ProvenCare

by Glenn D Steele

  Does this type of precision medicine make a difference? Projecting from our early experience, we are confident that we will be able to reduce the risk of breast cancer in women under 40 in our population by the identification of high-risk individuals and improved surveillance and treatment. Familial hypercholesterolemia appears to be found in one in 250 of our patients. According to the American Academy of Pediatrics, children in such families should be evaluated and statin treatment started by age eight to reduce the early heart damage and risk of early heart attacks.2 So we add value in this area, too.

  We expect that many patients will benefit directly from participation in this research because of our ability to validate and return clinically actionable results to them, such as starting appropriate youngsters on statins. In addition, all patients will benefit from the knowledge we gain regarding setting standards for genome-informed care. The study will transform our ability to foresee disease before the onset of symptoms, diagnose chronic and potentially fatal conditions before it’s too late to intervene, and determine how best to optimize the health and well-being of each patient.

  CARE IN PLACE

  We believe that every time a patient arrives at a provider for care, the organization should apologize that he or she had to come. Our goal is to treat patients at home, at work, or in the classroom, rather than in the hospital or clinic, and moving forward, providing the right care in the right place will be more important than ever.

  For example, a heart failure patient arriving at one of our emergency departments will be started on diuresis, and then “admitted” to his home where hands-on, in-place professional follow-up care will be administered until he’s recovered. A person experiencing a heart attack will be “admitted” to home with a paramedic, who will take care of her for the next three or four days as a “hospital” patient. Her cardiologist will round regularly via Skype until the patient is indeed “discharged” to home.

  A recent study demonstrated that for the typical medical appointment, patients drive about 40 minutes, wait approximately an hour to be seen, and spend 20 minutes with the doctor.3 The cost to the American economy of this nonproductive travel and waiting is astronomical. According to Geisinger, being patient-centered and caring means coming to you, either virtually or physically.

  If you’ve shown up at one of our facilities, we will make the best use of your time, first by eliminating the wait. In our clinics, there will be no waiting rooms, as they have no value; they will be converted to clinical space. As you enter the parking lot or garage, a transponder on your dashboard will alert us that you’re on site and will arrive in the clinic in three to eight minutes. We’ll get the exam room ready, and the physician will be there waiting with the cardiologist you’ve anticipated seeing for a second opinion because of your heart concern. They know all about you, thanks to our CRM system and clinical and genetic records, and they’ve prepared for your visit ahead of time via the OurNotes system that allows patients to help set the agenda. If you’ve asked a question this morning about needing a dermatologist, one will link in via telemedicine shortly.

  The doctor will not spend all of her time entering information into a computer, so the focus will be entirely on you. The computer is there to serve the doctor and provide prompts regarding what she may be missing. For example, the doctor may review your last five blood pressure readings from the EHR using a device that enables her to keep the focus on you personally. An assistant or intelligent system will record the visit notes, and you’re on your way in 15 to 20 minutes, feeling that your time and money were well spent.

  We’ve built physical spaces for such innovations, with pilots under way and patients being invited to participate. But it’s not just a physical location that makes it possible; it’s a completely different service mentality: we exist to serve you, and we value your time.

  FAMILY AS CAREGIVERS

  Consider all of the disruptions in the travel industry during the past decade. You’re now the travel agent and the airline check-in employee. Airline innovations such as online flight booking and check-in were ways to transition labor to the customer and lower costs. Similarly, we will transition care to patients and family members by training them to be part of the care team, but the goal here is to improve the quality of outcomes.

  With inpatients, we typically never ask the family member whether they’d like to provide food for the patient or whether someone would like to be the nursing assistant and change dressings. In our future vision, however, families will help care for patients. As we’ve explored this innovation, we’ve found that family members are willing and able to provide care to their loved ones.

  For example, one weekend Dr. Feinberg went to visit a patient at home, an Amish farmer who had fractured nine ribs when he was pinned by a large bull in his barn. Despite suffering significant pain and having trouble breathing, he initially refused to seek care and only relented when a physician friend urged him to go to the hospital, where he was admitted to relieve his pain and prevent pneumonia. The patient insisted on being released after two days because he preferred to be treated at home.

  Asked about his care in the hospital, the patient noted that he was treating his pain by applying to his ribs an herbal remedy made from plants in his yard, which to him was a more comfortable approach. He also observed that when our healers moved him they were “work hardened,” remarking that his wife was “more delicate” when she moved him. His wife, baking pies nearby, had never moved a trauma patient before, but she did it perfectly. While there were benefits to the patient being in the hospital where we could monitor him more closely, his family was taking better care of him because they were not “work hardened.”

  Healthcare often gets so caught up in regulations that the family can’t lay a hand on inpatients. But when they go home, their families become their nurses and often do a better job of caring. We presently are building an experimental inpatient unit to pilot the concept of having family members on the care team and working through the associated regulatory issues.

  A RALLYING CRY FOR CARE AND CARING

  Geisinger nurse Cassandra Thomas was enjoying a vacation in Florida with her family when the sky darkened and lightning struck the beach. Looking out the window, she saw someone down on the sand, and her nursing instincts told her something was terribly wrong. She ran down 16 flights of stairs and out onto the beach where, with lightning still in the area, she performed CPR on 15-year-old Cameron. Assisted by a police officer who was also on vacation and others, Cassandra continued CPR until paramedics arrived. Little did Cameron know how lucky he was to have someone, who is not only a nurse but a CPR instructor, put herself in harm’s way to help him. Cassandra’s efforts were heroic, but she didn’t think she was doing anything out of the ordinary.4 That is what care and caring are all about.

  Today, Geisinger is one of the most scientifically advanced and innovative healthcare organizations in America. But we also know that to be the best, we must care the best. We must never forget what got us here: the values we share with our neighbors, friends, patients, and loved ones. We’re committed to the good health of our community, with compassionate, kindhearted caring along with our advanced, innovative care.

  We’re also committed to sharing what we’re learning and doing in our journey. Our solutions are highly reliable, based on processes and tools refined in our clinical settings. Many of our best practices came from studying the ways of others, and we’re eager in turn to share our methods, trials, and results through published research and medical education. Numerous other health systems are replicating our improved patient outcomes, enhanced efficiencies, and reduced costs.

  We invite you to join them and us in this quest to be the best in care and caring.

  LESSONS LEARNED

  • Innovation in healthcare never ends.

  • Geisinger is continuing to challenge itself to improve in every way.

  • Scaling Geisinger’s innovations is one of our most importa
nt strategic commitments.

  • Caring is fundamental to caregiving.

  • Caring must go beyond meeting the accepted standards of care.

  • Know your patients better than Amazon.com knows its customers.

  NOTES

  ACKNOWLEDGMENTS

  1. J. Wennberg and Alan Gittelsohn, “Small Area Variations in Health Care Delivery,” Science 182, no. 4117 (December 14, 1973): 1102-08, https://www.ncbi.nlm.nih.gov/pubmed/4750608.

  2. Robert E. Andrews et al., Towards a New Model of Health Care Employer-Facilitated Care (Washington, DC: American Health Policy Institute, 2016), http://www.americanhealthpolicy.org/Content/documents/resources/Towards_a_New_Model_of_Health_Care.pdf.

  CHAPTER 1

  1. Miliard, Mike, “Geisinger CEO David Feinberg, MD, on patient satisfaction, population health, genomics and more”, Healthcare IT News, (2016, April 12), http://www.healthcareitnews.com/news/geisinger-ceo-david-feinberg-md-patient-satisfaction-population-health-genomics-and-more

  2. Anthony Shih, Karen Davis, Stephen C. Schoenbaum, Anne Gauthier, Rachel Nuzum, and Douglas McCarthy, “Organizing the U.S. Health Care Delivery System for High Performance,” Commission on a High Performance Health System (New York: The Commonwealth Fund, August 2008), http://www.commonwealthfund.org/usr_doc/Shih_organizingushltcaredeliverysys_1155.pdf.

  3. Reed Abelson, “In Bid for Better Care, Surgery with a Warranty,” New York Times, May 17, 2007, http://www.nytimes.com/2007/05/17/business/17quality.html?_r=0.

  4. President Barack Obama, address, Joint Session of Congress on Healthcare, September 9, 2009, https://obamawhitehouse.archives.gov/the-press-office/remarks-president-a-joint-session-congress-health-care

  5. President Barack Obama, remarks, town hall meeting, Southwest High School, Green Bay, Wisconsin, July 11, 2009, https://www.whitehouse.gov/blog/2009/06/11/a-town-hall-and-a-health-care-model-green-bay.

  6. Joe Klein, “The Long Goodbye,” TIME, June 11, 2012, http://time.com/735/the-long-goodbye/.

  7. Steve Sternberg, “Unsatisfied With Your Surgery? Get (Some of) Your Money Back,” U.S. News & World Report, November 11, 2015, http://www.usnews.com/news/articles/2015/11/11/unsatisfied-with-your-surgery-get-your-money-back.

  CHAPTER 2

  1. Gerard Anderson, Chronic Care: Making the Case for Ongoing Care (Princeton, New Jersey: Robert Wood Johnson Foundation, 2010), http://www.rwjf.org/en/research-publications/find-rwjf-research/2010/01/chronic-care.html.

  2. Elizabeth A. McGlynn et al., “The Quality of Health Care Delivered to Adults in the United States,” New England Journal of Medicine, June 26, 2003, http://www.nejm.org/doi/full/10.1056/NEJMsa022615.

  3. Arnold Milstein, “Perspective: Managing Utilization Management: A Purchaser’s View,” Health Affairs 16, no. 3 (1997): 87–90, http://content.healthaffairs.org/content/16/3/87.full.pdf+html.

  CHAPTER 4

  1. Glenn Steele Jr., Reinventing Health Care: The Geisinger Health System 2001–2015 (Danville, PA: privately published, 2015), 352.

  2. Ibid, 353.

  3. Ibid, 361–62.

  4. Ibid. 364, 365, 371.

  5. Lawrence F. Wolper, Healthcare Administration: Managing Organized Delivery Systems, 5th ed. (Burlington, MA: Jones & Bartlett Learning, 2010), 86.

  6. Reinventing Health Care, 357–59.

  CHAPTER 5

  1. Pennsylvania Health Care Cost Containment Council, www.phc4.org.

  2. A. S. Casale et al., “ProvenCare: A Provider-Driven Pay-for-Performance Program for Acute Episodic Cardiac Surgical Care,” Annals of Surgery 246, no. 4 (2007): 613–21.

  3. G. Pang, “Central Teachers Gain $7,000 Average: Health Care Savings Balance Raises in Contract,” Press Enterprise (July 6, 2009).

  4. Reed Abelson, “In Bid for Better Care, Surgery with a Warranty,” New York Times, May 17, 2007, http://www.nytimes.com/2007/05/17/business/17quality.html?_r=0.

  5. Ibid.

  CHAPTER 6

  1. Glenn Steele Jr., MD, PhD, Reinventing Health Care: The Geisinger Health System 2001–2015, ©2015 Geisinger Health System.

  2. Steele, Reinventing Health Care.

  3. Steele, Reinventing Health Care.

  4. Steele, Reinventing Health Care.

  CHAPTER 7

  1. Alexander Kulik, Marc Ruel, Hani Jneid, T. Bruce Ferguson, Loren F. Hiratzka, John S. Ikonomidis, Francisco Lopez-Jimenez, Sheila M. McNallan, Mahesh Patel, Véronique L. Roger, Frank W. Sellke, Domenic A. Sica, and Lani Zimmerman on behalf of the American Heart Association Council on Cardiovascular Surgery and Anesthesia, “Secondary Prevention After Coronary Artery Bypass Graft Surgery: A Scientific Statement From the American Heart Association,” Circulation (February 9, 2015): published online ahead of print, http://circ.ahajournals.org/content/early/2015/02/09/CIR.0000000000000182.

  2. Mark R. Katlic, Matthew A. Facktor, Scott A. Berry, Karen E. McKinley, Albert Bothe Jr., Glenn D. Steele Jr., “ProvenCare Lung Cancer: A Multi-Institutional Improvement Collaborative,” CA: A Cancer Journal for Clinicians 61 no.6 (November–December 2011): 382–96.

  CHAPTER 8

  1. 2010 Diabetes Burden Report, Pennsylvania Department of Health, http://www.statistics.health.pa.gov/HealthStatistics/OtherHealthStatistics/Documents/2010_Diabetes_Burden_Report.pdf.

  2. Thomas Nolan and Donald M. Berwick, “All-or-None Measurement Raises the Bar on Performance,” JAMA 295, no. 10 (2006): 1168–70, http://ow.ly/4n7Ktt.

  3. Frederick J. Bloom Jr. et al., “Primary Care Diabetes Bundle Management: Three-Year Outcomes for Microvascular and Macrovascular Events,” American Journal of Managed Care 20, no. 6 (June 26, 2014), http://ow.ly/4n7I8m.

  4. Daniel D. Maeng et al., “Value of Primary Care Diabetes Management: Long-Term Cost Impacts,” American Journal of Managed Care 22, no. 3 (February 29, 2016), http://ow.ly/4n7J5p.

  5. xG Health Solutions, ProvenCare Process Guide, Chronic Disease Methodology Diabetes Mellitus Management.

  6. Ibid.

  7. ProvenCare codes are customized, best practice clinical codes. Their purpose is to optimize care plans, health management reminders, performance monitoring, and evidence-based alerts. These codes are not billing codes and are not used for any reimbursement purpose.

  8. xG Health Solutions, ProvenCare Process Guide, Chronic Disease Methodology Diabetes Mellitus Management.

  9. Jan Walker et al., “The Road Toward Fully Transparent Medical Records,” New England Journal of Medicine 370 (January 2, 2014), http://ow.ly/4n7JXG.

  10. Bloom et al.

  11. Maeng et al.

  CHAPTER 9

  1. “Reinventing American Healthcare,” WVIA original feature presentation, 56:44, April 23, 2015, http://on-demand.wvia.org/video/2365467227/.

  2. Thomas Nolan and Donald M. Berwick, “All-or-None Measurement Raises the Bar on Performance,” JAMA 295, no. 10 (2006): 1168–70, http://ow.ly/4n7Ktt.

  3. See Figures 6.1 and 6.2.

  CHAPTER 10

  1. The Institute for Healthcare Improvement’s “Triple Aim” is to improve the patient’s experience of care (including quality and satisfaction); to improve the health of populations; and to reduce the per capita cost of healthcare. See IHI Triple Aim Initiative, http://www.ihi.org/engage/initiatives/tripleaim/pages/default.aspx, accessed September 27, 2016.

  CHAPTER 11

  1. For a concise explanation of biological products and how they differ from conventional drugs, see “ ‘What Are Biologics’ Questions and Answers,” U.S. Food and Drug Administration, accessed August 8, 2016, http://www.fda.gov/AboutFDA/CentersOffices/OfficeofMedicalProductsandTobacco/CBER/ucm133077.htm.

  2. Express Scripts Holding Company, Express Scripts 2015 Drug Trend Report. St. Louis: Express Scripts Holding Company, 2016, http://lab.express-scripts.com/lab/drug-trend-report.

  3. Steven G. Ivey (vice president, specialty pharmacy programs, MedImpact Healthcare Systems, Inc.), in discussion with Geisinger Health Plan, November 19, 2015.

  4. Aimee Tharaldson, “Speci
alty Drug Approvals in 2013,” (blog), Express Scripts Holding Company, March 26, 2014, http://lab.express-scripts.com/lab/insights/drug-options/specialty-drug-approvals-in-2013.

  5. Dean M. Wingerchuk and Jonathan L. Carter, “Multiple Sclerosis: Current and Emerging Disease-Modifying Therapies and Treatment Strategies,” Mayo Clinic Proceedings 89, no. 2 (February 2014): 225–40.

  6. Institute for Safe Medication Practices, “Cancer Risks of Biological Products for Psoriasis,” QuarterWatch (April 6, 2016), http://www.ismp.org/QuarterWatch/Default.aspx.

  7. Deena Beasley, “Analysis: Drug Costs Become Bigger Issue in Cancer Care,” Reuters, June 14, 2012, http://www.reuters.com/article/us-cancer-cost-idUSBRE85E05B20120615.

  8. Pharmaceutical Research and Manufacturers of America, “Cancer Chart Pack, Cancer Medicines: Value in Context,” 2014, http://www.phrma.org/sites/default/files/pdf/cancer-chart-pack-5-22-14.pdf.

  CHAPTER 12

  1. Press Ganey Associates works with more than 10,000 health care organizations nationwide, including more than half of U.S. hospitals, to improve patient care and experience.

  2. Wendy Chaboyer, Anne McMurray, and Marianne Wallis, “Bedside Nursing Handover: A Case Study,” International Journal of Nursing Practice 16, no. 1 (January 2010): 27–34. See also Wendy Chaboyer, Anne McMurray, Joanne Johnson, et al., “Bedside Handover: Quality Improvement Strategy to ‘Transform Care at the Bedside’,” Journal of Nursing Care Quality 24, no. 2 (April 2009): 136–42.