The substantial research opportunities at Geisinger are made possible by a rich array of resources and capabilities. Geisinger encompasses a number of distinct healthcare resources that provide a real-world setting for research. These include:
- System-wide Electronic Health Record
- System-wide Biobanking and DNA Effort
- System-wide Clinical Laboratory
- Stable Regional Population
- Geisinger Clinic (i.e., multi-clinic, multi-specialty practice)
- Geisinger Health Plan (an insurance company)
- Data warehousing(CDIS) and translational research
- IT and Health services infrastructure
Geisinger is one of the country’s “most wired” health care companies with an electronic health record (EHR) in all outpatient clinics, patient portal, and other digital means of delivering care. The EHR database contains information on more than three million patients. These records are utilized by clinicians for both in-patient and out-patient records with integrated electronic scheduling, clinical lab and radiology system. The patient portal, MyGeisinger, is used by nearly 70,000 patients and provides patients with secured access to their problem list, medications, allergies, immunizations, and test results. Community EHR (EMRLink) provides almost 700 non-Geisinger users (generally physicians who refer patients to Geisinger and their office staff) secure, real-time, HIPPA-compliant access to their patients’ EHR, with appropriate authorization. Patient information from a variety of sources is routinely integrated into a common database and includes:
- Age, gender, height, weight
- Lifestyle (e.g., smoking, alcohol)
- Clinical measures (e.g., BP, pulmonary function, BMD)
- Digital imaging (MRI, CT, X-ray)
- ICD-9 diagnoses with any lab, imaging, or prescription order
- Clinical notes
- A single state-of-the art laboratory unit, in place since 1993, collects and processes all lab and pathology material and has maintained a digital database since 1995
In addition to these data resources, two other initiatives are underway. First, a plan is being developed to digitize historical paper records, extending longitudinal information on patients back several decades. Second, a number of research initiatives are leading to the development of patient reported data capture using computerized questionnaires (e.g., touch screens) and use of digital pen technology to capture data on paper-based forms.
Efforts are underway to build a repository of blood samples (DNA and serum) called Geisinger MyCode TM. Sample collection focuses on primary care patients. Standardized specimen container type, transport, location tracking, and storage for 3,000+ patient encounters per day produces a resource for capturing quality serum, RNA, and DNA specimens prior to discard. The Geisinger MyCode will be a major resource for research that combines information obtained from DNA and serum with health information from the EHR and other sources intended to improve the prevention, diagnosis, and treatment of disease. The blood samples will be stored so that they can be used for a wide range of biochemical and genetic research for many years in the future. Geisinger MyCode will involve the collection of blood before the onset of diverse diseases in thousands of people. It will offer unique opportunities for research on the genetic causes of disease as well studies of protein mediators of disease, opening new approaches to prevention of disease, disability, and death. Data and samples will only be used for ethically and scientifically approved research that is consistent with the above purposes. MyCode has already collected 14,520 consents for blood to be drawn and has already banked 5,500 blood samples.
Directed by Conrad Schuerch, MD, the Geisinger Medical Laboratory (GML) consists of a highly standardized and integrated network of two hospital laboratories and 50 regional site laboratories. Testing in this “distributed laboratory” utilizes shared laboratory information system (LIS) test codes from standardized testing methodology across several different-sized networked instruments on a wide area network. Chemistry, immunology, and hematology instruments produce harmonized test results delivered by the LIS to the EpicCare electronic health record (EHR), no matter where the testing is performed in the Geisinger Health System. Besides delivering standardized results, very concise and retrievable longitudinal data have been archived “live” online since 1997. Thus, performing serial clinical outcome studies is greatly facilitated by accessible quality population lab data.
Recent census data indicate that, with the exception of two counties, the out migration rate is 4% every 5 years. This stable population provides unique opportunities for longitudinal research. Geisinger’s service region has a higher proportion of elderly, both over 70, and over 85, than the United States population. Pennsylvania possesses the third highest proportion of elderly among the 50 states, with currently 19.6% of the population being over 65, and possesses the largest population of rural elders. The primary care population of the Clinic is similar to the region’s resident population except the proportion of males is lower (i.e., 41% vs. 49%), primarily due to relatively fewer young adult males, compared to females.
One of the largest ambulatory care programs in Pennsylvania, 41 community practice clinic sites (primary care clinics with/without multi-specialty care and out-patient surgery) across central and northeastern PA and 12 specialty clinics such as Knapper Pediatrics and Woodbine outpatient surgery centery. Includes three hospitals, Danville, South Wilkes-Barre, Wyoming Valley and a nationally recognized addiction treatment program, Marworth.
A not-for-profit health maintenance organization, Geisinger Health Plan(GHP) has approximately 215,000 enrollees in 38 counties of northeastern and central Pennsylvania – one of the nation’s largest rural HMOs. GHP’s provider network includes more than 1,600 primary care physicians in more than 880 sites, as well as 56 participating hospitals. Specialists and allied health providers total more than 7,300. GHP’s network includes both Geisinger providers and non-Geisinger providers. Approximately half of GHP’s members have their healthcare delivered outside the Geisinger system. GHP conducts yearly measures of a wide number of healthcare quality variables. This includes using the Health Plan Employer Data and Information Set® methodology, a set of quality performance measures designed to enable purchasers to reliably compare the performance of different managed care plans. GHP also participates in the Consumer Assessment of Health Plans Survey.®
Real-time unfettered access todata from disparate sources, including an EHR system accelerates translational research and provides the foundation for comparative effectiveness studies. GHS has created a comprehensive enterprise-level data warehouse. The warehouse receives feeds from multiplesource systems, including our EHR, financial decision support, claims, patient satisfaction and high-use third-party reference datasets. The source data are transformed through a standard “Extract-Transform-Load” (ETL) process. Expansion to additional data source systems (e.g., niche specialty systems suchas oncology) is being accomplished in stages and will eventually encompass all high-value data sources. Clinical Decision Intelligence System (CDIS) is transforming opportunities for comparative effectiveness research. A de-identified research version of CDIS is accelerating the means by which data can be used to advance knowledge.
The Geisinger Center for Health Research and IT department have built a research IT environment to accelerate IT-related health services research. This resource reflects an important cultural shift at GHS (i.e.,emphasizing more collaboration between the IT department and the CHR) and facilitates inter-institutional collaborations around novel translational approaches to re-engineer how health care is delivered. The test environment ensures system level data security, while providing the flexibility needed by researchers to explore the use of novel IT solutions in health care. Secure environments have been created for server test environments that are completely isolated from the system that it will eventually be used on (the so-called “sandbox”environment). We also use a pilot testing server environment for real time testing in clinical care settings. The sandbox testing environment is completely isolated from other environments, with the exception of a connection to the shadow EHR (i.e., EpicCare). This allows testing for applications that are required to interact with the EHR, without impacting other systems. The EHR development environment is updated on a regular basis (e.g. once a month) to ensure that applications are tested on the most up-to-date version. The pilot environment is a live production environment with limited scope (e.g. one to two clinic sites). GHS IT and the Center have developed administrative procedures for contracting with software developers and for reviewing specifications of software development and implementation. This IT test environment has dramatically expanded opportunities for experimenting withnewly created software tools.