Geisinger Leaders on Interoperability and “Inter-App-Erability”

Sept. 10, 2014
At the Danville, Pa.-based Geisinger Health System, leaders have been involved in a panoply of clinical transformation and IT innovation projects

At the Danville, Pa.-based Geisinger Health System, leaders have been involved in almost continuous clinical transformation efforts for the past decade and more. Geisinger, which encompasses eight hospital campuses, two research centers, a 1,100-member multispecialty physician group practice, more than 21,000 employees, two research centers, and a 467,000-member health plan, serves more than 2.6 million residents across 44 counties in central and northeast Pennsylvania.

Geisinger is justly famous for the development of innovative care models such as ProvenCare® and ProvenHealth Navigator®, which have helped to transform the concept of value in care delivery and payment. Earlier this summer, HCI Editor-in-Chief Mark Hagland spoke with John Kravitz, the health system’s vice president, information technology, and associate CIO, and Alistair Erskine, M.D., its chief clinical informatics officer, to find out some of the latest developments there. This is part two of a two-part interview series.

In part one of the interview, Mr. Kravitz and Dr. Erskine discussed the extensive efforts of Geisinger leaders to develop advanced analytics capabilities, to innovate new care management strategies, and to create a culture of innovation at the integrated health system. Below are excerpts from the second part of the interview with the two executives.

Is all this work creating a culture of collaboration and innovation among clinician leaders, clinical informaticists, and IT leaders in the organization?

Alistair Erskine, M.D.: With regard to the physicians who become leaders in the organization, one thing that Geisinger does on purpose is to take a clinician leader and match them up with an administrator. So I have a vice president of clinical informatics that works directly with me, and we work daily together. She will tend to be more in charge of the change transformation aspects and some of the administrative aspects of the budget and even HR things; but she’s just as much a part of the equation. She has more of the business savvy, and I have more of the clinical leadership savvy, and that’s typical. Second, much like the typical integrated health system, our structure is very matrixed and flat. Formally, I may have one boss, but I actually have many bosses, and that ensures collaboration. And my remuneration is at risk, based on performance. In addition, it’s strongly encouraged that people have shared goals across departments and divisions, to make sure people are aiming at the same things.

Two more things: We have the Institute for Advanced Applications, which was created to do three things—healthcare reengineering; emergent technology (gadgets, Google Glass, portable ultrasounds, etc.); and a third thing, which is clinical innovation, around key areas that have been ongoing problems in healthcare. They’re the ones that came up with the care gap program. They’re also coming up with a new way of doing online documentation for physicians. So that’s IAA, the Institute for Advanced Applications. And it’s funded at Geisinger, to be able to form those functions. Another group, one I lead, is the Division of Applied Research and Clinical Informatics, or DARCI. Some people refer to that as the clinical informatics group or clinical transformation group or CMIO group; it has lots of names internally. One is your standard clinical transformation around optimizing work through the EHR, including making sure that the literature out there in JAMIA [the Journal of the American Medical Informatics Association] and Healthcare Informatics and elsewhere, is being absorbed and used.

Alistair Erskine, M.D.

When did the Institute for Advanced Applications begin?

Erskine: It began in concept when I arrived ten months ago; it had existed at Geisinger, but not under one roof; it was scattered previously. We just gave it a name. It’s got 70 people in it, and it’s a combination of people who are part of the Epic team, of the care gap team, of the eHealth and mobility team, and the analytics team. One department is clinical transformation; the second is Geisinger in Motion; and the third department is Data Science. Geisinger in Motion is all the things we’re doing with provider mobility, with patient mobility (remote access, etc.), all the things we’re doing relative to telehealth, and to HIE, which is what John talked about at AMDIS.

What are the biggest, broadest learnings so far in all this work?

One key element has to do with clinical transformation, via EHR optimization. We use Epic [the core EHR solution from the Verona, Wis.-based Epic Systems Corporation]. And we’ve customized Epic, because we’ve had Epic for 17 years, and Epic has been moving more slowly than we’ve wanted. So we’re working to take the customization, and we’re de-customizing in a very specific way. We don’t want to just put in “vanilla Epic”; we want to get closer to Epic and to create apps that work for us. We are finding that we want to be able to take some of our intelligence and feed it back into Epic. That customization is something that gets re-integrated into Epic. We’ve been talking about interoperability for years; but what will come is inter-app operability. Basically, what we’ve realized is that the apps need to be more “inter-app-erable.”

What we miss in the data we’ve got is the workflow, the context. So we’re saying, we want the data and the workflow and the context, to be more transportable. We’re using FHIR [the Fast Healthcare Interoperability Resources Specification, a standard for healthcare data exchange], and some third-party software, such as PatientKeeper; and rather than using PatientKeeper’s own apps, we’re looking at their back-end system that does the integration. So the idea that we can create apps that can sit on any different EHR, is a lesson we’re learning as we trying to purify our Epic, so we can be quicker on the upgrade. Because our bimodal function of IT, which is half the waterfall development process that Epic, Cerner, and Meditech use to enhance software, that slow, reliable process; and then that other mode, which is sprinting forward quickly towards innovation—those two functions have to coexist. So we use these apps and this app infrastructure to be able to promote integration that would otherwise be too slow for us. That’s what we’ve learned from clinical transformation.

What we’ve learned from mobility is that our patients, our members, our people who seek care at Geisinger, are ahead of us and dragging us into the 21st century when it comes to mobility. So we want to make sure we’re providing providers with Geisinger mobile phones, and that we put Epic, secured texting, and reference tools, on those phones, as well as great diagnostic images. What I want to do is to mobilize the physicians and un-tether them from the desktop. And the nurse can do barcoding with the IOS device, and the doctor can use the device instead of a pager.

John Kravitz: For the patients, we’re doing a couple of interesting things. With the ED [emergency department] and the EMS [[emergency medical services program], the paramedics, we have a pilot study with the health information exchange, so they can get access to the patient record, while they’re moving towards us, via mobile device. They can connect to the HIE and look up things like medication lists, while the patient is being transported, so it’s not dead time.

John Kravitz

Erskine: And e-face communication can query what’s going on in the patient’s home. So in those rare cases where there needs to be more information. And beginning August 1, we’re going to be handing out iPad devices to patients two weeks before they have an elective procedure, loaded with electronic forms to complete, videos on what to expect, and access to the patient portal so they can access their patient records. And they’ll keep that device when they get admitted, for information and entertainment. And when they’re discharged, they’re still connected to us, so we can take a quick look at a wound, make sure the medication reconciliation is done accurately; as well as provide reminders to them about when they’re supposed to take their meds, such as three times a day. And then they give the device back when they come for their follow-up.

Here’s an added element: typically, pre-hospitalization/clinic visit and scheduling; hospitalization and procedure; and post-hospitalization care and follow-up, are three separate events. But we’re trying to tie those three experiences together and make them more seamless. It’s how we’re dealing with the communication gaps that take place during transitions of care. We’re trying to keep up with the people out there who have gone mobile already, and we’re trying to …

What is your advice for CIOs, CMIOs, and other healthcare and healthcare IT leaders, as they begin to pursue initiatives like the ones taking place at Geisinger?

Kravitz: Most of those providers not in the top 1 or 2 percent of innovation, they’re trying to work on meaningful use, and interoperability is a key component of that. And most vendors are trying to move forward with analytics suites, and interoperability. You may not be with one of the top two vendors like Cerner and Epic, but it’s very important to look at your data and understand it, because [IT-facilitated innovation] is about data analytics and population health. And how can you create interoperable data structures? As we continue to improve and refine our data environment to make things more efficient and more catalogue-able; we’re always looking at ways to improve our infrastructure.

Erskine: And it doesn’t take a lot of people to create a vision and a roadmap for what one wants to accomplish, even in a smaller community hospital. Even there, a volunteer CMIO physician can think of three or four things that could be improved within the next year or two. So focusing on those few things, and then gathering momentum around your vision of how your organization will improve—will amass a direction that sometimes the IT organization is interested in following.

What will happen at Geisinger, and in the industry, in the next few years?

We’re doing a fair amount of merger and acquisition work at Geisinger. One organization we’ve signed a definitive agreement with and are waiting for legal’s signoff on is with AtlantiCare in New Jersey—that will be a merger of our organizations. And they’re a Cerner shop. And we’ve signed a similar agreement with Holy Spirit Health System in Harrisburg; and Lewistown has become officially a part of Geisinger. And these mergers and acquisitions obviously take a long time to execute.

Kravitz: And that’s more like a waterfall process. It can take a year to get each one into play; but we’ve been doing multiple acquisitions at the same time.

Erskine: And we’ve always done Epic, but these organizations joining us are doing OK not having Epic sometimes. They don’t want to do a rip-and-replace. So we’re working to universalize our IT environment. And more broadly in the industry, I think the industry has to decide what it wants to do with meaningful use Stage 3. The vendors have to decide how they’ll interact with the program; and we’ll all have to interact better around patient outcomes. And that’s going to be an ongoing struggle, as the technology changes and the deluge of data continues to mount, we have to make sure at the end of the day that we don’t just end up with a bunch of busy clinicians, that we’re meeting the patients’ needs.

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