heal teach discover serve frederick j. bloom, jr. md mmm assistant chief quality officer quality...

Heal • Teach • Discover • Serve

Frederick J. Bloom, Jr. MD MMM

Assistant Chief Quality Officer

Quality Improvement Using Systems of Care


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


Time Required for Primary Care of Patients

• Acute Care 4.6 hours/day• Preventive Care 7.4 hours/day• Chronic Care 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


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


Clinical Process RedesignComponents 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


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


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


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


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

Goal Non-SmokerInfluenza

Immunization HgbA1c <7 BP < 130/80 LDL < 100Complete

BundlePatient 1Patient 2Patient 3Patient 4Patient 5Percentage 80% 80% 60% 60% 60% 0%


Diabetes Bundle

Measures

HgbA1C measurement X

HgbA1C control X

LDL measurement X

LDL control X

Blood pressure control X

Urine protein testing X

Influenza immunization X

Pneumococcal immunization XSmoking status X

Patients who receive/achieve ALL of the above X

Yearly

Once before 65, Once after 65Non-smoker

DM Bundle Percentage

Yearly

< 100

< 130/80

Quality Standard

Every 6 months

Yearly

< 7

Measures

HgbA1C measurement X

HgbA1C control X

LDL measurement X

LDL control X

Blood pressure control X

Urine protein testing X

Influenza immunization X

Pneumococcal immunization XSmoking status X

Patients who receive/achieve ALL of the above X

Yearly

Once before 65, Once after 65Non-smoker

DM Bundle Percentage

Yearly

< 100

< 130/80

Quality Standard

Every 6 months

Yearly

< 7


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


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


Nurse Rooming Tool


Nurse Rooming Tool Improvements

0

1000

2000

3000

4000

5000

6000

7000

8000

Dec-05 Jan-06 Feb-06 Mar-0666687072747678

8082848688

Jul-07 Aug-07 Sep-07 Oct-07 Nov-07

MyG Enrollments Urine Microalbumin


DM Health Maintenance Alerts


DM HM Alerts for Patients


Diabetes Best Practice Alerts


Diabetes: Patient Letter/Report Card

Last 2-3 values displayed

LDL values and goals.

Last BP readings


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


Pneumococcal Immunization Age >65

0

500

1000

1500

2000

2500

3000

3500

Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug

2007/2008 2006/2007 2005/2006 2004/2005 2003/2004 2002/2003


Pneumococcal Immunization Age >65


Pneumococcal Immunization Age >65 High Risk Patients


Influenza Immunization

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

Sept Oct Nov Dec Jan Feb Mar

2007/2008

2006/2007

2005/2006

2004/2005

2003/2004

2002/2003


Influenza Immunization Age > 65


Influenza Immunization Age >65 High Risk Patients


Patient Outreach ProgramsContacting 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


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


Improving Diabetes Care for 23,254 patients

3/06 3/07 8/08 8/09

Diabetes Bundle Percentage 2.4% 7.2% 12.49% 12.63%

% Influenza Vaccination 57% 73% 73% 73%

% Pneumococcal Vaccination 59% 83% 85% 84%

% Microalbumin Order 58% 87% 86% 88%

% HgbA1c < 7.0 33% 37% 47% 44%

% LDL < 100 50% 52% 60% 61%

% BP < 130/80 39% 44% 51% 52%

% Documented Non-Smokers 74% 84% 85% 85%


Diabetes Bundle Primary Care Average

Diabetes Bundle Improvement (7/06-7/09)

R2 = 0.829

0%

3%

7%

10%

13%

16%

DM

Bundle

Per

centa

ge


Diabetes Bundle ImprovementNumber of Bundle Elements Achieved

% of all diabetic patients

20%

10%

0 1 2 3 4 5 6 7 8 All

3/31/06

6/30/06




20%

10%

0 1 2 3 4 5 6 7 8 All

3/31/06

9/30/06

6/30/06




20%

10%

0 1 2 3 4 5 6 7 8 All

3/31/06

9/30/06

6/30/06

12/31/06

7%

2.5%


0%

5%

10%

15%

20%

25%

30%

0 1 2 3 4 5 6 7 8 ALL

Diabetes Bundle ImprovementMovement Since Year 1

12/08

6/08

12/07

6/09

6/07

12/06



Improving CAD Care for 14,660 Patients

9/06 3/07 8/08 8/09

CAD Bundle Percentage 8% 11% 20% 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% 98%

% BP < 140/90 74% 74% 78% 79%

% Antiplatelet Therapy 89% 91% 92% 92%

% Beta Blocker use S/P MI 97% 97% 97% 97%

% Documented Non-Smokers 86% 86% 87% 87%

% Pneumococcal Vaccination 80% 80% 86% 86%

% Influenza Vaccination 60% 74% 75% 76%


CAD Bundle Primary Care AveragePrimary Care Average CAD Bundle

R2 = 0.843

0

5

10

15

20

25

CAD

Bund

le Pe

rcen

tage


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


Childhood Immunization


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



Recommendation

AGE/SEX

AdultPrevention

Bundle

18-49 50-64 Over 65

Female Male Female Male Female Male

Cancer Screening

Breast CancerMammogram every 2yr 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 CancerColonoscopy every 10 yrs or FOBT

yearly x x x (<85) x (<85) x

Prostate Cancer DiscussionDiscuss 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 (<75) x

Tobacco Screening Non-smoker x x x x x x x

Infectious Disease

Tetanus/Diptheria/ Pertusis Vaccine Tdap once then Td every 10 years x x x x x x x

Influenza Vaccine Yearly >50 x x 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 (>45) x x x x x

Obesity BMI in EPIC x x x x x x x

Substance Abuse

Alcohol MisuseAssess alcohol intake - Social

History Completed x x x x x x x

MAXIMUM NUMBER OF BUNDLE MEASURES FOR EACH AGE/SEX CATEGORY 9 6 10 9 11 10



• 203,695 Patients

• 66% of recommended tests performed on these patients

• Initial Adult Prevention Bundle Percentage = 9.2%


Improving Preventive Care for 206,595 Patients11/07 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%

Alcohol Intake Assessment 84% 88%


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


GHP GOLD HEDIS PerformanceGeisinger Clinic compared to Panel Providers

Study ResultsTotal Rate Clinic Panel Test of Means

orPopulation Inferences

Effectiveness of Care (a = .10), two tailComprehensive Diabetes Care:

HbA1c tested 94.2% 98.8% 87.7% Statistically Higher P<0.0001HbA1c Good control <7.0% 51.3% 55.8% 45.0% Statistically Higher P=0.0308

HbA1c Poor controlled >9.0% (Lower rate indicates better performance) 12.7% 5.4% 22.8% Statistically Higher P<0.0001

Lipid Profile performed 92.0% 95.4% 87.1% Statistically Higher P=0.0023LDL-C <100 54.5% 58.3% 49.1% Statistically Higher P=0.0643

Diabetic Retinal Eye Exams 88.1% 92.5% 81.9% Statistically Higher P=0.001BP controlled <130/80 44.3% 52.9% 32.2% Statistically Higher P<0.0001BP controlled <140/90 69.6% 75.4% 61.4% Statistically Higher P=0.0023

Kidney Disease monitored 93.4% 96.7% 88.9% Statistically Higher P=0.0016Breast CA Screening 83.5% 88.6% 77.6% Statistically Higher P<0.0001Colorectal CA Screening 65.8% 70.8% 60.5% Statistically Higher P=0.0324Cholesterol Mgmt after Acute Cardio - LDL Screening 93.0% 97.6% 88.3% Statistically Higher P=0.0003 - LDL <100 67.1% 72.6% 61.4% Statistically Higher P=0.0178Controlling High Blood Pressure 67.2% 73.9% 60.1% Statistically Higher P=0.0051Antidepressant Med Mgmt - Optimal Practitioner Contacts 16.1% 14.7% 17.0%Spirometry Testing for COPD 41.8% 59.4% 33.2% Statistically Higher P<0.0001Glaucoma Screening 76.7% 81.0% 71.9% Statistically Higher P<0.0001

HEDIS 2008


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


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


QUESTIONS?

[email protected]


DM Trending – Last 13 Months


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heal teach discover serve frederick j. bloom, jr. md mmm assistant chief quality officer quality...

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