"We Really Did Screw Up" - Kaiser Permanente Kidney Transplant Program
Baseline Magazine, May 14, 2007, Deborah Gage and Kim S. Nash
Kaiser opened its transplant center in 2004, but so bungled paperwork and procedures, according to state and federal investigators, that less than two years later, it shut down the facility.
Trouble at the center came to light last May, after the Los Angeles Times and KPIX-TV in San Francisco, which were tipped by a whistle-blower, reported on increasing wait times for Kaiser patients on the national kidney transplant list and other problems.
Few details about the exact nature of Kaiser's information management problems have been reported. However, in an attempt to document Kaiser's missteps, Baseline, for the past five months, has studied audit reports of the federal Centers for Medicare & Medicaid Services and California's Department of Managed Health Care (DMHC), which investigated Kaiser's transplant center, and reviewed court documents filed in cases against Kaiser. Interviews were conducted with key players, including patient Burks; whistle-blower and former employee David Merlin; officials at the United Network for Organ Sharing (UNOS), which oversees national transplant waiting lists; and health-care and information management consultants familiar with medical data governance and public information about Kaiser.
- An assortment of information management problems plagued Kaiser's kidney transplant center:
- During Kaiser's startup, there was no specific procedure established to transfer data on the initial 1,500 patients to UNOS, acknowledge officials from that organization as well as Kaiser.
- Kaiser compiled no master list or database of patient names to check that it had the records of all the patients who had transferred into its kidney program, according to Medicare and DMHC.
- More than 1,000 patient records had missing or incorrect data, such as erroneous Social Security numbers or missing test results, which delayed re-registrations on the national transplant list, according to Medicare. As of September 2005, a year after the facility opened, 330 Kaiser patients, including Burks, were still not credited with wait-list time they had accrued at the University of California, according to UNOS.
- The center, working mainly from paper records gathered from the University of California medical centers, according to Medicare, could take months to collect a missing data point, such as blood-test results, both Medicare and DMHC found.
- The transplant center, meanwhile, had no systematic way to track and analyze patient complaints, both Medicare and DMHC said, which would have alerted Kaiser to trends in problems.
- Kaiser staff worked with "inadequate" written guidance on how to do their jobs, according to DMHC, which also found that most of the center's staff lacked transplant experience. And while Kaiser named a transplant director, it failed to designate a chief executive responsible for the overall management of the center, a Medicare requirement.
In all, Kaiser failed to adhere to five state and 15 federal regulations.
The problems reflected Kaiser's "lack of effective planning," DMHC concluded, which "placed Kaiser patients at risk for disruption in care and potentially life-threatening delays in care."
In 2005, the center's first full year in business, twice the number of patients died waiting for kidneys at Kaiser as received transplants the reverse of regional trends, according to the Scientific Registry of Transplant Recipients (SRTR), a research group in Ann Arbor, Mich., that tracks U.S. transplant data. All 56 patients who received kidneys at Kaiser that year were still alive one year later, a key metric tracked by SRTR. However, Kaiser managed kidney transplants for just 6% of the patients on its waiting list, while UC-San Francisco, for example, transplanted 7% and UC-Davis 27%.... Most companies don't risk harming customers if they mismanage information. But the potential for data management disaster hides in every organization, according to Tom Redman, president of Navesink Consulting Group, which consults with companies about data quality.
... "We did not anticipate how complicated that was," George Halvorson, chairman and chief executive of Kaiser Permanente, told the Commonwealth Club, a current-events discussion group in San Francisco, in March.
A reader at the HIStalk blog asks:
"Core questions remain, including why it wasn't until Kaiser decided to close the center that it put in information technology, such as custom spreadsheets and a virtual private network between it and UC, to help manage patient data. Why, despite Kaiser's pioneering work in electronic medical records since the early 1990s, the new transplant center apparently managed most incoming patient data on paper. Why it didn't use one of the specialized transplant databases available from health-care technology vendors. Why it wasn't until the end that Kaiser developed basic policies and procedures, such as weekly meetings and monthly reports, to ensure data didn't go missing and appropriate parties stayed apprised of Kaiser's progress with patient records."
My remaining question is, who was the "we" who "did not anticipate how complicated that was," what were their backgrounds, and had they ever read my web site on healthcare IT difficulties?