“I am not a disease”: Kaiser Permanente’s data-driven approach to developing patient self-sufficiency

Bryan Sivak
5 min readMar 1, 2019

Michael, a retired professor living in the San Francisco Bay Area, was diagnosed with type II diabetes in 2004. Joining the 12 million Americans over 60 with the condition, Michael’s life became centered around his diagnosis. He struggled with fluctuating weight — attempting, as many diabetics do, to get his condition under control through self-directed diet and exercise.

None of the changes he made had a lasting impact; as a result, his symptoms worsened. Michael began experiencing continuous spikes in his blood pressure. In one of his follow up appointments, when he remembered to bring this concern up, his doctor ordered tests to investigate. Michael was informed that over the last few years he had lost nearly 50 percent of his kidney function as a result of his uncontrolled diabetes. So now, in his sixties, Michael was faced with managing two life-altering conditions.

Developing co-morbidities is a common occurrence for 25 percent of Americans. But changing the ingrained lifestyle behaviors which lead to these chronic conditions is difficult. Many people feel alone in managing this process. It requires a new level of accountability for one’s own health. But, in today’s healthcare environment, we have the technology to be more proactive and data-driven in care management — monitoring critical vitals, lifestyle, and activity insights to inform personalized care plans and treatments.

For the betterment of those who are battling chronic diseases — which now includes nearly one half of adult Americans — our healthcare system needs to improve processes, population management, and personal engagement to take advantage of the new paradigm of data-driven care delivery.

At Kaiser Permanente, care teams are leveraging remote monitoring programs to improve care for members with chronic conditions like Michael. Leaders here have rolled out the largest centrally deployed remote monitoring program with over 20,000 lives enrolled to date. The program focuses on members managing chronic conditions, including hypertension and gestational diabetes, with a primary focus on type II diabetes.

This new model of remote care iterates on past programs which used phone calls for members to provide remote data to care teams. Although the information was useful, this was a time-consuming, inefficient, and onerous process for both parties, as it relied on perfect member recall and provider data entry. It also took away from the provider’s ability to use these calls for discovery beyond biometric collection.

The new program, powered by Validic Impact, passively connects data from members’ home health devices into the clinical workflow, which are then visualized within the EHR. This program is delivering patient-generated health data from outside the hospital setting (i.e. in the home, at work, and on the go) directly into the clinical system to improve outcomes. The data provided to clinicians is standardized and visualized, to avoid giving providers a deluge of raw data — enabling efficiencies and saving time for all stakeholders.

“A unique thing about how we’ve implemented remote monitoring in collaboration with Validic is the device-neutral platform approach we’ve taken,” said Angie Stevens, executive director of Virtual Care at Kaiser Permanente, who leads the orchestration and deployment of these programs. “There are plenty of vendors out there with solutions for diabetes, heart failure, or any other number of diseases. People, however, are not a disease. They can’t be defined by a single condition. With the ability to passively gather vast amounts of data across a spectrum of elements, we can look at people holistically in the context of their own ‘normal’.”

Providers are able to view trends derived from member data, and the data is visualized in a way that easily elevates exception data, so a provider can determine when a member has an out-of-range value or is trending negatively. Put simply, care teams are able to proactively intervene before symptoms or conditions are exacerbated. Since implementing the new program, Kaiser Permanente has seen a number of important benefits, including high member and clinician satisfaction scores. Most importantly, among members enrolled in the remote monitoring program for type II diabetes, the average a1c dropped from 9.3 to 8.4 — a nearly one point decrease.

Michael’s journey bears this out. He joined a program of care in which he passively submitted his blood sugar, blood pressure, weight, and activity to his care team. The readings were delivered within the team’s electronic health record for clear visibility into his day-to-day progress against measurable goals. Based on his lifestyle and biometric data, Michael’s team provided him with specific feedback to guide his behavior week over week: eat fewer potatoes, change meal times, and walk at a higher intensity. The data gave Michael’s team the ability to provide him with specific, attainable action items on how to affect his behavior and lifestyle, and enable him to hit his personal health goals.

“More than just remotely monitoring people, our goal is to empower our members with timely information and support to better manage their own health,” said Stevens. “We can serve as their safety net as they move toward lasting lifestyle changes.”

In Kaiser Permanente’s Southern California region alone, over 450,000 members have diabetes. People like Michael agree that these data-driven remote monitoring programs improve their accountability and enable a deeper understanding of the direct impact of lifestyle choices. In a data-driven RPM program, Michael met his goals: to lose weight, reduce his medications, and to maintain kidney function.

In a time when over 133 million Americans are managing chronic conditions, there is an obligation to deliver quality care that makes the difference. Through programs like this at Kaiser Permanente, we can begin to move the needle on total health and encourage the growth of lifestyles that enable healthier behavior and more accountability.

To learn more about Kaiser Permanente’s partnership with Validic, join us for the upcoming KP Ventures/Rock Health Spotlight Series event on March 5th, 2019. Sign-up here: https://www.eventbrite.com/e/spotlight-series-enterprise-partnerships-with-early-stage-companies-tickets-56065978852

DISCLOSURE: Kaiser Permanente Ventures is an investor in Validic, and I am a member of the company’s Board of Directors