# Presentation: 316933

## Decision Support, Clinical Transformation and the Consumer

- Ronald A. Paulus, MD
*Chief Technology & Innovation Officer*
- September 17, 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 IT spending: ~ 4.2% of revenue
- Fully-integrated EHR
- > 85,000 active MyGeisinger users
- > 1,000 non-Geisinger physician users
- PACS and web-based image distribution
- > 3 million distinct 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. 

## ...

**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*

## Brief Examples

- Diabetes, Immunizations

## Clinical Transformation -  Diabetes

- Goal setting: “All Inclusive Bundle”
- Target population identification
- Patient centered strategies
- Patient reminders and report cards
- Patient goal setting
- Clinical process redesign
- Automating the processes
- Clinical decision support
- Health Maintenance and Best Practice Alerts
- Financial alignment

## Diabetes Bundle

## Patient Name

## Alerts Drive Order Set Creation

## Patient Reminder View

## Patient Education Letter

## Patient Trend ReportCard

**Patient Trend Report****Card**

**Most recent values displayed**

**Therapeutic goals are stated**

**Clinical consequences are stated**

## Site Based Monthly Reporting

## ProvenCareSM Diabetes Results(>25K patients)

**ProvenCare**SM **Diabetes Results****(>25K 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

## Direct Scheduling

- Approx 6,700 electronic appt reminders monthly
- Adolescent physicals parent e-reminders
- 50% opened, 33% immediate online appt. request

- Patient Response:
- 11% Direct Schedule
- 18%  Phone Call

**Direct Scheduling - Flu Shots**

## Influenza Immunizations

## Pneumococcal Immunization

## The Consumer (Patient) is the Key...

## The Real Caregivers...

- “People with chronic conditions are the principal care-givers. Each day, patients decide what they are going to eat, whether they will exercise and to what extent they will consume prescribed medicines.”                                         Bodenheimer et al, JAMA 2002

## Preference-based Cardiovascular Risk Mitigation Plans

- Cardiovascular risk screening
- Identify patients at risk
- Obtain data
- Risk assessment
- Risk communication
- Preference-based care plan
- Patient first decides on care plan
- Link to clinical decision support
- Integrate with patient education
- Objective: Continuous management to goal

## eCVD 1

## Goal: Fundamentally Re-engineer Decision Hierarchy

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

## Some Lessons Learned...

- It is not the tools or EHR, but rather their implementation into a *system of care *that drives success
- Non-physicians have a crucial role to play in improving quality and efficiency
- Spreading the work out over a team, each with clearly defined roles improves reliability
- Measures are never perfect, but improve with time and are vital to the change process
- Compensation helps focus attention, but is not sufficient to drive change alone
- Consumers (particularly those with chronic disease) are underexploited as a source of care

## 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