CEO SUMMARY: Every health reform proposal makes it a high priority to implement a universal electronic medical record (EHR). Because lab test data is the essential component of a successful EHR, laboratory managers and pathologists may soon have a once-in-a-lifetime opportunity to use EHR implementation to boost the value to lab testing services. This is exactly what the laboratory at Geisinger Health has achieved in the 15 years since the system first implemented its integrated EHR solution.
ONE ELEMENT that is common to every healthcare reform proposal is rapid adoption of a universal electronic health record (EHR). All stakeholders in healthcare seem to agree that implementation of a universal EHR will trigger substantial benefits.
Laboratory test data represents the largest single component of the average patient’s health record. Therefore, widespread adoption of EHRs will be both a threat and an opportunity for clinical laboratories and pathology groups.
With recent passage of a major health reform bill in the House, and with the Senate now debating its own version, lab executives and pathologists should be ready for a time of accelerated EHR deployment and implementation. Since lab test data underpins an effective EHR system, labs must get it right the first time.
For inspiration, laboratory professionals can look to the experience of the laboratory at Geisinger Health System. For more than 15 years, it has supported what many experts consider to be one of the nation’s most successful deployments of EHR within a large, integrated health system. It was 1994 when Geisinger, based in Danville, Pennsylvania, introduced its first EHR system.
“That was the year that Geisinger began rolling out an electronic health record system in all its hospitals and physicians’ offices throughout central and eastern Pennsylvania,” stated Jay B. Jones, Ph.D., Director of Chemistry & Health Group Labs for Geisinger. “From the very first days of EHR use, our lab has delivered robust and complete lab test data into the Geisinger EHR.” Jones was speaking at the Executive War College in New Orleans earlier this year.
“Over these 15 years, Geisinger has spent about $80 million building and upgrading our EHR,” noted Jones. “From the start, the EHR has been a core tool to improve clinical effectiveness. And, at the heart of that EHR system is laboratory test data.”
Founded in 1915, the Geisinger Health System serves some 2.6 million residents in central and northeastern Pennsylvania. Geisinger also runs the Geisinger Health Plan, which has 212,000 members.
Employing 11,000 full-time equivalent employees, the Geisinger Health System is one of the nation’s largest health systems. Similar in structure to the Mayo Clinic, Geisinger has 45 practice sites in 31 counties in Pennsylvania, along with 700 physicians in a closed staff-model group practice. It owns two hospitals. One is Geisinger Medical Center, a 422-bed tertiary hospital in Danville, and the other is 242-bed Geisinger Wyoming Valley Medical Center in Wilkes-Barre.
Geisinger’s laboratory services are fully integrated across all inpatient, outpatient, and outreach environments. The laboratory performs about 4.9 million tests per year. Around 5.6% of this volume is outreach testing.
Lab Recognized Opportunity
“From the start, our laboratory considered the EHR to be an opportunity,” recalled Jones. “The key to understanding this opportunity lies in the fact that Geisinger is an integrated health system. During the past two decades, our health system has actively consolidated and integrated our healthcare continuum.
“For example, at one time, we had 75 smaller practices,” he said. “Today, these smaller groups are being brought together into hub sites. As a consequence, our centralized clinics increasingly have between 20 and 40 multi-specialty physicians practicing in outpatient settings.
“Back in 1994, our first Epic EHR was initially deployed in the outpatient areas,” said Jones. “In the second phase, the EHR was implemented in inpatient services. Geisinger now has what is essentially a paperless inpatient and outpatient environment throughout the health system. It must be emphasized that the laboratory is at the core of this EHR system. The EHR would not function to its full potential without that laboratory component.
“To make the concept of integrated care work across the inpatient, outpatient, and outreach environments, it is essential that the clinical data needed by physicians and caregivers be available at the point of care,” added Jones. “That requires all our laboratory facilities to be linked in ways that allow us to collect lab data from patients anywhere it is generated, feed it into our LIS, and use this data to populate the EHR in real time.
“We’ve learned lots of lessons on how the clinical laboratory should properly support a system-wide EHR,” he explained. “The first goal back in the 1990s was to reduce variability of laboratory test results at all testing locations. During that time, we worked hard to standardize testing at all hospital and clinic sites and make sure that the lab test data generated at every testing site came into our LIS. Consolidation of laboratory testing was another strategy we used to help standardize testing across our integrated health system.
Capturing All POCT Results
“After the consolidation and standardization phase was completed, our next strategic lab goal was to support the EHR’s effectiveness by capturing all point of care (POC) test results and ensuring these results were part of a complete patient lab test record in our LIS,” continued Jones. “This project took place between 2000 and 2002. Today, across the many POC testing sites within the Geisinger system, our LIS captures nearly all those test results— mostly in real time and without manual input of the data.
“Keep in mind that, to support the effective EHR used in our integrated care continuum,’ he added, “our LIS needed to capture all this standardized lab test data and create a well-defined and traceable clinical archive. Not only has that been achieved, but our lab now has a data base of lab test information reaching back more than a decade. This lab data repository now supports serial population outcomes studies and similar clinical research.
“As our laboratory gained experience in supporting the EHR and working with it, we identified another opportunity to add value,” commented Jones. “Once the EHR was installed, we quickly recognized that it could be used for more than clinical documentation. Because we can access all the data from every patient encounter through the EHR, it became a great enabler for improving clinical effectiveness. We describe this activity as ‘enterprise analytics.’
“The goal of having an enterprise analytics system is to collect and store data on all the lab testing that we do across the entire enterprise,” observed Jones. “This includes at the point of care, in the core lab, in the rapid response labs, and in our outpatient clinics. At the same time, the objective is to reduce variability in laboratory test results.
“Regardless of where a lab test is performed in the care continuum, we capture that data and maintain a well-defined and traceable clinical archive in our LIS,” he added. “That enables us to fulfill the primary mission of our integrated health system: each time a patient comes to the Geisinger system, he/she gets accurate and prompt test results for that encounter.
Using Lab Data To Add Value
“However, our laboratory wants to do more than that,” he said. “We want add additional value to the system. We believe it is also a responsibility of the laboratory to archive that data so that it can be used to practice population medicine.
“This is where the EHR plays another role for us in the laboratory,” noted Jones. “Efforts are underway to develop a hybrid system within Geisinger Health. One element is to do what most health plans and hospitals do: deliver the best care for each individual encounter with a rapid response time.
“The second element is what sets Geisinger apart and what challenges our lab- oratory to find additional ways to add value: we aim to be the gold standard for population studies,” he explained. “That requires us to produce lab test data in a form that makes it useful for population studies, as well as to improve our clinical effectiveness.
Scaleable Analyzer Solutions
“One way our laboratory pursues this goal is to install scaleable analytical platforms,” stated Jones. “We’ve asked our vendors for chemistry and immunology instrumentation to deliver systems that fit both our smaller rapid response labs and our core lab. Similarly, we use the same reagent system throughout our laboratory organization, along with the same test codes, and the same reference ranges. All these elements are standardized through the LIS.
“Again, much of this standardization was driven by the need to properly support the use of the EHR while at the same time producing a complete data base of lab test results,” he explained.
“An early step was to standardize test codes in the LIS,” commented Jones. “Within our system, a blood glucose test is the same regardless of what instrument or which location performed the test. This happens because our lab runs identical reagents on platforms that are from the same vendor.
“In turn, having the same method codes, reference ranges, and critical limits supports standardization of results across 23 different lab testing sites within Geisinger Health,” he added. “This standardization of laboratory testing had another benefit for our parent health system.
“Many people are aware that, since 2005, Geisinger has been one of 10 pilot sites for the Medicare Physician Pay-for-Performance (P4P) Demonstration project,” noted Jones. “Our standardized and complete lab test data for patients, fed into the EHR in real time, played an essential role in supporting documented improvements in patient outcomes. Accordingly, Geisinger has done quite well with this pay-for-performance demonstration.” (See TDR, February 14, 2005.)
It is this functional, deployed EHR which allows the Geisinger laboratory to regularly identify new opportunities to add value and advance clinical care. That helps Geisinger to be well-positioned as long-discussed healthcare reforms finally take place.
“However it happens, the coming major reforms in healthcare are going to ask a lot of clinical laboratories,” predicted Jones. “One specific aspect will be supporting the added volume of testing that results from universal healthcare, which creates the need to serve large numbers of newly-insured patients.
Our standardized and complete lab test data
for patients, fed into the EHR in real time, played an essential role in supporting documented improvements in patient outcomes.”
“Think about the increased volume of tests for cholesterol, PSA screening, and other assays required to support early detection, active intervention, and effective patient monitoring across the entire population of the United States.
“We think our lab’s experience with the Geisinger EHR and the Medicare P4P program provides a window into how laboratories will operate in the future,” said Jones. “It takes the laboratory down the road of practicing population medicine and using practice parameters to deliver best practice medicine.
“Both concepts are elements of what our doctors call ‘Proven Care’,” explained Jones. “This is the name we gave to our focus on delivering the best patient care.
“Since Proven Care was instituted at Geisinger, the data collected demonstrates that our physicians deliver better and more effective care,” he noted. “This is validated by measurable improvements in patient outcomes at Geisinger Health.
Numbers Tell The Tale
“The numbers tell the tale,” continued Jones. “Since the start of Proven Care, Geisinger’s 30-day readmission rate after cardiac surgery has dropped 44%. The rate of patients with any complications dropped 21%, while our rate of re-operations for bleeding dropped 55%! If you are a patient, these improvements in outcomes are both welcome and help to distinguish Geisinger as a source of excellent care.
“To be more specific, diabetes provides a good example of how Proven Care works at Geisinger,” he explained. “It also illustrates how the EHR can cue the laboratory as to new ways to add value to clinical services.
“A team of clinicians developed practice parameters and best practice alerts to be associated with diabetes,” commented Jones. “The laboratory provided input to this team. These practice parameters and best practice alerts were then embedded into the EHR. This allowed all our doctors to get these alerts on their screens whenever they see a patient coded for diabetes.
“Geisinger’s EHR has the ability to guide the physician on how to order ‘smart tests’,” noted Jones. “These are combinations of tests that match best practices for patients with diabetes. The EHR also supports the use of pre-filled referrals. These are used if a patient with diabetes needs to be referred to the smoking cessation clinic, for example.
“The ‘smart tests’ feature is unique,” he said. “When the physician sees a patient with diabetes, the EHR presents a pop-up box,” stated Jones. “This pop-up box says, ‘Diagnosis of diabetes mellitus.’ Next, it lists the tests needed: ‘Hemoglobin A1c every six months (the standard is get each patient’s number to below 7%); microalbumin every 12 months; and, LDL every 12 months.’
“If the doctor clicks the box once, all those lab test orders automatically flow into the EHR, which immediately transmits these test orders to the laboratory,” he commented. “Physicians don’t need to click around on the computer to look for the various orders to put into the EHR. Everything is summarized for them.
“Similarly, it’s just a click away to order their medications and other diagnostic tests in the EHR system,” he observed. “This makes our EHR not just an efficient practice tool, but also a quality practice tool.
“Our pathologists and lab scientists can use the EHR to view the patient visit summaries,” he added. “They can also access the decision support information provided to physicians and the patient- specific and disease-specific summary screens. All this information allows us to drill down to see how we are doing collectively in managing the 20,000 patients with diabetes in the Geisinger system.
Improved Patient Scores
“As a result of all these steps, we have improved patient care, supported by measurable results,” he recounted. “We know, for example, that from January 2006 to the middle of 2006, the percentage of patients with diabetes that hit the 7% hemoglobin A1c target rose from 28% of all patients to 33%. That’s an improvement of 5%.
“Because of this improvement in patient test scores, Geisinger expects its diabetes patients to have fewer eye problems, fewer foot problems, and potentially fewer amputations,” he said. “In turn, given the Medicare program’s focus on P4P and efficiency, we are confident that we are doing the right thing and having the right impact.”
Jones may be understating things on that point. Geisinger Health is so confident that it can deliver high quality care that it has offered a warranty to patients related to errors. For example, if a coronary bypass patient develops an infection, neither that patient nor the health plan will need to pay for care related to the infection. These warranties are advertised to the public in a variety of ways.
This public “stake in the ground” to stand behind the quality of its clinical services is more evidence of how the integration of its EHR across inpatient, outpatient, and outreach settings is paying dividends. It is this type of innovation that shows the true path to worthwhile reforms of the American healthcare system.
Moreover, the accomplishments of the Geisinger laboratory, as shared here by Jones, provide inspiration and a road map for all laboratory administrators and pathologists who want to help their laboratory organization develop into an innovative source of clinical value.
In particular, for those laboratories in hospitals and healthcare systems yet to implement a fully-integrated EHR, the approaches used by the Geisinger lab to advance clinical care and support improved patient outcomes demonstrate why it is important for the laboratory to embrace the implementation of an effective EHR. An integrated EHR actually becomes an enabler for labs to step up and offer physicians innovative ways to add value.
How Medicare’s Pay-for-Performance Demo Motivates and Incentivizes Physicians
USE OF THE ELECTRONIC HEALTH RECORD (EHR) system at Geisinger Health System is one tool to improve patient outcomes. Another aspect is the financial incentives that are related to the Medicare Pay-for-Performance Demonstration that has been under way at Geisinger since 2005.
“As it is organized at Geisinger Health, our physicians have a financial incentive to follow the best practice alerts that are part of the EHR system,” observed Jay B. Jones, Ph.D., Director of Chemistry & Health Group Labs at Geisinger. “The incentive puts 20% of each doctor’s salary at risk. If they practice according to best practice alerts they win back that 20%. Therefore, being compliant with best practices is a pocket-book issue for them.
“Here’s how it works,” Jones explained. “In 2005, CMS wanted to incentivize health care systems like ours to get diabetes under control.” Medicare gave us practice parameters derived from national guidelines. One parameter involved getting hemoglobin A1c levels down under 7% for 90% of our patients with diabetes. Another goal was to collect urine albumin levels for these patients every year. For patients with hypertension, the Medicare P4P program wanted patients to achieve certain cholesterol levels.
“Data from our EHR told us that we had 20,000 patients with a diagnosis of diabetes,” he continued. “That would require us, as a participant in the P4P demonstration, to provide lab values and other data on those patients to the government. Because of our earlier standardization and the implementation of an integrated EHR throughout our health system, we already had everything in place to demonstrate improved patient outcomes. That is just one way that these investments are paying off for our laboratory and the parent health system today.”