The nearly 70 practices of the Geisinger Health System in Pennsylvania were already on the road to reducing the number of low-value procedures and treatments when the national Choosing Wisely initiative was launched by the American Board of Internal Medicine. The efforts of the Geisinger system included following protocols and procedures to determine when to do imaging for low-back pain and when to prescribe antibiotics for sinusitis. The Choosing Wisely initiative bolstered the rationale and provided justification for some of the decisions already being made by the Geisinger system practices, and validated their existing protocols and procedures.
Once introduced, the Choosing Wisely initiative acted as a catalyst to more actively engage physicians in promoting quality and safety. The Choosing Wisely lists, which are evidence-based sets of recommendations for avoiding unnecessary tests and procedures, are trusted and respected and provide valuable and accessible starting points for quality improvement. The lists are specifically vague and provide a high-level roadmap that individual practices can refine into unique turn-by-turn directions that their specific teams can follow.
Although each practice is part of the integrated Geisinger Health System, selecting, refining, and implementing the Choosing Wisely recommendations occurs at the practice level and not as part of a larger “top-down” initiative from the system's administration. These activities happen organically, with providers selecting the areas they'd like to work on and rolling out the changes on their own schedules. Recommendations are shared with clinicians and team members who interact with patients. Discussion focuses on “Which ones resonate? Which ones provide the most opportunity?”
After the initial selection phase, practices take advantage of the Choosing Wisely training videos that are relevant to their clinics and their specific efforts to minimize low-value care. In addition, the practices share educational materials from the Choosing Wisely and Consumer Reports websites with patients to start a dialogue about the care plan.
Choosing Wisely recommendations have been implemented over the course of three years throughout the practices and the 12 hospital campuses that are part of the Geisinger system. One of the first projects involved building a customized clinical decision support (CDS) function within the EHR system for evaluating low-back pain that follows the Choosing Wisely recommendations. Education around this CDS tool highlighted the fact that Choosing Wisely recommendations were being followed so that providers would know that the tool and its determinations were supported by evidence.
Tracking and measuring changes in procedures and treatments over time is standard. A centralized data warehouse captures both practice and hospital data. Decreases in antibiotic usage and high-end radiology usage have been observed at the practice level. On the hospital side, decreases in urinary catheter usage and blood transfusions have been documented.
While a system-wide recognition of the overuse of tests and treatments is critical to initiating change, organizational culture also plays a large role. Within the Geisinger system, the success of implementing Choosing Wisely recommendations is related to two key organizational tenets: a culture of safety and a culture of value. The decrease in the use of urinary catheters, which are often associated with healthcare facility-acquired infections, can be attributed to a culture of safety. The decrease in antibiotic use and radiology orders can be attributed to a culture of value.
Momentum for adopting the Choosing Wisely recommendations continues to build as the Geisinger system explores new ways to implement CDS tools for radiology and cardiac imaging. In addition, physicians within the Geisinger system are starting to use Choosing Wisely as a teaching mechanism for residents, thereby expanding its reach to the next generation of practitioners.
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