Clinical Care Integration


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Genomic Medicine at Geisinger – David Carey, PhD; Associate Chief Research Officer,
Director and Senior Scientist, Geisinger Clinic’s Weis Center for Research

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Clinical Care Integration

  1. 1. Genomic Medicine at Geisinger<br />David J. Carey, PhD<br />Weis Center for Research<br />Geisinger Clinic<br />Danville, PA<br />October 14, 2010<br />
  2. 2. Geisinger Health System<br /><ul><li>Integrated health care delivery system
  3. 3. Geisinger Clinic
  4. 4. ~800 physician group practice (1/3 primary care; 2/3 specialists); ~400 advanced practitioners
  5. 5. 40 community-based outpatient clinics
  6. 6. 2 Tertiary/quaternary specialty and teaching/research hospitals (Geisinger Medical Center; Geisinger Wyoming Valley) plus several ambulatory surgery centers
  7. 7. 230,000 member health plan (Geisinger Health Plan)
  8. 8. Strategic commitment to Healthcare IT
  9. 9. Regional demographics
  10. 10. 2.6 million in service area
  11. 11. Rural, older, poorer (relative to national averages)
  12. 12. non-transient population</li></li></ul><li>Gray’s Woods<br />Geisinger Health System<br />Geisinger Inpatient Facilities<br />Geisinger Medical Groups<br />Geisinger Health System Hub and Spoke Market Area<br />Geisinger Health Plan Service Area<br />Careworks Convenient Healthcare<br />Non-Geisinger Physicians With EHR<br />
  13. 13. Health Information Technology<br /><ul><li>Decision to implement Epic® EHR in 1995
  14. 14. > $100M invested to date (hardware, software, manpower, training)
  15. 15. Running costs: ~ 4.6% of annual revenue of ~$2.5B
  16. 16. EHR fully-integrated across all ambulatory and inpatient sites of care
  17. 17. > 3.5 million distinct patient records
  18. 18. EHR data: 1.6 million office visits per year, 15 million orders, 7,000 peak concurrent users
  19. 19. > 2,000 non-Geisinger referring physician users
  20. 20. Electronic check-in kiosks
  21. 21. Web-based patient portal (MyGeisinger); >150,000 users
  22. 22. Clinical data warehouse (CDIS)</li></li></ul><li>Clinical Decision Intelligence System (CDIS)<br />Clinical Data Warehouse<br /><ul><li>Created in 2008
  23. 23. Searchable data warehouse
  24. 24. EHR data (back to 2004)</li></ul> -demographic and lifestyle (e.g. age, height, weight, smoking) <br /> -clinical measures (e.g. blood pressure)<br /> -orders (prescriptions, imaging)<br /> -laboratory data<br /><ul><li>Financial data (e.g., billing, payment)
  25. 25. Operational data (e.g., events, scheduling)
  26. 26. Claims data (e.g., ambulatory, hospital, pharmacy)
  27. 27. Data broker process to access data for research </li></li></ul><li>Geisinger MyCodeTM<br />
  28. 28. Geisinger Clinic Biobank Inventory<br />Individual patients >32,000<br /><ul><li>Primary care 16,995
  29. 29. Specialty clinic >15,000</li></ul>Blood samples 21,408<br />Serum samples 31,063<br />DNA samples 13,931<br />Tissue samples 2,745<br />Total samples >72,000<br />
  30. 30. Age Distribution of Geisinger Primary Care Patients and MyCode Participants<br />(N=417,469)<br />(N=16,995)<br />
  31. 31. Research Data Broker and Clinical Decision Intelligence System (CDIS) Data Warehouse<br />searchable<br />exportable<br />Data<br />Broker<br />Research data<br />Investigator<br />CDIS<br />linkable<br />Governing Board<br />Claims<br />Ops<br />Central Biobank (MyCode)<br />>32,000 consented participants<br />>72,000 samples<br /><ul><li>Blood, serum, DNA, tissue</li></ul>Finance<br />EHR<br />Orders<br />Diagnoses<br />Lab values<br />Meds<br />Procedures<br />Etc.<br />TPO<br />PHI Firewall<br />
  32. 32. Common Conditions in the MyCode Primary Care Cohort (16,714 total patients)<br />ConditionNumber<br />Osteoarthritis 4,177<br />Breast cancer 387<br />Prostate Cancer 402<br />Coronary artery disease 1,495<br />Hyperlipidemia 9,214<br />Ischemic stroke 1,240<br />BMI >40 1,864<br />Type 2 diabetes 3,727<br />Asthma 1,910 <br />
  33. 33. HDL Cholesterol In the MyCode Primary Care Cohort<br />
  34. 34. BMI Distribution – MyCode Primary Care Cohort<br />800<br />Mean: 32.0<br />Median: 30.5<br />sd: 10.6<br />MyCode Females<br />600<br />Number<br />400<br />200<br />0<br />10<br />14<br />18<br />22<br />26<br />30<br />34<br />38<br />42<br />46<br />50<br />54<br />58<br />62<br />66<br />70<br />BMI<br />800<br />Mean: 30.0<br />Median: 30.0<br />sd: 7.1<br />MyCode Males<br />600<br />Number<br />400<br />200<br />0<br />10<br />14<br />18<br />22<br />26<br />30<br />34<br />38<br />42<br />46<br />50<br />54<br />58<br />62<br />66<br />70<br />BMI<br />
  35. 35. Weight Loss After Gastric Bypass Surgery<br />
  36. 36. Areas of Active Genomic Medicine Research (partial list)<br />Obesity and associated co-morbidities<br />Weight loss after gastric bypass surgery<br />Preeclampsia<br />Myoproliferative neoplasia<br />Abdominal aortic aneurysms<br />Antiplatelet therapy<br />Prescription drug addiction<br />Obstructive sleep apnea<br />Non-alcoholic steatohepatitis<br />Breast cancer<br />
  37. 37. Integration of Genomic Data with Clinical Care<br />Identify clinically relevant genomic information<br /><ul><li>strength of evidence (RCTs?)
  38. 38. insurance coverage</li></ul>Implementation<br /><ul><li>Use EHR to automate test order in response to specific treatment order or prescription
  39. 39. Interpretation of results – clinical action
  40. 40. clinical-prediction rules (algorithm driven?)
  41. 41. physician/patient education</li>