Informatics and e-Health Services 

 Information technology is widely viewed as a critical component for delivering high quality care.  The Geisinger Health System (GHS) has had an electronic health record (EHR) in place for more than a decade.  Researchers leverage GHS’s depth of experience with the EHR and other sources of digitized health information.  When combined with proximity to more than 40 outpatient clinics, investigators have access to a unique and compelling environment for research at the intersection of informatics and health services.  Our goal is to develop software, tools, processes, and care delivery models that empower patients to take an active role in managing their health.  By building strong relationships with our primary care providers, we can test these tools and care delivery models in one or more care settings using a variety of study designs (including RCTs across multiple clinics).   We place a strong emphasis on developing solutions that create value, are business-sensible, and lead to meaningful improvement in outcomes from both the patient and provider perspective. 

e-Diabetes

PI Walter F. Stewart, PhD, MD

Similar to eCVDII, the eDiabetes system is a software-based solution designed to screen primary care patients with Type II diabetes for risk of diabetes disease progression based on data from their electronic health record and patient-reported questionnaire data.  Participants will be individuals 18 years of age and older who have been diagnosed with Type II diabetes, and the pilot study takes place in the family practice departments at Scenery Park and Grays Woods clinics. Once eligible patients are identified, they complete an online questionnaire to determine their 10-year risk of macrovascular event (i.e., heart attack or stroke), while a background process determines if their most recent HbA1c value is out of control. Patients with moderate to high macrovasular risk or elevated HbA1c levels are next randomized into two groups.  As in eCVD-II, the intervention group has the opportunity to select their preferences for managing their specific elevated risk factors. The physicians of these patients receive clinical-decision support tailored to the patient’s specific risk factors. Patients randomized to the control group do not receive any type of management from the eDiabetes system. Analyses will be conducted to evaluate if the study tools increased detection of patients with uncontrolled diabetes, increased delivery of guideline-based care for the management of Type II diabetes, improved short-term outcomes in Type II diabetes clinical measures, and improved patient satisfaction and adherence

The focus of the eProjects is to identify patients at elevated risk for a chronic condition and optimally manage them according to tailored evidence-based guidelines. 

e-Migraine

PI Walter F. Stewart, PhD, MPH

The eMigraine study is a pre-post randomized controlled pilot study to determine if a systematic guideline-based approach to migraine detection and management can improve processes and outcomes and address the gap between what is known in this area and what is practiced at the primary care level. Participants are adults aged 18-45 with a primary care physician at Mt. Pocono Clinic Family Practice and will be randomized into two groups. The intervention group (N=1200) will receive the full protocol of the Primary Care Headache Management System (PCHMS), a set of tools which includes a web-based questionnaire used to screen patients who warrant clinical attention and to look for gaps in care, physician clinical decision support that is tailored to individual patients, and an after-visit summary that provides tailored treatment and management information to patients regarding their headaches.  The control group (N=400) will receive an abridged questionnaire and an after-visit summary that provides general guidelines on how to reduce headaches. Analyses will determine how often expert advice was offered and used and evaluate if the PCHMS improved migraine detection, treatment rates, and migraine impact on qualify of life. 

e-CVDII

PI Walter F. Stewart, PhD, MPH

The eCVDII study uses an integrated IT-based care model to detect and manage cardiovascular disease (CVD) risk at the primary care level.  The study includes the automated data capture of behavioral risk factors, an on-line quantitative risk assessment and calculation, CVD risk communication, a patient preference-based care plan, and expert real time clinical decision support.  Participants are men aged 45-75, women aged 55-75, and adults over 18 with coronary artery disease.  The randomized controlled pilot study is conducted in the family practice departments at Scenery Park and Grays Woods clinics. All eligible patients complete an on-line questionnaire to determine risk of heart attack in the next 10 years.  Patients with moderate-high CVD risk and modifiable risk factors will be randomized into two groups.  The intervention group (N=100) has the opportunity to select their preferences for managing their risk and their physicians receive clinical decision support that is tailored to the individual patient.  The control group (N=100) will not be managed for CVD risk by the study. Analysis will evaluate if the study tools improved detection of CVD risk factors, increased delivery of guideline-based care for the management of CVD risk, improved short-term outcomes in CVD clinical and behavioral measures, and improved patient activation and adherence. 

Rheum-PACER (Patient Centric Electronic Redesign)

PI Walter F. Stewart, PhD, MPH

Rheum-PACER (Patient Centric Electronic Redesign) has been implemented by the Geisinger Rheumatology Department as a clinical redesign based on American College of Rheumatology (ACR) best-practice guidelines of two ambulatory rheumatology practices. There are two main components to the redesign. The first component is the implementation of a web-based questionnaire, the Multi-Dimensional Health Assessment Questionnaire (MDHAQ), to obtain data directly from rheumatology patients. 

The second component of the redesign is a sophisticated web-based dashboard designed to obtain, aggregate, exchange, and display data from/with three key sources: patients (from the computerized questionnaire), providers (rheumatologists, nurses), and the electronic health record (EHR).  The dashboard is a web-based application that can be accessed seamlessly from within the EHR, but which is separate from the EHR itself.

We will conduct a pre-post evaluation of Rheum-PACER to assess the impact of the clinical redesign.

 The Veterans Health Project

 PI Joseph Boscarino, PhD, MPH

The Geisinger Health System (GHS) has approximately 55,000 veterans from all eras who use GHS for health care services among approximately 650,000 active patients. Similar to the Veteran’s Administration, GHS has an Electronic Health Record (EHR) system for all its patients since the 1990s. The purpose of this project is to enter veteran status information into the EHR at the patient encounter over the next 12 months. Once this has been achieved, the second phase is to undertake a descriptive study of health utilization and health problems experienced by different era veterans compared to non-veteran cohorts. Following this, the plan is to use these data in observational investigations, including case-control, cohort, retrospective, and prospective studies related to health outcomes.     

Improving Prophylactic Aspirin Use

PI: Nirav Shah, MD, MPH

Aspirin prophylaxis for the prevention of cardiovascular events is an underused preventive measure. Cardiovascular disease is responsible for 1 out of every 2.7 deaths, accounting for approximately 2.5 million deaths annually. Decisions regarding aspirin prophylaxis by clinicians and consumers require the balancing of benefits (reduced cardiovascular risk) and harms (including gastrointestinal bleeds). The primary purpose of this project is to measurably improve the implementation and uptake of a specific evidence-based clinical preventive service – appropriate prophylactic aspirin use among adults at risk for cardiovascular events – in a system of care. In a three-arm randomized controlled trial, we will compare 1) tailored messaging to the patient, 2) messaging plus clinical decision support, and 3) usual care in improving rates of prophylactic aspirin use.

Collaborating to strengthen nursing students’ clinical learning

PI: Adele Spegman, PhD, RN

All nursing students require experiences providing care to patients in clinical settings. The need to address the RN shortage is hindered by a concurrent faculty shortage and the limited availability of sites for clinical learning. Staff RNs in acute care hospitals take on the clinical preceptor role as their contribution to nursing education. While supervised experiences in the clinical setting are an essential component of preparing new nurses, the preceptor role is rarely coordinated between the schools and the healthcare institutions involved.

This project initiates a collaborative process to strengthen nursing students’ clinical learning while supporting the roles of nurse-preceptors and faculty. Best practice guidelines were developed by a team of staff nurses at Geisinger Medical Center and clinical faculty from four affiliated nursing programs. The resulting guidelines will be discussed at workshops for Geisinger Medical Center nurses and clinical faculty in spring 2009, and evaluated throughout the 2009-2010 academic year.

This project is supported with a Nursing Shortage Initiative grant awarded by the Pennsylvania Department of Labor and Industry. 

e-LOW BACK PAIN

PI Walter F. Stewart, PhD, MPH

Low back pain is a multi-factorial condition that can hinder a person's daily activities and result in an increase in health care and work-related costs. This study will build and pilot test an integrated IT-based care model using a web questionnaire, analytic algorithms to identify gaps in care, offer expert messages to patients and expert clinical decision support to the physicians to improve diagnosis and management of low back pain. A randomized controlled study design will be used to determine if the EHR-based protocol improves care processes and patient outcomes.