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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
5September 18, 2013 • HealthLeaders Media LIVE I Women’s Health Leadership
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
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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
Case Study // LESSON 2
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
Case Study // LESSON 3
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
15September 18, 2013 • HealthLeaders Media LIVE I Women’s Health Leadership
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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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.
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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.”