Lab Enterprise Analytics: Essential for Regional Healthcare Clinical Effectiveness in the EHR Era

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1 Lab Enterprise Analytics: Essential for Regional Healthcare Clinical Effectiveness in the EHR Era Jay B. Jones, PhD DABCC Geisinger Health System Danville, PA Geisinger Health System Erie Crawford Warren McKean Potter Tioga Bradford Susquehanna Wayne Lackawanna Forest Wyoming Elk Cameron Lycoming Sullivan Venango Clinton Pike Mercer Luzerne Clarion Jefferson GWV GSWB Montour Columbia Centre GMC Monroe Lawrence Clearfield Union Butler Armstrong Carbon Northumberland Snyder Northampton Schuylkill Beaver Indiana Mifflin Lehigh Cambria Juniata Allegheny Blair Perry Dauphin Westmoreland Lebanon Berks Huntingdon Bucks Washington Cumberland Montgomery Greene Fayette Somerset Bedford Fulton Franklin Adams York Lancaster Chester Philadelphia Delaware Geisinger Hospitals Provide Primary/Secondary/Tertiary Care Geisinger Med. Groups GMC Geisinger Med. Ctr. GWV Geisinger Wyoming Valley GSWB Geisinger South Wilkes Barre GHP Service Area GHS Service Area 1

2 GHS Empanelled Physician Sites rren McKean Potter Tioga Bradford Susquehanna Lackawanna Wayne rest Elk Cameron Sullivan Wyoming Lycoming Pike Jefferson Clearfield Centre Clinton Union Montour Columbia Luzerne Carbon Monroe Indiana Mifflin Snyder Northumberland Schuylkill Northampton Lehigh d Cambria Blair Huntingdon Juniata Perry Dauphin Lebanon Berks Bucks Montgomery Cumberland Somerset Bedford Fulton Franklin Adams York Lancaster Chester Philadelphia Delaware Empanelled Client Sites GHS 31 County Service Area WA MT OR ID WY UT CO NV CA AZ NM ND SD NE KS OK TX MN ME WI MI NH NY IA PA CTRI IL IN OH NJ WV DCDE MO KY VA TN AR NC MS SC AL GA LA FL GML Outreach Client Sites Erie Outreach Sites Warren McKean Susquehanna Potter Tioga Bradford Crawford Wayne GHS 31 County Service Area Forest Cameron Lackawanna Venango Elk Sullivan Lycoming Pike Mercer Clarion Clinton Columbia Jefferson Luzerne Clearfield Montour Monroe Centre Union Butler Carbon Armstrong Beaver Indiana Mifflin Northumberland Northampton Lehigh Allegheny Blair Juniata Dauphin LebanonBerks Bucks Washington Montgomery Cumberland Somerset Bedford Franklin York Lancaster Chester Philadelphia Fayette Greene Adams 2

3 The Electronic Health Record Era Number One Imperative for all Healthcare Systems (HHS mandated; essential for Universal Healthcare ) 20-30% of U.S. Healthcare Systems currently have an EHR (fewer % fully functional) Rolled out over several years usually starting in outpatient areas that have consistent work processes (GHS, 1994 and still rolling) Reengineered work processes, Culture shock Expensive and expertise intensive Once installed, EHR is a Great Enabler A Driving Business Strategy: Take IT to the Consumer Universal Healthcare : Universal Lab Testing Web Access 100,000 MyGeisinger users; GeisingerConnect for Docs Consumers want easy access to Healthcare info (Lab #1 in focus groups) dex.html 3

4 Recent Geisinger Health System Ink Medical Home AARP the_new_face_of_health_care.html ProvenCare PBS Jim Lehrer Report Surgery with a Warranty NY Times &pagewanted=1 Organized EHR & LIS in the Geisinger Enterprise $80M spent on EHR (EpicCare( EpicCare) WAN routers connect to Data Center and Rack & Stack Client Servers, LIS (SunQuest( SunQuest) 28 CS apps from Lab alone 4

5 Where is Lab Data archived? LIS - in situ data warehouse Instrument data managers (e.g. Middleware ) EHR (largely text- based) Separate Clinical & Financial Data Repositories Goal: To reduce variability of lab test results across enterprise testing locations to create a well defined and traceable clinical archive that will support serial population outcome studies. 5

6 Enterprise Analytics - Connectivity GRL GMC H917 W A N Moshannon Valley I-400 Scenery Park I-400 Lewistown I-400 P P E E C-501 W A N SunQuest DI-MW C-501 GSWB Scranton I-400 Pocono I-400 Tunkhannock I-400 P P P I-400 DI-MW GWV DI-MW Server DI-MW Shadow C-6000 C-501 E601 C-501 BioRad Unity Server LIS foundation info-structure Enterprise Analytics Scaleable Analytical Platforms - Chem/Immuno (23), Heme, Coag ABG, POCT on WAN with middleware client servers integrated with LIS Shared LIS test codes, methods, reference ranges, critical limits ( lean( informatics ) Common lot # QC (400+ Chem/Immuno channels); affiliate & peer QC reports Common calibrator lot # shared on like analytical platforms 6

7 LIS foundation info-structure Enterprise Analytics Blind Duplicates BDUPs performed in LIS and % variance from mean tracked via Levy Jennings graphs Single service directory on web (SiteExecutive( SiteExecutive) CAP web-based based proficiency testing (PT) CAP certified as a system laboratory (single 3 day inspection) POCT Interleaved in EHR (via middleware & LIS) Group purchased (Premier) savings & efficiency in Material Management Benefits go on and on and on Outcomes Institute (HHCHR) Lab parameters key to EHR Clinical Repository (CDS) CDS collaboration with IBM Outcome parameters for reimbursement under P4P Clinical Effectiveness Division Best practice alerts in EHR Incentivized best practice in EHR ProvenCare Outcome warranty MyCode Biorepository AHRQ grant for RHIO Translational D&r Excellent Outcomes & Health Care 7

8 CMS P4P Project Quality Measures Diabetes (Starting Oct., 2005) Glycemic testing & avoidance (HbA1c>9) Hypertension control (BP<130/80) Hyperlipidemia testing & control (LDL<100) Nephrology screening (urine microalbumin) Retinopathy screening (eye exam) Extremity neurovascular screening (foot exam) Infection prevention (flu & pneumonia prevention) CMS Pilot Project Quality Measures CVD (Starting Oct., 2006) Hyperlipidemia testing, treatment & control (LDL<100) Hypertension screening RX compliance (lipid lowering, beta blocker, anti-platelet) 8

9 Validating Test methods for Population Studies by Data Mining LDL cholesterol Calculated vs Direct Glomerular Filtration Rate (estgfr( estgfr) HbA1c; urine albumin; Ca; others 9

10 10

11 ProvenCare 11

12 Diabetes Care (Using the EHR to help us work Smarter) Order Entry Support Order List SmartSet Order Panels Pre-filled Referrals Reports Patient-specific Report Card (letter) Patient-specific After Visit Summary Panel-specific Profile Report (components, composite) Decision Support Patient-specific Health Maintenance Screens ( (EpicCare; MyGeisinger) Disease-specific specific Summary Screen Best Practice Alerts ( (Smart Set enabled) 12

13 Alert-specific Order Sets ProvenCare - Diabetes Care ( All or None Composite Measure) Component Measures HgbA1C measurement HgbA1C control LDL measurement LDL control Blood pressure control Retinal exam Urine (protein) exam Foot exam Influenza immunization Pneumococcal immunization Smoking status Use of ACE/ARB for microalbuminuria/dm nephropathy Use of ACE/ARB for hypertension Patients who receive/achieve ALL of the above Quality Standard Every 6 months < 7 Yearly < 100 < 130/80 Yearly Yearly Yearly Yearly Once Non-smoker Yes Yes Within prior 12 months FY07 X X X X X X X X X X 13

14 ProvenCare TM - Diabetes (comprehensive care; whole-system >20,000 patients) 9/30/06 12/31/06 % of all diabetic patients 20% 3/31/06 6/30/06 10% 7% 2.5% All # of components received or achieved (by patient) Diabetes Surrogate (Lab) Outcomes (resulting from ProvenCare) % Diabetic population A1C < 7 LDL < 100 BP < 130/80 20 Jan-06 Jun-06 14

15 Regional Health Information Organizations (RHIOs( RHIOs) Regional Systems are right-sized to optimize IT info-structure structure for clinical, financial, and collaborative solutions EHR made affordable (both in dollars and warmware expertise) to smaller systems Regional Labs are right-sized for delivery of outreach services within RHIO Evidence-based Best Practice alerts (or ProvenCare) ) may be shared via RHIO Organizational and Cultural Change Organization needs a Strategic Vision and a concrete plan with timeframes to roll out EHR and accessory systems Docs are most heavily impacted by change Cultural Change to lab as departmental LIS becomes secondary to EHR CPOE (Computerized Physician Order Entry) impacts lab heavily 15

16 Rolling out the EHR Literally! Specimen Tracking & Retrieval LIS identification of an active specimen from a Patient Registry Banking serum/dna in a Biorepository The Specimen is a Valuable Asset 16

17 MyCode Bio-bank 21,788 patients consented 90% consent rate Stable population EHR Bio since 1995 Serum and DNA Bio from routine specimen flow PA state grant for 200,000 patients Bio-marker Translational Studies Risk stratification of study population from EHR (i.e. preselect patients to LIS registry) Identify and retrieve specimen after lab testing De-identify and store specimens for bio-marker studies. ( boils( down N=specimens to test) Test bio-markers on risk groups to determine if additional predictive value obtained (ROC plots) If bio-markers improve predictive value, translation to lab testing is facilitated 17

18 POCT Enterprise Analytics Regional Anticoagulation Clinics 8 CLIA certificates Pharmacy does PTINR Lab billing/purchasing LIS connectivity Pharmacy tracks utilization & outcome 18

19 7-10 Minute Patient Coag Clinic Visit Patient Registers in lobby( Check in at Kiosk) Pharmacist Sees Appt in EpicCare EHR Pharmacist Greets patient in waiting area Pharmacist Chats, gets patient history, Finger sticks Pharmacist matches patient story with PTINR result Pharmacist presents card with PTINR result, dose adjustment, next appt schedule to patient Any other questions? Bye. Touch and Swipe Registration Kiosks in Lobbies /locations/const/gw/my_ visit/mv_welcome.html 19

20 Patient Reminder as well as Electronic Archive Comparison of GHS Anticoagulation Management Service with Literature Incidence of Adverse Events Reference Anticoagulation Clinics (1) Usual Practice (non-clinic Patients)* GHS Non- Clinic Patients (2) GHS Clinics Rate of Bleeding 7.65% 8.10% 35.30% 17.10% Rate of Thromboembolic Events 1.21% 3.30% 11.80% 20.60% (1) Chiquette E, et al. Arch Intern Med. 1998;158: Incidence of Events per patient per year (2) Based on 1997 GHS data - total of 228 patients on continious therapy 20

21 Drug Therapy Compliance 2003 Coag Clinic patient compliance average compliance with warfarin therapy = 82.3% Comparison <50% 57.5% of patients had compliance rates of 90% or greater Comparison <20% Stroke Prevention 2235 patients were actively managed on anticoagulation therapy during calendar year 2006, with a diagnosis of A-FibA For each every 33 A-fib A patients on anticoagulation therapy 1 stroke per year is avoided 68 potential strokes avoided during

22 A Concluding Thought: Lab Testing is a Core Asset of Regional Healthcare. A simplified Enterprise Analytics approach will enable efficient distribution of concise lab information to the multitudes of locations that will demand it. Thank You! 22

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