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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