AAMC Reporter: May 2007

Models in Quality: New System Gives Patients and Practitioners a Heads Up

Ronald Paulus, M.D., M.B.A., knew there was a problem with the diabetic patients receiving care within the Geisinger Health System: Many of them were not receiving their annual flu shots. Moreover, some had never gotten a pneumococcal vaccine, which wards off several types of pneumonia.

In the general population, this slip might have been mentioned with a resigned sigh. But in an at-risk population, it could be a matter of life and death.

"It's not hard to prevent, but over and over people don't get their vaccines and they die from it," said Paulus, chief technology and innovation officer for Geisinger Health System. "There are a million reasons why—they just don't remember, no one remembers to give it to them, or there are old wives' tales about getting the flu from the vaccine."

But instead of the resigned sigh, Paulus and a team of doctors, nurses, and technology specialists worked together to find an answer through a new program called ProvenCare. The program is aimed at changing the way the medical system delivers care. Doctors, nurses, and the hospital system itself are putting their money on the line, offering free care and lower bonuses if expectations are not met.

The program includes everything from post-surgery care guidelines to specific disease treatment and population- wide wellness benchmarks to streamlined communications between patients and various health care professionals. One of the more unusual components is a kind of patient "warranty" system, whereby a patient is not financially responsible for treatment if an avoidable infection or complication arises after surgery. There also are goals for every individual patient based on their health care needs. For example, a diabetic patient should not only automatically receive a flu and pneumonia shot (if they have not had one already), they should also have their feet and eyes checked, blood sugar measured, be asked about smoking habits, and so on.

In turn, a Geisinger doctor's quarterly bonus is based, in part, on what percentage of his or her time is spent ensuring that all the criteria are met.

"In the past, we've been good at treating acute illnesses but have not done as well treating chronic diseases," said Fred Bloom, M.D., a Wyoming, Pa., family practice physician affiliated with Geisinger. "There was much less of a comprehensive program for routine maintenance and preventative needs."

That is where Paulus' problem with the diabetic patients and flu shots come in. A group met to find a way to approach the problem. The first thing they did was cull the electronic medical database for at-risk patients. Then they sent letters to those patients noting that they were due for a flu shot, and provided a number to call to schedule a time to come in. Those who did not call in were then contacted by the hospital staff.

Finally, those who showed up for other non-flu-shot-related appointments received their shot as well, because a warning flag went up in the system, and nurses were given the OK to administer the vaccine without a doctor's pre-order. Patients can decline the flu shot or any other treatment that is offered and still be part of the program.

"The focus was to allow physicians to make complex medical decisions and allow the other levels of care to take care of things that don't require the physician," said Tammy Anderer, M.S.N., C.R.N.P., a nurse practitioner who helped develop ProvenCare. "I think from a nurse's standpoint, it's satisfying because you know you're involved in an important element of a patient's care and the results are measurable."

Not only were the results measurable, officials said, but they were also remarkable.

Out of a group of 16,000 high-risk patients, including those with heart failure, end-stage renal disease, and diabetes, 12,000 were immunized this year, Bloom said. Of the diabetes patients alone, 69 percent received a flu vaccine, compared to 57 percent last year, and 80 percent had their pneumococcal vaccine, up from 59 percent.

Now that the diabetes program is in place, Geisinger is working on other goals. A coronary artery disease initiative began last fall, tracking the use of beta-blockers, cholesterol control, and other medications.

They are also implementing an electronic reminder system that will work in two ways. The first is a secure e-mail network that will remind patients about a necessary appointment, such as a mammogram or allergy shot, and then give them an electronic link to the appointment calendar so patients can schedule a visit at their convenience.

The second step will allow pharmacies and doctors' offices to connect more efficiently, with pharmacists alerting the doctor when someone is not renewing their medicine.

"Then you can dig into why they aren't taking their medication," said Anderer. "Is it the side effects? Is it the expense?"

Another component of ProvenCare lies in the hospital setting. A nurse "rooming" tool is an electronic program that standardizes the protocols for putting patients into rooms. Nurses are prompted to identify the patient by name and date of birth, ask if they have a living will, reconcile the medication list, and respond to any vaccine alerts.

The biggest overall challenge in creating ProvenCare was finding a way to measure the different standards and get the doctors to agree to them, said Paulus. For example, if someone says they will stop smoking but does not, why should the doctor be penalized financially?

"We know the caregiving team can influence behavior through encouragement and education," said Paulus.

"But what people do when they leave the office is often out of the doctor's control."

The answer was to include the "nonsmoking" objective as a goal, but not expect all the measures to reach 100 percent, he said.

Bloom, who is also the department director for quality and performance improvement, said the ultimate hope is to develop an entire patient care program, rolling in diabetes needs with general well care and other medical issues as they come up.

"The RAND Corporation had a study that found that perhaps 50 percent of routine health maintenance and preventative needs were taken care of," Bloom said. "This is a huge opportunity for us to make sure our patients get all of the recommended aspects of care."

—By Dawn Fallik, special to the Reporter

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