How analytics has changed Geisinger
Glenn D. Steele Jr., MD, president and chief executive officer of Geisinger Health System, says the integrated delivery network's pioneering population health programs depend on insightful use of data to drive behavior change.
Serving 43 counties over some 20,000 square miles of northeastern Pennsylvania, Geisinger provides care for more than 2.6 million people; its innovative efforts to combat diabetes, coronary disease, COPD, hypertension and other chronic ailments have been held up as examples for the rest of the country.
Steele talked with Healthcare IT recently about how Geisinger employs analytics tools to improve patient care and the bottom line. Here are excerpts from the conversation.
Q: How is healthcare in general doing these days when it comes to using business intelligence and analytics?
A: Well, we're probably about to enter the 19th century. (Laughs.)
Q: Baby steps, right? But why are we so far behind other industries? What's standing in the way of smarter use of data?
A: We have legitimate regulatory concerns, and I think they've always taken precedence over true innovation in terms of how we look at our data, how we analyze it, how we distribute it. How we use it to change behavior. I don't think the balancing act between innovation and regulation is correct in most areas of healthcare data. We also have the intrinsic structural issue in healthcare, where it's been compartmentalized on both the payer and provider sides, and each of those seems to strive for an optimal function without actually any integrated structural aspirations. And that's changing as well, but obviously when you sell IT enabling into all those compartments, you're kind of handicapped right from the start.
We have a series of expectations, even in the biggest compartments that are most well-capitalized, the hospital-centrics; we have a series of expectations that up until recently were pretty simplistic: that if you put an electronic health record in it would automatically improve badly engineered and badly transacted systems. It doesn't work that way.
And then we have this great big divide between payer and provider where a huge amount of the data, which is collected on the transaction side, is kind of husbanded and treated as an intellectual property. And is either on-purpose not used, or inadvertently not usable, whether because of a lack of timeliness or a lack of functionality.
Q: What's finally bringing about that change? Improvements in the technology or shifts in attitudes and awareness?
A: Oh, I think it's both. I think it's both, and I think the more critical rate limiter is the attitudes and the intrinsic behavior, which, quite frankly, I think is amplified by a lot of the stakeholder business models, and it's also amplified by backward-looking regulatory issues. And I think we're going to have to blast through both of those things to get maximum functionality when you think about healthcare enabling through healthcare information technology.
Q: Describe Geisinger's use of analytics. Is there a mission statement or overarching philosophy to how you use BI?
A: Well, our top strategic aim is innovation and quality. Our structural advantage that we talk about internally and externally over the past 15 years is this payer-provider sweet spot. We've tried to figure out how our version of vertical integration between payer and provider can really optimally mesh the information and the use and analysis of it from both sides of the house. That's a 35,000-foot glib summary of what drives us, and continues to drive us.
But the end point is change in behavior. We realize that in order to capture the 30 to 40 percent of value that is now lost because of stuff in healthcare that doesn't help human beings – actually hurts them. In order to capture that, we have to fundamentally change behavior. And we have to change it on behalf of our providers as well as our patients, and on the insurance side of the house.
The way to change behavior is not just changing the incentives. Everybody has been – appropriately – whacking fee-for-service, and that's OK. I'm all right with that. You have to change the incentives but you also have to enable people with timely feedback about what they're doing, and the consequences of that, and what they should be doing. And that's all about data.
Again, we think that in order to achieve that continuing aspiration of innovation and quality, we've got to have, from both sides of the house, behavior change enabled by timely and usable data.
Q: Talk a bit about Geisinger's ProvenCare program, which puts evidence-based standards and patient engagement to work in the service of fixed-price procedures. How does data play into it?
A: A good example would be use of erythropoietin in patients who have anemia that's associated with chronic renal disease. This is really a paradigm; it's the result of lots of high-price but very effective biologicals. And the questions we asked when we looked at this group of patients with anemia secondary to chronic renal disease, is are they getting the best outcomes in terms of alleviation of their anemia?
What we found, in looking at the data and analyzing the data – and then looking at every step along the way at how this care was given to this group of patients throughout our system – we found that about 20 percent of those patients actually didn't need to be receiving the high-cost biological that is EPO. They could just as well have been treated with iron, at about one one-hundredth of the cost.
And, by the way, EPO has side effects, and those are cardiovascular toxicities, so stripping out the use of that high-expense biological was not only a cost-savings, but also a savings in terms of avoiding toxicity for a huge number of these patients.
Q: And what about Geisinger's Center for Clinical Innovation – one whose main goals is to "leverage IT and advanced analytics to support population health." What are some gratifying things that have come out of there, recently?
A: We have changed expectations with regard to how we treat patients with serious chronic disease. Type 2 diabetes was just the first one in a list. We've now expanded it to coronary artery disease, to COPD, to hypertension.
But probably our longest-lived commitment was to treat type 2 diabetes patients – there were probably 27,000 or so that we started with, almost eight years ago – to create a set of aspirations, a set of data feedback loops and to change our incentives, in terms of how we pay our primary care physicians. And really commit to a bundle of nine best-practice goals being achieved in all of these type 2 diabetics that we took off the shelf from all of these endocrinologists and diabetologists, but had never previously been engineered into the expectations for trying to achieve 100 percent of those goals in 100 percent of the diabetic patients.
After three years of improvement in these 27,000 patients, getting all of them up to and optimal for all nine of these expectations, it took only three years before we saw a significant diminution in their risk for heart attacks, for strokes, for amputations or for diabetic retinopathy.
For me as a clinician, someone who actually used to take care of patients, I mean, that's amazing – to actually see, after only three years, a beneficial effect on diabetes-related secondary disease.
Now we haven't even done the economic analysis of that, but presumably, if you're avoiding heart attacks and strokes, you're probably avoiding a lot of hospitalization – high-cost and high aggravation treatment.
Q: If healthcare is just now entering the 19th century, as you said, what will it take to get us into the 21st? Will we have to wait 200 years, or will it come faster than that
A: Oh no, I think we're in the midst of just huge change right now, and I think what it's going to take is winners and losers. We're going to have organizations that figure it out and also have a viable business model, and they're going to be different than what we see now, with this compartmentalized, fragmented, mom-and-pop industry.
That change could be painful. It's kind of like the grocery business 120 or 130 years ago – the supply chain issues and the consolidation and what have you put almost all of the small grocery stores out of business. On the other hand, the amount of household resources that use to go toward groceries – it used to be up to about 30 percent of discretionary money for a household – has gone down to low single digits now. And guess what's happening to healthcare.
I think this change is going to be extraordinarily fast. I think it's going to be quite disruptive, and I think there will be winners and losers. And my only wish would be that I was younger. If I had my experience and my knowledge now, and I were just beginning, in the midst of this transformation, I could do some real damage.