Choosing Wisely in the Aloha State

HMSA, Hawaii’s Blue Cross Blue Shield licensee, is the largest health plan in the state, serving more than 730,000 members. As part of its mission to improve the health of everyone in the Aloha State, HMSA is working to raise awareness about Choosing Wisely through a version of Consumer Reports’ “5 questions to ask your clinician” and a microsite that incorporates elements of Hawaii’s unique culture.

Two prominent physician organizations in the HMSA provider network have also implemented Choosing Wisely recommendations, with a shared goal of inspiring clinician-patient conversations. Learn more about the work that is underway at each organization:

The Queen’s Clinically Integrated Physician Network (QCIPN)

QCIPN has been working to coordinate care through a medical neighborhood protocol to encourage collaboration between primary care doctors and specialists. Dr. Anna Loengard, chief medical officer for clinically integrated work, said the quality committee convened groups of specialists to work on improving evidence-based care around six Choosing Wisely recommendations.

“We thought Choosing Wisely was a really good place to start when engaging specialists,” she said. “It was a building block for having conversations about promoting patient safety and quality. Specialists reviewed Choosing Wisely recommendations developed by national medical societies in their discipline and determined projects to pursue based on these recommendations.”

Examples of recommendations and the projects they inspired include:

• Chest computed tomography (CT angiography) – The group created a protocol in the electronic medical record (EMR) to help physicians determine when a test for pulmonary embolism might not be needed for patients with low clinical probability. The protocol helps determine if the patient has a low clinical prediction score as well as a negative D-dimer measure – both indicators that the test might not be needed. To prevent “alert fatigue,” Dr. Loengard said it was important to ensure this was a network initiative and fit into the normal workflow.
• Chronic dialysis – Nephrologists focused on discussing chronic dialysis with patients in later stages of kidney disease. They were encouraged to refer patients with advanced kidney disease to an online educational series and set up a process on referrals for dialysis.
• Preoperative tests for eye surgery – The group discussed reasons why preoperative tests might not be needed for low-risk patients, the reasons why these tests were continuing to be ordered, and why they might waste time and resources. Ophthalmologists designed a standardized referral template and surveyed primary care physicians to determine ways to make the experience more convenient for low-risk surgery patients.

“Part of the early success from this work is that physicians gathered to agree on the project and goals,” said Dr. Loengard. “Once you stop and have a conversation, it can change behaviors and get the group excited about learning about working together to improve care.”

Hawai’i Pacific Health

While attending a conference, Dr. Mark Baker, an emergency medicine physician, learned how Cedars-Sinai Health System incorporated dozens of Choosing Wisely recommendations into its EMR. He brought the idea back to Hawai’i Pacific Health and engaged the vendor that created those EMR alerts to do the same. The alerts include a brief explanation about why the test might not be needed and hyperlinks to relevant Choosing Wisely recommendations from specialty societies. Hawai’i Pacific Health is also piloting the use of Consumer Reports’ patient-friendly Choosing Wisely materials relevant to emergency care in eight emergency room departments.

“The challenge is creating an alert that works. It’s important to keep it brief,” Dr. Baker said. “A clinician who is in the middle of a busy day might not look at the reason for the alert while working but may look at references later. The alerts provide the IT staff with data on how often they are seen, followed, overridden or ignored. We can analyze which alerts are triggered most frequently and whether the frequency is going down. Since there are circumstances where tests need to be ordered, the goal is not to get to zero, but to make sure tests are ordered for good reasons.”

Alerts have been created for CT scans for pulmonary embolism, pre-operative chest X-rays, transfusions, cardiac imaging for asymptomatic patients, Pap tests and many more. A steering committee with broad representation from clinicians across the system meets to discuss ways to encourage buy-in about the alerts. They review data on how the alerts are utilized and where utilization varies by physician.

“Doing the test might be ingrained,” Dr. Baker said. “When we looked at who was doing Pap smears, we found that two physicians triggered a majority of the alerts. We talked about how patients were still requesting Pap smears and how we could share Choosing Wisely materials with these patients to help explain why they might not need one. In the next month, we could tell it made a difference. Having a  conversation with somebody and asking them to think about it works.”