HealthLeaders Media LIVE From Geisinger Women’s Health ... · PDF fileand director of...

Featuring a live event on Sept. 18, 201312:00–3:00 p.m. ET (11 a.m.–2 p.m. CT)Geisinger Health System | Danville, Pa. 2 Analysis Proving Best Practices Can Work

in Women’s Health

4 Case Studies 4 Lesson 1: Best Practices and

Reducing Perinatal Variability: The ProvenCareTM Model

8 Lesson 2: Redefine Patient Engagement: Standardize Education and Empower Interaction

11 Lesson 3: Integration Techniques for Women’s Cardiovascular Care

14 Resource Guide Additional Resources From HealthLeaders Media

Case study exCerpt

HealthLeaders Media LIVE From Geisinger

Women’s Health LeadershipBest Practices and Reducing Perinatal Variability: Geisinger’s ProvenCareTM Model

2September 18, 2013 • HealthLeaders Media LIVE I Women’s Health Leadership

Proving Best Practices Can Work in Women’s Health

Analysis

at its core, Geisinger’s

ProvenCareTM model is

built on a simple idea: mak-

ing certain that every procedure or

encounter is done in an evidence-

based way every time. The team at

Geisinger has proven over time that

the model can work quite well for a

surgical procedure, such as coronary

artery bypass graft.

Taking the model to perinatal care

was a much different undertaking.

The “episode” of care is stretched over

months, often among different pro-

viders. So in one visit the goal might

be to make certain that prenatal

nutrition counseling is offered, and in

another, that the right set of imag-

ing studies are done. In most cases

these tests are done, but the beauty

of ProvenCareTM is a system to know

and verify what has been done, and

exactly when.

Harry O. Mateer Jr., MD, direc-

tor of obstetrics and gynecology at

Geisinger Medical Center, says what

matters is that “all of those best prac-

tices are offered at the appropriate

time for each and every individual,

and that people don’t fall through the

cracks because you think somebody

else did it and you don’t have a good

way of documenting and making sure

it was done.”

Geisinger has some infrastructure

that supports ProvenCareTM, includ-

ing an Epic-based electronic health

record and its integrated delivery

structure. Still, the idea can work at

less integrated systems as long as the

foundation for communication among

providers is there. For example, the

clinical team began with a set of 103

best practices that would be followed

throughout pregnancy. Those were

based on collaboration among the

physician and nursing teams, and are

validated against the latest research

and updated regularly.

Any rebuilding or improvement in

women’s health must begin with an

assessment of patient communication.

When the team at Geisinger looked

into its own efforts at educating preg-

nant women, it found a discomfiting

variety of materials and messages

Strategic Relationships DirectorHealthLeaders Media

JimMolpus

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that were confusing to patients. Likewise, the volume of material being dumped

on patients was excessive. So the team edited down the material to present a

consistent message.

Geisinger also understands that women’s health is a lifetime encounter, so

connection and communication among the disciplines is critical. In one example,

the cardiovascular team is working with OB-GYN to educate women who devel-

op certain complications during pregnancy that they may face an elevated risk of

heart disease later in life.

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the women’s health physician

and leadership team at

Geisinger Health System

started with a challenge: Could they

take the core fundamentals of the

health system’s ProvenCareTM model

of best practices from a surgical

procedure such as a coronary artery

bypass graft and apply those to

perinatal care? Geisinger’s model—

which combines a uniform set of best

practices with accountable systems to

make certain the right care is followed

at the right time—had demonstrated

results in surgical procedures. But

could it work in an episode of care that

is nine months long?

Harry O. Mateer Jr., MD, director

of obstetrics and gynecology at

Geisinger Medical Center, says

despite some obvious differences

between perinatal care and a surgical

procedure, delivering consistent care

involves the same elements.

“The basis behind ProvenCareTM

is that we know that for certain

Best Practices and Reducing Perinatal Variability: The ProvenCareTM Model

Case Study // LESSON 1

procedures, whether it’s a surgical

procedure or a complex nine-month

ordeal such as pregnancy, that there

are certain aspects of care that

should be offered to all patients at

various points during the procedure,”

Mateer says. “So if it’s a surgical

procedure, all individuals should be

offered certain things prior to the

surgery, during the surgery, and

then after the surgery, and those

are usually called best practices in

most modern health literature. Most

physicians know what they have to

do. It’s just really making sure that it

does get done.”

In prenatal care, the best

practices can sometimes be lab

work, education, family history, social

history, or radiology studies, Mateer

says. What matters is that “all of

those best practices are offered at the

appropriate time for each and every

individual, and that people don’t fall

through the cracks because you think

somebody else did it and you don’t

» Serves more than 2.6 million residents throughout 44 counties in central and northeastern Pennsylvania

» Physician-led system including a 1,000-member multispecialty group practice

» 20,000 employees

» Six hospital campuses

» Two research centers

» 400,000-member Geisinger Health Plan

Geisinger Health System Danville, Pa.

By jiM MOLPuS


Patient Education

-'

Number of Prenatal Education Materials: Before & After Standardization

Num

ber

of E

duca

tion

Mat

eria

ls:

have a good way of documenting and making sure it was done.”

So how does a clinical team make certain all of that gets done? Hans P.

Cassagnol, MD, associate chief quality officer of Geisinger Health System

and director of obstetrics and gynecology for Geisinger Northeast, says

implementation is built around two primary tools.

“We actually used evidence-based medicine and the electronic medical

record to come up with a set of best practice measures that we were going

to hold all providers to,” Cassagnol says. “What we have done over the past

several years is use those two components with different ways of actually

guiding the providers into delivering the evidence-based medicine at every single

opportunity.”

The first speed bump that many health systems may face is to create the

initial set of best practices. Geisinger began with a set of 103 distinct best

practices for perinatal care. “Some of those best practices can be as easy as

something like taking vital signs—recognizing that a blood pressure has to be

taken at each and every visit. And some of those best practices are things that

may just have to be offered once but at a specific time during the pregnancy.

So in those 103 best practices, there are usually between about 240 to 300

Patient Education

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times when those particular best practices need to be validated during a normal

pregnancy.”

Even with its history of integration and consistency of care, when the

Geisinger team started the exercise it found “unnecessary variation” in how care

was delivered across its 25 clinic locations in the region. The leadership team

made certain to communicate that the goal of the program was not to restrict

physicians but to give them a defined framework, Cassagnol says.

“One of the biggest misconceptions is that whenever we actually go through

the process of delivering the best practice measures, people tend to think we

are restricting providers from practicing a certain way,” he says. “The goal is

to provide overall guidance of what’s the expected level of care in a particular

situation. There’s always going to be deviation from the guidelines. We just

want to make sure people are thinking about the guidelines, and what should be

done within the best practice measure. If there’s a good reason to deviate from

that, we just want to make sure there’s an active thought process behind the

deviation.”

Any set of best practices has to be fluid to embody the latest evidence. One

example is when growing evidence from the American College of Obstetricians

and Gynecologists (ACOG) suggested that women who delivered via elective

cesarean prior to 39 weeks saw an elevated risk of complications. John Nash,

MD, chairman of the Department of Obstetrics and Gynecology at Geisinger

Health System, says the physician team quickly moved to adopt procedures to

avoid elective cesareans prior to 39 weeks.

“All we had to do as a group was say, ‘This is now what [ACOG] says is the

standard. It is the best practice.’ How can we justify putting babies and moms

at risk?” Nash says. “That risk is fairly small, but why put them at any risk? How

could we defend ourselves if we got a bad outcome? So our Geisinger docs

got together and said, ‘We are not going to accept anybody that schedules a

C-section prior to 39 weeks.’ ”

To hardwire this particular best practice, the electronic health record tracks

“THErE ArE CErTAIN ASPECTS OF CArE THAT SHOuLD BE OffEREd TO aLL PaTiENTS AT vArIOuS POINTS DurING THE PrOCEDurE.”

— Harry O. Mateer Jr., MD, director of obstetrics and gynecology at Geisinger Medical Center

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all C-sections throughout the system, along with the gestational age of the baby

and the reason for the C-section. If by chance an indication shows up in the

system for an elective C-section prior to 39 weeks, a red flag alerts the senior

obstetricians to contact the delivering physician in real time to review, Nash

says. For the past two years, Geisinger’s elective delivery rate prior to 39 weeks

has been zero.

The order sets embedded into the health record are meant to support and

remind physicians of the benchmarks of care, but not to bog down workflow.

One revamp they call the “result Consult” allows the physician to divide all of

the different lab and radiology work by weeks of pregnancy. So a physician can

simply check if a patient at 20 weeks has had all of the recommended studies,

and if not, can order them according to the timeline. If an opportunity is missed,

the alert reminds the physician at the next visit that the recommended care is

overdue but still within the time window to correct, Cassagnol says.

“Hard stops”—orders that a physician has to click though in the course of

the patient encounter—are built into the health record selectively, Mateer says.

“We also have what are called best-practice alerts for certain high-

importance areas, such as receiving rh immune globulin for our pregnant

patients who are rh-negative,” Mateer says. “If something has not been

completed at a particular point in the pregnancy, an alert will come up at the

very top of the patient encounter. Then a drop box will allow you to complete

that in a very easy, timely fashion. We didn’t want to have best-practice alerts

for every component because that can get overwhelming if you have a hard stop

to every component of care, but for certain crucial areas of care we felt that

hard stops were beneficial and would then be harder for a physician to miss.”

aGrEE on EviDEnCE Any health system or multidisciplinary OB-GYN group has a set of evidence-based protocols, quality measures, and clinical goals. The question to ask may be: How robust is the review and accountability to

those measures? Is there a process for communication and intervention to assist those physicians or clinical teams who do not meet agreed-upon goals?

TakEaWayS: What Makes it Work?

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all of the work that went into

redesigning the perinatal

care process wouldn’t have

mattered much if the patient com-

munication was out of sync with it.

So when the work group that rede-

signed perinatal care began, members

went around and gathered all of the

informational pamphlets, brochures,

and other educational materials that

were being given to pregnant women

at Geisinger clinics. What they found

was less than unified, or in sync,

Cassagnol says.

“We found something like 120–

130 different educational materials

that different providers in different

clinic sites were giving either at

different stages of pregnancy or

all at once during the pregnancy,”

Cassagnol says. “We found out a

huge amount of them were not only

outdated, [but] some of them were

clearly wrong, and some of them were

so redundant it felt like at some clinics

they were literally giving the patient

a huge book at the very first prenatal

Redefine Patient Engagement: Standardize Education and Empower interaction


visit to read. And when we followed

up with the patient, invariably they

read almost none of the information

that we gave them.”

So after the work group looked

at the pile of material, it eliminated

“close to 90%,” Cassagnol says,

and streamlined that to a bundle of

between nine and 12 educational

materials that a patient would truly

need. But it isn’t just the message of

the educational material they agreed

on, but the timing of when materials

would be distributed during the

pregnancy, he says.

“We educated all the nurses and

all the frontline staff who were doing

this education at the clinic sites.

We came up with a grid where all

of us agreed on which two pieces of

material the patient gets at the first

visit. And then two months later,

she will get these two and so forth,”

Cassagnol says. “So as of today, if

you were to walk in the farthest

east of our clinic sites or you go to

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the farthest west clinic site 210 miles away, you’ll get exactly the same type of

prenatal information at exactly the same time during the pregnancy.”

Mateer says one of the added benefits of streamlined communication is

reducing the staff time wasted.

“We found that there was a great deal of variety and unnecessary

duplication. Some people were getting information on car seats at their first

prenatal visit when that’s something that clearly they’ll pay more attention to

later in pregnancy,” Mateer says. “And so for nursing we found that it’s been

much easier to take care of patients because there is a very set guideline for

what an individual should receive at that particular point in pregnancy.”

Education is more than passing out material, as patients will often have a

long list of questions throughout the course of a pregnancy. So Geisinger has

a robust set of interactive tools that patients can use to contact their prenatal

care team, Cassagnol says.

“At each clinic and pretty much throughout the system there are general

contact information numbers that the patients use to call a nurse at any

particular time. On top of that, there’s something that we have called

MyGeisinger, which is an activated secure patient portal. A vast majority of our

patients end up using it in their pregnancy to communicate directly to a provider

or pool of nurses about any particular questions that they have.”

Geisinger has taken the patient portal a step further than just secure

communication between patient and provider. OpenNotes allows a patient

to view the physician’s notes about a patient encounter 24 hours afterward.

Physician pushback was anticipated, with concerns over how much patients

would understand of physician notes, and whether physicians would then be

“WE FOuND SOMETHING LIkE 120–130 different eduCational materials THAT DIFFErENT PrOvIDErS IN DIFFErENT CLINIC SITES WErE GIvING EITHEr AT DIFFErENT STAGES OF PrEGNANCY Or ALL AT ONCE DurING THE PrEGNANCY.”

— Hans P. Cassagnol, MD, associate chief quality officer of Geisinger Health System and director of obstetrics and gynecology for Geisinger Northeast

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deluged with communication. A pilot study found that the greatest concerns

never materialized.

“One, patients loved to have access to the note that was just written about

them when they left the doctor’s office,” Nash says. “Two, the calls did not

overwhelm physicians, and three, there were very few issues about ironing out

differences in what the patient perceived and what the physician wrote.”

The tools within the MyGeisinger patient portal are just one part of an

extensive program of communicating with women about all of their health

needs, says kerri Potsko, rN, BSN, associate vice president for women’s health

at Geisinger Health System.

“I think we do really well with communicating to patients,” Potsko says. “We

send out an annual birthday letter letting them know what tests they are actually

due for that particular year. They might be overdue for a colonoscopy or it

might be time for their annual GYN exam. We try to get people from all different

angles. We’re also working to communicate via Facebook. We’re implementing

text reminders for appointments. We are doing a lot of community education

throughout the year to keep people aware of what’s going on.”

All of the communication has one goal, Potsko says. “It’s important for

patients to understand how important it is that they’re involved in the process.

The reason there is so much communication built into our perinatal program is

to make patients active participants in their healthcare. But even that wouldn’t

happen at all if it weren’t for the physician leadership within the perinatal

ProvenCare team believing in it.”

Look For nEW TooLS If ever there was an opportunity for new tools in patient engagement, it may lie in perinatal care. Pregnant women today are much more likely to want to email their physicians with questions than pick up the

phone. Geisinger’s Epic-based platform has secure tools for patient communication, and even the OpenNotes feature to share physician notes with patients.

TakEaWayS: What Makes it Work?

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integration Techniques for Women’s Cardiovascular Care


the statistics tell a power-

ful story: Heart disease is

the No. 1 killer of women

in the united States, according to

the Centers for Disease Control and

Prevention. The same number of

women and men die each year due to

heart disease. Yet slightly more than

half of women do not recognize that

heart disease is their top threat.

With such stark numbers,

leading health systems recognize

the need for forging a stronger link

between cardiovascular care and an

overall women’s health program. In

particular, Geisinger has worked to

integrate cardiovascular care into

its OB-GYN program, recognizing

pregnancy is a pivotal time in a

woman’s life that may uncover

risk for future coronary artery

disease, says kimberly A. Skelding,

MD, interventional cardiologist

and director of Women’s Heart &

vascular Health at Geisinger Health

System.

“Women who have had an

obstetrical complication such as high

blood pressure or hyperglycemia in

pregnancy, fetal loss, or intrauterine

growth retardation become at

higher risk for cardiovascular disease

later in life than women who had

no complications in pregnancy,”

Skelding says. “Even healthcare

workers have absolutely no idea of

that correlation, for the most part,

and patients don’t as well. After

her delivery, a patient’s pregnancy-

related issues vanish and she goes

on her way, not realizing that she’s at

higher risk in the next 20 years for

heart disease.”

Geisinger is working to make

certain these women are aware of

their elevated risk of heart disease

“early so that risk factors can be

treated proactively,” Skelding says.

“These women need to be educated

early on about how to decrease

risk factors by eating a healthy

diet and having an active lifestyle.

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And in addition they need to be more thoughtful of their blood pressure, their

cholesterol, and all the other risk factors.”

Having an integrated electronic health record allows Geisinger to build

the information exchange into the system, Skelding says. “We have recently

developed a new tool within our electronic health record which will list the OB

risk factors and have them available for both the primary care physicians as

well as the cardiologist so that they’ll at least be there, very easily available,

recognizable, and then they can be worked upon.”

On top of the data infrastructure, Geisinger adds staff education for both

the OB-GYN group and primary care to make them more aware of the risks and

to make their referrals.

Education also extends to staff and the community on recognizing that

women present the symptoms of heart disease differently than men, Skelding

says.

“Seventy percent of both men and women will have chest pain as part

of their symptoms, but women will also have, generally speaking, other

concomitant symptoms that cloud the picture,” Skelding says. “In addition,

women present later and they often explain away their symptoms, and they’ll

call a neighbor, call a friend, call a family member, and convince themselves

that it’s not their heart and then stay home.”

And even when women do go to the physician, communication about their

heart disease can be a challenge. Skelding says when she does community

education sessions about women and heart disease, she encourages the

audience to be “very pointed in their discussion about their symptoms.”

“Generally women will weave a story,” she says. “A man will come in and

“THESE WOMEN NEED TO BE EDuCATED EArLY ON ABOuT HOW TO deCrease risK faCtors BY EATING A HEALTHY DIET AND HAvING AN ACTIvE LIFESTYLE.”

—Kimberly A. Skelding, MD, interventional cardiologist and director of Women’s Heart & Vascular Health at Geisinger Health System

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say, ‘I’ve had chest pain. This is what I was doing and this is what it felt like.’

Women will say, ‘Well, I was at the grocery store, and I was doing this, because

I had to get peanut butter. The story starts to lose impact with healthcare

providers because they’re not used to listening to a narrative. They’re more

used to the more objective way of hearing a patient’s history. And that can

be a disservice to women if they don’t learn how to communicate effectively

with their healthcare providers. So we do talk to them about trying to be very

pointed and direct, to write down their symptoms, and try to get their message

clearer to their healthcare provider.”

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for further StudyLeadership at Geisinger has focused best practices and patient education to ensure that every procedure or encounter is done in an evidence-based way throughout the perinatal experience. For further study, consider the following resources:

The Patient Experience Challenge: HCaHPS and Beyond

This analysis is excerpted from

the August 2013 HealthLeaders

Media Intelligence Report, Patient

Experience Beyond HCAHPS:

Care Coordination and Cultural

Transformation.

At some point in the pursuit

of providing positive patient

experiences, one must come to

grips with the pivotal role that

communication plays. Perhaps

considering the rigors of mastering

their particular area of expertise and

of applying their knowledge to the

delivery of care for patients, some

might look on communication as

being a “soft” skill. But when it comes

RESOuRCE

GuIDE

Patient-related Focus

Q: In which of the following patient-related areas do you expect your organization to focus over the next three years for patient experience improvements?

Care coordination inside your organization 71%

Identifying concerns while patients still on-site 69%

Leadership rounds 55%

Care coordination outside your organization 49%

Noise levels 40%

Patient outreach programs 38%

Housekeeping 25%

Signage 22%

Dietary services 22%

to becoming patient-centered and delivering excellent patient experiences,

both the advisors to this Intelligence report and the survey respondents

alike acknowledge the importance of teaching, learning, and reinforcing

communication skills.

Nearly three-quarters of respondents (74%) expect to focus on patient

http://www.healthleadersmedia.com/intelligence/detail.cfm?content_id=290603&year=2013








experience training and education over the next three years, and 30% expect

to increase their spending on professional trainers or training materials. Says

report advisor William Maples, MD, senior vice president and chief quality

officer at Mission Health System, a not-for-profit, independent community

hospital system serving western North Carolina and the adjoining region,

“People may be looking at patient experience in terms of it being soft—the fluffy

side of medicine.” But he also points out that traditional process improvement

efforts won’t necessarily translate to patient experience improvement. “For so

long, I believed that we thought we could engineer our way into safety/no harm

and positive outcomes.”

Crossing the Chasm to Collaborative Care This analysis is excerpted from the April 2013 HealthLeaders Media

Intelligence Report, Collaborative Care: Hospitals Balance risk and revenue

With Physicians and Payers.

Collaborative care, which holds the promise of bringing together

stakeholders to lower the cost and improve the quality of patient care, is a

relatively new business model that is being embraced by providers and health

plans. While there is a high level of confidence among healthcare leaders that

Collaborative Care Components

Q: What collaborative care components do you have in place today?

Case or care managers 76%

Quality data 74%

Mid-level clinicians 64%

Operational data 56%

Team-based care 50%

Defined protocols for transitions of care 48%

Health information exchange 40%

Patient-centered medical home 36%

Compensation-based incentives 32%

Integrated HIT between ambulatory and inpatient 28%

Patient registries 25%

Regular review of shared patients 23%

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www.healthleadersmedia.com/intelligence/detail.cfm?content_id=290603&year=2013


















about the HostGeisinger is an integrated health services organization widely recognized for its innovative use of the electronic health record, and the development and implementation of innovative care models including ProvenHealth NavigatorTM, an advanced medical home model, and ProvenCareTM program. The system serves more than 2.6 million residents throughout 44 counties in central and northeastern Pennsylvania.

about UsHealthLeaders Media is a leading multi-platform media company dedicated to meeting the business information needs of healthcare executives and professionals. To keep up with the latest on trends in physician alignment and other critical issues facing healthcare senior leaders, go to www.healthleadersmedia.com.

Publisher EViLEE [email protected]

Leadership Programs DirectorjiM [email protected]

Editorial Director EdWaRd [email protected]

Managing EditorBOB [email protected]

Media Sales Operations ManageraLEX [email protected]

SponsorshipFor information regarding underwriting opportunities for HealthLeaders Media LiVE, contact [email protected] or 800-753-0131

Copyright ©2013 HealthLeaders Media, 5115 Maryland Way, Brentwood, TN 37027 • Opinions expressed are not necessarily those of HealthLeaders Media. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.

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collaborative care will improve population health, the potential for such a model

to deliver cost savings is a concern.

Collaborative care, it seems, is caught in a transition that is all too familiar

to those who are on the frontlines of healthcare reform implementation: making

large investments today in anticipation of returns (reduced healthcare costs)

somewhere down the road.

According to the results of the 2013 HealthLeaders Media Collaborative

Care Survey, 69% of healthcare leaders are in at least the early stages of

considering participation in a formal collaborative care model with 25% already

participating in one. “Collaborative care is definitely on everyone’s radar,”

says John katsianis, senior vice president and CFO of Dekalb regional Health

System, a two-hospital system in Decatur, Ga. “When you think about HCAHPS

and readmission penalties … we have the most money at risk if we don’t

perform.”

www.healthleadersmedia.com

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