iHT2 Health IT Summit Atlanta 2013 – Thomas Graf, MD, Chief Medical Officer, Population Health, Geisinger Closing Keynote: Accelerating HealthCare Delivery through EHR Optimization

Copyright Geisinger Health System 2013
Not for reuse or distribution without permission
Accelerating HealthCare
Delivery through EHR
Optimization
Thomas R Graf MD
CMO, Population Health and
Longitudinal Care Service Lines
Geisinger Health System

Heal • Teach • Discover • Serve
Geisinger Health System - Proprietary
“Let us bear in mind that the most important individual after all is
the patient. Our paramount thought must be to provide him means
by which he can have skilled diagnostic and therapeutic service in as
complete form as may be indicated in a given case, in the shortest
possible time consistent with thoroughness, and at the least cost to
him.” HL Foss, MD
11/4/1950
| 2

Geisinger Health System
An Integrated Health Service Organization
 Multispecialty group
• ~1,000 physicians
• ~520 advanced practitioner FTEs
• 65 primary & specialty clinic sites
(37 Community Practice Sites)
 Freestanding outpatient surgery center
 > 2.1 million clinic outpatient visits
 ~360 resident & fellow FTEs
Geisinger Medical Center
• Danville Campus – includes Hospital for
Advanced Medicine, Janet Weis Children’s
Hospital, Women’s
Health Pavilion, Level I Trauma
Center, Ambulatory
Surgery Center
• Geisinger Shamokin Community Hospital
Geisinger-Bloomsburg Hospital
Geisinger Wyoming Valley Medical Center
with Heart Hospital, Henry Cancer Center,
and Level II Trauma Center
• Geisinger South Wilkes-Barre campus with
Urgent Care, Ambulatory Surgery Center and
Inpatient Rehabilitation
Geisinger Community Medical Center
with specialized medical & surgical
services, including Level II Trauma and
comprehensive cardiac & orthopaedic services
Marworth Alcohol & Chemical Trtmt Center
Mountain View Care Center
Bloomsburg Health Care Center
 >72K admissions/OBS & SORUs
1,593 licensed inpatient beds
 ~400,000 members
(including ~63,000 Medicare
Advantage members)
 Diversified products
 ~30,000 contracted
providers/facilities
 43 PA counties
 PA Medicaid initiative
 Out of state TPA contracts
Provider
Facilities
Managed
Care Companies
Physician
Practice Group
Note: Numerical references based on fiscal 2012 budget plus impact of GSACH
, GCMC and GBH acquisitions.
| 3

Geisinger Health System coverage area
Revised 6-28-12. Geisinger PR & Marketing Department
4

Clinical Enterprise
Geisinger Health
Plan
Aligned objectives for the greatest impact
The Sweet Spot: Our realm of
partnership and innovation
| 5

Alerts
Prompts/Reminders
Order Sets
Automated care plans
Patient messages
Information Rx
…
Effectors
…
EBM Guidelines
Patient Preferences
Formulary/Economics
Other Inputs
EHR
Clinical,
Schedule
…
Real-time Clinical Status
Decision
Support
CDIS
Normalization, Transformation,
Analytic Application
FinanceClaims Ops
…
Clinical Decision Intelligence System
(CDIS)
| 6

Retail Clinic
Community
Practice Site
Retail
Pharmacy
Multi-
Specialty Clinic
Ambulatory Care
& Surgery Center
Specialty Center,
e.g. Cancer or Sleep
Urgent Care
Center
Tertiary/Quaternary
Medical Center
eICU
Inpatient Rehab
Outpatient Rehab
Home Care
Hospice
Specialty Outreach
(“Face-to-face” &
Telemedicine)
After-Hours
Care Center
ProvenHealth
Navigator
Destination
Medicine
Acute
Care
Community-Based Care
Post-Acute &
Transitional
Care
Geisinger Patient-Centered
Continuum of Care
Imaging Center
E-Visit
MyGeisinger
Adult Health Program
& Day Center
Lab Outreach Site
Work Site Clinic
Wellness
7
| 7

Higher Cost Associated with
Lower Quality
Baicker K, Chandra A. Health Affairs Web Exclusive, April 7, 2004: W4 184-97. | 8

The need for partners
• Working alone, primary care physicians lack the
data and some of the expertise to create optimal
care
– Utilization and cost data
– Care coordination techniques/focus
– Population management support
• Working alone, health plans lack the clinical
expertise and personal connectivity to create
optimal care
– Comprehensive definitions of quality
– Intimate patient and family knowledge and connectivity
• Re-engineering the payment paradigm required
9|

Triple Aim “-Plus”
• Improved Quality
• Reduced Total Cost of Care
• Improved Patient Experience
• And
• Improved Professional Experience
10|

11
Geisinger’s EHR Strategy
The IT strategic plan, developed in concert with the
organization’s overall strategic plan and approved in May
1995, set out high-level IT objectives:
– Function as a seamless organization serving as the
region’s health service leader.
– Establish a delivery system designed to manage the
continuum of care from healthy living through acute and
chronic care.
– Continually evaluate processes and implement
improvements in health services, incorporating the most
cost-effective utilization of resources to achieve
measurable improvement in the health of our service
area.
– Strive to provide people throughout our service area with
access to consistent quality in health care regardless of
where they enter our system.
11|

EHR Strategy Roadmap
EHR
Contract
Signed
First Ambulatory
Office Installed
Clinical Data
Warehouse
Implemented
Patient &
Health Plan
Portals
Implemented
Health
Information
Exchange
(HIE)
Implemented
NLP
ASP Offerings,
Telemedicine
1995
Began Inpatient
Implementation
Provider Portal
Implemented
Completed
Inpatient
Hospital
Implementation
1996 2001 2002 2003 2007 2008 2009 2011
Ambulatory
Office
Implementations
Completed
Optimization and Innovations
12|

Clinical Decision Intelligence
System (CDIS)
• Geisinger’s integrated (multi-source), enterprise-
wide business intelligence platform:
– Enable data-driven clinical and operational decision-
making throughout Geisinger
– Inform care to drive clinical outcomes
– Actionable data
– Timely; Near real-time as needed
– Evidenced based
– Aligned with strategic plan
• CDIS is "... a national model for patient
engagement, research, and education, as well as
leading to business and growth opportunities."
13|

Information-Transformation
Continuum…
Data Generation
Data
Aggregation &
Transformation
Performance
Measurement
& Analysis
Knowledge
Creation
Clinical
Transformation
 Required for
performance
measurement
 Enables
population-
based
management
 Typical EHR
“after-thought”
 Establishes
current state
 Can be
compared to
known or
possible
alternatives
 Trended over
time
 Insight derived
from empirical
analysis
 Critical adjunct
to EBM
 Deployed in
various ways
(order
sets, alerts, etc
.)
 Fundamental
clinical re-
engineering
 Must alter
clinical
workflows
 Eliminate, a
utomate, de
legate, incor
porate and
activate
 Care by-
product
 Patient-level
transactions
 Mixed forms
 Increasingly
will include
patient self-
reported data
14|

Clinical Reengineering
Case Study: Diabetes
• All-or-none bundle measure
• Workflow redesign
• EMR enhancements with clinical decision
support
• Activating patients
• Timely feedback
• Care Gaps and automating outreach
15|

| 16

Creating an ―All or None‖
Measure
• System wide input – specialty providers,
primary care providers, nursing, and
operations
• Use guideline and evidence-based
recommendations
• Focus on “Patient Goals”
17|

All or None Measure
Goal Non-Smoker
Influenza
Immunization HgbA1c <7 BP < 130/80 LDL < 100
Complete
Bundle
Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Percentage 80% 80% 60% 60% 60% 0%
Even if individual criteria have great results, when
calculated as an All-or-None metric – the need to
work differently (systems of care) becomes evident
18|

Diabetes Bundle
Measure Quality Standard
HgbA1c measurement Every 6 months
HgbA1c control Within goal (below 7 or 7-8)
LDL measurement Yearly
LDL control Within goal (below 70 or below 100)
Blood pressure control Within goal (below 130/80 or below
140/90)
Urine protein measurement Yearly
Influenza immunization Yearly
Pneumococcal immunization Once before 65, once after 65
Smoking Status Non-smoker
Patients who received 100%
of care
Diabetes Bundle Percentage
19|

Diabetes Taxonomy and the
Goals of Therapy
Old Diabetes Taxonomy ICD-9
DM, Controlled, Type II 250.00
New Diabetes Taxonomy ICD-9 (code)
DM Type 2, goal A1c below 7 250.00
DM Type 2, goal A1c 7-8 250.00A
DM Type 2, goal A1c to be determined 250.00B
DM Type 2, goal A1c: symptom mgmt 250.00C
Non-specific diagnoses
make it difficult to identify
goals of therapy
More accurately describes
patient needs, including ability
to exclude from performance
measure entirely
20|

Diabetes Bundle Score
• Individual component scores for Geisinger
Health System (GHS) patients were very
good – above the national benchmarks
• Initial GHS overall diabetes bundle – 2.4%
• Dramatic restructuring of care delivery
process needed – Greater individual effort
not going to be enough
21|

EMR-Enhancements: Nurse
Rooming Tool
22|

EMR-Enhancements: Diabetes
Management Decision Support
Alerts for Nurses: Protocol based
23|

Alert Impact for Microalbumin
for Diabetics
Rate of Annual Urine Microalbumin Monitoring
24|

EMR-Enhancements: DM Decision Support
Alerts for Providers: Requires Medical Decision
25|

EMR-Enhancements: Diabetes
Summary Report
26|

Patient Activation: Diabetes
Report Card
Last 2-3 values
displayed
LDL values
and goals
Last BP
readings
27|

Patient Activation: Portal-Based
Report Card
28|

• Population Health—Closing Care Gaps:
– Close preventive, chronic and restorative care gaps for targeted
patient populations by age/gender, disease, or condition
• Engaging Patients:
– Patient & family-centric care coordination
– Proactive outreach to influence
– Telephone, Web, Text
• Transform Culture by Leveraging Technology:
– Data mining using evidence-based protocols & registries
– Decision support (patient, clerical, nursing, provider-level)
– Seamless connections (patient, PCP, specialty, ancillary, payor)
– Strong relationships
Care Gaps Program
29|

Preventive Care Automation
• Adult Prevention
– Exam Room Decision Support
– Happy Birthday Model Outreach
Model
– Automated Letter or
Patient Portal Message & Direct
Scheduling
– Autodialer: ~2500 pts monthly
Preventive Care Message
“Sherry RN with Geisinger Clinic”
• 500 Calls Day & 250 Calls Early
Evening with Warm Transfer
Develop Processes to Close Care Gaps
30|

Improving Diabetes Care for
24,551 Patients
3/06 3/07 2/10 2/11
Diabetes Bundle Percentage 2.4% 7.2% 10.8% 11.5%
% Influenza Vaccination 57% 73% 76% 77%
% Pneumococcal Vaccination 59% 83% 84% 83%
% Microalbumin Result 58% 87% 79% 78%
% HgbA1c at Goal 33% 37% 46% 49%
% LDL at Goal 50% 52% 53% 55%
% BP < 130/80 39% 44% 52% 52%
% Documented Non-Smokers 74% 84% 85% 85%
31|

Diabetes Bundle Improvement
0%
5%
10%
15%
20%
25%
30%
35%
0 1 2 3 4 5 6 7 8 ALL
Total Number of Bundle Measures Each Patient Meets
%oftotaldiabetespatients
Entire Population Shifts Toward Better Care
Bundle
Increases
3/06
7/10
32|

Microvascular
• Retinopathy
– Less than 3 years
– Number needed to treat
to prevent 1 case is 151
– 331 cases prevented
Macrovascular
• Heart Attack
– Number needed to treat to
prevent 1 case is 82
– 610 prevented
• Stroke
– Number needed to treat to
prevent 1 case is 178
– 281 prevented
Value Driven Care
Patient Centered Outcome Improvements
33

MyGeisinger & Patient
Activation
34|

Geisinger’s Patient Portal
*As of June 30, 2011
• View health summary
• Lab results, medications,
diagnoses, allergies, discharge
instructions
• Message doctor’s office
• 65% clinical / 35% administrative
• Online scheduling of primary care and
women’s health appointments
• Renew prescriptions
• Patient entered information
• Electronic signatures
• Patient education
• “My Condition Centers” for asthma,
diabetes & hypertension
• Online videos
• Links to trusted health information
• Access primary care physician notes
(current research)
• “There’s an app for that”.
User Age Users Percentage
<18 years 23,439 13.51%
18 – 34 years 35,204 20.3%
35 – 54 years 61,985 35.74%
55 – 74 years 44,611 25.72%
>=75 years 8,197 4.73%
Total 173,436
35|

MyGeisinger: The Journey
• ~2,000 new users/month, 61% female / 39% male, 30.5% primary care penetration
• Progression: Fast follower to EMR plan (Primary Care , Specialty Care, Inpatient)
• Enhanced functionality over time: Administrative (caregiver access, pay my
bill, schedule an appt), Clinical (patient entered data, education, proactive outreach to
close care gaps
• Expanded access to data: Outpatient labs, Inpatient labs, other results
173,436
149,279
126,434
104,149
81,340
56,246
29,395
12,014
4,891
76657
0
25,000
50,000
75,000
100,000
125,000
150,000
175,000
200,000
Jun-01
Jun-02
Jun-03
Jun-04
Jun-05
Jun-06
Jun-07
Jun-08
Jun-09
Jun-10
Jun-11
36|

MyGeisinger for Patient Care
Patient-Entered Blood Pressure
• Initiated by the physician during patient visit
• Patient enters BP checked at home in
MyGeisinger; can chart results
• Physician receives immediate alert for
abnormal readings and message every 7 days
for normal readings
Impact: Provider and patient have better tools
to communicate and monitor blood pressure
between office visits
Lapband Surgery Follow-up
• MyGeisinger survey every 2-months post-
surgery for 12 months
• Questions (e.g. weight loss, vomiting) assess
patient status; patients doing well do not
require an office visit
Impact: Reduces unnecessary visits, more
timely intervention when needed, improves
staff efficiency, helps alleviate access and
patient satisfaction issues
Gestational Diabetes Monitoring
• OB patients borderline or with gestational
diabetes report glucose levels using MyG.
• Prior glucose management required patients
to call-in readings; compliance was an issue
Impact: Improves compliance with patient-
provided home readings and improves
timeliness of clinical intervention resulting in
reduced insulin use
Cholesterol Medication Adherence
• Patients non-adherent to their cholesterol
medication identified by Insurance claims data
• MyGeisinger survey to understand reasons for
non-adherence; offered services to assist (e.g.
financial assistance, pill box, pharmacist call)
Impact: Identification of patient-specific non-
compliance issue, allows for targeted
intervention that patient endorsed.
37|

Asthma Control Test (ACT)
Solution - Childhood Asthma Control Test (ACT)
–Distribute ACT to patients through MyGeisinger every 90 days in
lieu of an office visit
–Have ACT completed during the patient’s office visit (complete
ACT picture of the patient)
Results (as of June 30, 2011)
–MyGeisinger: 164 out of 488 (34% response rate)
• 3 – poor, 39 – moderate, 122 – well
–In Clinic: 535 submissions
• 59 – poor, 138 – moderate, 338 – well
Clinical Impact
–Of the 3 patients identified as poor outside the clinic visit
• All 3 patients received timely phone contact
• 2 patients seen by the physician; 1 patient seen in Urgent Care
• Longer term monitoring of ED visit impact
–Patients identified as poor during the office visit had issues
addressed during the visit
Use of Social Media tools to reach the patient or consumer
Problem Statement: Best practice is to deliver the ACT every 90 days for persistent
asthmatics. But patients often do not have a clinic visit at that frequency.
38|

Patient Perspective
• “I’ve been working hard to lower my
cholesterol over the past year by
exercising regularly and eating a well
balanced diet. My doctor and I have
been monitoring my cholesterol very
closely – and I was anxious to see my
latest results. With MyGeisinger, I can
review my test results and graph them
over time. It’s great to see how much
my hard work has paid off!”
• “Preparing my daughter for
kindergarten was an exciting event in
our lives. In addition to getting
everything she needed to start school,
I had to get a copy of her
immunization record. I simply logged
on to MyGeisinger, printed her record
and sent it to her school. With
MyGeisinger, getting a copy of her
immunization record was easy and
hassle-free.
• “I love it. I prefer this over using the
telephone!”
• “Made the appt. online - very easy
process.”
• “Better than trying to find time to call
my provider’s office during work
hours.”
Improved Access to Information Convenience
“As my father was slowly dying of liver
disease, I agonized over his condition.
But unlike most children who liver far from
their elderly parents, I took an active role
in his care. I used MyGeisinger to view
portions of my father’s record at Geisinger.
I checked his lab results and medications
on a regular basis and even requested
medication renewals and appointments for
my father from my home. MyGeisinger
gave me peace of mind.”
Patient/Family Activation
39|

Mobile Technology for
Patient Care
Increase patient activation by leveraging
communication channels that are part of a
patient’s lifestyle
• 234 million Americans 13 and older use some type of
mobile device (comScore)
• 82 million Americans own a Smartphone (comScore)
• 70% of users of a mobile device text (comScore)
• A typical U.S. mobile subscriber sends and receives 175%
more text messages than voice calls (Nielsen Mobile)
• Typical text messages are responded to within 60 minutes
(Mobile Marketing Association)
40|

Impact
• Kaiser Permanente - Appointment Reminders
• Reduced appointment no-shows at one clinic by 1,837 in a one month pilot
• Resulted in a savings to the organization of more than $275,000
• Mt. Sinai Hospital, NY - Teenage Liver Transplant Patients
• Goal to increase the rate of adherence to their medication regimen
• Pilot with 41 patients, showed decrease in rejection episodes from 12 to 2
• New York City Department of Health- Smoking Cessation
• Sent encouragement messages and tips in both English and Spanish
• Heavy smokers that got messages more than twice as likely to quit than
those who did not (53% vs. 25%)
• New York-Presbyterian Morgan Stanley Children’s
Hospital – Medication Reminders
• Send to heart transplant patients and their families to ensure meds are
taken as prescribed to reduce organ rejection
41|

iPhone Application for MyGeisinger
• iPhone Application Features
– Health Summary – view medications, allergies,
immunizations, and current health issues
– Test Results – view test result values and standard
ranges for released results
– Messaging – view and reply to messages from the
patient’s provider office, and create new medical
advice request messages
– Appointments – view or cancel upcoming
appointments, and view the summary from past
appointments
– Health Maintenance Reminders – view health
maintenance procedures and their due dates
– Proxy Access – view all features listed above for
family members to whom you have access
Approximately 13% of MyGeisinger logins are done using a mobile device.
8.2% of those were from an Apple device (e.g. iPhone, iPad).
Provides secure system to enter patient responses from SMS as well as
General MyGeisinger access.
42|

43

iHT2 Health IT Summit Atlanta 2013 – Thomas Graf, MD, Chief Medical Officer, Population Health, Geisinger Closing Keynote: Accelerating HealthCare Delivery through EHR Optimization

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iHT2 Health IT Summit Atlanta 2013 – Thomas Graf, MD, Chief Medical Officer, Population Health, Geisinger Closing Keynote: Accelerating HealthCare Delivery through EHR Optimization

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