Spotlight on Innovative Spine Care Delivery: Geisinger Neuroscience Institute's Dr. Jonathan Slotkin

Jonathan Slotkin, MD, is the Director of Spinal Surgery at the Geisinger Health System Neurosciences Institute and Director of Spinal Cord Injury Research for Geisinger Health System. He and his colleagues have spent the last 50 weeks applying Geisinger's patented ProvenCare® methodology to the acute episodic care of elective lumbar spine fusion surgery. More than two dozen providers, administrators, process improvement experts and information technology engineers have been working to reengineer care in a program called ProvenCare® Lumbar Spine. There have been significant contributions from neurosurgery, orthopedics, medicine, and many other service lines.

"It is safe to say that the overarching themes surrounding the Geisinger spine efforts are increasing the value of care delivery and performing analytics on the work we do," he says. "Finally, we are also decreasing unwarranted variation in care delivery. Those themes are intertwined. What we tried to do from the top down and bottom up is to infuse the design of our care delivery system with those themes."

Evidence-based medicine
The ProvenCare® model — first applied to cardiac surgery at Geisinger — generally includes six main steps to create the system: engage champions, compile evidence, establish best practice measures, process redesign, go-live beta and finally go-live production. The core of Geisinger's ProvenCare® model is process improvement to re-engineer acute episodic and chronic care delivery through:

•    Decreasing unwarranted variability
•    Error proofing
•    Failure mode redesign
•    Patient engagement
•    Improving work flow
•    Building consensus
•    Effect analysis

While the amount of strong level 1 and 2 data for cardiac surgery was instrumental in developing those standards, the lack of similar strong evidence in the spine field made defining standards more challenging.

Best practice development
When a particular treatment or procedure in spine didn't have strong evidence to support one pathway over another, the physicians and specialists at Geisinger consolidated their experience and expertise in the form of local expert consensus to agree upon the appropriate treatment pathway.

"Geisinger has demonstrated that when best practices elements are hardwired into the care delivery flow, you can for sustained periods cause 100 percent of the providers to make 100 percent correct medical decisions in every patient encounter," says Dr. Slotkin. "That's a lofty goal, but one we want to obtain. We always strive to obtain 100 percent compliance with best practices measures — all-or-none bundling."

The team first compiled all the level 1 and 2A evidence, which takes 10 to 12 weeks and then decided on best practices as a group. Consensus among surgical and non-surgical providers on every element of the best practices is essential to build a successful program.

"As you establish best practices, the system has observed that the very act of defining these best practices is one of the key drivers of the observed benefits — all providers review them and become refreshed in the literature," he says. "Achieving consensus among all the specialists isn't always easy, especially with around three-dozen best practices that span preoperative, perioperative and postoperative care. Once they are defined the system goes through re-engineering workflows to incorporate the best practices into workflows."

Workflow improvement
The team aims to decrease duplication of efforts, unwarranted tests and instances where necessary tests aren't performed to revamp the process. After these areas are identified and best practices are put in place, a "soft go-live" period allows the group to enroll a small number of patients — currently the spine project has close to 40 patients enrolled — to carefully scrutinize and measure how the best practices are performing.

"We will identify failures and figure out how to remedy those failures in our data collection phase," says Dr. Slotkin. "We always perform an analysis so we are measuring what we do and get continuous feedback in the form of data and provider observations.  Failure mode redesign techniques allow for rapid reworking of elements that are not yet quite right."

Re-engineering an entire workflow process is time consuming, especially at a time when many providers are feeling squeezed for time and unmotivated to work beyond clinical responsibilities. Geisinger developed an innovative payment structure to encourage physicians to take ownership over this process.

"Around 20 percent of the physician compensation at Geisinger is variable and dependent on participation and involvement in the process improvement, workflow redesign and other quality projects," says Dr. Slotkin. "It's not that productivity is unimportant, but that 20 percent is variable and much more weighted toward participation in non-clinical and quality improvement initiatives. Geisinger encourages hard work, but not extreme or unwarranted levels of productivity.  Drs. Lee, Bothe and Steele recently reviewed Geisinger's compensation model in an article in Health Affairs, and that article is instructive as to some of the ways to encourage provider participation in initiatives like these."  

Future preparation
In 2014, the group anticipates releasing the best practices along with a financial bundle that would cover the price for all pre-, peri- and postoperative care associated with lumbar spinal fusion. "We are designing the bundled payments in association with Geisinger Health Plan," Dr. Slotkin says. "We anticipate announcing a very novel and constructively disruptive pricing paradigm associated with this initiative."

While a similar model of care won't work in every situation, pressure from insurers and the federal health plan to coordinate care is bringing multidisciplinary spine specialists together around the country. Electronic medical records and health data analytics allow providers to capture more data than ever before and apply it to value-driven care.

"When we start to think about value-driven patient centered outcomes, spinal surgery nationwide, in my opinion, is one of the furthest behind and has more catching up to do," says Dr. Slotkin. "A lot of us have been very good at collecting clinical intelligence data over the past few decades and we're getting better at business intelligence, but I think within the next five to 10 years we as a field need to become better at predictive intelligence and analytics. As we all become awash in data the next question becomes what to do with it."

Dr. Slotkin and his team have been working on building spine dashboards drawing from four to five distinct data streams within Geisinger that include operative data sets, billing data, patient demographics, quality and outcomes data. His team is currently using the information to conduct business and clinical intelligence to figure out where they can increase care value in their delivery.

"It has been said before that in baseball, one extra hit per week can bring a batter from .275 to .300," says Dr. Slotkin. "We think finding that extra hit per week in the data is how we increase the value proposition. I urge providers to begin to entertain the importance of analytics in their practice."

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