Significant savings to the Kaiser Permanente health plan and dramatic increases in physician productivity have been realized in the Colorado Sleep Apnea/Sleep Disorders Clinic through improvements in the collection and application of comprehensive and consistent patient data. Cost savings are calculated at $0.02 PMPM due to reduced intra-Kaiser Permanente referrals and Pulmonologist productivity increases. Pulmonologist productivity gains are estimated by the involved physicians at 300 percent. Quality of care improvements include more rapid diagnosis, reduced data gaps, reduced referrals, and faster initiation of treatment plans. These direct benefits were obtained through 1) automating and systematizing patient data collection with a simple tablet computer, and 2) the use of group medical appointments conducted by respiratory therapists. Several additional benefits unrelated to the data collection process changes were also realized. These additional benefits derived from other modifications to the Clinic’s approach to sleep disorder diagnosis and treatment.

The Colorado Region of Kaiser Permanente as of November, 2003 totals approximately 432,000 members. The majority of sleep disorder and suspected sleep apnea referrals from primary care Permanente Medical Group (PMG) physicians in the region are made to Pulmonologists, with occasional referrals to ENT surgeons when the need for surgical correction is obvious. The Department of Pulmonary, Critical Care, and Sleep Medicine is located at the 20th Avenue Medical Center in Denver and sees patients referred from the Denver/Boulder area.

This background section is adapted from content obtained from the website of the National Sleep Foundation (www.sleepfoundation.org).

Excessive Daytime Sleepiness (EDS) is a condition in which an individual feels very drowsy during the day and has an overwhelming urge to fall asleep, even after getting enough nighttime sleep. People with EDS frequently doze, nap, or fall asleep in situations where they need or want to be fully awake and alert. This can be particularly dangerous at times, such as when driving a car or operating hazardous machinery.

EDS can interfere significantly with a person's ability to concentrate and perform daily tasks and routines. People with EDS often report feelings of low self-esteem, frustration, and anger about being misunderstood and regarded as unintelligent, lazy or uninterested in learning. They also report having difficulty with relationships -- in social situations, in the workplace, and within the family.

EDS is a sign of an underlying medical condition, typically a sleep disorder. The following sleep disorders are often associated with excessive daytime sleepiness: Narcolepsy, Sleep Apnea, Periodic Leg Movements in Sleep (PLMS), Restless Legs Syndrome (RLS), and Circadian Rhythm Disorder

Sleep apnea occurs in all age groups and both sexes but is more common in men (it may be under diagnosed in women) and possibly young African Americans. It has been estimated that as many as 18 million Americans have sleep apnea. Four percent of middle-aged men and 2 percent of middle-aged women have sleep apnea along with excessive daytime sleepiness. People most likely to have or develop sleep apnea include those who snore loudly and also are overweight, or have high blood pressure, or have some physical abnormality in the nose, throat, or other parts of the upper airway. Sleep apnea seems to run in some families, suggesting a possible genetic basis. (Source: www.sleepfoundation.org)

Prior to initiating the new intake methodology described below, the capacity of the Sleep Apnea/Sleep Disorders Clinic was 60 patients per month. Prior to implementing the new data collection model, patients referred to a specialist for sleep disorders or suspected sleep apnea were seen by a Pulmonology or Otorhinolaringology (ENT) physician, depending on the referrals initiated by the primary care provider. Most patients were referred to Pulmonology. Some patients were referred to both specialists by the primary care physician, creating duplication, delays, and additional cost.

In Pulmonology, the physician conducted the intake interview and gathered pertinent data utilizing paper forms and handwritten notes which were later dictated. Pulmonologists believe that under the old system, interviews were subject to the variability of a qualitative process and that dictations also varied based on recall of the interview and the quality of handwritten notes. Sleep studies were conducted on an outpatient basis by referral to one of two local hospitals, typically following the initial physician interview.

In 1997, several Kaiser Permanente clinics were utilizing an automated (rather than paper) form of the Quick Psycho-Diagnostic Screening Panel as supplied by Patient Tools, Inc. (PTI), Denver, Colorado. Kaiser Permanente quality improvement and Innovations Center personnel shared details of PTI’s automated data collection system with the Sleep Disorders/Sleep Apnea program Medical Director. The Medical Director saw applications for automating data collection in the Sleep Disorders Program and worked with PTI to develop an automated patient intake and data collection process specific to sleep disorders.

Patient Tools, Inc. worked with the Sleep Disorders Program to automate the Clinic’s paper intake questionnaire and implement two automated lifestyle and sleep assessment surveys. The total automation process resulted in a survey of over 100 questions answered by the patient on a simplified tablet computer.

Upon completing the automated questionnaire, the tablet device is “docked” to a data-transfer base linked via personal computer (PC) to off site calculation software and a database that stores all patient data. Calculated values and summary information is transmitted back to the Clinic PC in the form of a one-page document for the physician’s use at the first appointment.

The process for intake interviews was significantly improved according to the participating physicians. The data collection tablets provided complete and consistent data – the questionnaires are the same for every patient and the questionnaire logic prohibits question skipping.

With the tablets collecting complete and consistent data for every sleep disorder/sleep apnea patient, the Pulmonologists felt comfortable in allowing an experienced Respiratory Therapist (RT) to conduct the first patient visit. This first visit consists of data collection, a video on sleep disorders, patient education, and a group discussion.

To increase clinic throughput, reduce appointment backlogs, and increase patient satisfaction, the physicians determined that group medical appointments (GMAs) were feasible. Following implementation of the new data collection methodology, up to four patients were scheduled for the same group appointment. This 4-person GMA has worked successfully for the past six years. According to Dr. Stelzner, the Medical Director, savings derived from the RT-led GMA would have been impossible without the data consistency and completeness provided by the automated tablet-based tool.

In addition to implementing the new, streamlined data collection process, Pulmonologists changed the method of obtaining sleep studies. In place of hospital outpatient sleep studies (estimated to cost Kaiser Permanente approximately $2,000 each), home sleep studies were instituted. Patients for these studies were instructed and equipped for the home sleep study by Kaiser Permanente respiratory therapists at the time of the group medical appointment. According to the Clinic Medical Director, high sleep disorder scores on the automated assessment help support the validity of the home sleep study.

A second process change implemented as part of the modifications concerned the trial of Continuous Positive Airway Pressure (CPAP) during sleep to attempt to alleviate symptoms. CPAP treatment is now initiated the same day as the first Pulmonologist appointment. Patients are tried on CPAP first, before considering surgery. According to Dr. Stelzner, “When we send a patient to ENT now, they know it is for surgery, and all the up front evaluation is done, the patient has had their sleep study, and they failed CPAP. Our modified approach save the ENT physicians time too.”

The direct savings to Kaiser Permanente Colorado Region due to the computerized intake and assessment data services accrued from two sources. First, the referral process was streamlined by eliminating dual referrals to both Pulmonology and ENT. With better data, Pulmonologists reduced ENT referrals to only those patients clearly in need of surgical intervention, for example, for grossly enlarged tonsils. When referrals to ENT were necessary, the ENT physicians benefited from the extensive workup and sleep data obtained in Pulmonology. The need for an ENT physician available on call to the Sleep Disorders/Sleep Apnea clinic for patient evaluation was also reduced.

The second area of direct savings accrued from the higher productivity of the Pulmonologists who were, with better patient data in hand, able to see approximately four times as many patients in the same clinic hours per week. The length of the initial patient visit conducted by the Pulmonologists dropped from an average of 60 minutes to an average of 15 minutes, thus yielding a 300 percent increase in physician productivity.

Combined, these two savings are estimated to have saved Kaiser Permanente over $100,000 in 2003, or the equivalent of $0.02 per member per month (PMPM). Savings for the entire project totaled $5,000,000 over the first five years.

Savings to patients referred for sleep evaluation include both time and money from reduced waiting times for evaluation appointments, faster diagnosis, and more rapid implementation of treatment. These savings were not quantified.

According to the Medical Director of the Sleep Disorders/Sleep Apnea Program, the collection of patient data in a systematized and automated manner has had several benefits to quality of care:

• Patient data is collected consistently. Each patient answers the same 100+ questions and completes the same diagnostic assessment questionnaires.
• Patient data is complete. The logic within the tablet does not allow for skipping questions. The Program’s Medical Director states, “Key data elements in the intake process are never missed now due to the programmed question sequence of the data tablet.”
• Patient data from assessment questionnaires can be trended for a single patient longitudinally.
• Questionnaire and assessment data from all patients can be manipulated, graphed, analyzed, and even exported to other software.
• All patient data is maintained in a single relational database for research and analysis purposes.
• Referred patients are assessed, tested, and begun on treatment more rapidly than before due to the faster throughput of the Clinic.
• The automated intake questionnaire provides more detailed patient data than paper-based systems resulting from computed measures and scores.
• Standardization of patient sleep data collected with the automated system allows for comparisons of data across practices within an organization or across organizations to foster development of national comparative data.

Revisions to other aspects of the patient care process have yielded additional quality of care benefits. One example concerns the implementation of CPAP treatment. Under the previous system, and outside vendor was used to initiate in-home CPAP. Under the current system, CPAP masks are fitted in the Sleep Clinic by trained respiratory therapists, resulting in a higher rate of patient success. CPAP treatment is now initiated the same day as the initial physician visit.

Physicians utilizing the tablet-based data collection system report several benefits. First, productivity is greater due to the use of group medical appointments and the efficiency of having a comprehensive assessment completed prior to meeting the patient in the exam room. Second, physicians report increased job satisfaction with the elimination of repetitive questioning of patients (now handled by the computerized intake and assessment). Dictation time has been significantly reduced with the one-page assessment report provided by the Patient Tools system now in physicians’ hands. Third, outcomes management and treatment protocol reviews can be based on large quantities of reliable data.

Please refer to the Appendix for a sample summary report of the data provided to the Pulmonologist by the tablet-based system. The results of the home sleep study accompany this report, providing the Pulmonologist with a comprehensive picture of the patient’s sleep data at the time of the first physician contact. A shorter and more focused individual medical appointment with the Pulmonologist takes place. Referrals to ENT surgery are reduced, but extremely efficient when they do occur.

As of early December, 2003, the Sleep Disorders/Sleep Apnea Clinic of the Kaiser Colorado Region has collected questionnaires and assessments on 5,316 patients seen since 1997 (3,171 males and 2,145 females). All data collected by the tablet-based intake methodology is available to the Pulmonologists for research, analysis, and other uses via a secure, HIPAA-compliant, web-enabled database maintained by the vendor, Patient Tools, Inc. Selected items of the Kaiser Permanente medical record populate this database, however patient name and address are never one of the shared data elements. Next steps in advancing the utility of the data include delivering each patient’s assessment to their Kaiser Permanente medical record in electronic format.

Dr. Stelzner believes that such databases can be useful to Kaiser Permanente researchers and quality improvement staff due to the completeness, comprehensiveness, and digital format of the data collected via the intake tablet system. Return visit data and progression of patient progress over time (such as that measured by various lifestyle and symptomatology scores) can also stored in the same database.

The success of the intake process improvements has motivated Dr. Stelzner to look at other patient care situations in which better data “up front” can reduce morbidity, mortality, and costs. His next focus for automating and systematizing care will likely be the need for prophylactic beta blockers to reduce the incidence of perioperative myocardial infarction. With present paper-based interview and intake assessment procedures, he estimates avoidable myocardial infarctions are occurring due to missed risk factors in his metro Denver hospitals.

Thomas J. Stelzner, M.D.
Department of Pulmonary, Critical Care, and Sleep Medicine
Kaiser Permanente
1375 E. 20th Ave. 2nd Floor
Denver, Colorado 80205
303.861.3640

Alan D. Malik, Ph.D.
CEO
Patient Tools, Inc.
655 Broadway Suite 600
Denver, Colorado 80203
www.patienttools.com
800.745.9186

A Family Practice physician is saving an estimated 3.3 patient contact hours per week by utilizing an automated system for administration of a psychological disorder screening questionnaire. At a time value of $150 per hour, the physician calculates the automated system equates to a value of $24,000 gained versus a hardware, software, and assessment administration fee outlay of $3,000 per year, a benefit-to-cost ratio of 8:1. Although insurance reimbursement for assessment administration in the office is rare, the improved documentation of the office visit justifies coding of higher CPT visit levels in many patients.

The family practice office experiencing the gains and benefits discussed below is a solo practitioner office in Plantation, Florida. The office, consisting of one physician and one nurse practitioner, sees over 200 patients per week.

Primary care physicians today are seeking ways to increase revenue, hold down costs, and be far more efficient in the office. Automating clerical and routine tasks is one opportunity to gain efficiency.

As noted by consultant Nathan Kaufman, Senior Vice President for health care strategy at Superior Consultant Company, San Diego, “Physicians nationwide are not happy, and the reason is that their business model is under severe stress...the prospects do not look good for the immediate future if physicians do not change their business strategy.” In addition to first negotiating reasonable contract reimbursements, Kaufman goes on to note, “The second strategy is to focus on efficiency. Particularly in primary care...it is essential that the physician see at least three patients per hour. In order to reach this target, the office must run at an incredibly efficient pace.” (“Physicians May Need New Strategies As Reimbursement Falls, Expert Says”, MDOptions.com, April, 2003)

Primary care physicians (PCPs) today face two specific pressures from both managed care and government payers. The first pressure results from decreasing reimbursements. PCPs are thus forced to economize, to “do more with less”, and to maximize their in-office efficiency – all often accomplished by seeing more patients per hour as Kaufman notes. The second significant source of pressure on PCPs today results from third party payer pressures to limit expensive referrals/consultations and treat more conditions on their own.

Prior to implementing the described automated assessment tool, the Family Practice physician would personally interview patients suspected of presenting with a psychological component to a somatic complaint and patients presenting with a chief complaint of a psychological issue.

In 2000, the physician implemented the Quick Psycho-Diagnostic Panel (QPDä), a proprietary assessment created by Dr. Jonathan Shedler. This assessment is supplied on a simplified tablet computer by Patient Tools, Inc. (PTI) of Denver, Colorado. Patient Tools, Inc. supplies the tablet computer and secure, HIPAA-compliant website for questionnaire processing and results reporting.

The patient confidentially completes the QPDä assessment questionnaire in the waiting or exam room. Upon completing the questionnaire, the tablet device is “docked” to a data-transfer base linked via an existing office computer (PC) to off site calculation software and a HIPAA-compliant database that stores all patient data. Calculated values and summary information are transmitted back to the physician’s office immediately in the form of a summary report for the physician’s review while the patient is still in the office. The results are discussed with the patient and a treatment plan is initiated at that time.

The direct savings are estimated by the physician at an average of 10 minutes per patient. In early 2004, he estimates that the automated assessment is utilized on 20 patients per week for conditions ranging from anxiety and depression to bipolar disorder. The annualized savings are therefore 9600 minutes (160 hours) per year (48 working weeks per year). The physician values his productive office time at $150 per hour. Annualized value is therefore $24,000 due solely to the computerized assessment data service.

In addition to the time savings realized from the Patient Tools, Inc. service, other benefits include:

• The ability to review the assessment results printout face to face with the patient – sometimes a necessary step in convincing the patient of the need for treatment.
• Elimination of referrals to a psychiatrist or psychologist for diagnosis. Patients save time and money and treatment is sometimes initiated by the PCP.
• Since all patient data is stored on a secure, remote server provided by the vendor, longitudinal patient trending and population studies are easily performed.
• The data is complete. The comprehensiveness of the psychological assessment addresses a thorough range of symptomatology. The logic within the tablet device does not allow for skipping questions.
• The assessment printout provides both documentation and analysis and is easily added to the medical record.
• The quality of the assessment data is high. The sensitivity and specificity of the assessment instrument are excellent.

The administration of the QPDä assessment is thought by most billing agencies and consultants to be billable by the physician under CPT code 96100. Since CPT codes and billing regulations are fluid and subject to local interpretation, please consult a reputable authority regarding specific situations. Reimbursement, if billed, may or may not be granted and is carrier-specific.

Documentation for coding the physician office visit is provided in part by the assessment printout. A higher level, more complex visit may be justified by use of the automated assessment, review with the patient, and initiation of a treatment plan for the psychological issues. Again, each physician situation is unique, and a reputable authority should be consulted regarding coding issues.

The success of administering the psychological assessment tool using the automated tablet has prompted the Family Practice physician to consider other uses for the tablet. Other opportunities to automate patient data collection are in development. These opportunities include assessment of patients with potential bipolar disorder and the screening of employees at local businesses.

Jeffrey D. Greiff, M.D.
6782 West Sunrise Blvd
Plantation, Florida 33313
jgreiff@pol.net

Alan D. Malik, Ph.D.
CEO
Patient Tools, Inc.
655 Broadway Suite 600
Denver, Colorado 80203
www.patienttools.com
800.745.9186