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OBJECTIVE: To determine whether patient access to secure patient-physician messaging affects annual adult primary care office visit and documented telephone contact rates. STUDY DESIGN: Retrospective cohort and matched-control studies with pre-post analysis. METHODS: The cohort study sample included 4686 adult members of Kaiser Permanente Northwest (KPNW) who had been registered KP HealthConnect Online users longer than 13 months and had used at least 1 feature. The matched-control study sample included 3201 randomly selected controls matched by age/sex, selected chronic conditions, and primary care physician to 3201 registered users. We calculated the difference in primary care office visit and documented telephone contact rates in the pre- and post-periods (defined, respectively, as 3-14 months before and 2-13 months after registration for KP HealthConnect Online). Paired t tests were used to assess significance. RESULTS: Annual office visit rates decreased by 0.23 (-9.7%) visits per member in the cohort study. Annual office visit rates for users in the matched-control study decreased by 0.25 (-10.3%); the corresponding decrease for the controls was 0.08 (-3.7%). This 0.17 (-6.7%) reduction was significant (P < .003). Annual documented telephone contact rates for users in the matched-control design increased by 0.32 (16.2%) contacts per member; the corresponding rate for the control group was 0.52 (29.9%). This 0.20 (13.7%) difference was significant (P < .01). CONCLUSION: Patient access to the secure messaging feature of KP HealthConnect Online was associated with decreased rates of primary care office visits and telephone contacts.

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OBJECTIVE: To evaluate the effect of implementing comprehensive, integrated electronic health record systems on use and quality of ambulatory care DESIGN: Retrospective, serial, cross sectional study. SETTING: Colorado and Northwest regions of Kaiser Permanente, a US integrated healthcare delivery system. POPULATION: 367,795 members in the Colorado region and 449,728 members in the Northwest region. INTERVENTION: Implementation of electronic health record systems. MAIN OUTCOME MEASURES: Total number of office visits and use of primary care, specialty care, clinical laboratory, radiology services, and telephone contact. Health Plan Employer Data and Information Set to assess quality. RESULTS: Two years after electronic health records were fully implemented, age adjusted rates of office visits fell by 9% in both regions. Age adjusted primary care visits decreased by 11% in both regions and specialty care visits decreased by 5% in Colorado and 6% in the Northwest. All these decreases were significant (P < 0.0001). The percentage of members making > or = 3 visits a year decreased by 10% in Colorado and 11% in the Northwest, and the percentage of members with < or = 2 visits a year increased. In the Northwest, scheduled telephone contact increased from a baseline of 1.26 per member per year to 2.09 after two years. Use of clinical laboratory and radiology services did not change conclusively. Intermediate measures of quality of health care remained unchanged or improved slightly. CONCLUSIONS: Readily available, comprehensive, integrated clinical information reduced use of ambulatory care while maintaining quality and allowed doctors to replace some office visits with telephone contacts. Shifting patterns of use suggest reduced numbers of ambulatory care visits that are inappropriate or marginally productive.

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This paper describes Kaiser Permanente's (KP) enterprise-wide medical terminology solution, referred to as our Convergent Medical Terminology (CMT). Initially developed to serve the needs of a regional electronic health record, CMT has evolved into a core KP asset, serving as the common terminology across all applications. CMT serves as the definitive source of concept definitions for the organization, provides a consistent structure and access method to all codes used by the organization, and is KP's language of interoperability, with cross-mappings to regional ancillary systems and administrative billing codes. The core of CMT is comprised of SNOMED CT, laboratory LOINC, and First DataBank drug terminology. These are integrated into a single poly-hierarchically structured knowledge base. Cross map sets provide bi-directional translations between CMT and ancillary applications and administrative billing codes. Context sets provide subsets of CMT for use in specific contexts. Our experience with CMT has lead us to conclude that a successful terminology solution requires that: (1) usability considerations are an organizational priority; (2) "interface" terminology is differentiated from "reference" terminology; (3) it be easy for clinicians to find the concepts they need; (4) the immediate value of coded data be apparent to clinician user; (5) there be a well defined approach to terminology extensions. Over the past several years, there has been substantial progress made in the domain coverage and standardization of medical terminology. KP has learned to exploit that terminology in ways that are clinician-acceptable and that provide powerful options for data analysis and reporting.

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Further evidence in favor of the clinical IT business case is set forth in Kaiser Permanente's cost/benefit analysis for an electronic hospital information system. This article reviews the business case for an inpatient electronic medical record system, including 36 categories of quantifiable benefits that contribute to a positive cumulative net cash flow within an 8.5 year period. However, the business case hinges on several contingent success factors: leadership commitment, timely implementation, partnership with labor, coding compliance, and workflow redesign. The issues and constraints that impact the potential transferability of this business case across delivery systems raise questions that merit further attention.

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