How Will This Module Help Me?
Discusses 4 STEPS to incorporating Choosing Wisely in your practice.
Answers frequently asked questions about Choosing Wisely.
Provides tools and resources to help you and your team implement Choosing Wisely.
Do you ever find yourself wondering if your patients are receiving tests or treatments that are unnecessary or of limited benefit? Quiz Ref IDChoosing Wisely is a campaign from the American Board of Internal Medicine (ABIM) Foundation and Consumer Reports that aims to promote conversations between patients and clinicians to choose care that is supported by evidence, is not duplicative of other tests or procedures already received, has the lowest possible risk for harm, and is truly necessary.
The Choosing Wisely resources have more than 500 recommendations from 68 specialty societies that cover tests, treatments, and commonly encountered procedures. Each list provides evidence patients and physicians can use in their conversations to decide whether tests and procedures are appropriate for the situation. Using Choosing Wisely lists may help you recommend appropriate tests and hone communication skills to help educate your patients. Choosing Wisely is not a set of rigid guidelines, but rather a strategy for engaging with patients and colleagues.
Four STEPS to Implement Choosing Wisely in Your Practice
Engage Your Team.
Engage Your Patients.
Establish an Implementation Plan for the Practice.
Use Data to Understand and Improve Performance.
Quiz Ref IDCenter the conversation around the benefit for the patient. The national Choosing Wisely campaign has found that the issues of safety and patient-centered care resonate with physicians more than discussions of waste and cost reduction. Agree to pilot Choosing Wisely in one disease area or with one diagnosis and see how it works.
Conversation starters. It is also important to emphasize that Choosing Wisely recommendations are conversation starters, not mandates, and that medical decision-making is based on the patient's best interest and the physician's professional judgement. It is expected that physicians will sometimes deviate from the Choosing Wisely recommendations based on patients' unique circumstances and the physician's judgment.
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One important caveat is that it is important to be mindful of the fact that these decisions can have financial impact on patients. Some Choosing Wisely recommendations are based on recommendations that, under the ACA, impact insurance coverage. Health insurance plans may also choose not to cover services that are not recommended. If coverage for a non-recommended service is denied, physicians may need to be prepared to justify their decision to the health plan and/or the patient.
Quiz Ref IDConsider having your clinical support team provide patients with appropriate resources developed by Choosing Wisely when rooming patients for specific complaints (e.g., headache, upper respiratory infection, low-back pain, or cervical cancer screening). For example, when the nurse or medical assistant (MA) rooms a patient who presents with symptoms of a sinus infection, the patient can be given the Choosing Wisely handout on sinusitis. By reading the handout ahead of the physician visit, the patient may be more likely to agree to a non-antibiotic approach to treatment.
Care Team Education. It is important to educate the care team members who often field questions from patients, including:
Your MAs or nurses, who room patients and discuss after-visit summaries. These individuals could be trained to utilize Choosing Wisely materials as part of their professional development curriculum.
Your health coaches, who may have discussions with patients about specific treatment options and tests related to chronic disease management.
“Community health screening fairs often include unnecessary tests or tests with limited benefit, such as a carotid ultrasound screening in asymptomatic, low-risk patients. False positives are common, often leading these patients to be referred for a carotid endarterectomy that can be potentially harmful. It's disturbing when a previously healthy patient returns to the office with a facial droop having suffered a stroke as a result of a series of unnecessary and increasingly invasive procedures.”
-Marie Teresa Brown, MD, MACP, Internal Medicine, Oak Park, IL
Identify and Address Potential Barriers to Implementing Choosing Wisely. Have a conversation with your team about their concerns and allow time for discussion.
Patient–physician communication is the most important factor related to patient satisfaction with treatment recommendations.4 For example, a parent who arrives with a child with a lingering cough may expect an antibiotic, and using a Choosing Wisely handout can help to facilitate an informed discussion on the recommended non-antibiotic approach. Anticipating these conversations will make the move to Choosing Wisely easier.
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How do we begin the conversation?
Consider discussing the following with your colleagues as you look for areas that could be improved by following Choosing Wisely recommendations:
What guidelines do we currently follow?
Why are we concerned about inappropriate use or overuse?
What are we measuring and how are we measuring it?
What difference will it make to our patients and our practice if we reduce use of these specific tests or procedures?
Can we eliminate sources of potential harm by changing our procedures?
What defines low-value care?
Low-value care is care that either does not improve health outcomes or does so using resources that are disproportionate to the benefit that a patient derives. Simple examples include: duplicative testing, too-frequent testing, interventions that have been shown to be ineffective or unnecessary, and care that patients may not have chosen had they been better informed about the risks and benefits.
Step 2 Engage Your Patients.
Much of the success of implementing Choosing Wisely hinges on your ability to engage your patients in a dialogue about the purpose of tests, treatments, and procedures so they have a clear understanding of what's necessary, what's not, and what could cause them harm. Initiate the dialogue by demonstrating empathy for your patient's desires, needs, and concerns; their cues will tell you when they are ready for you to introduce decision aids or patient education as part of the conversation.
Consumer Reports partnered with the ABIM Foundation and leading medical societies on the Choosing Wisely campaign to create patient-friendly materials that discuss specific topics, such as use of antibiotics for sinusitis, CT scans for headache, frequency of Pap smears, and imaging for back pain. For example, many patients with chronic heartburn use proton pump inhibitors on a regular basis but may be able to control their symptoms with lifestyle modifications and/or an acid blocker such as a histamine H2 receptor antagonist. You can use the Choosing Wisely handout on heartburn to help facilitate the discussion with the patient.
You may choose to print these patient resources and make them available in the waiting area and in your exam rooms. If you use a patient portal, you might send targeted messages to patients before their appointment or provide handouts during rooming.
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How can we better partner with patients and families on this initiative?
Engage patients and families early and often. Patients may be confused by conflicting information they receive from their friends, family, physicians, consumer groups, medical societies, and advertising claims. You may consider including questions about testing procedures and communication about tests on your patient satisfaction survey. A patient and family advisory council or patient advisory board can assist you by vetting communication materials and evaluating the rollout of your new approach. Hosting a one-time focus group where a few patients discuss these topics with the clinicians can also be valuable.
Don't patients feel that more treatment is always better?
Initiating a conversation of what the patient understands and expects about a test or treatment helps distinguish between a patient's true demand for additional care and the physician's perception of a demand that may not, in fact, exist.
While some patients may have an expectation for imaging or antibiotics, for example, they may also be relieved to learn that costly treatments may not be needed immediately. This can be a good opportunity to encourage patients seeking non-recommended treatment to consult with their insurance plan to determine the extent to which the non-recommended service would be covered. Understanding the financial consequences of pursuing non-recommended care may have an impact on patient expectations.
Sometimes, highlighting negative consequences of overuse, such as the fact that radiation is harmful, is often all that is needed to balance patients' desire for more care with their desire to avoid harm.
Won't my patient satisfaction scores go down if I don't meet patients' requests for tests or antibiotics?
Offer a patient with a mild respiratory infection a “delayed prescription” for antibiotics (e.g., if the patient shows signs of bacterial infection several days after the visit, then the patient can fill the prescription). This may help the physician make the right choice while also meeting the patient's expectations. Patients are reassured knowing that there is a plan in place if their symptoms are not improving.
Likewise, a patient with acute back pain who is requesting an X-ray is often more comfortable knowing that the physician will order the test if he or she does not improve over time. Alternatively, a prompt referral to physical therapy may offset any disappointment regarding a belief that imaging is absolutely necessary; patients can be reassured that physical therapy is likely to lead to symptomatic relief. Positive and productive communication between the patient and practitioner has a greater impact on patient satisfaction than an antibiotic prescription or an order for more testing.4
Step 4 Establish an Implementation Plan for the Practice.
Some practices may want to go beyond simply increasing awareness and making handouts available at the point of care. If your practice decides to implement and systematize the Choosing Wisely initiative in a formal manner, then your implementation plan may be more elaborate.
Quiz Ref IDImplementation could take the form of a formal educational program for staff as well as checklists and protocols to help standardize the new processes. You may decide to work with your IT department to embed Choosing Wisely recommendations into clinical decision support (CDS) tools within the electronic medical record (EMR) by using alerts, reminders, or order sets. Choosing Wisely recommendations are intended to be starting points for conversation, not rigidly imposed guidelines.
To educate your practice about Choosing Wisely, consider using its physician communication modules. Watch the videos as a team and learn together during a scheduled team meeting.
Step 5 Use Data to Understand and Improve Performance.
Tracking and reporting will help determine if implementation of the Choosing Wisely recommendations has been effective in your practice. Sharing peer comparison data over time is one of the strongest measures of change and should be part of any performance improvement strategy.
Quiz Ref IDTo begin tracking your data, you could start by reviewing data in your EMR, pre-printed order sheets, or standing orders from your team members. Focus on the tests you suspect may be overused, inconsistently used, and/or that could be harmful to patients. Consider starting with clinical areas where statistics suggest overuse occurs frequently, such as lab testing or imaging.
Another target is any area where large amounts of variation exist. Review common tests and treatments by practitioner, establish a baseline, and then compare and contrast to identify variability. Examples include antibiotic use, X-rays for back pain, or frequency of Pap smears. Where possible, use recommendations that have tested and validated measures.
Patient–physician communication regarding the necessity of medical tests and treatments can be strengthened by using the tools and resources created by Choosing Wisely. Engaging patients, practitioners, and your care team—and committing to continue practicing evidence-based medicine—are key. Using the Choosing Wisely resources will support your practice in delivering higher-quality care and minimizing potential risks to patients.
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Choosing Wisely connects patients and clinicians by focusing on achieving the same goals.
Choosing Wisely recommendations are purposefully broad, allowing you to tailor them to your practice needs. They contain evidence-based references for further information.
Involve patients and families in the effort—they can review educational materials, help you determine an improvement topic, and test new strategies.
Anticipate unintended consequences, such as patients' health insurance coverage for certain services or the impact on referral patterns, when you limit some tests or increase testing in other areas.
Choosing Wisely may help you find the “sweet spot” in clinical practice: not too little, not too much, but just the right amount of care.
The data strategy for evaluating Choosing Wisely effectiveness should be timely and transparent to all in the practice. Be pragmatic about the measures that will be used.
Adequate time should be allotted to define and discuss current practice patterns. Organizational leadership must be engaged to support the work of implementing and evaluating Choosing Wisely.
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A main goal of STEPS Forward™ is to present the most up-to-date, actionable, practical toolkits with customizable resources that you can use to successfully implement meaningful and transformative change within your practice.
In 2018, CMS passed regulations to require that Appropriate Use Consultation for Advanced Diagnostic Imaging information is on the Medicare claim. 2019 is a voluntary year. However, as of January 1, 2020, it is mandatory.
We hope that this module continues to help you and your practice use Choosing Wisely® resources to make informed diagnostic imaging decisions with your patients.
We will update this module by January 2020 to provide the most current guidance. In the meantime, if you would like to be notified when the new module is released, please email us at firstname.lastname@example.org.
For further information, please refer to the CMS regulations passed in 2018:
Appropriate Use Criteria (AUC) for Diagnostic Imaging Services: Consultation of Specified Applicable AUC through a Qualified Clinical Decision Support Mechanism