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

2. 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

3. Heal Teach Discover Serve Time Required for Primary Care of Patients Acute Care 4.6 hours/day Preventive Care 7.4 hours/day Chronic Care10.6 hours/day 22.6 Hours/day

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

5. 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

6. 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 New Techniques Delegated Team Responsibilities Strategies to Pull Patients into Care Non Office Visit Based Care EMR Reminders Pay for Performance

7. Heal Teach Discover Serve 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

8. 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

9. 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

10. 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

11. Heal Teach Discover Serve Diabetes Bundle

12. Heal Teach Discover Serve Diabetes Bundle Score Not all patients should achieve each measure – for instance not all diabetics should have a HgbA1c < 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

13. 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

14. Heal Teach Discover Serve Nurse Rooming Tool

15. Heal Teach Discover Serve Nurse Rooming Tool Improvements MyG Enrollments Urine Microalbumin

16. Heal Teach Discover Serve DM Health Maintenance Alerts

17. Heal Teach Discover Serve DM HM Alerts for Patients

18. Heal Teach Discover Serve Diabetes Best Practice Alerts

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

20. 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 MyGeisinger patients

21. Heal Teach Discover Serve Pneumococcal Immunization Age >65 0 500 1000 1500 2000 2500 3000 3500 SeptOctNovDecJanFebMarAprMayJunJulAug 2007/20082006/20072005/20062004/20052003/20042002/2003

22. Heal Teach Discover Serve Pneumococcal Immunization Age >65

23. Heal Teach Discover Serve Pneumococcal Immunization Age >65

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

25. Heal Teach Discover Serve Influenza Immunization

26. Heal Teach Discover Serve Influenza Immunization Age > 65

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

28. 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

29. 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

30. Heal Teach Discover Serve Improving Diabetes Care for 23,254 patients 3/063/078/088/09 Diabetes Bundle Percentage2.4%7.2%12.49%12.63% % Influenza Vaccination57%73% % Pneumococcal Vaccination59%83%85%84% % Microalbumin Order58%87%86%88% % HgbA1c < 7.033%37%47%44% % LDL < 10050%52%60%61% % BP < 130/8039%44%51%52% % Documented Non-Smokers74%84%85%

31. Heal Teach Discover Serve Diabetes Bundle Primary Care Average

32. Heal Teach Discover Serve Diabetes Bundle Improvement Number of Bundle Elements Achieved % of all diabetic patients 20% 10% 012345678All 3/31/06 6/30/06

33. Heal Teach Discover Serve Diabetes Bundle Improvement Number of Bundle Elements Achieved % of all diabetic patients 20% 10% 01 2 345678All 3/31/06 9/30/06 6/30/06

34. Heal Teach Discover Serve Diabetes Bundle Improvement Number of Bundle Elements Achieved % of all diabetic patients 20% 10% 012345678All 3/31/06 9/30/06 6/30/06 12/31/06 7% 2.5%

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

36. Heal Teach Discover Serve Improving CAD Care for 14,660 Patients 9/063/078/088/09 CAD Bundle Percentage8%11%20% % LDL <100 or <70 if High Risk38%37%46%47% % ACE/ARB in LVSD,DM, HTN65%66%75%76% % BMI measured79%86%98% % BP < 140/9074% 78%79% % Antiplatelet Therapy89%91%92% % Beta Blocker use S/P MI97% % Documented Non-Smokers86% 87% % Pneumococcal Vaccination80% 86% % Influenza Vaccination60%74%75%76%

37. Heal Teach Discover Serve CAD Bundle Primary Care Average

38. 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

39. Heal Teach Discover Serve Childhood Immunization

40. 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

41. Heal Teach Discover Serve Adult Prevention Bundle Recommendation AGE/SEX Adult Prevention Bundle 18-4950-64Over 65 FemaleMaleFemaleMaleFemaleMale Cancer Screening Breast Cancer Mammogram every 2yr 40-49, every year 50-74x (>40) x x (<75) x Cervical CancerPap every 3 yr 21-64x (>21) x x Colon Cancer Colonoscopy every 10 yrs or FOBT yearly xxx (<85) x Prostate Cancer Discussion Discuss prostate cancer screening yearly 50-74 x x (<75)x Lung CancerNon-smokerSee Tobacco Screening Below Cardiovascular Disease Lipid ScreeningEvery 5 years M>35,F>45x (>45)x (>35)xxx (<75) x Tobacco ScreeningNon-smokerxxxxxxx Infectious Disease Tetanus/Diptheria/ Pertusis VaccineTdap once then Td every 10 yearsxxxxxxx Influenza VaccineYearly >50 xxxxx Pneumococcal VaccineOnce >65 xxx Chlamydia ScreeningYearly 18-25x (<26) x Metabolic, Nutritional and Endocrine OsteoporosisEvery 3 years >65 x x DiabetesEvery 3 years >45x (>45) xxxxx ObesityBMI in EPICxxxxxxx Substance Abuse Alcohol Misuse Assess alcohol intake - Social History Completedxxxxxxx MAXIMUM NUMBER OF BUNDLE MEASURES FOR EACH AGE/SEX CATEGORY961091110

42. Heal Teach Discover Serve Adult Prevention Bundle 203,695 Patients 66% of recommended tests performed on these patients Initial Adult Prevention Bundle Percentage = 9.2%

43. Heal Teach Discover Serve Improving Preventive Care for 206,595 Patients 11/077/09 Adult Preventive Bundle9.2%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-Smokers75%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% Alcohol Intake Assessment84%88%

44. Heal Teach Discover Serve 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

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

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

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

48. Heal Teach Discover Serve

51. 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

52. 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

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

54. Heal Teach Discover Serve DM Trending – Last 13 Months

55. Heal Teach Discover Serve