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Choosing Wisely® Case Report: Group Health Cooperative

A patient sees a TV commercial offering a cure or solution and asks about this specific treatment during his or her visit. Another patient attempts to self-diagnose and is convinced he needs a test or treatment discovered online. While these scenarios may not occur frequently, they are often interpreted by the clinician as demands for a particular product or service when they do. Many clinicians at Group Health Cooperative (Group Health), an integrated care and financing organization headquartered in Seattle, WA, initially believed that patients would be disappointed if they did not receive the care or treatment they wanted. This left clinicians feeling trapped between perceived patient demands and the organization's goal of minimizing low-value care.

Group Health decided to take a careful look at the patient requests they were fielding and discovered that many stemmed from a desire for an explanation of risks, benefits, and alternatives rather than a demand for a specific test or treatment. Group Health has worked to help busy clinicians shift from interpreting these scenarios as “demands for services” to seeing them as patient requests for more information on available options. While the first task of the clinician in these situations is to listen and demonstrate empathy, providing accurate and complete information is an important part of a successful visit. They turned to Choosing Wisely® to help educate patients who may have expectations or misinformation about the service their clinician is recommending (or recommending against).

The organization adopted Choosing Wisely recommendations in specific clinical areas that were simple, mainstream, and non-controversial. In primary care, they started with the clinical areas of antibiotic overuse for upper respiratory infections (URI) and the overuse of Pap tests. Antibiotic use for URI was a particularly easy win because there is professional consensus around the need to reduce antibiotic overuse. Emergency department, urgent care, and neurology clinics began with the Choosing Wisely clinical area of imaging for headaches. Having a focus, rather than trying to address a myriad of targets, was important for initial implementation and sustainability.

Group Health has a significant online presence, with nearly 70 percent of patient touches occurring through the patient portal or by phone. They leveraged this resource by embedding a patient-friendly Choosing Wisely microsite co-branded with Consumer Reports. Patients can access the microsite from the Group Health patient portal or website. Many clinics also hand out printed materials from Consumer Reports Health, such as visual aids that explain the duration of URI symptoms.

Group Health also has a comprehensive approach to the use of shared decision-making for preference-sensitive surgical conditions, such as joint replacement, back surgery, prostate surgery, and benign uterine conditions. This approach uses video decision aids as a foundation for better conversations between patients and clinicians. Often patients desire less medical care after viewing the videos.

To hardwire Choosing Wisely into the workflow, practices piloted a new process that emphasized handing educational materials directly to the patient rather than just displaying them in the exam room. Medical assistants and nurses received basic suggested scripts to help them discuss the materials with patients during the rooming process. Messages with talking points about URI and antibiotic use were sent to staff to reinforce guidelines.

To address overuse of Pap tests, Group Health added an innovation to their workflow: an electronic trigger tool that flags Pap test orders that are clinically inappropriate. A note is sent to the clinician if they've ordered an inappropriate Pap test. This note contains a clinical pearl along with key messages to help the clinician explain to patients why a Pap test is not recommended. Clinicians receive an email within a week of ordering Pap tests too frequently. This tool provides near immediate feedback and since its introduction, Group Health has observed a 25 percent reduction in the number of Pap tests performed. Group Health hopes that Choosing Wisely approaches will be ingrained in how clinicians practice, making the use of trigger tools on certain topics unnecessary over time.

As part of implementing Choosing Wisely, clinicians also adjusted their approach to conversations with patients. They began listening with empathy and granting grace. This entails clinicians acknowledging symptoms, demonstrating empathy, and asking what they can do to manage a patient's discomfort as opposed to telling the patient what cannot be done. At Group Health, Choosing Wisely is not viewed as a restriction on practice but as a mechanism to help clinicians focus on patient-centered and safer care.

Overall, prescribing rates are lower and patients are having better experiences in the exam room. Group Health has observed a 33 percent decrease in inappropriate Pap tests and inappropriate imaging for headache. Data is transparently reported so that clinicians can discuss the results with their peers to better understand variability.

Group Health was impressed by several of the unexpected benefits of using Choosing Wisely Consumer Reports Health materials. They felt the patient-friendly materials were better than anything they could have created themselves, which was both a surprise and a delight. They also underestimated the joy that gathering clinicians to talk about clinical medicine would bring to teams. This created a positive feedback loop and improved practice culture. Clinicians reaffirmed how satisfying it was to celebrate successes through sharing patient stories and rejoicing in individual accomplishments, holding them up as heroes to the group.

The next phase is to spread Choosing Wisely to Group Health oncology practices to support decision-making on advanced care planning and the use of chemotherapy at the end of life. In addition, the recommendations will be used to target the overuse of imaging studies in a variety of clinical settings.

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