Choosing Wisely at Crystal Run Healthcare

To Eric Barbanel, Choosing Wisely has become the “bible of value-based care.”

Eric Barbanel is an internal medicine physician at Crystal Run Healthcare, a multispecialty practice located an hour northwest of New York City that employs 350 clinicians. When Crystal Run sponsored an innovation contest designed to advance value-based care, Dr. Barbanel proposed implementing a set of Choosing Wisely recommendations. His idea was to work directly with physicians to reduce costs while simultaneously improving quality, without giving patients the false impression that care was being rationed.

Crystal Run focused on four recommendations from the American Academy of Family Physicians (AAFP), which covered the overuse of:

• imaging for low back pain;
• antibiotics for mild-to-moderate sinusitis;
• DEXA screening for osteoporosis in women younger than 65 and men younger than 70; and,
• annual EKGs.

The intervention included peer education and conversations, clinical decision support and data feedback.

Project leaders began by educating their fellow physicians about the recommendations, providing them with AAFP’s list and Consumer Reports’ patient-friendly descriptions of the recommendations. Crystal Run then embedded the recommendations in the practice’s electronic medical records (EMR) system so an alert would pop up when physicians entered a diagnosis relevant to one of the four recommendations, such as low back pain. The alert included a set of questions designed to ensure clinician awareness of the Choosing Wisely recommendations.

The EMR also made it possible to calculate how often physicians bypassed the alert and ordered the test or prescription anyway. According to Dr. Barbanel, the technical aspects of customizing the EMR in this way were straightforward and the work was performed by the practice’s IT department. Once the project was underway, the practice’s physicians received and discussed the data that demonstrated the practice’s overall trends in utilization of the relevant interventions.

To reach patients, practice administrators framed Consumer Reports’ “patient translations” for each of the four topics and hung them in the office where patients could read them. Dr. Barbanel said that patients have “intrinsic trust” in Consumer Reports, which enabled physicians to talk with patients about why they might not need a particular test or treatment without giving rise to what Barbanel describes as  “the ominous specter” of the rationing issue. Dr. Barbanel said he tells patients that he is trying to practice wisely, and that over-testing is the equivalent of “rotating your tires every 500 miles.”

Dr. Jonathan Nasser, who leads Crystal Run’s clinical transformation efforts, agreed that the campaign had made an impact on patients. He said that the Choosing Wisely brand and the specialty societies’ recommendations provided useful support for discussing unnecessary tests and treatments with the practice’s patient advisory panel.

Crystal Run’s pilot project resulted in utilization decreases for annual EKGs, MRIs for low back pain, and DEXA screening. For example, EKGs were ordered in conjunction with slightly more than 8 percent of annual physicals before the project was implemented in 2013; that number has now fallen to 5.5 percent. Interestingly, antibiotic usage went up slightly after the pilot project began. Crystal Run physicians are still reviewing the data to find out the reasons behind the increase.

“Choosing Wisely gave me a lot of confidence in my ability to tell patients that I’m working on their behalf to reduce unnecessary care,” Dr. Barbanel said. “Doctors think it takes so much more time to talk patients out of something they want, and that agreeing to order a test makes everyone happy. But I’ve found that those conversations are not usually that time-consuming; and once you have a conversation about one unnecessary test, if you have a relationship with your patients, they understand why you’re not ordering a different test. And when you don’t order a test, you save the post-visit time you would have spent reviewing the results.”