Bad Handoff NoBy Kim S. Nash Print
The information management problems that beset Kaiser Permanente's kidney transplant program.
Bad Handoff No. 1: Botched Transfer of Records
What Kaiser attempted to seed a new kidney transplant program by moving 1,500 patients from other hospitals during the course of several months had not been tried before, according to UNOS officials. Usually, new centers grow gradually after opening.
Problems emerged even before Kaiser's first surgery in October 2004, starting with confusion over letters it mailed that summer telling patients of the new venture.
Kaiser wrote that as of Sept. 1, 2004, its insurance side would no longer cover kidney transplants done at other hospitals. Unless they could find another way to pay for what is on average a $210,000 transplant in the U.S., patients should sign forms to drop UC and make Kaiser their new, and only, transplant center.
But getting those patient consents proved difficult, according to DMHC's report. For example, none of the letters DMHC reviewed included explicit instructions for patients about what to do with an enclosed "wait-time transfer form" UNOS requires before it will credit patients with wait time from their prior transplant center when they enlist at a new one.
Sherman, Burks' transplant coordinator, told Medicare investigators that a "large number" of patients failed to respond to the letter, didn't return the required consent forms or faxed forms to UNOS when they should have gone to Kaiser.
Ultimately, "lack of clarity" in those transfer documents, DMHC said, "was a significant factor in delaying members' access to kidney transplant services." Delays then mushroomed when Kaiser tried to set up patients' medical records. For example, Kaiser hired contractors to go to the UC hospitals to get paper copies of patient files. Confusion ensued there, too, Sherman told DMHC, as UC-San Francisco at one time told Kaiser that patients had to sign release forms before it would give out their information. Kaiser, however, thought it was entitled to the data without authorization from individual patients because of the health-care provider contract between it and the UC hospitals, she said.
It's unclear how the issue was resolved. A UC-Davis spokeswoman did not respond to questions by phone or e-mail.
A spokeswoman for UC-San Francisco would not discuss the management of Kaiser patients' data, saying, "These were Kaiser's issues, not our issues." But Kaiser's contractors brought back hundreds of patient histories. Laura de Belen, Kaiser's sole data coordinator, was on the receiving end of that paper tsunami.
De Belen still works at Kaiser and declined to talk about the kidney center. But during questioning by DMHC inspectors, she described working 10 to 16 hours per day, trying to process 100 files daily.
Key to that processing was updating the kidney wait-list database at UNOS, to reflect that patients had moved from UC to Kaiser. Heart, kidney, intestine, pancreas, liver, lung all transplantable organs fall under the purview of UNOS, which oversees 258 transplant centers and 58 organ procurement organizations in the U.S. When a patient moves or changes doctors, he might switch transplant centers and request that his wait time be transferred to the new center. That involves two steps—one electronic and one on paper.
First, as she had learned to do during an hour of UNOS training by telephone, according to Medicare, de Belen would log on to UNOS' secured Web site. With paper files in front her, she picked out the required patient demographics to type in, such as name, birth date and Social Security number. She also entered the needed clinical data, such as blood type, urine test results and dialysis information. This information is necessary to match transplant candidates to donated organs; without it, UNOS won't register patients on the national waiting list to receive organ offers.
Then, as UNOS directs, de Belen would fax in UNOS' wait-list transfer forms. UNOS prefers fax or mail for these forms so it has a physical record of patient and doctor signatures.
In a typical week, nationwide and across organ types, UNOS handles 10 to 15 such requests to change centers. Kaiser was submitting hundreds at once and many were imperfect, says Berkeley Keck, assistant executive director of information technology at UNOS.
Some of the Kaiser files lacked pieces of information, such as blood test results going back several years. One factor: Some patients had been at UC for a long time, as the wait for a kidney can last more than five years. Older data about them wasn't always immediately available from UC, residing in separate laboratory databases or stored offsite, according to Merlin.
Also, transplant centers can differ in how they do particular lab tests, and UC's standards might have been different from Kaiser's. For example, knowing that a patient's naturally occurring antibody proteins fight foreign bodies and could sabotage a new kidney, centers test patients for antibody reactivity levels. The University of Minnesota Medical Center-Fairview, for example, tests at a patient's initial evaluation, then monthly for two months, then quarterly, says Cathy Garvey, a transplant coordinator at the Minneapolis facility.
But other centers don't do it as frequently, Garvey says. Kaiser sometimes had to order fresh tests for incoming patients, Merlin notes, which also delayed registrations.
De Belen told Medicare and DMHC inspectors that she would lay aside each incomplete medical record for Sherman, Kaiser's then-only transplant coordinator, who in addition to her nursing and clinical duties had to hunt down the data by calling and faxing UC.
When Medicare officials asked de Belen about the prevalence of the problem, she estimated that all told, incomplete records numbered more than 1,000 two-thirds of the patients Kaiser was trying to absorb from UC.
Schiffgens, the Kaiser spokesman, would not say what kind of software de Belen used for patient record-keeping inside the kidney center if any at all. He did say de Belen was not using CIPS, or Clinical Information Presentation System, which is Kaiser's homegrown electronic medical records application, built in the mid-1990s. Nor was the transplant center running HealthConnect, he says, software from Epic Systems that is now replacing CIPS.
In comparison, the Tulane Center for Abdominal Transplant in New Orleans has two dedicated technology staffers to support patient databases that track health status, test results, appointments and other items. "It's almost impossible to run even a small transplant program if you don't have a database," says transplant administration director Marian O'Rourke.
At Kaiser, answers about missing or errant data took months in some cases, according to Medicare and DMHC. Merlin attributes the holdup to busy days at UC, which was focused on its own patients, and Kaiser staff being "overwhelmed" by the volume of data to manage. Sometimes, according to the Medicare report, Kaiser would lose track of patients for whom it had already requested, and in some cases received, missing information. For example, an e-mail message from UC-San Francisco to Kaiser in November 2004 urged Kaiser "to re-review your list" so UC staff didn't have "to repeat work that has already been done." UC spokeswomen declined interviews.
But there was no master list of patient data to review, Medicare and DMHC discovered. Why not is a mystery, says Larry Eisenberg, a lawyer in Irvine, Calif., for two of the patients suing Kaiser for medical negligence and other charges in state Superior Court in San Francisco.
Eisenberg wonders whether Kaiser's transplant center could have queried systems at Kaiser's health maintenance organization to generate lists of patients one, for whom the HMO branch of the company provided insurance coverage for kidney services, and two, who were at the time registered for transplants at UC. "They had to have information on the programs their patients are at," he says. "They're paying the bills. They had access to their own database."
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