Using the EHR to Transform Healthcare

James M. Walker, MD

Chief Medical Information Officer

Geisinger Overview

• 40 counties (mostly poor, elderly, and underserved)

• 4 hospitals; 30,000 discharges• 41 clinic sites• 650 physicians• 2.4 million patients in EHR• 200,000 patients in HMO

Susquehanna

Lackawanna

Union

Bedford FultonFranklin

Cumberland

Adams

Allegheny

Armstrong

Beaver

BerksBlair

Bradford

Bucks

Butler

Cambria

Cameron

Centre

Chester

Clarion

Clearfield

Clinton

Crawford

Dauphin

Delaware

Elk

Erie

Fayette

Forest

Greene

Huntingdon

Indiana

Jefferson

Juniata

Lancaster

Lawrence

Lebanon

Lehigh

Luzerne

Lycoming

McKean

Mercer

Mifflin

Monroe

Montgomery

Montour

NorthamptonNorthumberland

Perry

Philadelphia

Pike

Potter

SchuylkillSnyder

Somerset

Sullivan

Tioga

Venango

Warren

Washington

Wayne

Westmoreland

Wyoming

York

Geisinger Hospitals“Hubs” – Provide Primary/Secondary/Tertiary Care

GMCGeisinger Med. Ctr.

GWV Geisinger Wyoming Valley CENTRE

Geisinger Health System

CENTRE

Columbia

Carbon

GMC

Geisinger Med. Groups

GHS Service Area

GHP Service Area

GWV GSWB

GSWB

Geisinger South Wilkes Barre Centre

CENTRE COMMUNITY HOSP.

LEWISTOWN HOSP.

MOSES TAYLOR HOSPTAIL

POTTSVILLE HOSPITAL

TYLER MEMORIAL HOSPITAL

LOCK HAVEN HOSP.

BLOOMSBURG HOSP.

SUNBURY COMM. HOSP.

GOOD SAMARITAN HOSP.

COMMUNITY MEDICAL CTR.

PHILLIP[SBURG AREA HOSP.

CLEARFIELD HOSPITAL

SHAMOKIN AREA HOSP.

MERCY HOSPITAL SCRANTON

Clinical Information Systems

• Outpatient EHR – 10 years, 99% use• Inpatient EHR – 50% complete• Patient EHR – 57,000 users• Outreach EHR – 40,000 records shared• Digital, Remote Radiology• Regional Information Exchange (RHIO)

Susquehanna

Lackawanna

Union

Bedford FultonFranklin

Cumberland

Adams

Allegheny

Armstrong

Beaver

BerksBlair

Bradford

Bucks

Butler

Cambria

Cameron

Centre

Chester

Clarion

Clearfield

Clinton

Crawford

Dauphin

Delaware

Elk

Erie

Fayette

Forest

Greene

Huntingdon

Indiana

Jefferson

Juniata

Lancaster

Lawrence

Lebanon

Lehigh

Luzerne

Lycoming

McKean

Mercer

Mifflin

Monroe

Montgomery

Montour

NorthamptonNorthumberland

Perry

Philadelphia

Pike

Potter

SchuylkillSnyder

Somerset

Sullivan

Tioga

Venango

Warren

Washington

Wayne

Westmoreland

Wyoming

York

Geisinger Hospitals“Hubs” – Provide Primary/Secondary/Tertiary Care

GMCGeisinger Med. Ctr.

GWV Geisinger Wyoming Valley CENTRE

Geisinger Health System

CENTRE

Columbia

Carbon

GMC

Geisinger Med. Groups

GHS Service Area

GHP Service Area

GWV GSWB

GSWB

Geisinger South Wilkes Barre Centre

CENTRE COMMUNITY HOSP.

LEWISTOWN HOSP.

MOSES TAYLOR HOSPTAIL

POTTSVILLE HOSPITAL

TYLER MEMORIAL HOSPITAL

LOCK HAVEN HOSP.

BLOOMSBURG HOSP.

SUNBURY COMM. HOSP.

GOOD SAMARITAN HOSP.

COMMUNITY MEDICAL CTR.

PHILLIP[SBURG AREA HOSP.

CLEARFIELD HOSPITAL

SHAMOKIN AREA HOSP.

MERCY HOSPITAL SCRANTON

Non-Geisinger Physicians with EHR access

DefinitionsBetter care: higher quality, safer, more efficient

care

Healthcare team: Clinicians, the patient, family, managers, payers, regulators.

(Transformative) EHR

(Transformative) EHR

• Evolving - The ways an organization uses IT to improve patient care.

• A human creation.

A Human Creation

• Isn’t smart (not even as smart as the people who created it).

• Requires continuous monitoring and repair (unlike humans, who are largely self-managing).

• Isn’t a manager. (See first bullet.)

Transformative EHR

• Evolving• A human creation• Serves each member of the healthcare team.• Supports team work.• Provides succinct, valid, actionable

information.

EHR Demands and Rewards

• Passion for Transformation• Organizational Competencies• Attention to All Stakeholders• Attention to Process• Attention to Safety• New Teamwork• New Management Skills• Transformational Leaders• Coherent, Standardized Policies• Actionable Information• New Learning Style• New Forms of Compensation

Passion for Transformation

• The organization’s determination and ability to transform itself to provide better care is the single most critical EHR success factor.

• The EHR is one of the organization’s most important tools for transformation.

Passion for Transformation

• The organization’s determination and ability to transform itself to provide better care is the single most critical EHR success factor.

• The EHR is one of the organization’s most important tools for transformation.

• Top leadership uses the EHR to transform healthcare.

EHR Demands and Rewards

• Passion for Transformation

• Organizational Competencies

Organizational Competencies

• Organizational change • Continuous improvement

Change: Episodic or Continuous?

• EHR implementation is a project, an episodic change.

• Done right, it prompts and supports continuous change.

Change: Episodic or Continuous?

• EHR implementation is a project, an episodic change.

• Done right, it prompts and supports continuous change.

• A successful EHR project will create more clinician demand for process improvement than your managers and IT teams can support.

Organizational Competencies

• Organizational change • Continuous improvement• Adapting systems to users’ needs (HFE)

• IT resources (trained, experienced people)

EHR Demands and Rewards

• Passion for Transformation

• Organizational Competencies

• Attention to All Stakeholders

Attention to All Stakeholders

• In disconnected systems it wasn’t feasible.• Necessary for EHR implementation.• Cornerstone of reliable care.

Cornerstone of Reliable Care

Every phase of EHR implementation and optimization provides opportunities to improve every stakeholder’s – Knowledge and skills, – Work processes, – Performance, and – Satisfaction.

Cornerstone of Reliable Care

Every phase of EHR implementation and optimization provides opportunities to improve every patient’s– Knowledge and skills, – Self-care, – Wellbeing, and – Satisfaction.

EHR Demands and Rewards

• Passion for Transformation

• Organizational Competencies

• Attention to All Stakeholders

• Attention to Process

Attention to Process

• What process to implement?

What Process to Implement?

• Not current processes unchanged.• Not fully optimized processes.

– Limits to readiness and ability to change.– EHR redefines an optimal process.– EHR will itself change.

What Process to Implement?

• Not current processes unchanged.• Not fully optimized processes.

– Limits to readiness and ability to change.– EHR redefines an optimal process.– EHR will itself change.

• Iterative analysis and optimization.

Attention to Process

• What process to implement?• Iterative analysis and optimization.• Process and outcome measurement

EHR Demands and Rewards

• Passion for Transformation• Organizational Competencies• Attention to All Stakeholders• Attention to Process

• Attention to Safety

Safety Demand

• Highly coupled systems• Rapid propagation of error• Visible failure?• Graceful failure?• Repairable failure?

Safety Rewards

• More reliable systems• Better situation awareness• Prevention of error (commission and

omission)• Informative feedback

EHR Demands and Rewards

• Passion for Transformation• Organizational Competencies• Attention to All Stakeholders (solidarity)• Attention to Process• Attention to Safety

• New teamwork

New Teamwork

• Changed stakeholder relationships– Higher visibility of processes and results– Changing value of skills– Reassignment of work and responsibility

• Virtual teams– Less face-to-face– More interchangeable members– More transient members

Virtual Teams

• Generalists and specialists • Proxy access to patient EHR • Remote pediatric echocardiography • e-Consults• Virtual group practices

EHR Demands and Rewards

• Passion for Transformation• Organizational Competencies• Attention to All Stakeholders• Attention to Process• Attention to Safety• New Teamwork

• New Management Skills

New Management Skills

• Sophisticated information use• Process re-design

– Needs assessment– Needs prioritization

• Coherent policies• Understanding the limitations of coercion

The Limits of Coercion: Hard Stops

• Hard stops may not be safe.• Nor efficient.• Nor necessary.

The Limits of Coercion: Hard Stops

• Hard stops may not be safe.• Nor efficient.• Nor necessary.• Better care depends on motivated clinicians

supported by reliable processes.• And informative feedback.

New Management Skills

• Sophisticated information use• Process re-design

– Needs assessment– Needs prioritization

• Coherent policies• Understanding the limits of coercion

• Project management support

EHR Demands and Rewards

• Passion for Transformation• Organizational Competencies• Attention to All Stakeholders• Attention to Process• Attention to Safety• New Teamwork• New Management Skills

• Transformational Leaders

Transformational Leaders

• Required for a transformational EHR.• Attracted by the EHR’s power as a

transformational tool.– Physicians– Nurses– Managers– Researchers– Educators

EHR Demands and Rewards• Passion for Transformation• Organizational Competencies• Attention to All Stakeholders• Attention to Process• Attention to Safety• New Teamwork• New Management Skills• Transformational Leaders

• Coherent, Standardized Policies

Standardization

• EHRs don’t do fuzzy logic.• Can enable the transition to standards.

– Support more flexible standards than paper.– Let users justify variance in real time.

EHR Demands and Rewards• Passion for Transformation• Organizational Competencies• Attention to All Stakeholders• Attention to Process• Attention to Safety• New Teamwork• New Management Skills• New Leaders• Coherent, Standardized Policies

• Actionable Information

Actionable Information

• What do we record and report?– To ourselves– To patients, payers, and regulators

• What do we ask patients?

LBP & the Great American Novel

The patient notes new low-back pain.There is no personal history of cancer, trauma, or long-term

steroid use. The patient has noted no fever, unexplained weight loss, urinary retention, saddle anesthesia, fecal incontinence, sciatica, or bone pain.

On exam, the lungs are clear to auscultation and percussion, the breasts are normal {LBP PROSTATE:9363}. There is no spinal tenderness to percussion. Both ipsilateral straight-leg raising and crossed straight-leg raising are negative. There is no ankle-dorsiflexion nor great-toe-extensor weakness. {LBP REF:9365}

Actionable Information

• What do we record?• What do we ask patients?• Display by variance• Benefits and risks

Benefits and Risks

EHR Demands and Rewards• Passion for Transformation• Organizational Competencies• Attention to All Stakeholders• Attention to Process• Attention to Safety• New Teamwork• New Management• New Leaders• Coherent, Standardized Policies• Actionable Information

• New Learning Style

New Learning Style

• Need-based• Just-in-time• Just-enough

New Learning Style

• Need-based• Just-in-time• Just-enough

• Clinicians don’t need to learn genomics. They need actionable information.– Test the UGT1A1*28 allele before dosing

irinotecan.

Decision Support as Education

• Bochicchio (2006). J Am Coll Surg 202(3): 459-67.

Appropriateness of antibiotic use among ID fellows improved throughout a 6-month study.

• Downs (2006). BMJ.332:692-96.Decision-support software and practice-based workshops both significantly improved rates of dementia diagnosis.

EHR Demands and Rewards• Passion for Transformation

• Organizational Competencies

• Attention to All Stakeholders

• Attention to Process

• Attention to Safety

• New Teamwork

• New Management Skills

• New Leaders

• Coherent, Standardized Policies

• Actionable Information

• New Learning Style

• New Forms of Compensation

New Forms of Compensation

• Required for widespread EHR adoption.– 97% of practices have electronic billing systems.

• EHR makes new forms of compensation feasible.

Pay for Performance

• Individualized population risk management – CMMS demonstration project

• High-reliability procedures• Adverse event follow-up• 636+ evidence-based care-quality measures

jmwalker@geisinger.edu