Geisinger Executive Explains How His System Integrates Healthcare

Alfred Casale, MD, is assistant chief medical officer of the Geisinger Health System in Danville, Pa., which employs 800 physicians, runs three hospitals totaling almost 900 beds and operates a health plan and a pharmacy.

Q: Now that President Obama sees Geisinger as a model for the nation, some hospital executives disagree. You are in a rural area, away from big-city competition. Your doctors are employed. You have your own health plan. How can you serve as a model for other hospitals?

Alfred Casale: We've all been talking about an integrated delivery system as if there is only one flavor, but there are many ways of becoming integrated. We have adapted to our own circumstances. Other systems will come up with different models to meet their circumstances.

For example, Geisinger came up with an electronic health record in 1995, which is comparatively early but it was almost a necessity for us. We are spread out across 43 primary different sites, covering one-third of the state. Coordinating the system through paper records would have been next to impossible.

Now we are fully electronic. We have an electronic medical record, physician order entry, digitized lab studies. We still have a chart folder on each patient but it is practically empty, consisting of a few consent forms and some paperwork that still needs to be scanned into the electronic system. We offer patients "My Geisinger," which is a secure Internet site that patients can log onto to review their medical record, schedule visits, pay bills and ask non-urgent medical advice.

Q: Can a system be integrated without Geisinger's substantial cadre of employed physicians?

AC: You don't have to be fully integrated to benefit from integration. Even within the Geisinger system, there are various levels of integration. Our health plan, for example, has about 90 non-Geisinger hospitals and 1,900 doctors in its network. Some integrated models can be applied to them. Primary care physicians who are not employed by Geisinger also have access to the EHR in the hospital. They can do virtual rounds from their office or home if they choose to do that. They also have access to many special programs through the health plan. We do not require them to have an EHR and we don't help them buy one. That is their decision to make.

Q: However, you clearly believe that an EHR and a fully integrated system are preferable.

AC: Yes, I do. For example, having an integrated system with an EHR makes the patient's initial office visit more efficient. The doctor is not gathering data on the patient; it is already in his or her hands. Without any records at hand in the initial visit, all we're going to be able to do is talk in generalities. We can also have those records in the first visit. We can also send patients a few floors away to have a test, then they can come back and review the test with the doctor. People appreciate having everything done in one place and it also makes for more effective healthcare.

Q: That sounds convincing, but creating an integrated system means doctors have to give up independent practice. Would most American physicians agree to become employees in a large healthcare system?

AC: I don't know the answer to that. Attitudes change, U.S. healthcare evolves. Anyway, it would be inaccurate to say that physicians give up their independent judgment when they come to Geisinger. Precisely the opposite is true. When we talk about the Geisinger way, we are not talking about cookbook medicine or "Stepford surgeons." Doctors are not cogs in the wheel here; they are the wheels. They decide our direction.

For example, for our ProvenCare program, doctors at Geisinger had to come up with best practices for patient care. We have developed guidelines for acute surgical care, starting with coronary artery bypass grafting. We looked for standards in the external world and came up with a good set from the American Heart Association standards. Then we went to hip replacement and didn't find external standards, so we developed standards internally.

When you develop best practices, you realize there are a lot of gray areas where experts disagree on what is the right thing to do. So we ask, "Can we at least define the things that we believe are necessary to do?"

We take these best practices and redesign the day-to-day care of patients in our system. The best practices are a kind of default — this is what is going to happen unless the physician says things should be done differently. We don't compel physicians to behave in a certain way, but we do compel them to think. If they want to diverge from the best practice, they need tell us why Mrs. Jones' case is different. They need to explain it.

Learn more about Geisinger Health System.