A Private RLHS—Kaiser Permanente
A few private healthcare systems are developing their own oncology-specific RLHS, including Kaiser Permanente (KP), the nation’s largest not-for-profit healthcare plan, which serves more than 8 million members in nine states and the District of Columbia. With its heavy investment in health services research and health information technology, and its commitment to rapid translation and quality improvement, KP strives to be a RLHS, reported Dr. Wallace, medical director of the organization’s Health and Productivity Management Programs.
“A lot of the learning [in health care] will be dependent on observational research, so plan for it,” Dr. Wallace said. Such planning is proactive and prospective, he stressed, and requires determining what data need to be collected and entered in a database so at a later date one can assess what treatments or treatment processes were most effective and efficient. “There is a cost for us as a society for throwing away data not just for the patient who has a rare disease but for all patients, because if the patient in front of me is a 75-year-old woman who has a history of a heart attack, and she has bad arthritis and seven or eight other nuances, how do I decide how to best deliver her care if I do not have a database that allows me to cull out 100 people just like her to understand the appropriate nuances and choices of therapy? We can do that now and what keeps us from doing that is basically a failure to respond.”
He estimated that about 80 percent of cancer patients can be treated
with standard protocols and “if we can get to the point where those 80 percent take about 30 percent of our effort, then we have a lot of time to deal with the people that need customized care.”
KP has about 200 oncologists working in at least 40 sites. To create more systematic and less variable care, the system brought together a group of its oncologists, nurses, and pharmacists from a variety of different settings to develop more than 300 standard protocols for chemotherapy and clinical trials. These protocols were evidence based, but can be personalized and modified to meet patient variability and individual needs. “We wanted to test the hypothesis that, if we do that, it will lead to appropriate variability rather than random variability for our practice population,” Dr. Wallace said.
All care is electronically documented, including not just what specific treatment is given, but its indication (e.g., whether it is curative, secondline, or palliative). To address safety concerns, there are processes built in to ensure that “when you order a drug, you have absolute confidence that it will be translated into an order that will be translated into a bar code that will correspond to the patient to whom you are giving the drug,” Dr. Wallace said. Providers are also alerted when they approach the near-maximum dose for chemotherapy, and the entire healthcare team can view a treatment plan simultaneously and enter pertinent information electronically.
Kaiser physicians are given regular reports of their cancer care and how it compares to their peers on various measures, such as hospitalization rates, clinical trial enrollments, et cetera. When there is variability within and between practices, the providers are encouraged to try to determine the cause of the variability and what best practices to follow within their office or clinic because, as Dr. Wallace noted, “if you are not using the data to facilitate that conversation, there is no learning. Rapid learning takes place both at the practice level and at the system level.” If there is variability in certain regions and/or practices, KP can focus retraining and education efforts in that area to address the discrepancy in care.
KP has just begun testing its new system for oncology care and found that between 63 and 84 percent of its standard treatment protocols were used without modification. “This means physicians can focus their time on customizing care so care is patient driven, not clinician driven,” Dr. Wallace said. Encouragingly, new developments in chemotherapy were rapidly translated in the system. Within just a week of its being published that lower-dose Avastin was as effective at treating colon cancer as high dose, that shift in treatment began diffusing through the practices that are a part of KP,
resulting in a savings of about $200,000 per practice site (i.e., a dividend in a capitated system such as Kaiser’s), Dr. Wallace reported.
KP also captures patient ethnicity and race to examine health disparities and determine patient subsets that it is failing to reach with its efforts to improve care. For example, it found that Hispanics in general, especially Hispanic men, are less likely to undergo colon cancer screening than other population subgroups, so KP is trying to target its colon cancer screening messages more appropriately to those men. Collecting data on race and ethnicity can also reveal treatment differences. “Knowing race and ethnicity of patients is part of being able to do accurate, prospective, observational research. I think that this type of capability is going to change how we are going to do things,” Dr. Wallace said.
KP is also beginning to look at population health and has found that its patients in southern California were more likely to survive breast, colon, melanoma, and lung cancer at all stages than indicated in SEER data collected from patients from the same geographic area. This is worth exploring further, Dr. Wallace noted.
Dr. Wallace finished his presentation by stressing the need to design healthcare systems so that “knowledge generation is just an expected byproduct of care” collected in all sites, rather than in unique sites. “We need to proactively recognize that observational studies are how we are going to build the knowledge base going forward, and plan to do that in a structured and thoughtful way,” he said.