinking about how you do your owrk and about eficiencyHelp /volunteers /criticisms / a cool title pleae?I have today to do this PS SHARON YOU DID do good by giving out 4 flu shots at home You are always coolJeanOn Tue, Oct 28, 2008 at 5:37 PM, Dr. Gordon <gmooreidealhealthnetwork> wrote:OK, so who wants to go but has no proposal in the hopper and would like to do one with me?I'm presuming that I'll do the same ones I did with Sharon this past year (if that's cool with you Sharon).This past year I did an IMP overview and can put someone else up there with me.I can do others too….G-- If you are a patient please allow up to 12 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD ph fax -- If you are a patient please allow up to 12 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD ph fax

[Guest guest]

Dear ,

I did two months of Kaiser in peds/hospital during my residency, one of the outside rotations. Actually, it was a pretty good rotation: I liked the easy access to chronic disease plans and enjoyed working with some of the more experienced MDs who had learned to navigate the system and could get more expensive and difficult to approve procedures done. However, I noticed that the patients of less experienced MDs were in hospital because the cheapest alternatives had been done and had not worked. The system is rigid, however, and not really suitable for small towns or rural areas. Here, Kaiser patient have to travel many miles, and getting copies of their records out of the system is nearly impossible. Kaiser is the quintessential "silo" information system.

You ought to do well, I would think. I am glad to see they let you work up in stages. Good luck.

Joanne Holland

OK, so who wants to go but has no proposal in the hopper and would like to do one with me?I'm presuming that I'll do the same ones I did with Sharon this past year (if that's cool with you Sharon).

This past year I did an IMP overview and can put someone else up there with me.

I can do others too….

G-- If you are a patient please allow up to 12 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD ph fax

-- If you are a patient please allow up to 12 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD ph fax

[Guest guest]

Great update . Best of luck to you and Bessie--quite the move. Sounds like you are doing well!

For me too, going the opposite direction of yourself (moving from large multispeciality to IMP) I see all of the many layers of good and bad of both systems. In big systems, resources are incredible and ease of getting work done fantastic.

I'm a little too rebellious and couldn't work within the large system where change is a slow process, but I think you have a better head for that and might truly become a great leader in your group if you so desire.

The main reasons I left were too many overworked doctors who did their work more as check in and check out for the day, I wanted more time with patients and wanted the freedom to see folks regardless of their insurance status. I am thrilled that I had the experience of a big group however. But must say, I'm completely delighted to now be working in an IMP.

Look forward to on-going conversations of how IMP can influence the big groups and big groups can inform IMPs.

As a side, it's been great with my husband working as a hospitalist. I think between both our worlds we're helping to improve communication between the outpatient and in patient world. So always lots to learn from all area.

cheers to you,

melissa weakland

ballard neighborhood doctors

seattle WA

OK, so who wants to go but has no proposal in the hopper and would like to do one with me?I'm presuming that I'll do the same ones I did with Sharon this past year (if that's cool with you Sharon).

This past year I did an IMP overview and can put someone else up there with me.

I can do others too….

G-- If you are a patient please allow up to 12 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD ph fax

-- If you are a patient please allow up to 12 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD ph fax