Information Technology Innovations
Here and Abroad
National Health Policy Conference
February 2, 2005
Glenn Steele, Jr., MD, PhD
President and CEO
Geisinger Health Systems
Information Technology Innovations Geisinger
Mission: Enhance the quality of life through an integrated health service
organization based on a balanced program of patient care, education, research and
community service.
G e is in g e r H e a l th S y s te m
E rie
W arre n
M cK ea n
T io g a
P o tte r
Su sq ue ha nna
B ra d fo rd
C ra w fo r d
W ay ne
M arw o rth C h e m i ca l D e p e n d e n c y T re at m e n t C e n te r
FF oo rree sstt
S u l li v a n
C a m ero n
E lk
Vena ng o
W yo m in g
Lac ka w an na
P ik e
L y c o m in g
M ercer
C lin to n
C
C llaarr io
io nn
C o lu m b ia
JJ ee ffffeerrss oo nn
M o n to u r
C l e a r f ie l d
L a w re n c e
U n io n
C e n tre
B u t le r
A r m s tr o n g
Be av er
G e is in g e r W y o m in g V a lle y M e d i c a l C e n te r
L u z ern e
M o n ro e
G e is in g e r M e d ic a l C e n t e r
Carbo n
Sn yd er
N o r t h u m b e r la n d
In dd iiaa nn aa
In
N o rth a m p t o n
S c h u y l k il l
L e h ig h
M if f l in
C a m b r ia
A lle g h e n y
B l a ir
JJuu nn iiaa ttaa
P err y
W e s t m o r e la n d
D a up h in
Leb an on
Ber ks
Bucks
H u n tin gd o n
W a s h in g to n
M o n tg o m e r y
C u m b er lan d
S o m ers et
FF aa yy ee ttttee
B e d fo rd
F r a n k li n
F u lt o n
G reen e
York
Adams
Lan ca ster
Ch ester
P h i la d e lp h ia
D e la w a r e
G e is ing e r In p a tie n t F a cilities
G e is ing e r H e a lth S ys te m S e r v ic e A r e a
G e is ing e r M ed ic a l G r o up s
G e is ing e r H e a lth P la n S e r vic e A r e a
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Information Technology Innovations Geisinger
Anatomy
¡ Service area population: 2.3 million
¡ 41 counties (20,000-sq. miles) in central and northeastern
PA
¡ ~ 650 physicians: Geisinger Clinic group practice
¡ 17 fully-integrated, multidisciplinary clinical service lines
¡ Two medical centers/Heart Hospital/Chemical & Alcohol
Treatment Center
¡ Two ambulatory centers
¡ 41 community practice sites; ~ 200 physicians
„ Primary and specialty care
Information Technology Innovations Geisinger
Anatomy
¡ Small, focused core of scientists – Weis Center for
Research
¡ Center for Health Research & Rural Advocacy
„ Outcomes
„ Studies on aging
„ Epidemiology
„ Advocacy for rural health and access
„ Clinical Trials
„ e-Health initiatives
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Information Technology Innovations Geisinger
Anatomy
¡ Geisinger Health Plan (GHP)
„ ~243,000 subscribers
„ 35,000 M+C
„ 7,000 empanelled physicians
„ 55 non-Geisinger hospitals
„ 41 PA counties
Information Technology Innovations Geisinger
Electronic Health Record (EHR)
- Out-patient roll-out initiated in 1995
- Inpatient roll-out nearing completion
- ~ 3M patient charts in system
ƒ
Designed to improve:
„ Quality and safety
„ Efficiency
„ Satisfaction (customer and clinician)
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Information Technology Innovations Geisinger
EHR
¡ Order entry; note documentation
¡ Labs, radiology, operative notes, etc.
¡ Clinical Decision Support
„ SmartSets; pop-up alerts and reminders; drug and
vaccine recalls
¡ Physician DRG entry at time of visit
¡ Patient engagement – access to EHR (MyGeisinger)
„ HIPAA-compliant, web-based access to EHR
Information Technology Innovations Geisinger
Non-Proprietary EHR
¡ External physician links (GeisingerConnect)
¡ Episode information
¡ Hospitalization
¡ Referrals
¡ Full EHR access – 162 practices
¡ AHRQ planning grant for regional HIT network
¡ AHRQ implementation grant submission due: April 2005
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Information Technology Innovations Geisinger
EHR – Quality and Safety
¡ Easier to “do the right thing at the right time”
¡ Drug-drug and drug-allergy checking
¡ Patient-specific, real-time alerts and reminders
¡ Documentation standardized, complete, searchable, and
legible
¡ Automated reports on aggregated data
¡ Digital imaging
¡ ICD-9 coding of all orders by provider
Information Technology Innovations Geisinger
Pay-for-Performance – Geisinger Response
¡ Integrate into service lines
¡ Focus on areas of eminence
¡ Expand market
¡ Utilize health information technology to improve and
streamline care
¡ Encourage patients’ participation in their care
¡ Charge committee to design and assess pay-for
performance models
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Information Technology Innovations Geisinger
PAY-FOR-PERFORMANCE
Information Technology Innovations Geisinger
C lick on m easure
for d etails
C lick H ere
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Information Technology Innovations Geisinger
Information Technology Innovations Geisinger
P4P - The Sweet Spot
9 Clinical process is less error-
prone
9 Clinical outcomes are more
Patients
The Health Plan
predictable
The
Clinical
Enterprise
9 Price (global) is more predictable
9 Provider network is more
marketable
9 Clinical outcomes are more
predictable
9 Per-case costs are more
predictable
9 Per-case margins improve
9 Malpractice claims decrease
(maybe)
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Information Technology Innovations Geisinger
Pay-for-Performance
¡ CMS Demonstration Project
„ Chronic disease
Information Technology Innovations Geisinger
Chronic Care (CMS Demonstration Project Model)
◆Diabetes, CHF, HTN, A-fib, etc.
◆Providers rewarded for coordinating and managing overall
healthcare needs
◆Explicit incentives for process and outcome
improvement and cost savings
◆ Bonus from savings produced by successful chronic care
management - 80% of savings available for provide
incentives
◆End-points – longitudinal/long-term
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Information Technology Innovations Geisinger
¡ EHR is key component for:
„
„
„
„
Improving quality
Improving safety
Performance tracking for P4P programs for chronic and
episodic diseases
Incenting to “do the right thing”
Information Technology Innovations Geisinger
¡ EHR allows performance reporting by department
and by physician
Diabetes Registry Report by Department & Provider
Reporting Period: 1/1/2003 – 12/31/2003
Report Generated: 1/5/2004 at 9:40:07 a.m.
PROVIDER/DEPT
Family Physician A
Family Physician B
Family Physician C
Family Physician D
Family Physician E
Family Physician F
Family Physician G
Family Physician H
Family Physician I
Family Physician J
Family Physician K
Family Physician L
Family Physician M
#
DIABETES
275
116
23
116
103
97
123
94
22
119
65
58
103
#ENC.PST YR
DIAB.PRIM DX
973
394
78
392
350
330
418
320
75
405
221
197
350
3ENC PST YR
DIAB. ANY DX
1322
552
109
549
490
462
585
448
105
567
309
276
490
Department Total
1314
4468
6255
%DIAB
%DIAB
W/AIC ORDER WAIC RESULTS
89%
89%
81%
80%
73%
71%
69%
68%
83%
83%
77%
75%
88%
88%
76%
75%
69%
69%
80%
80%
77%
76%
80%
80%
85%
85%
79%
78%
AVG MOST
RECENT AIC
7.1
7.0
6.8
6.7
7.3
7.0
6.9
7.2
7.1
6.8
7.0
7.2
7.1
7.0
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Information Technology Innovations Geisinger
Pay-for-Performance
Chronic Care Model
Measurement Corridor
_________________________________________________________________
DRG Payment + Bonus
(Bonus from 80% of Savings*)
Bonus Payment Parameters
Financial Performance
Quality Bonus**
Percent of Savings
70%
30%
* Savings calculated on per capita Medicare fee-for-service formula
** Quality Bonus = Points awarded for each established quality measure met
Information Technology Innovations Geisinger
Episodic Care
¡ Identify high-volume DRGs
„
DRG 107 – CABG with cath
„
DRG 109 – CABG without cath
„
DRG 209 – Total hip replacement
¡ Determine performance parameter corridors
¡ Pilot with GHP
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Information Technology Innovations Geisinger
EHR and Pay-for-Performance
In addition to real-time performance tracking, EHRs provide
Ability to “hardwire” processes that support safety and
quality:
ƒ Smart texts (e.g., history and physical)
ƒ Outpatient orders
ƒ Pre-operative checklists
ƒ Orders (pre-op, post-op, transfer, discharge)
ƒ Daily progress notes
ƒ Lab and anticoagulation flow sheets
Information Technology Innovations Geisinger
Patient Responsibilities
¡ Patient actively involved in contributing to good outcome
„ Receives results summary with explanation
„ Receives “curriculum” (via MyChart*) that enables an
understanding of their contribution to good outcome
„ At admission, patient receives a checklist to help keep
track of AHRQ “43 Best Practices Process Benchmarks”
*Patients’ web-based access to EHR
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Information Technology Innovations Geisinger
Episodic – Example
¡ DRG 106 (CABG) – Performance Parameters
„ Mortality (in-hospital, 30 and 90-days post episode)
„ LOS in ICU; total LOS
„ Infection rate (wound)
„ Complications (e.g., pneumonia, pulmonary embolism,
CNS event)
„ Blood product use
„ Re-admission within 90 days of episode
„ Patient functional status
„ Patient satisfaction
„ Cost per episode
Information Technology Innovations Geisinger
Episodic Care
¡ Assess metrics per case:
Results
Payment Structure
Less than expected
No charge to GHP
Expected
DRG payment
More than expected
DRG + bonus payment
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Information Technology Innovations Geisinger
First Principles
¡ A need to show benefit to four constituencies
¡ What’s in it for:
¡
1) The patient
¡
2a) The physician
providers
¡
2b) The hospital
¡
3) The payor (employer, government)
¡
4) The insurance company
Information Technology Innovations Geisinger
First Principles
¡ Payment only for acceptable outcomes
¡
(e.g., no expectation of more reimbursement (bonus) for
¡
simply doing “the right thing”)
¡ Treatment of all complications “gratis”
¡ “No fault” medical malpractice evolution
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Information Technology Innovations Geisinger
Caveats
¡ Scalability?
¡ Generalizability to non-Geisinger settings?
¡ Applicability to Fee-for-Service
¡ Who loses in a non-integrated system?
¡ Appropriate demographics?
Information Technology Innovations Geisinger
Caveats
¡ But:
„ Obligation to “experiment”
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