DevOps: Enabling Business Transformation in Health Care

As health care evolves to a more “consumer” centric model, software delivery teams in these organizations are finding new and innovative ways to work to support the speed and experimentation expected by their business partners.

In this presentation, Alice Raia shares how Kaiser Permanente has built a DevOps practice to meet these needs, and is contributing to a larger transformation internally and externally with their members’ experience.

Alice Raia

Today I want to share with you the story of Kaiser Permanente’s DevOps journey.

It’s a journey that is not only changing the way we work in IT but is also changing the way we work with our business partners, and it’s contributing to a larger transformation in the way we deliver care to our members.

I’d like to start by talking about who Kaiser Permanente is for those of you that are not familiar with us. We are the largest integrated healthcare system in the United States. We have 12.2 million members spread across eight regions.

We have 216 thousand employees, about 22 thousand physicians, 50+ thousand nurses. We’re a very large organization, but we’re especially proud to be rated in the top five of the top 50 companies being recognized for the diversity of their employee workforce. We’re also very much invested in being a partner in health. Not only to our members but to the communities in which they live. That’s Kaiser Permanente at a glance.

Now, I want to talk to you about who I am.

I’m the vice president in IT of digital presence technologies. Which is primarily digital engagement with our consumers and our members. I not only own KP.org, and our mobile apps that are consumer-facing, we have a mobility center of excellence, and I also own the DevOps practice for the organization, as well as the agile software delivery process.

My business partner is Le Quach, a director in our newly formed office of transformation. This is a group that our CEO, Bernard Tyson, spun up that reports directly into him. Their major goal in life is to transform the way we deliver healthcare, offering new models to our members, meeting them where they want to be met, weaving health and wellness into their daily lives.

Before I dive into what we’ve done, and how it’s making a difference, I’d like to talk about our journey. Everyone’s got a different path on how they got to DevOps, but ours was a little unique because for us even more important than the ‘how’ was the ‘why.’

Let Me Start with Where We’ve Come From

Back in 2015, we didn’t have a lot of investment in our digital consumer assets. It was a nice website, nice mobile apps, but we were faced with the fact that we had problems, and struggled to release. It was hard. We could release code once every quarter in a large batch. This isn’t a novel story, but it was difficult for us. Then we had an a-ha moment, or rather, an uh-oh moment.

We were tasked with a strategy to change the way we engaged with our consumers. The organization was willing to invest a large sum of money to change the face of healthcare in this country. In order to do that, we were faced with rising expectations of our business partners. Predictability, quality, and time to market were going to be critical in our ability to innovate and experiment with new care models.

This was the moment we decided we must do something differently. We decided to embark on building a modern engineering practice.

How did we explicitly get there? Well, the idea was born in 2016, , meaning I begged the CIO. We executed a series of value stream mappings against our specific release process for KP.org. Which was very eye-opening. We all knew there were inefficiencies and waste in the model, but this specifically pointed out to us where we needed to focus and concentrate.

I then went back to my CIO after he agreed that this was the right way to go, and asked for an investment. That investment was granted, and we sequestered the DevOps team that was going to build our practice.

We wanted a little separation away from the daily ins and outs of work and allow these folks to start with a fresh sheet of paper.

Then, we activated the practice when it was 80% done. This is an interesting construct. For those of you who may also work in highly regulated industries, we’re not big fans of taking one step forward until everything is done, signed off, etc.

However, we intentionally started when it was 80% done because we knew we’d have to iterate. We knew there were things that we were going to have to accommodate for once teams started using the practice. Then we iterated, and we iterated, and we iterated. We have a few very good teams who were willing to sign up to be early adopters, and they helped us to material this practice.

As of today, we have 30 squads on the practice. I’ll show you some statistics later on how many people that means, and how many pipelines, etc. But 30 teams are now starting to leverage the practice in these digital assets, and the intent is to spread this all to the rest of IT.

This Is How We Got Where We Are Today

Here are some specific ways in which IT is changing the way we work. I talked a little bit about our DevOps practice, but it has also helped us with some innovation and some experimentation.

We’re introducing a new site reliability engineering function within our organization, pulling Ops more into Dev. Quite frankly, we had a development problem to solve first, so we started with Dev, and now we’re going into Ops.

We’re moving to the cloud. We’re refactoring. We’re making sure we’re following microservices pattern. There’s a lot of change here in modernizing this enterprise practice, and enduring practice, but it’s also involving a cultural transformation. There are absolutely new mindsets that are necessary. There are new ways of behaving that we’re asking our teams to accommodate. And we’re adopting things like design thinking, empathy, and co-creating with our business partners.

This collective approach, DevOps, the new ways of operating, new places to put our code, cloud, microservices — all of this comes as a package. It’s not any one of these things that are making a difference. It’s all of them that are contributing to that transformation and helping us to enable our business in these new paths.

Now I’d like to do now is introduce our business partner, Le Quach, who has worked with our teams, extensively in Southern California to build these experiences, and thinking about how we’re going to do things to expand telehealth and to meet our members outside of a medical facility.

Le Quach

Kaiser Permanente’s new medical office buildings are an example of how we’re leveraging technology to improve the care experience for our members and our providers. Leverage cutting edge technology to create intuitive, convenient experiences for our members from before they arrive, and extending beyond their visit.

The check-in process is an example of where technology has transformed the member experience. Traditionally, when you check-in you come into the office. You wait in line. You get in front of a desk. You’re processing paperwork. It’s very impersonal. It’s very DMV-like. Instead, we’ve introduced two technologies that have enhanced efficiency, as well as the interpersonal interaction with our members.

One such technology is an express check-in. People can connect while they’re still at home, make their payment, answer questionnaires, and check-in in the comfort of their own home.

Another example of technology improving the care to our members is the tablets. We’ve provided tablets to our receptionists and essentially untethered them from the long reception desk. Our receptionists are now free to roam around when patients come in. They are able to greet them and help those who need physical assistance. When paperwork is necessary, they sit down at a table, or eye-to-eye, ask questions and do that work on a tablet which makes for much more interpersonal interaction.

As a result, the receptionists love it. They’re able to connect to the patients in a way that they’ve always wanted to. Members also love it because they feel as if they’re being cared for in a much more personal, less transactional way.

The exam room visit with the doctor has also been transformed. Now, with digital technology, and a monitor in the room, we can video in the family, friends, caregivers, and other people who are there to support our members in their health journey.

With the teleconsole, we can call in different specialists and providers to give a diversity of opinions, and give a true care team approach. Being able to call in a teleconsole also helps our patients avoid having to go to additional visits with specialists.

Technology has extended our ability to reach into the home, and beyond the doctor’s visit. We’re able to send them home with video, with email, and other resources to support their healthy lives.

In addition, telehealth, telemonitoring has allowed us to keep tabs on our members, and monitor their health. Later on, in the future, we want to create an infrastructure to support more self-care, more acute care in the home setting, nudges to support clinical adherence and healthy behaviors, or ways of connecting people to people because that’s what matters most.

Technology has changed the way that the care team collaborates with each other within the clinic. They are armed with tablets, and mobile devices, they’re untethered from their computers, and their offices, that allows them to collaborate, either planned or spontaneously and promote the idea of team-based care.

To get this done, we embarked upon a process of co-creating technologies. This means taking a human-centered approach design, and immersion to understand the needs, and to develop solutions to meet that need. That meant working in anti-disciplinary teams, mashing up technologists, clinicians, operations, facilities, and design all towards accomplishing a shared vision of a better experience for our members, and our providers. The result is what I call radical collaboration for on the spot solutions, and development in real-time. It also meant easier adoption, and integration into operations.

For these new clinics, we developed over ten new technologies in a span of 18 months. Most importantly, this approach developed a deep mutual appreciation between business and IT. It’s with this appreciation that I thank you for inviting me to share how technology has been used to enhance the very human interaction between getting care and being well. Thank you.

Alice Raia

There are a couple of things that resonate with me when Le talks about how this radical collaboration has helped us in our mission to provide outstanding affordable care and transform the healthcare system. First, the anti-disciplinary team concept is something that is pretty foreign. Putting technologists, business folks, physicians, nurses, operations folks, and pharmacists together is something that gives us a robust set of offerings but was never even considered. Usually, we’re all in our own worlds. A lot of this new way of working has been tried and is now starting to permeate throughout the organization.

Secondly, the way we’re changing IT is by engaging with our business members and maturing our engineering practice. Le talked about how we’ve re-imagined the face-to-face experience, those interactions both with the clinical staff, as well as with our members. We are now looking at ways we can reach into the home, and use technology to provide care. We’re tightening and blurring those lines between the business and IT. We are co-located teams that are driving towards outcomes, not a hierarchical organization.

We’re also broadening our member and community impact. So, it’s very important to us that we also provide ways to increase health in the communities with which we serve whether those folks are our members, or not.

Let’s Talk DevOps

One of the things I talked a little bit about earlier was the fact that our digital assets are so important, and so interwoven in our member’s daily lives. We often joke that KP.org and our mobile apps are our ninth region.

If you look at some of the statistics, and how people are self-serving, we have outstanding registration ranks. They rival banking. We have 6.5 million registered users who regularly use our site in order to self-care and self-triage. Things like prescription refills: 28 million a year. That’s 28 million people who did not have to go to a pharmacy. 51 million lab results reviewed online, that prevented a phone call, or a doctor sending something to someone. 28 million emails to physicians, all of this work is facilitated by our engineering practice on the teams that are building these capabilities. 59% of our encounters happened virtually, and that is the trend of the future.

The way we’re going to increase that is by leveraging technology, experimenting, and innovating, which our engineering practice can support. Our DevOps practice is doing pretty well for those 30 teams that are on it currently. We have about over a thousand developers leveraging five pipelines that we’ve built. We average about 400 code commits per day, and we are on pace to deliver 80 releases a year using these pipelines. If you remember when we started in 2015, we went from four releases a year up to 82, and that’s just the consumer-facing digital teams. We are going to expand this practice to the rest of the organization. We have over 700 applications in our organization, and we fully expect those teams to be able to realize some of these benefits as well.

But again, the largest transformation for us has been with our mindset it took a change in behavior to get here. We have become a learning organization. We are open and transparent with our content. We don’t border or fence based on which team you’re on. We share best practices. We go out, and we evangelize. We help people understand the benefits.

We’ve also adopted the mentality that “a developer’s the most important person in the cycle” which has also been a mind shift. How can I, if I am not a developer, provide the most outstanding service to that developer so that we are all driving towards incredible outcomes for our members?

What’s Next for Us?

I’ve alluded to the fact that we’re going to spread this to the rest of IT. We’ve already started conversations with our IT partners across the organization in our pharmacy systems, in our electronic medical records system, in some of the other systems of engagement that we have with our brokers, or organizations, large organizations that are our customers.

The spread will happen. We’re also looking at how we accommodate data teams with a DevOps model. We’re looking at chat ops. What is the next evolution of our pipelines? We’re looking right now, and are very focused on solidifying data sec ops so that we can bring applications that are held to socks controls onto our practice.

Finally, again, it’s always about mindsets, talents, skills, and making sure folks have what they need in the organization. We’re even starting to think about certification programs for DevOps engineers. Can we have different belt levels? How do we get our business partners trained in order to participate with us in this type of model?

It’s been a journey for them as well, and we’re really excited about going here. We wake up every morning trying to figure out how we can improve this model because, again, what’s important for us is offering that affordable, high-quality care to our members, and that is our North Star, whether it be in our practice, or what we deliver, it is held up against that lens.

This was an excerpt from a presentation by Alice Raia, Vice President, Digital Presence Technologies, Kaiser Permanente.

You can watch the video of the presentation, which was originally delivered at the 2018 DevOps Enterprise Summit in Las Vegas.

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