Recording some 2 million annual outpatient visits, Geisinger Health System encounters practically every chronic condition under the sun. To manage this massive patient flow, the Danville, Pa.-based delivery system has developed electronically enabled clinical pathways for 15 diseases it treats most frequently.

The pathways-a set of protocol that defines responsibilities across the continuum of care-were built one disease at a time, says Jim Walker, M.D., the chief health information officer at the 900-physician integrated delivery system. Care delivery is supported by an EHR, from Epic, and adjoining systems which Geisinger designed internally. Serving both inpatient and outpatient settings, the EHR works in tandem with a data warehouse and clinical decision support engine. Both remain invisible to providers, Walker says.

To build the automated support tools, Walker convenes groups of specialists who would typically treat a patient during the course of care. "We imagine the process if it were perfect for the patient," he explains. "So wherever the patient is, inpatient, outpatient, specialist, generalist, dialysis clinic, at home, everybody can know what has happened and what is next. We don't ask the same question 40 times. We decide who is responsible for what and what information is needed when. It is hard work but clear work."

In some cases, the system triggers orders based on test results. The analytics component of the set-up identifies patients in need of treatment, and pushes an message to the appropriate person-either a call center person, if a simple appointment is lingering; a physician, for a clinical matter; or sometimes the patients' PHR, via a portal, which is integrated with the EHR.

"The patient knows more about their problems than anybody else," Walker explains.

Geisinger has about 172,000 patients who have created PHRs. "The more chronic problems, the more likely they are to use it," he says. That explains why patients between 49-64 years old are the biggest PHR users, with patients over 65 coming in second.

Walker says that the health system is about to publish a paper documenting significant improvements in both care quality and cost reduction, largely due to its disease management efforts. The initial focus was potentially big-ticket diseases, such as heart failure and diabetes. "We are not interested in bending the cost curve, we want to break it," he says.

For more on chronic care I.T., click here to read HDM's August print cover story. HDM is also hosting a Web seminar featuring providers who are on the front lines of disease management. To register for the event, click here.


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