Rheumatology Practices Need Sharp Focus on Patient Care Safety, Quality

“It is not necessary to change. Survival is not mandatory.” —W. Edwards Deming

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For practices to survive, change is a requirement—not an option—in the rapidly evolving practice of rheumatology care.

Pharmaceutical therapies are advancing quickly, opening the door for game-changing therapies in the treatment of chronic autoimmune disorders. With these advances comes a need for increased focus on patient safety, a message also being reinforced as new payment models reward coordinated patient care and quality patient outcomes.

To support this emphasis on quality and safety, daily practices in rheumatology clinics are being rewired to improve coordinated care, standardize processes and minimize care gaps in practice. Although these are lofty goals for some, these are areas of hard-fought progress for others. Many rheumatology clinicians are well on their way in the process to rework the necessary pieces into practice to advance patient-centered care, leverage electronic tools (without creating extra work) and optimize clinician time to focus on what matters.

For example, with the Rheum-PACER system in place at Geisinger Health System in Danville, Pa., information is aggregated from the electronic health record (EHR), the nurse, the provider and the patient, who answers a touchscreen questionnaire at the beginning of a clinic visit. This information is displayed in real time and supports care coordination among all members of the rheumatology team.

The Web-based system serves two important goals. The first is to catch care gaps in data (missing patient information) and quality (care that needs to happen) to effectively trigger timely reactions in the care process. The second is to drive care processes that become proactive, so patients and clinicians can spend their time working toward new goals in treatment, explains Eric Newman, MD, who works in the Department of Rheumatology at and is vice chair for clinical innovations in the Division of Medicine at Geisinger.

Eric Newman, MD

Research led by Dr. Newman on the effectiveness of the Rheum-PACER system showed significant improvements in care quality and efficiency, and a 26% increase in productivity.¹ Dr. Newman says the Rheum-PACER software is just one example of hardwired safety in practice that is positively affecting patients. He notes that they are always improving the system, because providing best-in-class care through continuous process improvement is a journey, not a destination.

Start with a Strong Safety Culture

No matter where you and your practice colleagues are in this process, the key is to keep moving forward. But none of it will work if an openness to improvement through team collaboration and individual ownership is not a deeply engrained goal for all, Dr. Newman explains, adding that the remnants of an historic “feudal” healthcare culture in which the physician leads and support staff follow is the No. 1 reason implementing and sustaining a successful safety program fail.

“Culture is key to hardwiring more advanced levels of safety in our daily work—if you have physicians, or other team members, in your practice who are unwilling to change or think about new ways of practicing, you need to win them over or ask them to work elsewhere because change is our reality,” says Dr. Newman.

Safety work requires what Dr. Newman calls a teaming culture, in which all members of the team feel comfortable and willing to talk openly, respect ideas and agree on the value of always striving to improve safety.

Investigate a Better Way

A focus on research to improve safety is driving quality improvement work at Brigham and Women’s Hospital (BWH) in Boston, where

Sonali Desai, MD, MPH

Sonali Desai, MD, MPH, medical director of quality for the Department of Medicine and the medical director of Ambulatory Patient Safety for the hospital, is preparing to launch her team’s latest quality improvement project. The project goal is to standardize important verification steps necessary to safely prescribe certain immunosuppressant medications to rheumatology patients. These steps include confirming influenza and pneumococcal vaccination, confirming important baseline tests for infections, such as tuberculosis and hepatitis, and ensuring risk/benefit conversations about the medication take place with patients.

“This conversation is very important [because] our patients have a number of questions we want to address, but sometimes this conversation can take up all of the time in a clinic visit. We need to be sure to take the time to explain a medication’s risks and benefits but balance that with using a basic checklist approach to ensure we have reviewed and addressed key safety and quality issues, such as vaccinations,” Dr. Desai says.

In the forthcoming BWH quality improvement initiative, her team will seek ways to incorporate prompts for these verifications into the EHR in a way that is streamlined within physician and nursing workflows to prevent extra or duplicative work. She is collaborating with other departments (e.g., Pulmonary, Nephrology and Gastroenterology) that prescribe immunosuppressant medications to ensure there is a multidisciplinary approach.

‘Culture is key to hardwiring more advanced levels of safety in our daily work—if you have physicians, or other team members, in your practice who are unwilling to change or think about new ways of practicing, you need to win them over or ask them to work elsewhere because change is our reality.’ —Dr. Newman

A previous quality improvement project Dr. Desai led focused on implementing simple paper-based clinician reminders to verify patient influenza and pneumococcal vaccinations in four ambulatory clinic settings, including rheumatology, before prescribing medication, and results were promising.²

For example, between February 2009 and January 2015, vaccination rates for pneumococcal vaccinations increased from 50% to 87% following implementation of the paper-based reminder intervention.³ Dr. Desai attributes this positive change to two important steps—integrating routine workflow and sharing performance data—which, when implemented together, effectively engaged specialists and staff in vaccine adherence improvement.

“There was concern at the beginning of this project about how workflow could be negatively impacted by the additional time required for this intervention, particularly for nurses. However, once we tested the intervention within the clinical workflow and shared the initial data with our team, we all understood how this improvement could be successfully implemented for measured improvement,” Dr. Desai explains.

She says taking this paper-based intervention to electronic form will be a new challenge, but it also provides new opportunities, such as a patient-facing component to help track patient information, educate patients and involve them in their own care.

Share the Data

Jinoos Yazdany, MD, MPH

Collecting and sharing data on quality improve­ment research around vaccinations has also been an area of focus for Jinoos Yazdany, MD, MPH, associate professor in the Division of Rheumatology, and associate clinical co-director of the Lupus Clinic at the University of California San Francisco (UCSF). She has focused much of her work on researching quality measures to improve care for patients with rheumatic diseases.

One of her roles is chair of the ACR’s RISE (Rheumatology Informatics System for Effectiveness) Registry Research & Publications Subcommittee, which manages access to aggregate, de-identified patient data, including outcomes data on patient safety measures, such as tuberculosis screening prior to starting high-risk biological medications.

“RISE aims to decrease the burden of data collection on practices, to streamline participation in federal quality programs and to facilitate local rapid-cycle quality improvement by providing continuous performance feedback and benchmarking,” wrote Dr. Yazdany and her colleagues in their analysis in Arthritis Care & Research, December 2016.

RISE works by automatically collecting data from a participating practice’s EHR system and transferring it to a secure central data warehouse. The system is compatible with about 30 different EHR programs and eliminates data entry for practices. Through an online dashboard, providers can see analytics of their performance on quality measures as compared to national benchmarks and the overall performance of providers participating in RISE. They can also run customized queries on their own patient population and perform basic data analyses.

Locally, Dr. Yazdany is also leading research on the performance of quality measures in patient populations at UCSF. For example, one study she co-authored evaluated reasons that immunosuppressed patients with systemic lupus erythematosus did not receive pneumococcal and influenza vaccinations. Study results suggested the most common reason (87%) these patients failed to receive pneumococcal and influenza vaccinations was because physicians didn’t recommend them.⁴

She says a growing collection of scientific papers and demonstration projects authored by rheumatologists, including Dr. Newman and Dr. Desai, show that a dedicated quality improvement project focused on safety work, such as improving vaccination rates, can make a large impact on improving the quality of care for rheumatology patients.^5,6

The future of this work is moving it into electronic formats, Dr. Yazdany says. “Many of us are developing feasible ways to introduce electronic safety checks into clinical practice in ways that seamlessly incorporate user interfaces and workflows that are not disruptive or time consuming—this is the right direction to be moving in.”

Carina Stanton is a freelance science journalist based in Denver.

References

1. Newman ED, Lerch V, Billet J, et al. Improving the quality of care of patients with rheumatic disease using patient-centric electronic redesign software. Arthritis Care Res (Hoboken). 2015 Apr;67(4):546–553.
2. Desai SP, Lu B, Szent-Gyorgyi LE, et al. Increasing pneumococcal vaccination for immunosuppressed patients: A cluster quality improvement trial. Arthritis Rheum. 2013 Jan;65(1):39–47.
3. Pennant KN, Costa JJ, Fuhlbrigge, et al. Improving influenza and pneumococcal vaccination rates in ambulatory specialty practices. Open Forum Infect Dis. 2015 Oct 1;2(4):ofv119.
4. Lawson EF, Trupin L, Yelin EH, et al. Reasons for failure to receive pneumococcal and influenza vaccinations among immunosuppressed patients with systemic lupus erythematosus. Semin Arthritis Rheum. 2015 Jun;44(6):666–671.
5. Harris JG, Maletta KI, Ren B, et al. Improving pneumococcal vaccination in pediatric rheumatology patients. Pediatrics. 2015 Sep;136(3):e681–e686.
6. Baker DW, Brown T, Lee JY, et al. A multifaceted intervention to improve influenza, pneumococcal, and herpes zoster vaccination among patients with rheumatoid arthritis. J Rheumatol. 2016 Jun;43(6):1030–1037.