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At Geisinger, we work to keep people healthy, and a key component is developing innovative ways to identify and manage clinical conditions, ideally outside of the hospital setting.

While this may seem unusual for a health organization with more than a dozen hospital and trauma campuses, this notion of making health easier is front and center in our approach to patient care.

Geisinger is a non-profit, integrated health system that dates to the 1915 founding of its flagship hospital, Geisinger Medical Center in Danville, PA. The physician-led system now comprises nearly 1,800 physicians, 13 hospital campuses, two research centers, an innovation institute, a medical school and a health plan with more than 550,000 members. In addition to fulfilling its mission to bring better health to its patients and members, Geisinger has a long-standing commitment to quality, medical education, research, innovation and community service.

For many years, the practices of the U.S. healthcare industry have made hospital admissions and emergency departments central to care delivery. Not only are these sites more expensive for providing care, but they haven’t always delivered the best health outcomes or experiences either.

Our focus instead spans the care continuum, where we’re increasingly building programs to manage populations outside the hospital walls, with a particular emphasis on expanding primary care access. This orientation makes healthcare easier by meeting people where they are. It’s easier to get to a clinic than a hospital, and the home is even more convenient still. We are uniquely positioned to do this because of the breadth of our organization, which is designed to improve care for more than 1.5 million patients in Pennsylvania and New Jersey.

To meet patients in these locations instead of in hospital facilities, patients need to stay as healthy as possible. We can help them do this by getting a complete picture of each patient’s health status, enabling them to manage existing conditions and even proactively determining whether they’re at risk for developing a disease that could be prevented. That’s where our Anticipatory Management Program (AMP) app comes in.

Assessing risk to improve care

At Geisinger, we’re no strangers to innovation. We’re well recognized as one of the earliest adopters of electronic health records (EHR) and for our development of transformative approaches to care delivery (click the + in the Quick Take below), such as ProvenCare® or, more recently, the Fresh Food Farmacy or Geisinger at Home. Continuing this tradition of innovation, the Steele Institute for Health Innovation was formed in 2018. This institute forges a new generation of leading-edge solutions that aim to drive greater affordability, improve quality and increase access.

With AMP, we recognize that improving care quality, identifying gaps in care and the patient’s risk for developing an illness are all tightly intertwined. The industry often defines care gaps as missed health screenings based on patient gender, health status, socio- economic factors and age. These screenings include mammograms, colonoscopies, prostate and nephropathy screenings, regular hemoglobin A1c (HgbA1c) tests and dozens more.

By filling these gaps, Geisinger can take better care of individuals, understand our communities’ disease burden more deeply and coordinate interventions appro- priately. Each of these capabilities is important to Geisinger as we, and the industry, move steadily away from fee-for-service business models and toward value-based models in which reimbursements are based on the quality of health outcomes. Without complete health information, it becomes that much more difficult to optimize health outcomes.

Closing gaps with digital

Previously, identifying and closing gaps had been a largely manual process. The ambulatory and primary care practices used paper forms to list patients’ care gaps, making it difficult to capture discrete data such as errors or omissions caught by physicians.

Our teams needed a more effective way to create a complete and accurate view of patients and care gaps, ideally embedded in the physicians’ workflows. We also needed to be more proactive about identifying potential conditions, not just current documented health.

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The Doctor Ordered Food

Geisinger prescribes healthy food combined with clinical intervention and education to take on Type 2 diabetes

By Allison Hess

At Geisinger, our Fresh Food Farmacy™ program is showing us that grocery carts filled with lean meats, whole grains and fresh fruits and veggies are as effective as some medications.

Type 2 diabetes is a major issue in the central Pennsylvania communi- ties we serve. To meet our patients with uncontrolled Type 2 diabetes where they are, we had to address a key obstacle: food insecurity. Type 2 diabetes responds to a better diet, but many of our patients with the condition regularly experience hunger and/or don’t have money for or access to healthy foods.

Our Fresh Food Farmacy program addresses those problems. We opened our first Food Farmacy in 2016 and launched two more this summer. The Farmacy provides food for patients and their households to make 10 meals per week using fresh fruits, vegetables, whole grains, lean meats and other staple items. Patients work with care teams to set and meet goals to control their diabetes and may receive food prep and meal planning advice, nutritional guidance, health education classes and healthy recipes.

We rely on data analytics to show our Food Farmacies are improving population health, closing care gaps and reducing the cost of care. Data from our initial patients enrolled in our first Fresh Food Farmacy in Shamokin, PA, shows those patients experienced an average two-point drop in HbA1c levels, along with lower weight, blood pressure, triglycerides and cholesterol. In comparison, common diabetes medications, on average, help to lower a patient’s HbA1c by a half point. Published data shows there is an $8,000 to $12,000 cost savings for every one point in HbA1c reduction. Applied to our results, we could potentially see medical savings of $16,000 to $24,000 per patient per year.

These patients also had 27% lower emergency room usage and 70% lower hospital readmission rates, as well as higher participation in primary care and specialty care services, compared with a similar unenrolled population. Patients receiving eye exams increased more than 16%, and more patients participate in other preventive care services, including foot exams, mammograms and colonoscopies.

While frequent check-ups, as well as devotion to prescribed therapies and physical-fitness regimens, can contribute to better outcomes, our Fresh Food Farmacy demonstrates that a proper diet can go a long way toward enabling those with chronic illnesses to live healthier lives.


Allison Hess is the Vice President of Health Innovations at Geisinger. A 12-year Geisinger veteran, she focuses on building transformative, scalable, measurable and sustainable solutions that improve health, care delivery and the patient experience while lowering cost. Allison earned her bachelor of science in health education with a concentration in psychology from Bloomsburg University. In addition to several certifications, she is currently pursuing her MBA and has been recognized for her leadership and employee engagement efforts within the organization. Allison can be reached at

Being both a provider and payer enabled us to combine data captured in Geisinger Health Plan medical claims with clinical data in the EPIC™ EHR and, in doing so, migrate from an analog process to a digital one. This enables us to capture diagnosis information from the health claims. All the claims data funnels into a data warehouse, which stores data from a legacy health plan system, as well as claims data from the recently implemented Cognizant TriZetto® Facets® core administrative platform.

Using custom algorithms, we were able to generate insights from these combined data sets and deliver them to our physicians using AMP, which was developed and deployed in partnership with our innovation and care teams.

When a physician pulls up a patient record, she accesses this application and information as part of her workflow right at the point of care. This makes it easier to keep an accurate and relevant record of a patient’s clinical conditions, thereby triggering the right interventions and care plan.

With these data sets and algorithms, we can find clinical markers in a patient’s EHR – such as an elevated blood glucose reading or high body mass index – that enable us to say with confidence that he or she may be suffering from an as-yet undiagnosed disease. Armed with this data during an exam, a physician can decide which screenings or interventions are appropriate, and our care teams and health coaches can help ensure these happen.

When we introduced the EHR-embedded application in 2017, we targeted our patients 65 years of age and older, many of whom have multiple chronic and complex conditions and visit their primary care physicians several times a year. We recently extended the feature to cover patients with disabilities, as well.

Keeping it simple

To address physicians’ time pressure, we introduced several program components that have added to AMP’s success. For example, the app’s user experience is optimized into the current workflow to decrease duplicate effort; physicians tell us the interface is intuitive. We partnered with our end-users to ensure the product’s ease of use, including the use of color cues, like red to mark an item as incorrect. Ongoing one-to-one and group training sessions emphasize the correlation between closing care gaps and more effective care teams. This helps keep the focus on the clinical problem, not the technology solution.

We’ve had to overcome several challenges along the way. For example, the health plan’s claims processing system captures data coded according to the ICD-9 or ICD-10 healthcare industry coding standards. However, the EHR system allows physicians more freedom in their note- taking verbiage. In the ICD-10 code set, Type 2 diabetes without complications is coded E11.9. But in a clinical record, physicians might write “Type 2” or “Type II” or “Type Two.” Given this, we had to map the data carefully so that claims data could interact meaningfully with the EHR.

Daily, weekly and monthly application use reports, analytics and dashboards suggest that physicians have widely accepted the app. The reports also help target individual teams or physicians who exhibit sub-optimal app use.

Redesigning primary care with data

The app is one aspect of our broader primary care redesign, where we’ve implemented a team-based care model for a defined patient panel. Instead of being a single practitioner, each physician is teamed with additional staff such as nurses, case managers, health managers, community health assistants and pharmacists, all supporting comprehensive care for patients.

While the app and its underlying analytics, algorithms and data warehouse help streamline patient management for teams, a key ingredient in the primary care redesign was to make it easier for care teams to communicate regularly about the patient’s care. For example, teams conduct daily 10- to 15-minute huddle meetings, run by trained moderators, to plan their days as efficiently as possible by being more proactive rather than being reactive. Items covered may include appointment cancellations and schedule openings, newly discharged patients who need follow-up visits, patient calls for advice that indicate a need for a visit, or patients with multiple care gaps to address.

Data drives the care teams. Whiteboards, aka “huddle boards,” display aggregate data, results and targets. Physicians use their personal dashboards to identify individual patients. Care gaps that aren’t addressed during a visit are investigated promptly as “missed opportunities.”

Patients have benefited from the app in many ways. For example, physicians say their typical 15- to 20-minute appointment blocks don’t provide ample time to cover all their patients’ health issues, especially those with multiple chronic conditions.

Appointments would run long, making physicians late for other patients, or subsequent follow-up appointments would be needed to cover missed topics, which increased inconvenience and cost. Physicians were bearing the brunt of the stress of trying to manage this situation.

Now, whenever a patient 65 years or older schedules a visit, the system automatically blocks double the appointment length, or 40 minutes instead of 15 or 20. While not every patient may need that additional time, simply adding a time cushion has taken some of the pressure off providers, who generally report a greater sense of fulfillment. We have rolled out that capability to all of our ambulatory care sites.

Anchoring new attitudes

The AMP app is an anchor for an extended program in which we track every variable possible related to primary care. The goal has been to fully inform the primary care teams with all of the information inputs available. To that end, the EHR needs to be as comprehensive as possible so the care teams can adapt the care plans accordingly. In turn, great care management helps patients avoid chronic conditions, worsened symptoms, hospital admission or emergency room visits, all of which add to healthcare costs.

Understanding the disease burden is also important for deploying care programs and resources appropriately. The data helps us better understand the patient load, or panel, each physician is carrying. Two physicians may each have a 2,000-patient panel, but if one group largely comprises younger, healthy patients vs. older patients with multiple chronic conditions, the workload will not be balanced.

Previous procedures to monitor panel size and track patients didn’t ensure accurate, up-to-date primary care physician data in EHRs. Now, provider groups review records, and the physician who sees a patient the most frequently will have that patient attributed to him. The system also tracks provider productivity. Whether a provider’s panel seems overly light or heavy, it can be balanced, sometimes by shifting patients to other providers or recruiting new providers.

This effort and others implemented at Geisinger are all part of the value-based care model and outcomes-driven business model. These models require much more than simply getting away from using current procedural technology coding widgets for billing. They require changing the physician culture and mindset, as well as addressing all the factors that affect a patient’s health.

Whether we are providing fresh produce to diabetic patients or developing a precision medicine therapy, it’s our physicians and primary care teams that connect our patients with these services. The app helps these teams, and our associates, successfully care for communities and individuals.


Jaewon Ryu, M.D., J.D., is the President and CEO at Geisinger. Before coming to Geisinger, he served as president of integrated care delivery at Humana and previously held leadership roles at the University of Illinois Hospital & Health Sciences Systems and at Kaiser Permanente. Dr. Ryu received his undergraduate education at Yale University and his medical and law degrees from the University of Chicago, after which he completed his residency training in emergency medicine at Harbor-UCLA Medical Center.

Karena Weikel, A.S.A., M.A.A.A., F.A.H.M., C.S.F.S., is Vice President, Risk and Revenue Management at Geisinger. She is a risk professional with 17 years of healthcare experience and is responsible for managing Geisinger’s overall cost of care, trend mitigation, data management, vendor relations, under- writing, provider economics, risk adjustment, operational and regulatory reporting, rate filing support, and organization-wide financial analytics for all lines of business.

Juliann Molecavage, D.H.A., M.S.H.A., B.S.H.M., is Associate Vice President, Quality and Primary Care Services at Geisinger Health. Her focus is on quality, primary care practice redesign and information technology solutions and operations, and she has led many organization-wide strategic initiatives. Juliann graduated from Walden University with a doctorate in healthcare administration. She is responsible for overseeing quality initiatives for the Geisinger Medicine Institute as well as the implementation of new models of care for Geisinger.

Rebecca A. Stametz, D.Ed., M.P.H., is the Associate Vice President, Product Innovation in the Steele Institute for Health Innovation at Geisinger. She directs a cross-functional, design-led department that deploys software engineering and advanced analytics to create and deliver enhanced value through health information technology throughout the care continuum. As a principal, her research focuses on program implementation, medical transparency, family-patient engagement and learning healthcare system models. Rebecca holds a master’s of public health from East Stroudsburg University and a doctorate of education in adult education from Pennsylva- nia State University.

David Riviello is Senior Clinical Informatics Analyst in the Steele Institute for Health Innovation at Geisinger. His primary role in this initiative has been to advance the analytics and algorithms feeding AMP and measuring key performance indicators. David earned a B.S. in mathematics at Bloomsburg University.

The authors may be reached at

To learn more, read the full Cognizanti journal, Navigating the digital age: What senior leaders worldwide have learned from pushing the boundaries of change, or contact us.