Geisinger has FHIR in its sandbox

BOSTON—Geisinger Health System has a $6 billion research and development shop that is a microcosm of the entire healthcare space, said the organization’s chief clinical informatics officer Alistair Erskine, MD, speaking at AMIA’s iHealth 2015 Conference.

Geisinger’s Institute for Advanced Applications contains several centers including the Center for Clinical Innovation, the Center for Healthcare Systems Reengineering and the Center for Emerging Technology and Informatics. Goals include optimizing the EHR to close care gaps and more predictive work; electronic data warehouse and data science; and distributed services.

Erskine’s group, he said, puts apps into a production environment to analyze, innovate and change behavior. “We’re in the business of changing behavior to produce better outcomes and better health.”

That business is called xG Health Solutions—an implementation arm that takes an effective strategy and commercializes it, he said.

Erskine said the system’s ProvenCare—a set of processes for reeningeering diabetes care—led to improvements but “not to the point we wanted. The problem is that all this knowledge is locked in the Epic implementation. It took a lot of time to configure and tweak the tool and we were at a loss when someone wanted access to information. The things we were doing were not shareable.”

He shared Geisinger’s experience with an app designed for rheumatoid arthritis patients. The app matches patients and symptoms with medication regimens and provides a means to understand at any point why a patient is not on a disease-modifying agent.

The process, Erskine noted, is not a multi-year business. “It’s important to understand that this approach doesn’t take an army of people using web-based language.” They used three web developers, 736 programming hours and $17,859 in programming costs. “It’s not an incredible lift like you sometimes see with other activities that involve configuration.”

The RA app assesses six key areas, including function and pain. Patients use a computer screen in the waiting room to answer questions which is then combined with information from both the doctor and nurse. That all becomes part of the same overall note. The app easily visualizes joints’ tenderness, swelling and other factors. “We can quickly document those, pull previous visits and see changes over time. The use just hits the ‘send to EHR’ button and only relevant labs are sent with that.”

The app allowed users to transition data integrity points quickly and efficiently via the data visualization layer.

Consortium and alliances already exist to advance efforts involving FHIR standards but no one’s sure what happens next, Erskine said. “It’s one thing to pull information from the EHR. It’s entirely different to push information back in. When these apps start to write orders back to the EHR and do other things it will test our resolve in how these work.”

Since almost every provider has customized its EHR, every upgrade takes longer, Erskine said. Over time, he said, ideally more things will turn from customization to app which makes it simpler to get to the latest version of code with less testing, time and energy.

One issue is the fact that major health IT developers are still in a process of when to put FHIR standards into production. Cerner has said its next release will support a series of FHIR standards, Erskine said. “As soon as that becomes available, the small community hospital doesn’t need to buy apps. xG Health developed things we’ve tested in our petri dish and then we hand it over and xG makes it available.”

There are 49 FHIR standards but “we can do a ton of work off of the first 10.” Making those available would “kick off a lot of innovative work.”

It makes a lot of sense to apply a standard sets of profiles on top of FHIR resources, he said. “Right now, the experience we’ve had is that health IT vendors aren’t necessarily motivated to all have the same standards. We as an industry ought to be heavily involved with some of these profiles and coordinate with ONC to make sure we at least agree on a subset that can get us started.”

He recommended that everyone “toy with the sandbox in anticipation—most likely that’s where the puck is going. It makes sense to understand it but not yet put a ton of resources into it.” He suggested that providers demand FHIR during contract negotiations. “If vendors remain unmotivated to adopt these standards, they won’t align.”