Using the EHR to Transform Healthcare

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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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TYLER MEMORIAL HOSPITAL
MOSES TAYLOR HOSPTAIL
COMMUNITY MEDICAL CTR.
MERCY HOSPITAL SCRANTON
LOCK HAVEN HOSP.
CLEARFIELD HOSPITAL
BLOOMSBURG HOSP.
PHILLIPSBURG AREA HOSP.
SUNBURY COMM. HOSP.
CENTRE COMMUNITY HOSP.
POTTSVILLE HOSPITAL
SHAMOKIN AREA HOSP.
LEWISTOWN HOSP.
GOOD SAMARITAN HOSP.
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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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TYLER MEMORIAL HOSPITAL
MOSES TAYLOR HOSPTAIL
COMMUNITY MEDICAL CTR.
MERCY HOSPITAL SCRANTON
LOCK HAVEN HOSP.
CLEARFIELD HOSPITAL
BLOOMSBURG HOSP.
PHILLIPSBURG AREA HOSP.
SUNBURY COMM. HOSP.
CENTRE COMMUNITY HOSP.
POTTSVILLE HOSPITAL
SHAMOKIN AREA HOSP.
LEWISTOWN HOSP.
GOOD SAMARITAN HOSP.
Non-Geisinger Physicians with EHR access
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Definitions

• Better 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

• Isnt smart (not even as smart as the people who
  created it).
• Requires continuous monitoring and repair (unlike
  humans, who are largely self-managing).
• Isnt 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 organizations determination and ability to
  transform itself to provide better care is the
  single most critical EHR success factor.
• The EHR is one of the organizations most
  important tools for transformation.

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Passion for Transformation

• The organizations determination and ability to
  transform itself to provide better care is the
  single most critical EHR success factor.
• The EHR is one of the organizations 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 wasnt 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 stakeholders
• 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 patients
• 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 EHRs 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 dont 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
  PROSTATE9363. 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 REF9365

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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 dont need to learn genomics. They
  need actionable information.
• Test the UGT1A128 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.332692-96.
• 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

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• jmwalker_at_geisinger.edu