Using the EHR to Transform Healthcare

1. Using the EHR to Transform Healthcare James M. Walker, MD Chief Medical Information Officer

2. 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

3. TYLER MEMORIAL HOSPITAL MOSES TAYLOR HOSPTAIL COMMUNITY MEDICAL CTR. MERCY HOSPITAL SCRANTON LOCK HAVEN HOSP. CLEARFIELD HOSPITAL PHILLIP[SBURG AREA HOSP. BLOOMSBURG HOSP. SUNBURY COMM. HOSP. CENTRE COMMUNITY HOSP. SHAMOKIN AREA HOSP. POTTSVILLE HOSPITAL LEWISTOWN HOSP. GOOD SAMARITAN HOSP.

4. 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)

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

7. Definitions Better care: higher quality, safer, more efficient care Healthcare team: Clinicians, the patient, family, managers, payers, regulators. (Transformative) EHR

8. (Transformative) EHR • Evolving - The ways an organization uses IT to improve patient care. • A human creation.

9. 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.)

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

11. 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

12. 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.

13. 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.

14. EHR Demands and Rewards • Passion for Transformation • Organizational Competencies

15. Organizational Competencies • Organizational change • Continuous improvement

16. Change: Episodic or Continuous? • EHR implementation is a project, an episodic change. • Done right, it prompts and supports continuous change.

17. 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.

18. Organizational Competencies • Organizational change • Continuous improvement • Adapting systems to users’ needs (HFE) • IT resources (trained, experienced people)

19. EHR Demands and Rewards • Passion for Transformation • Organizational Competencies • Attention to All Stakeholders

20. Attention to All Stakeholders • In disconnected systems it wasn’t feasible. • Necessary for EHR implementation. • Cornerstone of reliable care.

21. 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.

22. 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.

23. EHR Demands and Rewards • Passion for Transformation • Organizational Competencies • Attention to All Stakeholders • Attention to Process

24. Attention to Process • What process to implement?

25. 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.

26. 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.

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

28. EHR Demands and Rewards • Passion for Transformation • Organizational Competencies • Attention to All Stakeholders • Attention to Process • Attention to Safety

29. Safety Demand • Highly coupled systems • Rapid propagation of error • Visible failure? • Graceful failure? • Repairable failure?

30. Safety Rewards • More reliable systems • Better situation awareness • Prevention of error (commission and omission) • Informative feedback

31. EHR Demands and Rewards • Passion for Transformation • Organizational Competencies • Attention to All Stakeholders (solidarity) • Attention to Process • Attention to Safety • New teamwork

32. 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

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

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

35. New Management Skills • Sophisticated information use • Process re-design • Needs assessment • Needs prioritization • Coherent policies • Understanding the limitations of coercion

36. The Limits of Coercion: Hard Stops • Hard stops may not be safe. • Nor efficient. • Nor necessary.

37. 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.

38. New Management Skills • Sophisticated information use • Process re-design • Needs assessment • Needs prioritization • Coherent policies • Understanding the limits of coercion • Project management support

39. 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

40. Transformational Leaders • Required for a transformational EHR. • Attracted by the EHR’s power as a transformational tool. • Physicians • Nurses • Managers • Researchers • Educators

41. 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

42. 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.

43. 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

44. Actionable Information • What do we record and report? • To ourselves • To patients, payers, and regulators • What do we ask patients?

45. 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}

46. Actionable Information • What do we record? • What do we ask patients? • Display by variance • Benefits and risks

47. Benefits and Risks

48. 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

49. New Learning Style • Need-based • Just-in-time • Just-enough

50. 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.