SummaryTwo rheumatology clinics used information technology and redesigned associated care processes to provide systematic chronic disease management to all patients. Through an electronic system that pulls data from various parts of a separate electronic medical record and patient questionnaire completed at the start of each visit, clinicians have easy access to all relevant information before and during the visit, allowing them to quickly and systematically analyze the patient’s progress and condition and focus scarce visit time on solving problems and providing necessary interventions and support. Early results suggest the program has been widely adopted by physicians and has generated improvements in the provision of needed services and patient-reported symptoms.Moderate: The evidence consists of pre- and post-implementation comparisons of various measures of management of rheumatologic conditions and patient-reported symptoms, along with post-implementation data on clinician use and perceptions of the new system.
Developing OrganizationsGeisinger Health System; The American Institutes for Research
Date First Implemented2009
One large clinic on Geisinger's main campus introduced the program in September 2009, while a second, smaller community-based clinic introduced it a few months later.
Patient PopulationThe program serves patients with rheumatologic conditions.
Problem AddressedRheumatologic conditions are common, debilitating, and costly. Close monitoring and support can reduce disease activity and joint damage and improve patient functionality and quality of life without creating additional costs. However, relatively few organizations—even those with electronic medical records (EMRs)—have systems and processes in place to give providers usable, easy-to-access information at the point of care that allows for effective monitoring and support.
- A common, debilitating, and costly condition: Rheumatologic conditions are common, debilitating, and costly, as outlined below:
- Common: Roughly 20 percent of U.S. adults (50 million individuals) have been diagnosed with arthritis (by far the most common rheumatologic condition). By 2030, an estimated 67 million adults will have the disease.1
- Debilitating: Over a third of those with arthritis (and 45 percent of obese individuals with the condition) face disease-related activity limitations, making it the most common cause of disability in the country. Roughly a third of the 23 million working-age adults with arthritis (equivalent to more than 5 percent of all working-age adults) report that the condition limits the ability to perform their job. Arthritis also frequently causes patients to stop exercising regularly, as they experience or fear experiencing pain, damaged joints, and/or other symptoms, and because they lack information on how to exercise safely. This lack of physical activity, in turn, increases the risk of other chronic diseases and interferes with management of these conditions. For example, more than half of U.S. adults with diabetes or heart disease also have arthritis.1
- Costly: In 2003 (the most recent data available), the total cost of arthritis in the United States was $128 billion, including $81 billion in direct medical costs and $47 billion in lost earnings. Each year, arthritis leads to nearly a million hospitalizations and 44 million outpatient visits.1
- Unrealized potential of systematic monitoring: Close, systematic monitoring of patients with rheumatoid arthritis (the most debilitating form of arthritis) can improve function, reduce joint damage and disease activity, and improve quality of life without increasing the costs of rheumatologic care.2,3 However, few organizations—including those with EMRs—have instituted processes to allow for effective monitoring and support. For example, a test performed at Geisinger’s rheumatology clinics before implementation of this program found that a clinician would have needed to spend 17 minutes searching various components of the EMR to find all the information needed to provide optimal patient care. Resource limitations made it impossible to conduct such searches in advance of every visit, forcing Geisinger clinicians to treat patients without access to needed information.
Description of the Innovative ActivityTwo rheumatology clinics used information technology and redesigned associated care processes to provide systematic chronic disease management to all patients. Known as the PACER (Patient-Centric Electronic Redesign) system, the program pulls data from a separate EMR and patient touchscreen questionnaire completed at the start of each visit, giving clinicians easy access to all relevant information. Clinicians quickly and systematically analyze the patient’s progress and condition right before the visit, allowing them to focus scarce visit time on solving problems and providing necessary interventions and support. Key program elements include the following:
- Nightly computer run of next day’s patients: Each night, an automated program generates a list of all patients being seen the next day, and pulls relevant patient-specific information from the EMR, including problem list, diagnoses, medications, and existing laboratory values.
- Electronic patient questionnaire at start of visit: After patients check in at the front desk, they are directed to a computer station to complete a touch-screen questionnaire. (As discussed in more detail in the Planning and Development section, frontline staff use standard scripts to introduce the questionnaire and have a financial incentive to encourage patients to complete it.) Roughly 80 percent of patients complete the questionnaire; some decline to do so due to discomfort with the technology, while others arrive too late to complete it. (The scheduling system sets up appointment times to allow patients 15 minutes to complete this task, but inevitably a few patients end up being late.) Key steps in this process include the following:
- Patient confirmation: Using the list generated the night before, the system confirms the patient's identity and that he or she is scheduled for a visit at this time.
- Touch-screen questions adapted from validated tool: Using a touch screen, the patient answers a series of questions (patterned after a validated, paper-based tool known as the Multidimensional Health Assessment Questionnaire) that cover symptoms, relevant recent events that might have occurred (e.g., hospitalizations, broken bones, infections, important new symptoms, medication side effects, changes in marital status or work status) and other areas. The system has built-in error checks and real-time scoring capabilities.
- Real-time help as needed: The patient can click a "Help" button at any time. Staff at the nurse’s station—who can follow the status of any patient using specially designed tracking software on their computer screen—see a red flashing light when a patient clicks this button, allowing them to come immediately to provide assistance.
- Movement to next step upon completion: Once a patient finishes (by clicking the "Done" button), the computer at the nurse’s station flashes green, signaling that it is time for the nurse to take vital signs and confirm certain information through followup questions (e.g., details of events since the last visit, employment/insurance status).
- Brief physician review before seeing patient: Prior to seeing a patient, the physician will spend 1 or 2 minutes reviewing critical information, typically using a dual-screen computer in his/her office that runs the EMR and PACER side by side. The PACER system has a series of easy-to-navigate tabs that allow the physician to see information pulled from various sources (e.g., the EMR, the just-completed questionnaire) with the click of a button, including tabular displays of trends in key measures of disease activity, such as pain levels. The system also allows for mapping of various interventions along the same timeline, letting the doctor quickly see if a particular treatment has led to improvements in key metrics (e.g., pain) and/or caused problems, such as side effects after introduction of a new drug. This review does not appear to create an additional burden on physicians, as an initial analysis found that the amount of time physicians spend reviewing the patient chart before the encounter did not increase after program implementation.
- Examination focused on problem-solving, education, and support: Because the physician enters the examination room fully aware of the patient’s recent history and current status, there is no need to spend the first 5 to 10 minutes of the visit gathering this type of information (as occurred before implementation of the program). Rather, the physician begins with problem-solving, systematically querying the patient and following up on information in PACER. During the examination, the physician also uses the PACER system as appropriate to educate the patient, showing him/her the easy-to-comprehend displays alluded to earlier. This information helps the patient and doctor to collaboratively set goals, such as reducing pain-level scores. An initial analysis found that the program had no impact on the total amount of time the physician spends with the patient; rather, it affects how that time is used.
- Easy-to-understand visit summary for patient: PACER automatically creates a patient-friendly summary of the visit written in plain English. (Prior to implementation of this program, the EMR created a 12-page after-visit summary that few if any patients could comprehend.) The summary covers the name of the doctor, symptoms and problems, goals that have been mutually set, and relevant patient instructions. The summary also includes graphical displays of trends in key metrics since the last visit, including a notation of whether previously set goals have been met. Patients can briefly review the after-visit summary on the screen with staff at the front desk, and also take home a printed copy for more indepth review.
- Automated documentation: The PACER system automatically creates and prepopulates a clinic note, including conversion of patient instructions into a care plan. As a result, physicians may be able to spend less time on documentation (although the initial analysis found that this time savings has not yet materialized) and the resulting note becomes more robust.
- Population health management through performance reports: An in-progress upgrade of the system will create a “best-practice” tab with a built-in database and reporting tools. (Over the last 2 years, over 20,000 questionnaires have been completed that will be part of this database.) This system will be used to stimulate quality improvement by providing departments, divisions, and individual physicians with periodic reports that let them understand how they perform versus peers and/or best practices. It will also produce “exception” reports that identify groups of patients in need of a specific service or intervention, thus allowing office staff to proactively reach out to them to schedule a visit.
Contact the InnovatorEric Newman, MD
Director, Department of Rheumatology
Vice Chairman for Clinical Innovation, Division of Medicine
Geisinger Medical Center
100 N. Academy Avenue
Danville, PA 17822-2152
Phone: (570) 271-6416
Fax: (570) 271-5845
American Institute for Research
101 Conner Drive, Suite 301
Chapel Hill, NC 27514
Phone: (919) 918-2318
Innovator DisclosuresDr. Newman and Ms. Smeeding have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
ResultsEarly results suggest that PACER has been widely adopted by physicians and has generated improvements in the provision of needed services and patient-reported symptoms.
Moderate: The evidence consists of pre- and post-implementation comparisons of various measures of management of rheumatologic conditions and patient-reported symptoms, along with post-implementation data on clinician use and perceptions of the new system.
- Widespread adoption and anecdotal praise by physicians: A review of one clinical measure (clinical disease activity index or CDAI) found that 12 out of 13 full-time rheumatologists had the appropriate CDAI information entered for the majority of their patients. One full-time doctor used the system with less than 5 percent of his patients, while one part-time physician who very seldom works at the clinic did not use the system. Anecdotally, several physicians who regularly use the system have praised its ability to identify patients overdue for a service, ensure that all needed tests and procedures have been completed, identify potential drug interactions, communicate relevant information about patients seeing multiple providers, and encourage patients to share pertinent information with them.
- Greater adherence to recommended processes: The program has promoted adherence to recommended care processes. For example, the percentage of patients taking methotrexate (a drug) with a laboratory result for hepatitis B or C on file increased from less than 1 percent before program implementation to 8.5 percent after. (Patients with hepatitis should not take this drug, and hence confirmatory testing needs to take place.) Similarly, the percentage of patients prescribed a tumor necrosis factor agent with a tuberculosis skin test on file rose from 11.5 percent before implementation to nearly 17 percent after. (Patients with tuberculosis should not take this type of drug.)
- Improvements in self-reported symptoms: Since implementation of the program, patient symptoms have improved significantly, as measured by self-reported metrics on the Multidimensional Health Assessment Questionnaire. Statistically significant improvements occurred on the questionnaire’s global score and “rapid 3” score (an amalgamation of the physical function, pain, and global scores) for all patients, while those with rheumatoid arthritis also reported significant improvements on the pain score.
- No impact to date on patient satisfaction or activation/adherence: Since implementation of the program, patient satisfaction scores have generally not changed, nor have scores on measures of patient activation and adherence. Anecdotally, staff initially reported a few complaints from patients about having to complete the questionnaire.
Context of the InnovationA large, integrated delivery system, Geisinger Health System serves a population of 2.6 million residents in 42 predominantly rural counties in central and northeastern Pennsylvania. The system includes the Geisinger Clinic, a network of 41 community practice sites spread throughout the service area, along with three hospitals and more than 50 other clinical sites across the state. Geisinger employs nearly 11,000 full-time and over 2,500 part-time staff, including 800 full-time physicians. The system operates three rheumatology clinics—a large clinic in Danville (at Geisinger’s main campus) and two smaller clinics in State College and Wilkes-Barre.
An early adopter of EMRs (in 1999), Geisinger has a long history of using information technology to improve patient care processes and outcomes. The impetus for the PACER program came from leaders in the Danville clinic. Because rheumatologic care tends to be complex, physicians often found that needed information was missing or too difficult to access. (As noted earlier, clinic leaders conducted a test and found that it took 17 minutes to find all the information embedded in the EMR that clinicians felt they needed to provide optimal care.) As a result, clinic leaders began investigating the potential to develop a parallel, software-based system that could pull relevant information from multiple sources, and to redesign care processes accordingly to maximize the value of this information before, during, and after patient visits.
Planning and Development ProcessKey steps included the following:
- Securing funding: Geisinger and the American Institutes for Research worked together to develop a proposal to the Agency for Healthcare Research and Quality (AHRQ) Accelerating Change and Transformation of Organizations and Networks (ACTION) program. The proposal fit into ACTION’s task order related to innovations that reduce waste and increase efficiencies through process redesign.
- Developing system, with input from key stakeholders: Creation of the PACER system and integration of the system with the EMR involved the work of many individuals, including rheumatologists and information technology staff, over a significant period of time. Throughout the process, developers met regularly with each of the three different groups who would be using the system—front desk staff, nurses, and physicians. In particular, the task of combining data from the patient survey and the EMR proved to be quite challenging and time-consuming, including dealing with security issues.
- Training users: Program leaders decided to implement PACER at two of the three Geisinger rheumatology clinics—the large clinic in Danville and the smaller clinic in State College. Front desk staff, nurses, and physicians from these clinics attended training sessions over a period of several months to learn to use the system. During these sessions, program leaders distributed and explained various tools related to PACER, such as scripts for front-line staff to introduce the questionnaire.
- Redesigning office space and care processes: Each adopting clinic revamped office space and/or processes as necessary to take advantage of the PACER system. At the large clinic, for example, the waiting area was revamped to accommodate physical work stations where patients complete the questionnaire.
- Revamping employee review and compensation: Clinic leaders revamped the employee evaluation process and bonus criteria to assess and reward front desk and nursing staff based on the percentage of patients completing the electronic questionnaire. Physician staff were also incentivized to participate in the use of PACER.
Resources Used and Skills Needed
- Staffing: While precise data are not available, upfront system development and implementation required a sizable investment of time by information technology experts and clinic staff. Since the system became operational, the program has required no new staff, as existing personnel use it as part of their regular job responsibilities. The system has the potential to reduce the workload for physicians and staff, but analysis to date would suggest that such time savings have not yet been realized.
- Costs: Data on upfront development and implementation costs are not available. Organizations interested in this system should contact the program developer at Geisinger, who is in the process of developing mechanisms that will allow PACER to be licensed for adaptation, implementation, and use in other settings.
Funding SourcesAgency for Healthcare Research and Quality
The AHRQ ACTION program provided funding of $399,999, which covered a portion of the costs of system development and implementation, as well as the total costs associated with evaluation.
Tools and Other ResourcesDetailed information on the Multidimensional Health Assessment Questionnaire can be found at http://www.mdhaq.org/.
Getting Started with This Innovation
- Identify physician champion: Implementing this type of program without a physician champion can be risky, as new information technology systems will provide little value if not consistently used. The physician champion plays a key role in getting other doctors on board.
- Leverage existing resources: Creating a similar system from scratch could be prohibitively expensive for many organizations. Consequently, organizations wishing to adopt this system may decide to build on the existing PACER system, customizing it to the organization's unique needs. (The system is separate from the EMR and can be used with multiple EMR systems.) As noted, interested organizations may contact the program developer at Geisinger.
- Elicit stakeholder input: The program’s success depends on physicians, nurses, and other office staff consistently using the new technology and following related care processes, and on patients reacting positively to the questionnaire and other aspects of the approach. These stakeholders will be much more likely to do these things if they have the opportunity to provide input into system design (or adaptation) and implementation.
- Expect some staff resistance, provide adequate training and support: Nurses and front-desk staff take on increased responsibilities as a result of this program, and some may initially express resentment or frustration as they get used to the new work process. Extensive training and support (e.g., the scripts for front-line staff) can help minimize disruptions during the transition period after implementation.
- Build time for questionnaire into scheduling: Geisinger sets the visit start time to allow 15 minutes for the patient to complete the questionnaire. For example, a patient scheduled to be seen by the physician at 1:30 p.m. will have an official "nurse visit" at 1:15 p.m., which allows sufficient time to complete the questionnaire and have the nurse complete the vital signs and PACER-related duties. This approach to scheduling will likely be more effective than asking patients to come 15 minutes “early” to complete the questionnaire, as too many patients will ignore this request.
Sustaining This Innovation
- Continue to elicit feedback and make necessary adjustments: Mechanisms should be established to get regular feedback from clinicians, office staff, and patients on any issues or problems that arise, with necessary refinements made on a timely basis.
- Ensure availability of adequate technical support: Resources should be available to quickly address any technical issues that arise with respect to the technology.
- Encourage physicians to share data with patients: Patients will be less likely to resist the extra time and effort required to complete the questionnaire once they see how the information positively affects their time with the doctor.
- Continually look for opportunities to reduce costs, improve workflow: Shortly after implementation, the clinics used a researcher (paid for by funds from the AHRQ contract) to observe and assist patients as they filled out the questionnaire. Recognizing the high cost of this approach, program leaders revamped the system and redesigned associated care processes so that nurses would be alerted whenever a patient needed help, thus eliminating the need for this full-time position.
- Consider financial incentives: Financial incentives can help ensure that office staff consistently encourage patients to complete the questionnaire, and that nurses and clinicians routinely use the system, follow associated work processes in everyday practice, and pay attention to and act on any opportunities for improvement identified in performance reports.
Additional Considerations and Lessons
- Consider applicability to other specialties: This type of system works best for chronic medical conditions where optimal care requires access to many disparate pieces of information, and where there is a frequent need to analyze patient outcomes over time in the context of the treatment prescribed. Currently, PACER versions are being developed for nephrology and pain therapy, while specialists in hematology/oncology (cancer) and pulmonary medicine (chronic obstructive pulmonary disease) have also expressed interest.
Goekoop-Ruiterman YP, de Vries-Bouwstra JK, Allaart CF, et al. Clinical and radiographic outcomes of four different treatment strategies in patients with early rheumatoid arthritis (the BeSt study): a randomized, controlled trial. Arthritis Rheum. 2005 Nov;52(11):3381-90. [PubMed]
Grigor C, Capell H, Stirling A, et al. Effect of a treatment strategy of tight control for rheumatoid arthritis (the TICORA study): a single-blind, randomized controlled trial. Lancet. 2004 Jul 17-23; 364(9430):263-9. [PubMed]
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Service Delivery Innovation Profile
Original publication: December 21, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: December 05, 2012.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: November 21, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.