Choosing Wisely^®Promote Patient-Physician Conversations to Improve Patient Engagement and Choose Appropriate Care

1. Discusses 4 STEPS to incorporating Choosing Wisely in your practice.

2. Answers frequently asked questions about Choosing Wisely.

3. 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.

1. Engage Your Team.

2. Engage Your Patients.

3. Establish an Implementation Plan for the Practice.

4. 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.

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.

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.

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.

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.