Host Intro (Gene Kim)

The next speaker is Alice Raia. She is VP of Digital Presence Technologies at Kaiser Permanente.

Last year at the conference, her talk was one of my favorites. It was this amazing experience report of how she is modernizing the technology organization in the healthcare industry, where they deal with not only patients, but also the providers: doctors, nurses, pharmacists, in an integrated clinical setting. Of all the places where we want technology to work, it is there.

She is going to talk about the continuation of the journey at Kaiser. Not only is she helping more and more parts of the organization, but she is also working with a group of physicians and staff in Southern California to totally reimagine what healthcare should look like for patients.

Alice Raia.

Alice Raia

Thank you. Good morning, everyone.

I wanted to thank Gene and the programming committee for inviting me back to talk to you guys about the story of Kaiser Permanente's DevOps journey. It is a journey that not only is changing the way we work in IT, but it is changing the way we work with our business partners, and it is actually contributing to a larger transformation in the way we deliver care to our members.

I would like to start off a little bit 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 216,000 employees, about 22,000 physicians, and 50-plus thousand nurses. We are a very large organization. But we are especially proud to be rated in the top five of the top 50 companies being recognized for the diversity of their employee workforce, and we are also very much invested in being a partner in health, not only to our members, but to the communities in which they live. That is Kaiser Permanente at a glance.

Now I want to talk to you about who I am. You will see my business partner, Le Quach, up here. I want to introduce her as well. Unfortunately, Le Quach could not be here today. She is back at the home office working hard on transformation. But I do have a video where she is going to talk a little bit about how this new engagement model that we have got, in partnership with business and IT, is really making a difference for us in moving the needle forward.

As Gene said, I am the vice president in IT of Digital Presence Technologies. That primarily is 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 lead the DevOps practice for the organization, as well as I am the owner of the Agile software delivery process.

Le, pictured here, is a director in our newly formed Office of Transformation. This is a group that our CEO, Bernard Tyson, has spun up that reports directly into him, and 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. Le is a director in that organization. She is working with her team to create these new models, and you are going to see some of those models in a few videos that I have brought along with us today.

One of the things I really want to stress here is that we are changing the way we work with our business partners. You will hear that referenced quite often in the talk I am going to be going into here, as well as some examples that Le will be giving in her videos.

Before I dive into what we have done and how it is making a difference, I would like to talk about our journey. Everyone has a little different path on how they got to DevOps, but ours was a little bit unique, and even more important than the how is the why. Let me start off with where we have come from.

Back in 2015, our reality for our digital consumer assets was that we did not have a lot of investment in them. They were kind of cool. It was a nice website, nice mobile apps. But we were faced with the fact that we had problems and struggles releasing. It was hard. We could get code out about once every quarter, large batch. I am not telling any of you anything that you probably have not heard here already, but it was difficult. Then we had an aha moment, an uh-oh moment. I have heard other people refer to it a little bit differently here.

Our moment was that we were tasked with a strategy on changing the way we engage with consumers. The organization was willing to invest a large sum of money to do so, so that we could 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 our moment where we decided we must do something differently.

We decided to embark on building a modern engineering practice with those goals in mind: changing mindsets to ensure that we could deliver quicker time to market with predictability and high quality every single time.

How did we explicitly get there? We started in 2016, when the idea was born, and the idea being born means I begged the CIO. We executed a series of value stream mappings against our specific release process for kp.org. It was actually very eye-opening. We all kind of 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 said CIO after he agreed that this was the right way to go and asked for an investment. That investment was granted, and the way we operated, we actually sequestered the DevOps team that was going to build our practice. We wanted a little separation away from the daily goings-on of the work and allowed those folks to start with a clean sheet of paper. Very smart people in a room pulled together best practice and tried to understand how we could build this so that it would work in a highly regulated healthcare environment, but also press on the status quo and the cultural norms that we face every day.

We activated the practice when it was 80% done. This is a really interesting construct. For those of you who may also work in highly regulated industries, we are not big fans of taking one step forward until everything is done, signed off, blah, blah. We intentionally started when it was 80% done because we knew we would have to iterate. We knew there were things that we, who were putting the practice together, were going to have to accommodate for once teams started using the practice.

Then we iterated, and we iterated, and we iterated. We had a few very good teams who were willing to sign up to be early adopters, and they helped us to mature this practice.

As of today, we have 30 squads on the practice. I will show you some statistics later on how many people that means and how many pipelines, et cetera. 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.

I talked about how this is changing the way we engage with our business partners and changing care models. I have got a couple of videos I want to show you.

This is some specific ways in which IT is changing the way we work. I talked a little bit about our DevOps practice. We are engaging. We have 30 teams on it. It also helps us with some innovation and some experimentation. We are introducing a new site reliability engineering function within our organization, pulling ops more into dev, and quite frankly, honestly, we had a development problem to solve first, so we started with dev, and now we are going into ops. We are moving to the cloud. We are refactoring. We are making sure we are following microservices patterns.

There is a lot of change here in modernizing this enterprise practice and engineering practice, but it is also involving a cultural transformation. There are absolutely new mindsets that are necessary. There are new ways of behaving that we are asking our teams to accommodate.

We are adopting things like design thinking, empathy, co-creating with our business partners, which you will hear a little bit more about in a couple of minutes. This collective approach, DevOps, new ways of operating, new places to put our code, cloud, microservices, all of this comes as a package. It is not one of these things that is making a difference. It is all of them that are contributing to that transformation and helping us to enable our business in these new paths that they want to go down.

Now I would like to introduce the video. In this first video you are going to see a day in the life of a care delivery team and a few of our members at Kaiser Permanente, and it showcases some of the technologies and approaches that we have put in place that are differentiating us. I will come back and talk a little bit about them after we see the video. Can you roll the video, please?

Care Delivery Video

Hey, sis. It is Dave. Yeah. I am good. No, I am in front of her house right now. Absolutely. No. Well, she has been down since Dad passed. Yeah. Well, when she sees you, she is just going to light up, I have no doubt.

Hey, man. Hey. Kiss your mom off to work? He is not doing too good, okay? Oh, puppy, you do not feel good? Let me see. Let me know how it goes, okay? Okay. You feel warm, Papa.

Good morning, Laquita. Good morning, Tanya. How are you? Fine, you? I am good, thank you. How was everybody's weekend? It was great. It was good. Awesome. How is it going? It is good. How was your weekend, buddy? Good. How about yours? It was good. Good. Just hung out with the family at home this weekend. How about yourself? I worked urgent care. It was not too bad though. Not too bad? Okay.

Very nervous. Very nervous. It is going to be okay, Mom. Shh.

Hi. Good morning. Yes, I am looking for a video appointment with Dr. LeCount. That will be for Felipe Solis. How is my schedule looking this morning? It is pretty good, but can we actually add in Monica Solis for a video appointment at 11:00 a.m.? Oh, sure. I will see them at 11:00. Okay. Thank you. You are welcome.

Oh, great. We are going to see the doctor at 11:00. No.

Hey, Dr. Saadi. Yeah, Laquita? Do not forget this afternoon you have telehealth. Got it.

All right, here we go. Here we go. Come on, Sven. You okay? All right? Yeah. Hey, man, are you all right? Nah, it really hurts. I think you need to go to the emergency room. It just takes so long there. I do not want to wait. Let me know if you want me to take you. Thanks, man.

Hi, Ms. Rhodes. Hi. How are you? Hi, Tracy. Good to see you. Good to see you guys. Welcome. Great to see you again. You look amazing. Thank you so much. She does, does she not? Oh, yes, she does. I am going to get you all checked in for your visit today.

Hi, Monica. Hi, Felipe. Hi, Dr. LeCount. Oh, my goodness. He is getting bigger. He sure is.

I was just going up for a rebound and I came down and I am just in a lot of pain right now. I can hardly move it. If you can, try to reach up like how I am doing and touch your opposite shoulder. Like this? Good. He has had a little bit of orange juice and a couple sips of water. He did eat dinner last night. Okay. Did he keep that down? Yes, he did.

What I am thinking when I am looking at him, he looks very comfortable in your arms. I am thinking he has a viral syndrome, and with that, we need to make sure that we keep him as comfortable as possible. We do not have to worry about a separation of the shoulder. So I cannot play for a while? I really do not want you playing until you can do those full range-of-motion activities with the arm without any pain. All right. Sounds good. Thanks a lot, doc. Appreciate it. You are welcome, Andrew. Feel better soon.

She will be with you guys in just a few minutes. Surprise. Hi. Oh my goodness. Hi, Mom. How are you? Wonderful. I am feeling much better. Hi. Hey. Hi, Ms. Frost. Good to see you. Good to see you. Thank you so much for coming in. It is my pleasure. Thanks for joining us. Nice to see you again. And hi, Pam. I am Jacqueline LeCount. I am taking care of your mother.

Dr. LeCount. Hi, Michelle. Hi. Can I please order that foot X-ray for Ms. Sarah? Now, what is it for? Her left foot. She is still having left foot pain. Yes. Can you order that for me, please? Thank you.

Okay, let me see how many emails I have. Two emails. Hello, London? Hi, it is Mommy. I am going to be able to make your performance this evening.

It was good seeing Pam, huh? Yes, it was really nice seeing her again. I think everything is going to be fine. You took care of us, so now we are going to take care of you.

How is your shoulder? I am all right. I just cannot play for a couple weeks. Have you talked to a doctor? Yeah, I did. And you did not have to go in? Nah, I did not.

Alice Raia

What you saw in that video is a very different way for our clinical staff to work, a very different way for our members to engage with us immediately when they need us, and on their terms. A lot of those technologies that you saw were actually developed and co-created with our Southern California business partners in the clinical setting.

What I would like to do now is introduce my business partner, Le Quach, who has worked with our teams extensively in Southern California to build these kinds of experiences and is thinking about the future on how we are going to do things to expand telehealth and to meet our members outside of a medical facility. Can we cue the next video with Le, please?

Le Quach Video

Kaiser Permanente's new medical office buildings are an example of how we are leveraging technology to improve the care experience for our members and our providers. These new medical offices 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 are processing paperwork. It is very impersonal. It is very DMV-like.

But we have introduced two technologies that have really enhanced the efficiency as well as the interpersonal interaction with our members. One technology is express check-in. People can connect while they are 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 have 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. They are able to give them hugs. They are able to help those who need physical assistance. When paperwork is actually necessary, they sit down at a table, eye to eye, ask questions, and do that work on a tablet, which makes for a much more interpersonal interaction.

As a result, the receptionists love it. They are able to connect to the patients in a way that they have always wanted to. Members also love it because they feel as if they are being cared for in a much more personal and 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 teleconsult, we can teleconsult and 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 teleconsult 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 are able to send them home with video, with email, and other resources to support their healthy lives. In addition, telehealth and telemonitoring have allowed us to keep tabs on our members and monitor their health. Further 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 is what matters most.

Technology has changed the way that the care team collaborates with each other within the clinic. Because they are armed with tablets and mobile devices, they are untethered from their computers and their offices, and that allows them to collaborate together, either planned or spontaneously, and really, really 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 to design and immersion to understand the needs and to develop solutions to meet that need. That meant working in antidisciplinary 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 solutioning and development in real time. It also meant easier adoption and integration into operations. For these new clinics, we developed over 10 new technologies in the span of 18 months.

Most importantly, this approach developed a deep mutual appreciation between business and IT. It is 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

Thank you. A couple of things 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. The antidisciplinary team concept is something that is really, really 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. We are all in our own world. A lot of this new way of working has been tried and is now starting to permeate throughout the organization.

A couple of things that I just wanted to touch on, on how the work we are doing, which is foundational with DevOps and the way we are changing the way IT is engaging with our business members and maturing our engineering practice, is making a difference.

You saw the reimagined face-to-face experience, those interactions both with the clinical staff and with our members. We are now looking at ways that we can reach into the home and use technology to provide care. We are tightening and blurring those lines between the business and IT. We are co-located teams that are driving towards outcomes, not a hierarchical organization. And we are also broadening our member and community impact. It is 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.

We are at a DevOps conference, so I wanted to talk a little bit about DevOps, you guys. One of the things I did talk about a little bit earlier was the fact that our digital assets are so important and so interwoven in our members' daily lives. We often joke that kp.org and our mobile apps are kind of our ninth region.

If you look at some of the statistics and how people are self-serving, we have outstanding registration rates. 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 is 28 million people who did not have to go to a pharmacy. Fifty-one million lab results reviewed online. That prevented a phone call or a doctor having to send something to someone. Twenty-eight million emails to physicians.

All of this work is facilitated by our engineering practice on the teams that are building these capabilities. Fifty-nine percent of our encounters happened virtually, and that is the trend of the future. The way we are going to increase that is by leveraging technology, experimenting, and innovating, which our engineering practice can support.

Our DevOps practice is actually doing pretty well for those 30 teams that are on it currently. We have over 1,000 developers leveraging five pipelines that we have built. We average about 400 code commits per day. We are on pace to deliver 80 releases a year using these pipelines. If you remember when I started the talk, back in 2015, four releases a year, up to 82. Right now, this is just the consumer-facing digital teams. We are going to expand this practice to the rest of the organization, and we have, I think, 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 mindset. It does take a change in behavior to get here. We have become a learning organization. We are open and transparent with our content. We do not border or fence based on which team you are on. We share best practices. We go out and we evangelize. We help people understand the benefits, because quite frankly, there is not always an NPV. But everything you have all been hearing about here at this conference around quality, time to market, innovation, leading and lagging indicators are all the case for this.

We have also had to adopt a little bit of a "the developer is the most important person in the cycle" mentality, and that is a bit of a mind shift. We think about producer-consumer: 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 is next for us? I have alluded to the fact that we are going to spread this to the rest of IT. We have 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 large organizations that are our customers. The spread will happen.

We are also looking at how we accommodate data teams with a DevOps model. We are looking at ChatOps: what is the next evolution of our pipelines? We are really looking right now and are very focused on solidifying DataSecOps so that we can bring applications that are held to SOX controls onto our practice.

Finally, it is always about mindsets, talents, skills, and making sure folks have what they need in the organization to be able to go here. We are 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 kind of model? It has been a journey for them as well.

We are really excited about going here. I have to thank a number of my team who are all here this week. We wake up every morning trying to figure out how we can improve this model, because what is really important for us is offering that affordable, high-quality care to our members, and that is our North Star. Everything we do, whether it be in our practice or what we deliver, is held up against that lens.

Finally, I would like to thank all of you for inviting me here and having the program committee come out here. We think we have a very compelling story to tell. We are excited about the work we are doing. It is not always easy. I talk about our teams pushing on cultural norms every day. But it can be done. It can be done when the folks in the business realize that this is a way to enable a transformation. This is a way to enable adding whatever that value is that you want to add to your consumer base. Quite frankly, this ties all back to our mission to provide high-quality, affordable care to our members. Enjoy the rest of the afternoon, you guys, and thank you for having me.