Starting Uncommon Conversations
WESTMED Medical Group Medical Director Richard Morel, MD, often talks about the “WESTMED Way” – a process through which clinicians in the New York-based multispecialty group practice tackle variation reduction projects. Ideas for projects are often initiated by clinicians around routine tests or procedures, some of which Choosing Wisely® society recommendations identify as potentially unnecessary.
“People tend not to discuss common scenarios,” Dr. Morel said. “They talk about unusual cases. Choosing Wisely is a great way to begin discussing some of these common tests and brainstorm topics for projects that reduce unneeded care.”
The “WESTMED Way” involves a physician champion leading a project with the help of a steering committee and input from the entire department. The clinicians create guidelines for appropriate ordering for certain conditions, often based on Choosing Wisely recommendations, and incorporate these guidelines into an order form that is embedded into the electronic health record (EHR). Physicians are prompted to fill out the form if they order a test or treatment for a specific condition. Metrics are then tracked on how many times the forms are filled out and, subsequently, if ordering behaviors begin to change. Projects have a patient-education component as well – through Consumer Reports handouts, posters hung in the office, website content and social media encouraging patients to have conversations with their physician.
One example of a project at WESTMED was a multi-department effort focused on reducing antibiotic overuse. Physicians were asked to pledge not to write prescriptions for antibiotics for patients presenting with sinus infections unless they met one of the three criteria outlined in recommendations from the American Academy of Family Physicians, the American Academy of Pediatrics and the American Academy of Allergy, Asthma & Immunology.
Dr. Morel said the team decided to expand the scope of this effort after discovering how difficult it was to track results for sinusitis ordering since it’s a condition that physicians tended to code differently. As a result, they created a complete upper respiratory pathway to reduce variation on antibiotics for sinusitis as well as chest X-rays, strep tests and antibiotics for bronchitis and are tracking metrics for this pathway.
The team also realized that it was helpful to offer an alternative for patients when advising against a certain test or treatment. Dr. Morel said that Consumer Reports educational handouts provide information to patients about managing symptoms. The handouts are embedded into the EHR with the option to print them out for patients at when they check-out.
For another project, the obstetrics department was inspired by two American College of Obstetricians and Gynecologists Choosing Wisely recommendations around non-medically indicated induced labor and created a pathway around appropriate ordering for labor inductions.
WESTMED has a total delivery rate of about 3,000 per year. After the intervention, they found that 89 percent of the total number of EHR ordering forms, which included information about appropriate ordering guidelines, were filled out for labor inductions. The number of primary C-sections fell from 28.3 percent in 2013 to 24.3 percent in 2015, which Dr. Morel said shows progress.
“If the primary C-section rate is down, the total C-section rate will likely continue, because if the patient avoids an initial C-section they might not need additional C-sections for subsequent pregnancies,” Dr. Morel said.
