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. 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

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. 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

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

8. 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 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. 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. 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. 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. 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. 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. 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.

51. 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.

52. 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

53. Required for widespread EHR adoption. –97% of practices have electronic billing systems. EHR makes new forms of compensation feasible.

54. Pay for Performance Individualized population risk management –CMMS demonstration project High-reliability procedures Adverse event follow-up 636+ evidence-based care-quality measures

55. jmwalker@geisinger.edu