using the ehr to transform healthcare james m. walker, md chief medical information officer
TRANSCRIPT
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Using the EHR to Transform Healthcare
James M. Walker, MD
Chief Medical Information Officer
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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
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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
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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)
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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
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DefinitionsBetter care: higher quality, safer, more efficient
care
Healthcare team: Clinicians, the patient, family, managers, payers, regulators.
(Transformative) EHR
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(Transformative) EHR
• Evolving - The ways an organization uses IT to improve patient care.
• A human creation.
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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.)
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Transformative EHR
• Evolving• A human creation• Serves each member of the healthcare team.• Supports team work.• Provides succinct, valid, actionable
information.
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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
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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.
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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.
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EHR Demands and Rewards
• Passion for Transformation
• Organizational Competencies
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Organizational Competencies
• Organizational change • Continuous improvement
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Change: Episodic or Continuous?
• EHR implementation is a project, an episodic change.
• Done right, it prompts and supports continuous change.
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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.
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Organizational Competencies
• Organizational change • Continuous improvement• Adapting systems to users’ needs (HFE)
• IT resources (trained, experienced people)
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EHR Demands and Rewards
• Passion for Transformation
• Organizational Competencies
• Attention to All Stakeholders
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Attention to All Stakeholders
• In disconnected systems it wasn’t feasible.• Necessary for EHR implementation.• Cornerstone of reliable care.
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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.
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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.
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EHR Demands and Rewards
• Passion for Transformation
• Organizational Competencies
• Attention to All Stakeholders
• Attention to Process
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Attention to Process
• What process to implement?
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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.
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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.
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Attention to Process
• What process to implement?• Iterative analysis and optimization.• Process and outcome measurement
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EHR Demands and Rewards
• Passion for Transformation• Organizational Competencies• Attention to All Stakeholders• Attention to Process
• Attention to Safety
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Safety Demand
• Highly coupled systems• Rapid propagation of error• Visible failure?• Graceful failure?• Repairable failure?
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Safety Rewards
• More reliable systems• Better situation awareness• Prevention of error (commission and
omission)• Informative feedback
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EHR Demands and Rewards
• Passion for Transformation• Organizational Competencies• Attention to All Stakeholders (solidarity)• Attention to Process• Attention to Safety
• New teamwork
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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
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Virtual Teams
• Generalists and specialists • Proxy access to patient EHR • Remote pediatric echocardiography • e-Consults• Virtual group practices
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EHR Demands and Rewards
• Passion for Transformation• Organizational Competencies• Attention to All Stakeholders• Attention to Process• Attention to Safety• New Teamwork
• New Management Skills
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New Management Skills
• Sophisticated information use• Process re-design
– Needs assessment– Needs prioritization
• Coherent policies• Understanding the limitations of coercion
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The Limits of Coercion: Hard Stops
• Hard stops may not be safe.• Nor efficient.• Nor necessary.
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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.
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New Management Skills
• Sophisticated information use• Process re-design
– Needs assessment– Needs prioritization
• Coherent policies• Understanding the limits of coercion
• Project management support
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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
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Transformational Leaders
• Required for a transformational EHR.• Attracted by the EHR’s power as a
transformational tool.– Physicians– Nurses– Managers– Researchers– Educators
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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
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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.
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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
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Actionable Information
• What do we record and report?– To ourselves– To patients, payers, and regulators
• What do we ask patients?
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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}
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Actionable Information
• What do we record?• What do we ask patients?• Display by variance• Benefits and risks
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Benefits and Risks
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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
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New Learning Style
• Need-based• Just-in-time• Just-enough
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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.
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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.
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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
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New Forms of Compensation
• Required for widespread EHR adoption.– 97% of practices have electronic billing systems.
• EHR makes new forms of compensation feasible.
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Pay for Performance
• Individualized population risk management – CMMS demonstration project
• High-reliability procedures• Adverse event follow-up• 636+ evidence-based care-quality measures