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Choosing Wisely® Case Report: Geisinger-Milton

At Geisinger-Milton, a primary-care practice in Milton, PA, following the Choosing Wisely methodology supports their core mission of “doing what's right for patients.” When Choosing Wisely recommendations were rolled out to all Geisinger Health System practices in 2013, this meant incorporating the recommendations into existing preventive medicine and chronic care bundles. The Geisinger-Milton practice specifically leveraged the Choosing Wisely recommendations to support ongoing efforts to decrease the number of inappropriate Pap smears, limit antibiotic use, and reduce rates of routine prostate-specific antigen (PSA) screening.

The biggest challenge to fully implementing the Choosing Wisely recommendations has been in addressing overuse of antibiotics. Patients often come with the expectation that an antibiotic will “fix them,” so the practice has focused on education to reframe the conversation. Posters on the clinic walls explain the risks of antibiotic overuse, and a great deal of effort has gone into teaching the care team about the risks and benefits of antibiotic use for bronchitis and upper respiratory infection.

Conversely, one of the biggest successes following implementation of the Choosing Wisely recommendations has been a decrease in sepsis cases following prostate biopsy, from three to four cases per year to one case per year. Fewer PSA screens have resulted in fewer false positives and thus fewer biopsies, which ultimately reduced the risk of post-surgical sepsis. It is also important to note that no corresponding increase in cancer mortality has been observed with this change.

Because the practice incorporated the Choosing Wisely methodology into existing protocols and procedures, there was no resistance and the process was simple—it became a natural part of the workflow. The EHR already included best-practice alerts for health maintenance topics, and parameters were modified to follow the Choosing Wisely lists. Alerts now flag specific diagnoses, orders, and procedures. The care team was initially notified of the updates that were made to the existing EHR alerts based on the Choosing Wisely lists; however, no additional training was required to begin following the lists.

Positivity is essential when thinking about Choosing Wisely and how to apply the lists in practice. Emphasize what to do rather than what not to do. That means refraining from saying “don't do this” without understanding what will work for each patient's unique situation and providing an alternative solution. Even the few negative alerts in the EHR have been reframed to position the recommendation in a positive light and help patients determine what they want to do.

Currently, the Geisinger-Milton practice has adopted approximately 30 percent of the Choosing Wisely recommendations that apply to their patient panel. Their goal is to incorporate more radiology lists to preempt preauthorization discussions. Eventually, they hope to expand to 80 to 90 percent adoption and begin working in areas not covered by their care bundles.

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