# Presentation: 316935

## Data Infrastructure Requirements: From “Data” to Clinical Transformation

- Ronald A. Paulus, MD
*Chief Technology & Innovation Officer*
- May 3, 2007

## Geisinger Anatomy

- Integrated delivery system formed in 1915
- Group Practice: >650 physicians (~200 primary care)
- 38 community practice and 12 specialty outreach sites
- Hospitals: 3 tertiary/quaternary care medical centers
- Health Plan: ~210,000 member health plan, >7,000 empanelled physicians, >50 non-Geisinger hospitals
- ~11,000 total FTEs
- ~2.5 million in service area
- Active in 41 of 67 Pennsylvania counties
- Rural and aging population, largely non-transient
- Strategic commitment to HIT and clinical transformation
*Striving for Perfection *is the Vision for the Second Century

## Electronic Health Record (EHR)

- Decision to implement Epic®: 1995
- > $80M invested (hardware, software, manpower, training)
- Running costs: ~ 4.2% of annual revenue of $1.7B
- Fully-integrated EHR
- > 75,000 active MyGeisinger users
- > 1,000 non-Geisinger physician users
- PACS and web-based image distribution
- > 3 million patient records

**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**

## Information-Transformation Continuum...

- 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, automate, delegate, and activate

**Data Generation**

**Data Aggregation &  Transformation**

**Performance Measurement & Analysis**

**Knowledge Creation**

**Clinical Transformation**

- Care by-product
- Patient-level transactions
- Mixed forms
- Increasingly will include patient self-reported data

**Notes:**
Healthcare delivery is inherently complex and knowledge-dependent.  To serve the needs of any clinical counter, relevant patient-centered knowledge must be accessible to the person supplying care at the “right time” in the workflow.  Such knowledge can be delivered proactively before decisions are made, interactively as decisions are made, asynchronously such as via a pager, or passively as reference information that can be queried online.  As biomedical research changes the standard of care at a rapid pace, the knowledge base required for safe care is growing exponentially. Knowledge Application is the science of leveraging knowledge at the right places in clinical workflow to support enhanced care-giver effectiveness, work-satisfaction, patient satisfaction and overall care quality.  This view of Knowledge Application is broader and inclusive of the traditional definition of clinical decision support.  Knowledge can be delivered through clinical applications in the form of templates for documentation, order sets for protocol-driven care management, dashboards and reports for feedback, and as alerts, reminders or suggestions. .   In a high-performance learning organization, process and outcomes data is captured as a byproduct of workflow and rapidly analyzed to determine new models for process improvement.   In essence, robust knowledge application evolves into and merges with knowledge discovery whereby the knowledge repository “learns” from the clinical outcomes in the patient database. 

## Bridging the Inferential Gap

**Bridging the Inferential Gap**

- Lack of evidence-based standards for much (most?) of medical care
- Mismatch between RCT populations and “real-world” practice
- Counter-balancing factors often not considered (e.g., economics, preferences)
- Matching intervention to need/opportunity

## ...

**Claims**

**Decision Support**

- EBM Guidelines

- Patient Preferences

**Clinical**

- Formulary/Economics

**...**

-  Alerts

-  Prompts/Reminders

-  Order Sets

-  Automated care plans

-  Patient messages

-  Information Rx

-  **...**

* ****Effectors***

*** ******Other**** ****Inputs***

*Population Trends*

*Real-time Clinical Status*

*Empirical Norms*

***...***

*Normalization, Transformation,    Analytic Application*

## Goal: Fundamentally Re-engineer Decision Hierarchy

**Goal: Fundamentally Re-engineer Decision Hierarchy**

## Brief Examples

- Diabetes, Immunizations, CABG

## Diabetes Clinical Process Transformation

- Standardization of clinical practices
- Nurse Rooming Tool, Standing Orders
- Automated identification of diabetics and care plan status
- Health Maintenance Alerts, Disease Summary Screen
- Automated identification of suboptimal care
- Best Practice Alerts
- Automatic order set creation
- Automatic generation of patient-specific report cards at checkout
- Automatic outreach to patients
- Influenza/Pneumococcal Campaign, Chronic Disease Return Visit program

## Diabetes Bundle

## DM Best Practice Alerts

## DM Health Maintenance

## MyGeisingerPatient Reminder View

## Patient Education Letter

## Patient Trend Report

**Patient Trend Report**

**Most recent values displayed**

**Therapeutic goals are stated**

**Clinical consequences are stated**

## Site Based Monthly Reporting

## ProvenCareSM Diabetes Results(>20K patients)

**ProvenCare**SM **Diabetes Results****(>20K patients)**

**% of all diabetic patients**

**# of components received or achieved (by patient)**

**20%**
**10%**

**0**

**1**

**2**

**3**

**4**

**5**

**6**

**7**

**8**

**All**

**3/31/06**

**9/30/06**

**6/30/06**

**12/31/06**

**7%**

**2.5%**

## ADA/NCQA Diabetes Physician Recognition Program

**ADA/NCQA Diabetes Physician Recognition Program**

- Picked one date at random: 11/12/06
- Look back at the last 200 consecutive patients seen in all sites
- All sites need to contribute patients to the 200 total
- 100 possible points (75 needed to qualify)
- Geisinger Clinic score = 85
*Not a single, manual chart review was required to fulfill this process*

## Hardwiring Pneumococcal Vaccine with Influenza Vaccine

- Patients due for Influenza vaccine were contacted and activated to schedule
- If due for Pneumococcal vaccine, patients made aware and asked to receive it along with influenza vaccine
- Nurses given standing order to administer Pneumococcal vaccine
- Best Practice Alerts in EPIC as a clinical reminder to provide Pneumococcal vaccine

## Influenza Immunizations

## Pneumococcal Immunization

## CABG Reliability Transformation

** ****% of patients receiving **_**all**_** 40 components of care**

**Feb 07**

**Nov 06**

**May 06**

***Go-Live***

**Aug 06**

**Feb 06**

**P = 0.001**

**Notes:**
Before the program started only 60% of patients received all 40 ProvenCare elements.

Within 90 days performance was at 100% reliability.

Over the next 90 days 4 failures occurred, in 1 case antibiotics were administered 64 minutes before incision, and in 3 cases insulin was not started intraoperatively when glucose exceeded 110.

Thereafter all elements of care have been delivered at 100% reliability over a 6 month period.

This trend is significant with p= .001 by the Cochran-Armitage Trend test.

## Example CABG Results

|  | Conventional Care (n=137) | ProvenCareSM (n=117) |       Difference |
| --- | --- | --- | --- |
| Blood Product Usage | 23.4% | 16.2% | (7.2%) |
| Any Pulmonary Complication | 7.3% | 2.6% | (4.7%) |
| Prolonged Ventilation | 5.8% | 2.6% | (3.2%) |
| Readmit to  ICU | 2.9% | 0.9% | (2.0%) |
| Discharge to Home | 81.0% | 90.6% | +9.6%** |
| Length of stay | 6.3 days | 5.3 days | (1.0 days) |

****p=.033**

## Thank You.

Ronald A. Paulus, MD
Chief Technology & Innovation Officer
rapaulus@Geisinger.edu 
570-214-9285

- Ronald A. Paulus, MD
- Chief Technology & Innovation Officer
- _[rapaulus@Geisinger.edu](mailto:rapaulus@Geisinger.edu)__ _
- 570-214-9285