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1. Copyright 2010 Keystone Health Information Exchange®
Health Information Technology
and Exchange
2010 Pennsylvania Broadband Summit
September 20, 2010
Jim Younkin
KeyHIE Director
2. Copyright 2010 Keystone Health Information Exchange® a. Population
In the area directly adjacent to Geisinger Medical Center…
These five counties have an area of 1,934 square miles and a population of 256,203 living in 69 towns (2000 census). All five counties are officially designated as rural by the Rural Urban Commuting Area Codes (RUCA); four of the five are designated as Medically Underserved Areas/Populations (MUA/P).
The five county region’s population is categorized as: 94% White, non-Hispanic, with the remaining 6% a combination of Hispanic (2.1%), Black, non-Hispanic (2.5%), Asian & Pacific Island, non-Hispanic (.75%) and All Others (.9%). In addition, the community includes a small percent of Amish and Mennonite (.14%), captured in the White, non-Hispanic count). In terms of health coverage, approximately 18% of the area’s population is uninsured, in excess of 5% are underinsured, and 16% are medically-underserved.
b. Healthcare Providers
Area residents receive the great majority of their care (primary to tertiary) from six hospitals (Berwick Hospital Center, Bloomsburg Hospital, Evangelical Community Hospital, Geisinger Medical Center, Shamokin Area Community Hospital, and Sunbury Community Hospital), 282 physicians, 21 long-term care facilities, five home health agencies, and other healthcare organizations (HCOs).
Rural Pennsylvania has a large number of veterans (including reservists at approximately 24,000 in the five-county area served by KBC. b The KBC service area has only one VA clinic at its eastern edge, a community-based outpatient clinic in Berwick, PA. The next closest VA outpatient clinic is one hour away in Williamsport, PA. The nearest VA Hospital is in Wilkes Barre, PA—also an hour away.
a. Population
In the area directly adjacent to Geisinger Medical Center…
These five counties have an area of 1,934 square miles and a population of 256,203 living in 69 towns (2000 census). All five counties are officially designated as rural by the Rural Urban Commuting Area Codes (RUCA); four of the five are designated as Medically Underserved Areas/Populations (MUA/P).
The five county region’s population is categorized as: 94% White, non-Hispanic, with the remaining 6% a combination of Hispanic (2.1%), Black, non-Hispanic (2.5%), Asian & Pacific Island, non-Hispanic (.75%) and All Others (.9%). In addition, the community includes a small percent of Amish and Mennonite (.14%), captured in the White, non-Hispanic count). In terms of health coverage, approximately 18% of the area’s population is uninsured, in excess of 5% are underinsured, and 16% are medically-underserved.
b. Healthcare Providers
Area residents receive the great majority of their care (primary to tertiary) from six hospitals (Berwick Hospital Center, Bloomsburg Hospital, Evangelical Community Hospital, Geisinger Medical Center, Shamokin Area Community Hospital, and Sunbury Community Hospital), 282 physicians, 21 long-term care facilities, five home health agencies, and other healthcare organizations (HCOs).
Rural Pennsylvania has a large number of veterans (including reservists at approximately 24,000 in the five-county area served by KBC. b The KBC service area has only one VA clinic at its eastern edge, a community-based outpatient clinic in Berwick, PA. The next closest VA outpatient clinic is one hour away in Williamsport, PA. The nearest VA Hospital is in Wilkes Barre, PA—also an hour away.
3. Copyright 2010 Keystone Health Information Exchange® Geisinger’s EHR EHR
Demographics, Results, All OP orders (CPOE), Provider documentation, Meds, history, problems, health maintenance, alerts, IP results, physician & nursing documentation, e-MAR, IP Orders
Integrated scheduling, registration, and reporting systems
E-Prescribing
Available all venues of care (Inpatient and ambulatory)
All 800+ providers fully live as of end of 2002
3M unique patients in the database
>10M total office visits documented in EpicCare as of January, 2008 2007 Sample Stats
6M appointments
1.6M Office Visits
>1.2M Telephone encounter
>12,000 user IDs
Concurrent users: Average daily peak >6200
>8M Orders
700K immunizations, injections, treatments
MyGeisinger-
Web-access for patients to their EHR information, secure messaging, etc
120,000 users
GeisingerCONNECT
>1,300 Non-Geisinger providers
Decision to implement Epic®: 1995
> $80M invested (hardware, software, manpower, training)
Running costs: ~ 4.2% of annual revenue of $2.0B
Fully-integrated EHR - 40 community practice sites; GMC in-patient; GWV nursing documentation; GWV and GSWB Emergency Department live on EPIC
> 3 million patient records
~ 120,000 active users of MyGeisinger
New goal = 200,000
1,300 non-Geisinger users; confidential access (referring physicians)
E-prescribing
55 clinics
369,713 scripts (first year)
0.3% failure rate
Inpatient EHR
Value-added, closed-loop care processes
70% of orders from standardized order sets
MyGeisinger (networked PHR)
Medicine List with electronic renewals
Secure e-messaging
Immunizations
Test Results
Problem List
Electronic Interview
Self-Scheduling
Clinical Decision Support
Access to your own medical record information
Health & fitness information
Understanding and paying bill
Library information
Clinical trial information
EHR Savings:
$3 chart, $575,000
Cost of file folder
Cost of paper
Cost of handling (retrieval, delivery, return, refile)
Reduced daily printing/faxing:
Paper/equip $30k/yr
Labor effic $120k/yr
Reduced transcription use:
Total lines decreased 2,038,398 million
Cost per line of transcription $0.2149
Cost savings $438,052/yr
Reduced Denials due to missing referrals:
$1.1M/yr
Formulary savings:
$1,000 per physician = $400,000/yr
Coding, documentation and compliance
$200k to $1M / yrDecision to implement Epic®: 1995
> $80M invested (hardware, software, manpower, training)
Running costs: ~ 4.2% of annual revenue of $2.0B
Fully-integrated EHR - 40 community practice sites; GMC in-patient; GWV nursing documentation; GWV and GSWB Emergency Department live on EPIC
> 3 million patient records
~ 120,000 active users of MyGeisinger
New goal = 200,000
1,300 non-Geisinger users; confidential access (referring physicians)
E-prescribing
55 clinics
369,713 scripts (first year)
0.3% failure rate
Inpatient EHR
Value-added, closed-loop care processes
70% of orders from standardized order sets
MyGeisinger (networked PHR)
Medicine List with electronic renewals
Secure e-messaging
Immunizations
Test Results
Problem List
Electronic Interview
Self-Scheduling
Clinical Decision Support
Access to your own medical record information
Health & fitness information
Understanding and paying bill
Library information
Clinical trial information
EHR Savings:
$3 chart, $575,000
Cost of file folder
Cost of paper
Cost of handling (retrieval, delivery, return, refile)
Reduced daily printing/faxing:
Paper/equip $30k/yr
Labor effic $120k/yr
Reduced transcription use:
Total lines decreased 2,038,398 million
Cost per line of transcription $0.2149
Cost savings $438,052/yr
Reduced Denials due to missing referrals:
$1.1M/yr
Formulary savings:
$1,000 per physician = $400,000/yr
Coding, documentation and compliance
$200k to $1M / yr
4. TeleStroke Program Less than 5% of people who have a stroke receive clot-busting thrombolytic medications
Geisinger is the region’s only:
Certified Primary Stroke Center
Neurovascular Intervention Center
Emergency physicians consult with neurosurgeons to diagnose and treat stroke patients
24/7 coverage
1--Despite FDA approval and a nation-wide education campaign, less than 5% of people who have a stroke receive clot-busting thrombolytic medications, a lifesaving therapy.
2--Our TeleStroke program connects your physicians with our neurosurgeons using two-way interactive equipment so that a neurosurgeon can virtually sit-in on the procedure.
3--We currently have 5 neurosurgeons participating in this program who collectively provide coverage, 24/7.1--Despite FDA approval and a nation-wide education campaign, less than 5% of people who have a stroke receive clot-busting thrombolytic medications, a lifesaving therapy.
2--Our TeleStroke program connects your physicians with our neurosurgeons using two-way interactive equipment so that a neurosurgeon can virtually sit-in on the procedure.
3--We currently have 5 neurosurgeons participating in this program who collectively provide coverage, 24/7.
5. e-ICU Program E-ICU Program
Physician ‘virtual presence’ in a patient’s room
Reduction in mortality rates by more than 30%
Reduction in length of stay by more than 25%
Reduce operating costs
Increased patient satisfaction 1--With a Level 1 Trauma Center in Danville and a Level II Trauma Center in Wilkes-Barre, Geisinger receives a high amount of patient transfers for specialized care.
2--The Trauma Transfer program is a ‘store and forward’-style program where the referring physician or department send patient information to Geisinger to prepare the trauma team to receive the transfer.
3--Our team will begin ordering medications, preparing surgical rooms, whatever is necessary to care for the transferred patient at the moment of arrival.
4--This streamlined approach can be lifesaving and is a huge patient satisfier.1--With a Level 1 Trauma Center in Danville and a Level II Trauma Center in Wilkes-Barre, Geisinger receives a high amount of patient transfers for specialized care.
2--The Trauma Transfer program is a ‘store and forward’-style program where the referring physician or department send patient information to Geisinger to prepare the trauma team to receive the transfer.
3--Our team will begin ordering medications, preparing surgical rooms, whatever is necessary to care for the transferred patient at the moment of arrival.
4--This streamlined approach can be lifesaving and is a huge patient satisfier.
6. Copyright 2010 Keystone Health Information Exchange® Problem – Outside Lab Results Paper is no longer “good enough” Must be scanned
Delay for results
Harder to find
Must open image to see result
Limits functionality (trending) Geisinger providers seeing patients near community hospitals may order lab work that is performed at a community hospital laboratory. Results are typically sent back to the provider on paper, either faxed or printed locally. Since Geisinger providers use an EHR, the paper result must be scanned and then manually linked to the patient’s electronic health record before the provider can see the result. Because of this interim scanning process, results are often not available to clinicians for more than a day after the lab sends them. In addition, the results are often difficult to locate in the chart because scans are not displayed in the same place as lab studies performed by the in-house laboratory. The scanned images also cannot be trended as discrete data, which limits the effectiveness of the EHR. For these reasons, providers that practice near community hospitals consider it highly desirable to have an interface of lab results from the community hospital into their EHR system.
Geisinger providers seeing patients near community hospitals may order lab work that is performed at a community hospital laboratory. Results are typically sent back to the provider on paper, either faxed or printed locally. Since Geisinger providers use an EHR, the paper result must be scanned and then manually linked to the patient’s electronic health record before the provider can see the result. Because of this interim scanning process, results are often not available to clinicians for more than a day after the lab sends them. In addition, the results are often difficult to locate in the chart because scans are not displayed in the same place as lab studies performed by the in-house laboratory. The scanned images also cannot be trended as discrete data, which limits the effectiveness of the EHR. For these reasons, providers that practice near community hospitals consider it highly desirable to have an interface of lab results from the community hospital into their EHR system.
7. Copyright 2010 Keystone Health Information Exchange® The Case for HIE The current health care system is fragmented
8. Copyright 2010 Keystone Health Information Exchange® The Case for HIE The current health care system is fragmented
Health information is kept in silos
Radiology studies
20% of hospital radiology tests are duplicates (CITL)
$60 average cost for radiology tests
20% of 912,000 annual KeyHIE radiology exams is 182,000 duplicates
$10.9 million savings potential (182,000 * $60)
Lab studies
13%-20% duplicate laboratory tests (Indiana/Santa Barbara)
$27.75 is the average cost per lab test
13% of four million annual KeyHIE labs = 520,000 duplicates
$14.4 million savings potential (520,000 * $27.75)
9. Copyright 2010 Keystone Health Information Exchange® The Case for HIE The current health care system is fragmented
Health information is kept in silos
Critical clinical information is not available to healthcare providers
14% of PCP office visits
Emergency Departments
15% of ED visits (47,250 / 315,000 annual ED visits to KeyHIE hospitals)
$26 savings for 40% of ED visits
40% of 315,000 annual ED visits to KeyHIE hospitals is 126,000
$3.3 million in potential savings (126,000 * $26)
10. Copyright 2010 Keystone Health Information Exchange® The Case for HIE The current health care system is fragmented
Health information is kept in silos
Critical clinical information is not available to healthcare providers
Possible savings through KeyHIE
(based on current KeyHIE membership)
$10.9 million – Reduction of duplicate radiology studies
$14.4 million – Reduction of duplicate lab studies
$3.3 million – ED visits
=======================
$28.6 million annual savings
11. Copyright 2010 Keystone Health Information Exchange® Use Case 1: Emergency Department Unconscious, approximately 30 year old female
Motor Vehicle Accident
Multiple lacerations and internal injuries are suspected Use case #1
The emergency department receives an unconscious approximately 30 year old female that was involved in a motor vehicle accident. Multiple lacerations and internal injuries are suspected. Using the KeyHIE regional portal network, it is discovered that the patient is also pregnant. Without knowing her pregnancy status the clinician would for the pregnancy test results from the laboratory, but with KeyHIE clinician can immediately start treating the patient avoiding medications and procedures that would harm the fetus. Use case #1
The emergency department receives an unconscious approximately 30 year old female that was involved in a motor vehicle accident. Multiple lacerations and internal injuries are suspected. Using the KeyHIE regional portal network, it is discovered that the patient is also pregnant. Without knowing her pregnancy status the clinician would for the pregnancy test results from the laboratory, but with KeyHIE clinician can immediately start treating the patient avoiding medications and procedures that would harm the fetus.
12. Copyright 2010 Keystone Health Information Exchange® Use Case 2: Emergency Department
A patient with a seizure disorder, arrives unconscious
Use Case #2:
With Exchange:
A patient with a seizure disorder arrives unconscious in a local emergency dept.
Physician examines the patient and using KeyHIE looks up their medical history to discover the patient was previously seen at another regional facility with a diagnosis of seizures.
Targeted treatment with anticonvulsants stabilizes the patient and reduces the chance for delays or errors in treatment.
Without Exchange:
Physician examines patient and orders multiple tests (which may be unnecessary or redundant) to determine the etiology of coma.
Treatment may be inaccurate or erroneous due to lack of patient past medical history.
Potential errors in treatment such as allergic reactions or side effects from treatment may occur.
Result: Increased errors, cost and length of stay in the ER. Use Case #2:
With Exchange:
A patient with a seizure disorder arrives unconscious in a local emergency dept.
Physician examines the patient and using KeyHIE looks up their medical history to discover the patient was previously seen at another regional facility with a diagnosis of seizures.
Targeted treatment with anticonvulsants stabilizes the patient and reduces the chance for delays or errors in treatment.
Without Exchange:
Physician examines patient and orders multiple tests (which may be unnecessary or redundant) to determine the etiology of coma.
Treatment may be inaccurate or erroneous due to lack of patient past medical history.
Potential errors in treatment such as allergic reactions or side effects from treatment may occur.
Result: Increased errors, cost and length of stay in the ER.
13. Copyright 2010 Keystone Health Information Exchange® Health Information Exchange
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29. Copyright 2010 Keystone Health Information Exchange® Contact Information Jim Younkin – Director, KeyHIE
IT Program Director, Geisinger Health System
jryounkin@geisinger.edu
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31. Copyright 2010 Keystone Health Information Exchange® Miscellaneous Slides
32. Copyright 2010 Keystone Health Information Exchange® Because PA requires patient consent before sharing specially protected health information, such as drug/alcohol tests, HIV, and psychotherapy notes, we have implemented an opt-in architecture based on an authorization form being signed at each facility. This authorization stays in effect for the life of the patient unless it is revoked.
Without the auth, we can indicate that a patient was seen at a particular facility, but we do not allow access to any clinical information.
Our architecture stores the authorization flag in the EMPI and requires the portal to determine whether clinical information can be retrieved from specific facilities. In the future we would like to migrate to the HITSP standard that maintains this information in the document registry. This will allow other systems to ensure access rules are enforced using standard methodology.Because PA requires patient consent before sharing specially protected health information, such as drug/alcohol tests, HIV, and psychotherapy notes, we have implemented an opt-in architecture based on an authorization form being signed at each facility. This authorization stays in effect for the life of the patient unless it is revoked.
Without the auth, we can indicate that a patient was seen at a particular facility, but we do not allow access to any clinical information.
Our architecture stores the authorization flag in the EMPI and requires the portal to determine whether clinical information can be retrieved from specific facilities. In the future we would like to migrate to the HITSP standard that maintains this information in the document registry. This will allow other systems to ensure access rules are enforced using standard methodology.
33. Copyright 2010 Keystone Health Information Exchange® KeyHIE Data Flow Use existing HIE infrastructure and tools to share information among providers…
Regional HIE agreements / Governance
KeyHIE Clinical Viewer
Patient Index, Encounter Index
Integration Engine
Clinical Document Store
Use existing HIE infrastructure and tools to share information among providers…
Regional HIE agreements / Governance
KeyHIE Clinical Viewer
Patient Index, Encounter Index
Integration Engine
Clinical Document Store
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35. Copyright 2010 Keystone Health Information Exchange®
