The Kaiser Permanente Electronic Health Record: Transforming And Streamlining Modalities Of Care

Abstract

We examined the impact of implementing a comprehensive electronic health record (EHR) system on ambulatory care use in an integrated health care delivery system with more than 225,000 members. Between 2004 and 2007, the annual age/sex-adjusted total office visit rate decreased 26.2 percent, the adjusted primary care office visit rate decreased 25.3 percent, and the adjusted specialty care office visit rate decreased 21.5 percent. Scheduled telephone visits increased more than eightfold, and secure e-mail messaging, which began in late 2005, increased nearly sixfold by 2007. Introducing an EHR creates operational efficiencies by offering nontraditional, patient-centered ways of providing care.

Full text

The Kaiser Permanente
Electronic Health Record:
Transforming And Streamlining
Modalities Of Care
EHRs can help achieve more-efficient contacts between patients and
providers, while maintaining quality and satisfaction.
by Catherine Chen, Terhilda Garrido, Don Chock, Grant Okawa, and
Louise Liang
ABSTRACT: We examined the impact of implementing a comprehensive electronic health
record (EHR) system on ambulatory care use in an integrated health care delivery system
with more than 225,000 members. Between 2004 and 2007, the annual age/sex-adjusted
total office visit rate decreased 26.2 percent, the adjusted primary care office visit rate de-
creased 25.3 percent, and the adjusted specialty care office visit rate decreased 21.5 per-
cent. Scheduled telephone visits increased more than eightfold, and secure e-mail
messaging, which began in late 2005, increased nearly sixfold by 2007. Introducing an EHR
creates operational efficiencies by offering nontraditional, patient-centered ways of provid-
ing care. [Health Affairs 28, no. 2 (2009): 323–333; 10.1377/hlthaff.28.2.323]
Agrowing body of literature confirms the value of electronic
health records (EHRs) in improving patient safety, improving coordination
of care, enhancing documentation, and facilitating clinical decision making
and adherence to evidence-based clinical guidelines.1However, less is known
about EHRs’ impact on the efficiency of outpatient care. A recent Congressional
Budget Office (CBO) report notes the paucity of documented benefits of health in-
formation technology (IT) for providers and hospitals that are not part of inte-
grated systems.2In this paper we report on the impact of implementing an inte-
grated EHR system on the use of various types of ambulatory care in one Kaiser
Permanente (KP) region as an example of impact throughout the entire system.
Kaiser EHR
HEALTH AFFAIRS ~ Volume 28, Number 2 323
DOI 10.1377/hlthaff.28.2.323 ©2009 Project HOPE–The People-to-People Health Foundation, Inc.
The authors are all affiliated withKaiser Permanente (KP). Catherine Chen (catherine.chen@kp.org) is manager,
National Clinical Systems Planning and Consulting, at the KP headquarters in Oakland, California. Terhilda
Garrido is vice president, Strategic Operations, there. Don Chock is director, Performance Assessment, at KP
Hawaii in Honolulu. Grant Okawa is associate medical director, Knowledge Management, of the Hawaii
Permanente Medical Group. Louise Liang is senior vice president, Quality and Systems Support, in Oakland.

KP is the largest U.S. not-for-profit integrated health care delivery system, serv-
ing 8.7 million members in eight regions. Members receive the entire scope of
health care: preventive care; well-baby and prenatal care; immunizations; emer-
gency care; hospital and medical services; and ancillary services, including phar-
macy, laboratory, and radiology. Nationwide, KP employs approximately 156,000
technical, administrative, and clerical personnel and caregivers and 13,000 physi-
cians.
KP HealthConnect
In 2004, KP began implementing KP HealthConnect, a comprehensive health
information system with numerous functionalities, including (1) an EHR with
comprehensive documentation across care settings—inpatient and outpatient,
clinical decision support, and complete, real-time connectivity to lab, pharmacy,
radiology, and other ancillary systems; (2) secure patient-provider messaging
available through a member Web site that also provides personal health records;
and (3) electronic interprovider messaging about care that is automatically incor-
porated into patients’ records.
The purpose of our study was to examine the impact of KP HealthConnect on
several types of ambulatory care patient contacts: outpatient, urgent care, and
emergency department (ED) visits; external referrals; scheduled telephone visits;
and secure patient-physician e-mail messaging.
Study Data And Methods
The KP Hawaii region was the first in Kaiser Permanente to fully implement KP
HealthConnect in the outpatient setting. KP Hawaii has approximately 225,000
members, a figure that was consistent during the four-year study period.
We conducted a retrospective observational study using administrative data.
The baseline year was 2004; KP HealthConnect implementation in primary care
beganinAprilandwascompletedinNovember.Implementationinspecialtycare
was completed in June 2005, and the patient-provider secure messaging function
became available in September 2005. The comparison year was 2007.
Data on rates of outpatient, urgent care, and ED visits; external referrals; sched-
uled telephone visits; and secure patient-physician messaging were extracted
from the regional data warehouse.3Annual total office visit rates per region were
stratified by primary care and specialty care and age/sex-adjusted to a fixed age/
sex distribution over the time period, using four age categories (0–19, 20–44, 45–
64, and 65+).
Our study included the entire regional membership, allowing us to use the
Wilcoxon-Mann-Whitney test to assess the statistical significance of the changes
between 2004 and 2007 in rates of total office visits, primary care visits, specialty
care visits, scheduled telephone visits, secure patient-physician messaging, exter-
nal referrals, urgent care visits, and ED visits.
324 March/April 2009
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Study Findings
nOffice and telephone visits. Age/sex-adjusted total office visits per member
decreased 26.2 percent between 2004 and 2007 (p<0.001), and total scheduled tele-
phone visits per member increased nearly ninefold (Exhibit 1). Exhibit 2 summa-
rizes the changes in office and telephone visits.
nSecure messaging. In September 2005, KP Hawaii launched My Health
Manager,thesecureonlinepatient-physicianmessagingfunctionofKP
HealthConnect. In the remaining months of 2005, members initiated more than
3,000 secure e-mail messages, a rate of 0.03 secure messages per member. In 2006,
members sent nearly 25,000 messages (0.11 per member). In 2007, they sent more
than 51,000 messages (0.23 per member). The increase between 2005 and 2007 was
statistically significant (p<0.001).
The total number of patient contacts via office and telephone visits and secure
messaging increased 8.3 percent after EHR implementation, from 5.18 contacts per
member per year in 2004 to 5.61 contacts per member per year in 2007 (p<0.001).
nOther factors. We explored other factors that could explain decreased use of
ambulatory care visits. Enrollment in KP Hawaii did not change over the four-year
study period, nor did the proportions of members over age sixty-five (12 percent)
and those with at least one chronic condition (29 percent). The ratio of providers to
members remained stable over time at 1.9 physicians per 1,000 members. The rate of
referrals to external providers decreased 53 percent between 2004 and 2007
(p<0.001).
The rate of ED and urgent care visits increased between 2004 and 2007—ur-
gent care visits by 19 percent (p<0.001) and ED visits by 11 percent (p<0.001)
(Exhibit 3).
nQuality and patient satisfaction. KP Hawaii captures Healthcare Effective-
ness Data and Information Set (HEDIS) data as part of its routine quality surveil-
Kaiser EHR
HEALTH AFFAIRS ~ Volume 28, Number 2 325
EXHIBIT 1
Changes In Office Visit Rates Among Kaiser Permanente (KP) Hawaii Members,
1999–2007
SOURCE: Authors’ analysis using data from the Kaiser Permanente Hawaii Data Warehouse and secure messaging database.
2.5
2.0
1.5
1.0
Office visits per member
1.0
1999 2000 2001 2002 2003 2004 2005 2006 2007
Primary care
Specialty
Electronic health record implemented

lance.4Between 2004 and 2007, many scores were not comparable over time because
of changes in the HEDIS measure set. For the majority of measures that were compa-
rable, performance remained stable during the study period (Exhibit 4). Overall
quality was, at the least, maintained.
We were unable to use Consumer Assessment of Healthcare Providers and Sys-
tems (CAHPS) data to assess patient satisfaction because measures were not com-
parable across all years.5However, results from KP Hawaii member satisfaction
surveys remained essentially unchanged. In 2004, 84 percent of surveyed KP Ha-
waii members rated their overall visit satisfaction at 8 or above on a scale of 1 to 10;
in 2007, 87 percent did so. In 2004, 78 percent of KP Hawaii members rated the
326 March/April 2009
Electronic Health Records
EXHIBIT 2
Changes In Office Visit Versus Telephone Visit Rates Among Kaiser Permanente (KP)
Hawaii Members, 1999–2007
SOURCE: Authors’ analysis using data from the Kaiser Permanente Hawaii Data Warehouse and secure messaging database.
6
4
2
Visits per member
0
1999 2000 2001 2002 2003 2004 2005 2006 2007
Office visits
Scheduled phone visits
Electronic health record implemented
EXHIBIT 3
Ambulatory Care Contact Per Member Rates Among Kaiser Permanente (KP) Hawaii
Members, Selected Years 2004–2007
Type of contact 2004 2005 2007 Net change Percent changea
Total office visitsb
Primary care
Specialty care
5.01
2.24
1.40
–c
–c
–c
3.70
1.67
1.10
–1.31
–0.57
–0.30
–26
–25
–21
Scheduled telephone visits
Secure e-mail messaging
0.17
–d
–c
0.03
1.68
0.23
1.51
0.23
869
597
All ambulatory care contacts 5.18 –c5.61 0.43 8
External referrals
Urgent care
ED visits
0.04
0.13
0.16
–c
–c
–c
0.02
0.15
0.18
–0.02
0.02
0.02
–53
19
11
SOURCE: Authors’ analysis using data from the Kaiser Permanente Hawaii Data Warehouse and secure messaging database.
NOTE: ED is emergency department.
aAll results are statistically significant (p< 0.001).
bThe number of total office visits is greater than the sum of primary and specialty care visits because total office visits include
care rendered by nurse practitioners, physician assistants, registered nurses, optometrists, social workers, and rehabilitative
therapists, as well as physicians.
cNot applicable.
dNot available.

level of interest and attention of their health care providers at 8 or above; in 2007,
79 percent did so. Additionally, in 2007, 90 percent rated their satisfaction with
telephone visits at 8 or above.6
Discussion And Policy Implications
We examined the impact of an integrated EHR on ambulatory care use and
found a 26.2 percent decrease in the annual age/sex-adjusted total office visit rate
over four years. In 1999, office visits accounted for 99.6 percent of all ambulatory
care contacts. Eight years later, they represented 66 percent of patient contacts.
Scheduled telephone visits accounted for 30 percent of patient contacts, and se-
cure messaging represented the remaining 4 percent (Exhibit 5). Between 2004
Kaiser EHR
HEALTH AFFAIRS ~ Volume 28, Number 2 327
EXHIBIT 4
Healthcare Effectiveness Data And Information Set (HEDIS) Scores Of Kaiser
Permanente (KP) Hawaii Members, 2004 And 2007
Measure 2004 2007 Trenda
Commercial population
Childhood immunization status—combination 2
Appropriate testing for children with upper respiratory infection
85.9%
88.9
85.9%
92.3
No change
Favorable
Appropriate testing for children with pharyngitis
Colorectal cancer screening
Breast cancer screening in women ages 52–69
86.0
37.2
73.2
88.0
41.4
81.4
Favorable
Favorable
Favorable
Chlamydia screening for women
Ages 16–20
Ages 21–25
All, ages 16–25
52.3
48.3
50.0
60.0
62.4
61.3
Favorable
Favorable
Favorable
Comprehensive diabetes care
HbA1c testing
Poor HbA1c control
85.9
35.0
88.6
40.4
Favorable
Unfavorable
Use of imaging studies for low back pain
Antidepressant medication management
Effective acute-phase treatment
Effective continuation-phase treatment
81.7
64.5
52.8
76.8
62.2
47.4
Favorable
Unfavorable
Unfavorable
Follow-up after hospitalization for mental illness
Within 7 days
Within 30 days
66.7
75.4
73.1
85.1
Favorable
Favorable
Medicare population
Colorectal cancer screening
Breast cancer screening in women ages 52–69
51.8
78.8
58.9
87.6
Favorable
Favorable
Comprehensive diabetes care
HbA1c testing
Poor HbA1c control
93.9
15.6
96.8
16.6
Favorable
Unfavorable
Antidepressant medication management
Effective acute-phase treatment
Effective continuation-phase treatment
Osteoporosis management in women with a fracture
64.0
57.1
36.6
73.8
63.3
27.9
Favorable
Favorable
Unfavorable
SOURCE: Kaiser Permanente Hawaii HEDIS data.
aTrends reflect changes in the HEDIS scores; no statistical significance testing was conducted.

and 2007, these new modalities of care enabled an overall increase in patient con-
tacts and access of 8 percent.
Although ED and urgent care use rose between 2004 and 2007, the increase rep-
resents only approximately 5 percent of the volume of the decrease in total office
visit rates. Therefore, it is unlikely that the rise reflects a shift in the location of
care from office-based sites to ED and urgent care settings. Further, the rise in ED
and urgent care visit rates was delayed relative to the decrease in office visit use,
which suggests alternative causes.
nMaintenance of quality. The majority of twenty-two HEDIS scores that were
comparable between 2004 and 2007 were at least maintained, with a few excep-
tions: poor HbA1c control in both the commercial and Medicare populations, man-
agement of antidepressant medications in the commercial population, and osteopo-
rosis management in women with a fracture in the Medicare population.7
nOrganizational assists. Organizational efforts to shift ambulatory care use
could also explain the changes in rates. Copayments increased $2 per visit per year
between 2004 and 2007 as part of a stepped program to increase consumer cost
sharing in the most prevalent benefit plan. However, previous larger copayment in-
creases were not related to similar decreases in office visit rates.
The initiation of total panel management (TPM) in 2004 might have had a mini-
mal impact on office visit use. In the TPM model of care, primary care teams iden-
tify members of their patient panel who need medications, testing, or other evi-
dence-based care and then use multiple strategies to address these needs, such as
telephone visits and secure messaging, in addition to office visits. TPM can reduce
theneedformultipleofficevisitsamongpeoplewithchronicconditions;however,
only 10 percent of KP Hawaii clinics were engaged in TPM during the study pe-
328 March/April 2009
Electronic Health Records
EXHIBIT 5
Distribution Of Patient Contacts Over Time Among Kaiser Permanente (KP) Hawaii
Members, 1999–2007
SOURCE: Authors’ analysis using data from the Kaiser Permanente Hawaii Data Warehouse and secure messaging database.
4
3
2
1
Contacts per member
0
1999 2000 2001 2002 2003 2004 2005 2006 2007
Scheduled phone visitsOffice visits
5
Secure messaging

riod. In addition, office visit use uniformly decreased in clinics without TPM.
nAn EMR head start. The existence of an earlier electronic medical record
(EMR) may also have affected our findings. KP Hawaii had partially phased in an-
other electronic system, Clinical Information System (CIS). At the time of KP
HealthConnect implementation, a third of care sites had had full CIS functionality
for just over two years; the rest had read-only access.8An 87 percent drop in daily
pulls of paper charts after KP HealthConnect was implemented indicates that CIS
was largely used alongside paper charts. However, the two systems shared some
functionality. It is possible that CIS also slightly reduced office visits, which would
have attenuated the effects we observed from KP HealthConnect.
nEfficiency and productivity. We did not examine changes in the efficiency or
productivity of providers immediately around the time of implementation. Tempo-
rary decreases in productivity of as much as 15 percent are common at implementa-
tion.9
EHRs may increase the time it takes to document patient visits.10 We did not
examine the impact of KP HealthConnect on net efficiency. Doing so would have
required quantifying costs of increased documentation time and savings in nurs-
ing, receptionist, and appointment clerk time from decreased office visit rates. In
addition, costs to patients of office visits—such as out-of-pocket expenses and
time costs of travel, parking, and missed school or work—are often overlooked
when one is calculating net efficiency. An average visit in the community can con-
sume 103 minutes (Exhibit 6). In contrast, e-mail messaging and scheduled tele-
phone visits consume much less time; logic suggests that the efficiency gains offset
any increases in documentation time.
nStudy limitations. Limitations of our study include the fact that the system ar-
Kaiser EHR
HEALTH AFFAIRS ~ Volume 28, Number 2 329
EXHIBIT 6
Average Time Spent By Patients For An Ambulatory Care Visit In The Community,
1998–2008
Patient activity Minutes
Travel to and from ambulatory carea
Receptionist check-in/outb
Waiting room waitc
Exam room waitd
Time with providere
50
10
15.9
10.4
16.4
SOURCES: See below.
aC.B. Forrest and B. Starfield, “Entry into Primary Care and Continuity: The Effects of Access,”American Journal of Public
Health 88, no. 9 (1998): 1330–1336.
bL.A. Backer, “Strategies for Better Patient Flow and Cycle Time,” Family Practice Management 9, no. 6 (2002): 45–50.
cK.M. Leddy, D.O. Kaldenberg, and B.W. Becker, “Timeliness in Ambulatory Care Treatment: An Examination of Patient
Satisfaction and Wait Times in Medical Practices and Outpatient Test and Treatment Facilities,” Journal of Ambulatory Care
Management 15, no. 42 (2003): 138–149.
dLeddy et al., “Timeliness in Ambulatory Care Treatment.”
eKaiser Permanente, internal study, 2008.

chitecture and implementation schedule precluded a randomized controlled trial.
We were also unable to compare our findings against utilization rates in other KP
regions because they were all in various stages of implementing KP HealthConnect
during our study period. However, we note that the rate of ambulatory care visits
has been rising since the mid-1990s in the United States as a whole.11
Additional limitations include the fact that our data on quality and patient sat-
isfaction were drawn from contemporaneous tools and were not specific to this
study. Changes in the HEDIS measure set between 2004 and 2007 restricted our
ability to compare quality before and after EHR implementation. The long-term
effects of telephone visits and secure patient-physician messaging on efficiency,
quality, and patient satisfaction are unknown and require measuring impacts dur-
ing a longer time period.
Our report falls short of a comprehensive evaluation of the impact of KP
HealthConnect, which would require monetizing efficiency shifts. This is chal-
lenginginKP’sintegratedcoststructureandbeyondthescopeofthisstudy.In
contrast to fee-for-service systems, Permanente Medical Group physicians receive
a fixed salary regardless of the number of services rendered. Permanente Medical
Groups provide medical care for members under a mutually exclusive contract
with the Kaiser Foundation Health Plan.
nEconomic impact of EHRs. Further study may yield important findings
about the overall economic impact of implementing a comprehensive EHR in the
outpatient setting. It should be noted, however, that the CBO suggests that the
adoption of more health IT is generally not sufficient to produce significant cost sav-
ings in the absence of incentive structures that reward (or, at a minimum, do not
disincent) efficiencies.12 The U.S. Department of Health and Human Services (HHS)
suggests that a comprehensive evaluation would include measures of quality, pa-
tient safety, costs of direct care, administrative efficiencies, decreased paperwork,
and expanded access.13
nConsistency with previous KP study. Our findings are consistent with those
ofastudyKPpublishedin2005.
14 Decreased office visits and increased scheduled
telephone visits indicate that to some degree, telephone visits can substitute for of-
fice visits with immediate access to complete, current patient information via an in-
tegrated EHR. However, the previous study did not involve the more comprehensive
KP HealthConnect system or secure e-mail messaging. KP also documented that se-
cure e-mail messaging can provide an asynchronous, convenient substitute for some
office and telephone visits.15
The 26.2 percent reduction in office visits indicates greater efficiency of care
with an integrated EHR. With complete patient data available, unnecessary and
marginally productive office visits are reduced or replaced with telephone visits
and secure e-mail messaging supported by easy access to patients’ medical rec-
ords. For example, doctors reported that the EHR enabled them to resolve pa-
tients’ health issues in the first contact or with fewer contacts.16 In sum, our study
330 March/April 2009
Electronic Health Records

strongly suggests that an integrated and comprehensive EHR shifts the pattern of
ambulatory care toward more-efficient contacts for patients and providers while
at least maintaining quality of care and patient satisfaction.
nImportance of aligned financial incentives. Importantly, our results were
obtained in an integrated delivery system with an economic model that aligns finan-
cial incentives with providing effective and efficient care, regardless of how that care
is delivered. As the CBO notes, “How well health IT lives up to its potential depends
in part on how effectively financial incentives can be realigned to encourage the op-
timal use of the technology’s capabilities.”17
A specific example from KP Hawaii illustrates the potential that health IT
holds for transforming care when incentives are properly aligned. The Hawaii re-
gional team of nephrologists took advantage of the ready availability of compre-
hensive clinical information on all patients to risk-stratify the entire regional pop-
ulation with chronic kidney disease. Using evidence-based guidelines to
electronically review the health records of thousands of members, they instituted
proactive, risk-driven, electronic consultations instead of relying only on primary
care providers to refer patients for specialty care. These consultations sometimes
recommended traditional specialty visits but often provided care recommenda-
tions remotely, using electronic communication. Nephrologists used KP Health-
Connect’s internal messaging feature to provide KP primary care physicians with
clinical management advice tailored to specific patients. Over three years, major
improvements occurred in key indicators of quality of care for chronic kidney dis-
ease.18
nPolicy implications. Until public and private policies reward care strategies
other than face-to-face visits, few providers will adopt them. Only in 2008 did the
Centers for Medicare and Medicaid Services (CMS) add codes for telephone con-
tacts that are intended to supplant office visits and for online management. Medi-
care, however, listed both services as noncovered for 2008, leaving it to the discre-
tion of individual insurers whether to pay for these services.19 Private insurers
reimburse providers for online visits on a very limited basis.20
nFactoring in consumers’ preferences. Aligning nonfinancial incentives for
using EHRs to improve the efficiency of care is also necessary. For instance, the Na-
tional Committee for Quality Assurance (NCQA) relies on office visits as the pre-
dominant indicator of quality-related activity.21 However, consumer choice is a key
component of value-driven care.22 Increasing evidence identifies patients’ clear pref-
erences for and satisfaction with e-mail messaging with their doctors.23
The KP experience is similar; among users of KP HealthConnect in KP North-
west, 85 percent rated their satisfaction as 8 or 9 on a nine-point scale.24 In a sepa-
Kaiser EHR
HEALTH AFFAIRS ~ Volume 28, Number 2 331
“Until public and private policies reward care strategies other than
face-to-face visits, few providers will adopt them.”

rate survey, 85 percent of users indicated that the ability to communicate electron-
ically with their physicians enabled them to better manage their health.25
If face-to-face visits remain the gold standard for quality, care standards will
not reflect the preference of consumers for alternative, more convenient modes of
care when they are appropriate or reinforce more efficient care delivery options.
Kaiser permanente’s work in this area is still in progress. We will
continue to evaluate the impacts of KP HealthConnect on care and admin-
istrative efficiencies, quality, safety, and access over the long term. This re-
port is interim, insofar as KP continues to innovate and improve workflows to cre-
ate a new value equation for patients and purchasers. However, it provides a view
into the transformation of ambulatory care that emerges and is increasingly possi-
ble when technology and incentives align with patients’ preferences.
The authors thank the many physicians, operations leaders, and analysts in the Kaiser Permanente Hawaii region
for their contributions. In particular, they thank Yvonne Zhou, Amy Watts, Cynthia Okamura, Fred Shaw, Rod
Pederson, Brian Lee, Ravi Poorsina, and Samantha Quattrone for their support and insights; Arnold Matsunobu,
JanHead,andMikeChaffinfortheirsponsorshipearlyintheproject;andJenniGreenforadviceandhelpin
writing this paper.
NOTES
1. See, for example, R. Kaushal, K.G. Shojania, and D.W. Bates, “Effects of Computerized Physician Order En-
try and Clinical Decision Support Systems on Medication Safety: A Systematic Review,” Archives of Internal
Medicine 163, no. 12 (2003): 1409–1416; L.C. Burton et al, “Using Electronic Health Records to Help Coordi-
nate Care,” Milbank Quarterly 82, no. 3 (2004): 457–481; J. Hippisley-Cox et al., “The Electronic Patient Rec-
ord in Primary Care—Regression or Progression? A Cross Sectional Study,” BMJ 326, no. 7404 (2003):
1439–1443; J. Butler et al., “Improved Compliance with Quality Measures at Hospital Discharge with a
Computerized Physician Order Entry System,” American Heart Journal 151, no. 3 (2006): 643–653; and B.
Chaudhry et al., “Systematic Review: Impact of Health Information Technology on Quality, Efficiency, and
Costs of Medical Care,” Annals of Internal Medicine 144, no. 10 (2006): 742–752.
2. Peter R. Orszag, Congressional Budget Office, “Evidence on the Costs and Benefits of Health Information
Technology,” Testimony before the House on Ways and Means Subcommittee on Health, 24 July 2008,
http://www.cbo.gov/ftpdocs/95xx/doc9572/07-24-HealthIT.pdf (accessed 22 December 2008).
3. “Total office visits” include care from medical and osteopathic doctors, resident physicians, nurse practi-
tioners, physician assistants, registered nurses, optometrists, social workers, and rehabilitative therapists.
“Primary care visits” include clinic-based care from internal medicine, family practice, and pediatric physi-
cians. “Specialty care visits” include clinic-based care by other specialty and subspecialty physicians.
“Scheduled telephone visits” include prearranged phone calls between providers and patients. “External
referrals” include only non–Kaiser Permanente ambulatory consultations. “Emergency department visits”
include visits to KP and non-KP emergency departments (EDs). “Urgent care visits” include care at KP ur-
gent care centers; these are not included in total office visits.
4. National Committee for Quality Assurance, “HEDIS and Quality Measurement,” 2008, http://www.ncqa
.org/tabid/59/Default.aspx (accessed 21 November 2008).
5. Agency for Healthcare Research and Quality, “CAHPS: Surveys and Tools to Advance Patient-Centered
Care,” 2008, http://www.cahps.ahrq.gov/default.asp (accessed 21 November 2008).
6. Kaiser Permanente, internal study, 2007.
7. Hawaii regional clinicians conducted a close review of antidepressant follow-up and noted discrepancies
between care that occurred and care that was “counted” under HEDIS criteria. For instance, if follow-up
on the use of antidepressant medications occurred during a visit but depression was not the primary diag-
nosis, it did not count toward the HEDIS measure. Scheduled telephone visits that were inaccurately
332 March/April 2009
Electronic Health Records

coded as “telephone encounters” also did not count toward the measure.
8. J.T. Scott et al., “Kaiser Permanente’s Experience of Implementing an Electronic Medical Record: A Quali-
tative Study,” BMJ 331, no. 7528 (2005): 1313–1316.
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Affairs 24, no. 5 (2005): 1323–1333.
10. L. Poissant et al., “The Impact of Electronic Health Records on Time Efficiency of Physicians and Nurses: A
Systematic Review,” Journal of the American Medical Informatics Association 12, no. 5 (2005): 505–516.
11. E. Hing, D.K. Cherry, and D.A. Woodwell, “National Ambulatory Medical Care Survey: 2004 Summary,”
Advance Data from Vital and Health Statistics no. 374, 23 June 2006, http://www.cdc.gov/nchs/data/
ad/ad374.pdf (accessed 22 December 2008); and D.K. Cherry, D.A. Woodwell, and E.A. Rechtsteiner, “Na-
tional Ambulatory Medical Care Survey: 2005 Summary,” Advance Data from Vital and Health Statistics
no. 387, 29 June 2007, http://www.cdc.gov/nchs/data/ad/ad387.pdf (accessed 22 December 2008).
12. Orszag, “Costs and Benefits of Health Information Technology.”
13. U.S. Department of Health and Human Services, “Health Information Technology Home,” 2008, http://
www.hhs.gov/healthit (accessed 21 November 2008).
14. T. Garrido et al., “Effect of Elect ronic Health Records in Ambulatory Care: Retrospective, Serial, Cross Sec-
tional Study,” BMJ 330, no. 7491 (2005): 581.
15. Y.Y. Zhou et al., “Patient Access to an Electronic Health Record with Secure Messaging: Impact on Primary
Care Utilization,” American Journal of Managed Care 13, no. 7 (2007): 418–424.
16. Garrido et al., “Effect of Electronic Health Records.”
17. Orszag, “Costs and Benefits of Health Information Technology,” 7.
18. B. Lee and K. Forbes, “The Role of Specialists in Managing the Health of Populations with Chronic Dis-
ease: The Example of Chronic Kidney Disease” (Unpublished manuscript, Kaiser Permanente, 2008).
19. B. Whitman, “2008 CPT Codes Clarify Billing for Phone and Electronic E/M,” 2008, http://www
.acpinternist.org/archives/2008/01/billing.htm (accessed 21 November 2008).
20. M. Merrill, “Insurers Reimburse IADMD Members for Online Visits,” He althca re IT News , 29 February 2008,
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