Implementation of an EHR - The Geisinger Method
In nearly every institution in the world, standardization is a must for modern times. The use of new technology can be found everywhere, from small schools to large businesses, from the community to the government level. One of the ways such technologies are being implemented in the medical field is through the integration of hospital databases and the EHR (Electronic Health Record).
Implementation of a hospital database is not so easily carried out, however, and it requires a skilled set-up team, cooperative hospital staff, and a trustworthy provider to make it happen. Often due to poor hospital database design methodology, projects intended to implement such programs are usually not successful (1). Only a limited number of hospitals have been entirely successful in implementing the proper designs for a usable database, one of which is the Geisinger Medical Center.
For nearly a decade now, "Geisinger has been recognized as one of the nation's '100 Most Wired Hospitals and Health Systems'" by the journal of the American Hospital Association (2). There are countless advantages to utilizing more advanced streams of technology in running a hospital, particularly in the case of an EHR. Some of these main advantages include better chance of correct patient info being entered the first time, making it easer to catch an error in entered patient information before it has harmful consequences to the patient, and keeping information up to date and coherent with regards to current standards. Because medical technology is changing everyday, staying connected by the use of an accessible database is an important function of the modern hospital.
Geisinger Medical Center would not be so successful today if not for the early stages of its database development. As one of the first hospitals to implement the use of such complex and connective technology, Geisinger and its associates went through many years of work and experimentation to arrive at where they are today. Under the successive leadership of MDs Dr. Harold Foss, Dr. Leonard Bush, Dr. Henry Hood, and Dr. Stuart Heydt, Geisinger's first EHR system was put into action starting in the early 1990s. The first team to work on implementing ambulatory EHR had to centralize IT operations and infrastructure during a time when the tools they had to use were fairly new.
With a stable population of 2.3 million to be served, Geisinger knew its base would be more community oriented. By placing attention on both the population of the patients, employees, and IT Department, they were able to calculate successfully the proper size of the database that would be most fitting to their needs. With regards to their financial base, Geisinger "retains its earnings for investment in program improvements (3). As a not-for-profit organization, they were able "to make the long-term investment in IT that an effective EHR requires" (4).
In the project's very early stages, members were initially discouraged by inadequate technology which would support a system-wide EHR in the late 1980s. Newer technologies like E-mail, internet, and digital imaging were introduced a few years later, and they were able to take the database to the next level. This stage in Geisinger's development of their first successful EHR proved that even when an initial vision does not appear possible at first, a little patience for the technologies to catch up with the times is often worth it in the end.
As the database grew more advanced and held more information, it was important that the team take into consideration such factors as consistency and communication. The Senior Vice President for Medical Informatics along with the Board of Directors came out with a kind of goal informative message to be "presented at all levels of the organization" (5). This message had a most crucial role in listing the five main objectives for the EHR project: "improving access; reducing costs; enhancing clinical communications; improving business processes; and providing clinical decision support" (6). All physicians and hospital administrators were made fully aware of the goals of the EHR project. One of the wisest moves in implementing new technology in such a large community is making sure everyone at every level has the same understanding of why a drastic switch is being made. People want to know the advantages of new technologies, and to be assured that they are actively avoiding the common slip of fixing what is not broken.
Most important was the strategy followed by the teams called upon to provide designs for the database interfaces. Experts from technological standpoints and visual designers were divided into teams, which were set up following a very organized and specific outline of roles. Using something called a "needs assessment," the teams were able to follow fixed guidelines for how to approach their needs in the course of the project. Meeting with stakeholders, keeping track of deadlines, meeting project goals, and keeping within the budget are only a few of the things a needs assessment ensures for project members.
A fixed and firm timeline was set for the teams to complete their final reports to be presented to the Board of Directors. After receiving Board approval, teams followed a "workflow" process to organize the time and space needed for everyone to get their given job done in time. Teams were required to meet with the primary stakeholders (for this project that would mean the managers, clinicians, and hospital administrators) to better learn what needs must be met in designing a database for the specific practice. From these interviews and environmental research, the teams were able to organize their gathered data and compile this data into maps and flow charts so that they could prioritize the system's needs.
The whole point of such a large scale project is to have the design teams be as well-informed as possible. The only way to do that is to do loads of research by first-hand interaction with the environment and the people who will be utilizing the database on a daily basis. Also important in this case is the communication between the separate teams and the hospital staff with the IT Department, the IT Department with the design committee, etc. A grouping of symbiotic relationships between the different facets of a project is the primary building block of a successful project as it helps to maintain stability and balance between all of the involved branches.
What things were learned from Geisinger's attempts in implementing an EHR? Some advice is given in Walker, Bieber and Richard's book, Implementing an Electronic Health Record System. EHR implementation is all about transformation. An organization undergoing such changes is susceptible to kinks in the strategy, but it is also given the potential to progress toward improvement. The organization must be willing to invest in the resources for ongoing IT commitment, as well as hiring and promoting workers "with a passion for quality improvement" (7).
Geisinger's implementation of the EHR was a success, but if its managers and team members had not been as flexible, or as well-prepared and willing to notify everyone in the organization, the project would not have done so well. Even as it was successful in the end, it took many years of trying and failing to reach a point where the system was satisfactory. This project's leaders were effective because they were willing to cooperate with both each other and the rest of the community who would be directly affected by the changes they were interested in making.
Of course it is always possible to avoid missteps that were taken to hinder the process, and many of those mistakes are easy to spot in hindsight. But an important part of the learning process involves making mistakes, and any good engineer will say that the biggest mistakes often result in the best progressive steps toward improving a product or design. By listening to stakeholders’ feedback and being willing to make appropriate changes when the stakeholders called for them, Geisinger’s teams were successful in the end as a collective whole.
As with any long-term and drastic project, more than just the inside workings of the team must be made aware of why and how the project is being carried out. With Geisinger's early efforts, I would say their best move was all-around communication. By sharing and being open to many opinions, and taking multiple views into consideration, they were able to fulfill their goals with strength of purpose. From their ongoing success in the field of medicine, Geisinger serves as a model example for how all organizations should go about implementing not only an EHR database but any technological advancement to be used in a working environment.
Pangalos, G.J. (1986). Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/3755488
Lagrosa, Dawn (2010). Retrieved from
Implementing an Electronic Health Record System (ISBN: 1846283302)