Making the 'Right Thing' the 'Easy Thing' in Wound Care

Have you ever heard of a surgeon offering a warranty on a procedure? I can hardly get a warranty on a home appliance repair. A warranty is not the legal term for what Geisinger offers patients after a hip replacement, but that is effectively what it is. If patients ever have a problem with a hip replacement (meaning, for the rest of their lives), Geisinger will take care of the problem at no charge. How can they do that? Ten years ago, Geisinger introduced the ProvenCare model,¹ a program to ensure delivery of reliable, evidence-based care that has since been proven to reduce mortality, complications, length of stay, and hospital readmissions. It’s also increased the company’s profitability. I recently heard Dr. David Feinberg, MD, MBA, Geisinger Health System’s chief executive officer, speak about ProvenCare at the National Quality Forum (NQF) annual conference held March 12-13 in Washington, DC. Geisinger began by working with clinicians to establish best practices that had the effect of reducing variations in care. Then, the company redesigned its electronic health record (EHR) by adding “real-time decision support” to improve physician compliance with agreed-upon best practices. The goal was to, “make the right thing to do the easy thing to do.” Haere’s the part that really got my attention: The company did not ask physicians to agree on the best new technology or on how to implement some complicated clinical pathway. Instead, it revolutionized care by getting physicians to agree on the lowest common denominator of good care, which began by defining the standards “that no one could argue with.” When I heard this, I almost cried. 

In 2011, we started a U.S. Wound Registry (USWR) initiative called “Do the Right Thing” after an analysis of data from 18 hospital-based outpatient wound centers showed that patients living with venous leg ulcers (VLUs) were provided adequate compression during only 17% of visits.² Why? Because some clinicians believed they had to obtain venous Dopplers to demonstrate that patients with no symptoms of a deep venous thrombosis (DVT) did not have a DVT before they could initiate compression, and because compression was withheld for days while patients were scheduled for arterial Dopplers in the hospital’s vascular laboratory when they could have immediately performed less expensive arterial screening in the clinic. Additionally, patients were told that elevation and salt restriction were sufficient and/or compression was provided with ineffective products (eg, elastic bandages). These variations in care can result in improper care, delay effective treatment, prolong time in service, and negatively affect outcomes. The USWR partnered with clinical associations including the Association for the Advancement of Wound Care and the American Professional Wound Care Association through the Alliance of Wound Care Stakeholders to develop quality measures for diabetic foot ulcers (DFUs) and VLUs. Clinicians had no trouble agreeing on at least two basic points for active VLUs: 1) patients should receive arterial screening (if possible on the first visit) and 2) patients living with V LUs should have evidence-based compression at each visit after arterial screening. For DFUs, clinicians agreed that patients needed arterial screening initially and evidence-based offloading documented at each subsequent visit. We worked to get these measures approved by the Centers for Medicare & Medicaid Services (CMS) as part of the USWR’s qualified clinical data registry (QCDR).³ Then, Intellicure, as an EHR company, went a step further and programmed real-time clinical decision support (CDS) reminders into the EHR to ensure clinicians provided these simple steps at each visit for VLUs and DFUs. Those clinicians who did so earned credit for passing these quality measures, and the data were reported to the USWR for Merit-Based Incentive Payment System (MIPS) credit. The Wound Healing Index⁴ was embedded behind the scenes so that the DFU and VLU healing rate quality measures could also be reported. The CDS tools were colored “markers” on the “decision-making” page, which provided reminders such as DFU offloading, arterial screening, and VLU compression. Opening these CDS tools provided the rationale for performing the action with links to relevant clinical practice guidelines and an opportunity to select an exclusion, if one applied. The “reminder” disappeared if the clinician performed the required activity. Some clinicians ignored the decision support recommendations and did not participate in quality reporting. Others, however, decided to go after maximal bonus money under MIPS. They not only used CDS to optimize clinical care, as they signed off each chart, they could see their quality performance scores. In other words, practitioners were provided with what you might call the “questions on the examination” (the quality measures they needed to perform), and they knew whether they were passing or failing the examination (the measures) each time they signed off a chart and logged into the EHR. The most engaged practitioners also participated in MIPS clinical practice improvement activities designed to optimize their adherence to arterial screening recommendations. Since the last day of December, the USWR has been hard at work analyzing 2017 MIPS performance data for clinicians at different levels of MIPS participation, ranging from the minimum needed to avoid a penalty to those seeking the maximum possible bonus. Since offloading, compression, and arterial screening are so basic, I confess that I wasn’t sure there would be any measurable impact from real-time clinical decision support for these interventions. However, I returned from the NQF feeling encouraged as a result of Dr. Feinberg’s talk. At least we had the right approach, even if our success was likely to be modest. Are you curious about the results? 

Here’s the difference between practitioners who did not participate in quality reporting through the USWR compared to those who participated fully in MIPS using USWR quality measures: DFU offloading documented at each visit was 34.9% in non-reporters versus 66.8% in reporters. Non-reporters documented compression of VLUs at each visit only 49.8% of the time versus 53.3% of the time in MIPS participants. Arterial screening of patients living with leg ulcers was documented only 38.2% of the time in non-reporters versus 60.7% in MIPS participants. Of course, it’s logical to assume the practitioners who engaged in quality reporting were just better “documenters” because they wanted bonus money. If so, there should be no difference in patient outcomes between the groups. But that’s not what we found. The DFU healing rate of practitioners who did not report MIPS quality measures to CMS through the USWR was 55.3% versus 65.1% in the USWR’s QCDR participants (P = 0.000054). The VLU healing rate was 54.5% in the non-reporters versus 65.2% in the USWR participants (P = 0.000006). These differences are very meaningful when considering that in 2017 these practitioners cared for 830 DFUs and 865 VLUs, and that, when multiplied across the country, Medicare’s annual cost for treating these problems is in the billions.⁵ (In case you missed it, we’ve already published a paper on “fantasy healing rates” that debunks the canard that 95% of wounds heal.⁶) We might have also proven that practitioners participating in MIPS through the USWR’s QCDR are simply more motivated (and perhaps better) clinicians. Some private payers believe this, because they are already calling the USWR and wanting to know how they can send beneficiaries to clinicians with the highest performances on these measures. However, I suspect that what we really have done is confirm that the Geisinger approach works in the field of wound care. For DFUs and VLUs, the USWR defined a lowest common denominator of good care that nobody could argue with, and then developed QCDR quality measures to reflect these practices. Real-time clinical decision support was placed inside an EHR to drive these best practices, leveraging bonus payments under MIPS as the incentive. The next phase of the Quality Payment Program is likely to be some sort of “episode-based” payment in which efficiency of care will matter greatly. So, our next step will be to determine if the way we have reduced variations in care for VLUs and DFUs shortens time in service and reduces the cost of outpatient care, which is the most expensive aspect of chronic wound care. What do you think we are going to find in 2018? I think we are going to find that when you make the “right thing the easy thing in wound care,” it’s also the least expensive thing. I will be talking about these very topics at the Symposium on Advanced Wound Care Spring conference in Charlotte, NC. I hope to see you there! 

Caroline E. Fife is chief medical officer at Intellicure Inc.; executive director of the U.S. Wound Registry; medical director of St. Luke’s Wound Clinic, The Woodlands, TX; and co-chair of the Alliance of Wound Care Stakeholders.

References

1. ProvenCare. xGHealth Solutions.® Accessed online: https://xghealth.com/provencare

2. Fife CE, Carter MJ, Walker D. Why is it so hard to do the right thing in wound care? Wound Repair Regen. 2010;18(2):154–8.

3. MIPS Program Quality Measures. USWR. Accessed online: www.uswoundregistry.com/qualitymeasures

4. Fife CE, Horn SD, Smout RJ, Barrett RS, Thomson B. A predictive model for diabetic foot ulcer outcome: the wound healing index. Adv Wound Care (New Rochelle). 2016;5(7):279-87.

5. Nussbaum SR, Carter MJ, Fife CE, et al. An economic evaluation of the impact, cost, and medicare policy implications of chronic nonhealing wounds. Value Health. 2017;21(1):27-32. 

6. Fife CE, Eckert KA, Carter MJ. Publicly reported wound healing rates: the fantasy and the reality. Adv Wound Care. 2017;7(3):77-94.