Quality Improvement Using Systems of Care Frederick

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Quality Improvement Using Systems of Care Frederick J. Bloom, Jr. MD MMM Assistant Chief Quality Officer Heal • Teach • Discover • Serve

Adults in the US received 54. 9% of recommended care • Acute care – 53. 5% • Care for chronic conditions – 56. 1% • Preventive care – 54. 9% N Engl J Med 2003; 348: 2635 -45 Heal • Teach • Discover • Serve

Time Required for Primary Care of Patients • Acute Care • Preventive Care • Chronic Care Heal • Teach • Discover • Serve 4. 6 hours/day 7. 4 hours/day 10. 6 hours/day 22. 6 Hours/day

Improving The Reliability and Consistency of Care Delivered to a Population • Chronic Care – DM Improvements – CAD Improvements • Preventive Care – Childhood Immunizations – Adult Preventive Bundle Heal • Teach • Discover • Serve

Operational Flows • Improving reliability and safety in health care is about designing consistent operational flows • An electronic health record is a tool to help create consistent designs, but is not itself the answer • Sustained improvement does not rely on “I’ll remember to do it the next time”, does not rely on vigilance and hard work • Operational flows make sure that the care we all know should be provided, happens every time Heal • Teach • Discover • Serve

Clinical Process Redesign Components of a System of Care Established Techniques • Guideline Development • Education • Measurement • Timely Feedback of Data • Patient Education Heal • Teach • Discover • Serve New Techniques • Delegated Team Responsibilities • Strategies to Pull Patients into Care • Non Office Visit Based Care • EMR Reminders • Pay for Performance

Workflow Principles 1. Automate work that can be done outside of a office encounter 2. Distribute work that is done at an office visit to trained non-physician staff when possible 3. Create reminders and EMR tools to enhance the reliability and efficiency of care provided at the office encounter Heal • Teach • Discover • Serve

Systems of Care - Diabetes • All or None “Bundle” measure for Diabetes • Clinical process redesign – Automating the processes • Clinical decision support – Health Maintenance and Best Practice Alerts • Patient specific strategies using registry report data • Patient centered strategies – Patient report cards • Compensation Heal • Teach • Discover • Serve

All or None Measures • Measure the percentage of patients who receive all related services, not the scores of the individual measures • Better reflects the patient’s interest and desires – to have all recommended care provided • Encourages a systems approach to achieving all goals rather than work on one measure at a time • Gives a more comprehensive scale for tracking systemic improvements Heal • Teach • Discover • Serve

All or None Measure Even if individual criteria have great results, when calculated as an All or None metric – the need to work differently (systems of care) becomes evident Heal • Teach • Discover • Serve

Diabetes Bundle Heal • Teach • Discover • Serve

Diabetes Bundle Score • Not all patients should achieve each measure – for instance not all diabetics should have a Hgb. A 1 c < 7 • Individual component scores for GHS were very good – above the ADA recommended goals • Yet initial GHS score was only 2. 4% • Easy to recognize that a dramatic restructuring of the care provided to diabetics was needed Heal • Teach • Discover • Serve

DM Clinical Process Redesign • Standardization of clinical practices – Nurse Rooming Tool, Standing Orders • Automated identification of diabetics and care plan status – Health Maintenance Alerts, Disease Summary Screen • Automated identification of suboptimal care – Best Practice Alerts • Automatic generation of appropriate orders – Smartsets and Order Panels • Automatic generation of patient specific report cards at checkout • Automatic outreach to patients – Influenza / Pneumococcal Campaign, Chronic Disease Return Visit program Heal • Teach • Discover • Serve

Nurse Rooming Tool Heal • Teach • Discover • Serve

Nurse Rooming Tool Improvements My. G Enrollments Heal • Teach • Discover • Serve Urine Microalbumin

DM Health Maintenance Alerts Heal • Teach • Discover • Serve

DM HM Alerts for Patients Heal • Teach • Discover • Serve

Diabetes Best Practice Alerts Heal • Teach • Discover • Serve

Diabetes: Patient Letter/Report Card Last 2 -3 values displayed LDL values and goals. Last BP readings Heal • Teach • Discover • Serve

Flu / Pneumovax Outreach to Patients • One technique of successful improvement is to link a process that needs improvement with an already reliable process • Linked pneumococcal vaccination with the influenza vaccination campaign in the minds of our patients, nurses and physicians • A pull strategy using letters, phone calls from our call center and e-mails to My. Geisinger patients Heal • Teach • Discover • Serve

Pneumococcal Immunization Age >65 3500 3000 2500 2000 1500 1000 500 0 Sept Oct Nov 2007/2008 Heal • Teach • Discover • Serve Dec Jan 2006/2007 Feb 2005/2006 Mar Apr 2004/2005 May Jun 2003/2004 Jul Aug 2002/2003

Pneumococcal Immunization Age >65 Heal • Teach • Discover • Serve

Pneumococcal Immunization Age >65 High Risk Patients Heal • Teach • Discover • Serve

Influenza Immunization 40, 000 2007/2008 35, 000 2006/2007 30, 000 2005/2006 25, 000 2004/2005 15, 000 2003/2004 10, 000 2002/2003 5, 000 0 Sept Heal • Teach • Discover • Serve Oct Nov Dec Jan Feb Mar

Influenza Immunization Age > 65 Heal • Teach • Discover • Serve

Influenza Immunization Age >65 High Risk Patients Heal • Teach • Discover • Serve

Patient Outreach Programs Contacting Patients in Need of Care • Chronic Disease Return Program – Patients under care for DM, CAD, COPD, ESRD without an visit in 6 months • Patients 19 months old who are behind on immunizations • Patients due for screening colonoscopy, DXA screening Heal • Teach • Discover • Serve

Timely Feedback of Data • EPIC EMR allows collection of clinical data without manual chart reviews • Data is collected on an individual physician basis, but summarized into site reports to encourage team based solutions and accountability • 9 components the Diabetic Bundle being collected this year • Bundle percentage is the percentage of the site patients who are achieving all 9 of their diabetic goals Heal • Teach • Discover • Serve

Improving Diabetes Care for 23, 254 patients 3/06 3/07 Diabetes Bundle Percentage 2. 4% 7. 2% % Influenza Vaccination 57% 73% 73% % Pneumococcal Vaccination 59% 83% 85% 84% % Microalbumin Order 58% 87% 86% 88% % Hgb. A 1 c < 7. 0 33% 37% 44% % LDL < 100 50% 52% 60% 61% % BP < 130/80 39% 44% 51% 52% % Documented Non-Smokers 74% 85% 85% Heal • Teach • Discover • Serve 8/08 8/09 12. 49% 12. 63%

Diabetes Bundle Primary Care Average Heal • Teach • Discover • Serve

Diabetes Bundle Improvement Number of Bundle Elements Achieved 20 % of all % 6/30/06 diabetic patients 3/31/06 10 % 0 Heal • Teach • Discover • Serve 1 2 3 4 5 6 7 8 All

Diabetes Bundle Improvement Number of Bundle Elements Achieved 9/30/06 20 % of all % 6/30/06 diabetic patients 3/31/06 10 % 0 Heal • Teach • Discover • Serve 1 2 3 4 5 6 7 8 All

Diabetes Bundle Improvement Number of Bundle Elements Achieved 9/30/06 20 % of all % 12/31/06 6/30/06 diabetic patients 3/31/06 10 % 7% 2. 5% 0 Heal • Teach • Discover • Serve 1 2 3 4 5 6 7 8 All

Diabetes Bundle Improvement Movement Since Year 1 6/09 % of all diabetic patients 12/08 6/08 12/07 6/07 12/06 Heal • Teach • Discover • Serve

Improving CAD Care for 14, 660 Patients 9/06 3/07 8/08 8/09 CAD Bundle Percentage 8% 11% 20% % LDL <100 or <70 if High Risk 38% 37% 46% 47% % ACE/ARB in LVSD, DM, HTN 65% 66% 75% 76% % BMI measured 79% 86% 98% % BP < 140/90 74% 78% 79% % Antiplatelet Therapy 89% 91% 92% % Beta Blocker use S/P MI 97% 97% % Documented Non-Smokers 86% 87% % Pneumococcal Vaccination 80% 86% % Influenza Vaccination 60% 74% 75% 76% Heal • Teach • Discover • Serve

CAD Bundle Primary Care Average Heal • Teach • Discover • Serve

Childhood Immunization Process Improvement • Standard Geisinger Immunization Schedule • Health Maintenance Alerts in EPIC • Automatic generation of letters to parents of children behind on immunization at ages 8 and 19 months • Call to patients at 19 months to schedule needed appointment • List to primary care physician at age 22 months if still behind Heal • Teach • Discover • Serve

Childhood Immunization Heal • Teach • Discover • Serve

Adult Prevention Bundle • Based on US Preventive Services Task Force (USPSTF) Recommendations and 2007 ACIP Immunization Schedule • Received input from a broad group of primary care physicians from CPSL and GIM and also selected specialists • Roll Out 1/08 Heal • Teach • Discover • Serve

Adult Prevention Bundle AGE/SEX 18 -49 Recommendation Female 50 -64 Male Female Adult Prevention Bundle Over 65 Male Female Male Cancer Screening Breast Cancer Mammogram every 2 yr 40 -49, every year 50 -74 x (>40) x x (<75) x Cervical Cancer Pap every 3 yr 21 -64 x (>21) x x Colon Cancer Colonoscopy every 10 yrs or FOBT yearly x x x (<85) x Prostate Cancer Discussion Discuss prostate cancer screening yearly 50 -74 x x (<75) x Lung Cancer Non-smoker See Tobacco Screening Below Cardiovascular Disease Lipid Screening Every 5 years M>35, F>45 x (>45) x (>35) x x x (<75) x Tobacco Screening Non-smoker x x x x Infectious Disease Tetanus/Diptheria/ Pertusis Vaccine Tdap once then Td every 10 years x x x x Influenza Vaccine Yearly >50 x x x Pneumococcal Vaccine Once >65 x x x Chlamydia Screening Yearly 18 -25 x (<26) x Metabolic, Nutritional and Endocrine Osteoporosis Every 3 years >65 x x Diabetes Every 3 years >45 x (>45) x x x Obesity BMI in EPIC x x x x Substance Abuse Alcohol Misuse Assess alcohol intake - Social History Completed Heal • Teach • Discover • Serve MAXIMUM NUMBER OF BUNDLE MEASURES FOR EACH AGE/SEX CATEGORY x x 9 x 6 x 10 x 9 x 11 x 10

Adult Prevention Bundle • 203, 695 Patients • 66% of recommended tests performed on these patients • Initial Adult Prevention Bundle Percentage = 9. 2% Heal • Teach • Discover • Serve

Improving Preventive Care for 206, 595 Patients 11/07 7/09 Adult Preventive Bundle 9. 2% 24% Breast Cancer Screening (q 2 40 -49, q 1 50 -74) 46% 60% Cervical Cancer Screening (q 3 yr Age 21 -64) 64% 73% Colon Cancer Screening (Age 50 -84) 44% 60% Prostate Cancer Discussion (Age 50 -74) 72% 73% Lipid Screening (Every 5 yr M > 35, F > 45) 75% 81% Diabetes Screening (Every 3 yr > 45) 85% 86% Obesity Screening (BMI in Epic) 77% 94% Documented Non-Smokers 75% 78% Tetanus Diphtheria Immunization (every 10 yr) 35% 61% Pneumococcal Immunization (Once Age >65) 84% 86% Influenza Immunization (Yearly Age >50) 47% 53% Chlamydia Screening (Yearly Age 18 -25) 22% 32% Osteoporosis Screening (every 3 yr Age > 65) 52% 64% 88% Heal • Teach • Discover • Serve Alcohol Intake Assessment

Proving a Difference in our Market Geisinger Health Plan Patients • About 50% cared for by Geisinger Clinic Physicians About 50% cared for by Panel Physicians • About 30% of Geisinger Clinic patients are GHP • HEDIS scores should be a fair comparison Heal • Teach • Discover • Serve

GHP GOLD HEDIS Performance Geisinger Clinic compared to Panel Providers Heal • Teach • Discover • Serve

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Pay for Performance • Insurers starting to pay more for higher quality performance – Geisinger Health Plan and other HMO’s – Medicare • Geisinger Primary Care Physicians earn 10 -20% of salary based on quality performance • $8, 000/year available for Diabetes, CAD and Adult Prevention Incentives Heal • Teach • Discover • Serve

Lessons Learned • It is not the tool created in the electronic medical record, but its implementation into a system of care that makes it successful • Spreading the work out over a team, each with clearly defined roles improves reliability • Measures are never perfect, but improve with time and are vital to the change process • Compensation helps focus attention, but is not sufficient to drive change Heal • Teach • Discover • Serve

QUESTIONS? fbloom@geisinger. edu Heal • Teach • Discover • Serve

DM Trending – Last 13 Months Heal • Teach • Discover • Serve

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