KAISER HAS ACHES, PAINS GOING DIGITAL
Kaiser Permanente’s $4-billion effort to computerize the medical records of its 8.6 million members has encountered repeated technical problems, leading to potentially dangerous incidents such as patients listed in the wrong beds, according to Kaiser documents and current and former employees.
At times, doctors and medical staff at the nation’s largest nonprofit health maintenance organization haven’t had access to crucial patient information, and system outages have led to delays in emergency room care, the documents show.
For the record:
12:00 a.m. Feb. 17, 2007 For The Record
Los Angeles Times Saturday February 17, 2007 Home Edition Main News Part A Page 2 National Desk 1 inches; 31 words Type of Material: Correction
Electronic medical records: An article in Section A on Thursday about Kaiser Permanente’s electronic medical records project misspelled the name of the company’s chief executive. It is George Halvorson, not Halverson.
Other problems have included malfunctioning bedside scanners meant to ensure that patients receive the correct medication, according to Kaiser staff.
Concerns about Kaiser’s effort, called Health Connect, recently led the California Department of Managed Health Care to request information about the project, a first step before a possible formal investigation.
The HMO’s problems come as it plans to expand the computerized system over the next two years to nearly three dozen more hospitals -- most in California -- where the sickest patients are treated and ensuring patient safety is most difficult. Currently, the system is fully rolled out only in two hospitals, Baldwin Park Medical Center and South Sacramento Medical Center.
Kaiser’s effort, one of the largest and most ambitious electronic medical records projects in the country, is seen as a possible national model. With evidence suggesting that digitized recordkeeping can lower health costs and save lives, President Bush is pushing for every American to have an electronic medical record by 2014.
But the glitches illustrate the difficulties a massive healthcare provider might encounter trying to implement a complex computerized system.
Kaiser officials acknowledge that Health Connect has had technical challenges but say those have been resolved and patient safety has never been compromised. Patients should feel safe getting care at any Kaiser facility, they say.
They add that medical staff revert to paper records and established downtime procedures when the new computerized system isn’t available.
“This is one of the largest and most ambitious efforts anywhere in the world to modernize our healthcare system,” Kaiser Chief Executive George Halverson said. Considering that, he said, “it couldn’t be going better.”
Kaiser’s size -- millions of members, 12,000 physicians, 431 medical offices and more than three dozen hospitals covering nine states -- makes trying to go paperless a Herculean effort. Some problems are inevitable.
And Health Connect has had early successes. During routine data analysis using its digital records two years ago, Kaiser was the first to identify problems with Merck & Co.'s arthritis drug Vioxx, which was later pulled from the market after a study showed it increased the risk of heart attack.
Because the computerized system reminds women leaving doctors’ offices to return for their mammograms on time, the number of women receiving timely tests has increased throughout the system, Kaiser said.
Moving beyond paper
Still, Kaiser’s recent problems do not bode well for American medical providers as they seek to automate their record-keeping, analysts say.
Nine out of 10 doctors nationwide continue to use paper records, making it difficult for providers to share patient information. Computerized records that contain patient appointments, medical charts and electronic prescriptions have the potential to speed up the delivery of care, lower costs and reduce routine errors that are blamed for 98,000 deaths a year in the U.S. -- with 7,000 from prescription mistakes.
Computer-linked health systems also may help reveal the forces pushing up costs, make it easier to analyze the risks and benefits of prescription drugs and improve the understanding of dramatic variations in medical care and access to it.
They could reduce the nation’s $1.9-trillion healthcare bill by as much as $81 billion a year, according to a Rand Corp. report. The question is how easily and safely providers can make the technological transition.
There are examples in which poorly designed electronic medical record systems may have increased errors rather than reduced them.
A 2005 study in the journal Pediatrics found that when the Children’s Hospital of Pittsburgh installed an electronic medical system several years ago, mortality increased from 2.8% of patients to 6.6%.
Four years ago, Cedars-Sinai Medical Center in Los Angeles suspended its multimillion-dollar computerized physician order system after doctors complained it was possibly endangering patient safety and required too much work.
“The challenges of [building these systems] have been way underestimated,” said Dr. Ashish Jha, assistant professor of health policy and management at the Harvard School of Public Health, who didn’t comment on Kaiser’s program specifically because he hadn’t studied the project.
Internal Kaiser “Availability Trend” reports documenting the reliability of Health Connect over nine months last year found the system was available 88% of the time some days, and less than 80% in certain locations.
Experts say that rate is considered very low for the healthcare industry, which increasingly is aiming for systems with availability in the “multiple nines” or 99.99%.
The risk of errors rises when medical staff switch procedures, like reverting to paper records.
Kaiser said its reliability statistics included all outages, even minor ones, and therefore were artificially lower than others in the industry.
A 772-page problem report covering Feb. 27 through Nov. 5 of last year showed nearly two dozen reported instances in which Health Connect’s unreliability may have risked patient safety. These were discussed in notes contained in the documents that summarized medical staff’s concerns and opinions from outside experts.
The incidents include:
* On March 14, care for a patient at an emergency room in Baldwin Park was delayed when the system shut down for 1 hour and 19 minutes.
* On April 17, a pharmacist at Kaiser’s Zion Medical Center in San Diego, where the system has been partially rolled out, reported a “potential patient safety issue” when an order of medication for an infant in intensive care wasn’t completed because the system went down for 19 minutes, forcing the staff to revert to manual processing.
* On Sept. 6, staff at the South Sacramento hospital reported that lab orders were intermittently dropped in the system. That forced workers to devise a patchwork solution to ensure the orders were completed until the problem was resolved, 5 hours and 29 minutes later.
By far, the biggest challenge occurred over several weeks in April and May, when much of the system was repeatedly unavailable, including once for nearly a day and another time for more than two days.
The main problem originated at Kaiser’s primary data center in Corona, which houses Health Connect servers and backup power supplies. Poor design of the system’s technology infrastructure and power problems led to a series of crises, according to documents and interviews with Kaiser employees.
It was during this time that a rash of potentially risky events occurred, documents and Kaiser medical staff say. A problem report during that time listed two events. In one, patients at an unnamed Southern California hospital were listed in the wrong beds, potentially not getting the treatment they needed and possibly “receiving the incorrect medications.” In another case, staff at the Baldwin Park Medical Center reported lab workers may have missed crucial patient requests from doctors.
Bruce Turkstra, Kaiser’s interim chief information officer, confirmed the Corona mishap and said, “There is no excuse for it.” But officials said Kaiser quickly corrected the problem by expanding its server center to another location in Los Angeles and fixed the underlying problem that led to the shutdown.
Turkstra added that the HMO had methodically researched all reported possible safety issues and, when needed, corrected the problems. He said the system’s availability has improved and now averages 99.2%.
But several current and former Kaiser employees say the HMO hasn’t corrected all its problems with Health Connect.
“We were told this would be a panacea, but it’s not that,” said Justen Deal, a Los Angeles Kaiser project supervisor who worked on the new system. He was placed on leave in November, after sending a critical e-mail about the project to most of the organization’s 153,000 employees.
“The truth is there are a lot of people inside the company who are worried the project is costing too much and is putting patients at risk,” Deal said.
Adrienne Clements, a nurse at South Sacramento Medical Center, said parts of the new system work better than older paper records. But she worries about several recent problems, including malfunctioning bedside scanners. Clements said the hospital was considering replacing the machines.
Kaiser has a choppy history of trying to go digital. In 2002, it canceled a five-year effort to switch to electronic records, writing off $442 million. Executives discovered it couldn’t accommodate Kaiser’s size.
In November, the HMO’s then-chief information officer, J. Clifford Dodd, who arrived in 2002 largely to help implement Health Connect, left the organization. Kaiser said the departure wasn’t related to problems with Health Connect.
Health Connect also is costing a lot more than anticipated. Its current price tag is more than double its original $1.8-billion estimate, calculated in February 2003. Halverson said costs rose in part because Kaiser decided to add electronic medical records in all its hospitals later that year. The board approved a $3.2-billion budget in September 2003. But officials can’t fully explain why the budget figure they cite now is $800 million higher.
Nonetheless, the added costs come just as Kaiser faces myriad other financial pressures. That has forced it to make wide-ranging cuts, which have been felt by Health Connect, employees said.
Kaiser recently demanded and received a rate cut from its technology vendors, and some IT employees took as long as a week off without pay.
Some current and former employees worry that such cuts may add to Health Connect’s problems. “This is the worst [technology] project I have seen in my 25 years in the business,” said Andrew Brewer, a systems analyst for Kaiser who worked on the project for two years before voluntarily leaving the HMO last week.
Brewer said the recent cuts saddled him and his colleagues with too much work and have led to employees’ being asked to take on tasks they haven’t been trained for.
“This is not the way things should be done on projects this big or this important,” he said.