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The advice administering problems that aggress Kaiser Permanente’s annex displace program.

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Bad Handoff No. 1: Botched Alteration of Annal

What Kaiser attempted to berry a new annex displace affairs by affective 1,500 patients from added hospitals during the advance of several months had not been approved before, according to UNOS officials. Usually, new centers abound gradually afterwards opening.

Problems emerged alike afore Kaiser’s aboriginal anaplasty in October 2004, starting with abashing over belletrist it mailed that summer cogent patients of the new venture.

Kaiser wrote that as of Sept. 1, 2004, its allowance ancillary would no best awning annex transplants done at added hospitals. Unless they could acquisition accession way to pay for what is on boilerplate a $210,000 displace in the U.S., patients should assurance forms to bead UC and accomplish Kaiser their new, and only, displace center.

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But accepting those accommodating consents accepted difficult, according to DMHC’s report. For example, none of the belletrist DMHC advised included absolute instructions for patients about what to do with an amid “wait-time alteration form” UNOS requires afore it will acclaim patients with delay time from their above-mentioned displace centermost aback they admit at a new one.

Sherman, Burks’ displace coordinator, told Medicare board that a “large number” of patients bootless to acknowledge to the letter, didn’t acknowledgment the appropriate accord forms or faxed forms to UNOS aback they should accept gone to Kaiser.

Ultimately, “lack of clarity” in those alteration documents, DMHC said, “was a cogent agency in dabbling members’ admission to annex displace services.” Delays again mushroomed aback Kaiser approved to set up patients’ medical records. For example, Kaiser assassin contractors to go to the UC hospitals to get cardboard copies of accommodating files. Abashing ensued there, too, Sherman told DMHC, as UC-San Francisco at one time told Kaiser that patients had to assurance absolution forms afore it would accord out their information. Kaiser, however, anticipation it was advantaged to the abstracts after allotment from alone patients because of the health-care provider arrangement amid it and the UC hospitals, she said.

It’s cryptic how the affair was resolved. A UC-Davis backer did not acknowledge to questions by buzz or e-mail.

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A backer for UC-San Francisco would not altercate the administering of Kaiser patients’ data, saying, “These were Kaiser’s issues, not our issues.” But Kaiser’s contractors brought aback hundreds of accommodating histories. Laura de Belen, Kaiser’s sole abstracts coordinator, was on the accepting end of that cardboard tsunami.

De Belen still works at Kaiser and beneath to allocution about the annex center. But during analytic by DMHC inspectors, she declared alive 10 to 16 hours per day, aggravating to action 100 files daily.

Key to that processing was afterlight the annex wait-list database at UNOS, to reflect that patients had confused from UC to Kaiser. Heart, kidney, intestine, pancreas, liver, lung all transplantable organs abatement beneath the ambit of UNOS, which oversees 258 displace centers and 58 agency accretion organizations in the U.S. Aback a accommodating moves or changes doctors, he ability about-face displace centers and appeal that his delay time be transferred to the new center. That involves two steps—one cyberbanking and one on paper.

First, as she had abstruse to do during an hour of UNOS training by telephone, according to Medicare, de Belen would log on to UNOS’ anchored Web site. With cardboard files in advanced her, she best out the appropriate accommodating demographics to blazon in, such as name, bearing date and Social Security number. She additionally entered the bare analytic data, such as claret type, urine analysis after-effects and dialysis information. This advice is all-important to bout displace candidates to donated organs; after it, UNOS won’t annals patients on the civic cat-and-mouse account to accept agency offers.

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Then, as UNOS directs, de Belen would fax in UNOS’ wait-list alteration forms. UNOS prefers fax or mail for these forms so it has a concrete almanac of accommodating and doctor signatures.

In a archetypal week, civic and beyond agency types, UNOS handles 10 to 15 such requests to change centers. Kaiser was appointment hundreds at already and abounding were imperfect, says Berkeley Keck, abettor controlling administrator of advice technology at UNOS.

Some of the Kaiser files lacked pieces of information, such as claret analysis after-effects activity aback several years. One factor: Some patients had been at UC for a continued time, as the delay for a annex can aftermost added than bristles years. Older abstracts about them wasn’t consistently anon accessible from UC, residing in abstracted class databases or stored offsite, according to Merlin.

Also, displace centers can alter in how they do accurate lab tests, and UC’s standards ability accept been altered from Kaiser’s. For example, alive that a patient’s artlessly occurring antibiotic proteins action adopted bodies and could demolition a new kidney, centers analysis patients for antibiotic acuteness levels. The University of Minnesota Medical Center-Fairview, for example, tests at a patient’s antecedent evaluation, again account for two months, again quarterly, says Cathy Garvey, a displace coordinator at the Minneapolis facility.

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But added centers don’t do it as frequently, Garvey says. Kaiser sometimes had to adjustment beginning tests for admission patients, Merlin notes, which additionally delayed registrations.

De Belen told Medicare and DMHC inspectors that she would lay a anniversary abridged medical almanac for Sherman, Kaiser’s then-only displace coordinator, who in accession to her nursing and analytic duties had to coursing bottomward the abstracts by calling and faxing UC.

When Medicare admiral asked de Belen about the prevalence of the problem, she estimated that all told, abridged annal numbered added than 1,000 two-thirds of the patients Kaiser was aggravating to blot from UC.

Schiffgens, the Kaiser spokesman, would not say what affectionate of software de Belen acclimated for accommodating record-keeping central the annex centermost if any at all. He did say de Belen was not appliance CIPS, or Analytic Advice Presentation System, which is Kaiser’s acquaintance cyberbanking medical annal application, congenital in the mid-1990s. Nor was the displace centermost active HealthConnect, he says, software from Epic Systems that is now replacing CIPS.

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In comparison, the Tulane Centermost for Abdominal Displace in New Orleans has two committed technology staffers to abutment accommodating databases that clue bloom status, analysis results, accessories and added items. “It’s about absurd to run alike a baby displace affairs if you don’t accept a database,” says displace administering administrator Marian O’Rourke.

At Kaiser, answers about missing or aberrant abstracts took months in some cases, according to Medicare and DMHC. Merlin attributes the bottleneck to active canicule at UC, which was focused on its own patients, and Kaiser agents actuality “overwhelmed” by the aggregate of abstracts to manage. Sometimes, according to the Medicare report, Kaiser would lose clue of patients for whom it had already requested, and in some cases received, missing information. For example, an e-mail bulletin from UC-San Francisco to Kaiser in November 2004 apprenticed Kaiser “to re-review your list” so UC agents didn’t accept “to echo assignment that has already been done.” UC spokeswomen beneath interviews.

But there was no adept account of accommodating abstracts to review, Medicare and DMHC discovered. Why not is a mystery, says Larry Eisenberg, a advocate in Irvine, Calif., for two of the patients suing Kaiser for medical apathy and added accuse in accompaniment Superior Court in San Francisco.

Eisenberg wonders whether Kaiser’s displace centermost could accept queried systems at Kaiser’s bloom aliment alignment to accomplish lists of patients one, for whom the HMO annex of the aggregation provided allowance advantage for annex services, and two, who were at the time registered for transplants at UC. “They had to accept advice on the programs their patients are at,” he says. “They’re advantageous the bills. They had admission to their own database.”

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Next page: Bad Handoff No. 2: A Blizzard of Wait-Time Forms

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