U. Program sets standards in care

Penn's Disease Management program provides protocols for treating many ailments. Over the past year, the University of Pennsylvania Health System has dealt with challenges ranging from the collapse of a major area competitor to a $100 million budget shortfall to the downgrading of its bond rating. Yet despite these financial setbacks, the Health System has moved to the forefront of national healthcare in many areas, particularly in the field of providing consistent levels of care throughout the $2 billion system that employs over 18,000 people and includes four wholly-owned hospitals and 12 affiliates. Penn's Health System won three major national awards last year for its 2-year-old Health and Disease Management Program, which has sought to write sets of protocols for treating common diseases in an effort to provide all Health System patients with the best possible care. The guidelines set by this program will soon be used in hospitals nationwide, following the signing of a three-year agreement with a Texas-based healthcare network. In theory, doctors will follow a "decision-tree," where an answer to one question leads the physician to a customized set of additional questions and eventually to a treatment method. The protocols -- used mainly, but not exclusively, by primary care doctors -- tell the doctors information such as what tests are recommended for a specific patient, when to go to a specialist, which medications are best and when to schedule follow-up visits. "What all this attention is doing is giving us strong support and validation that the direction we're going in is the one that's being recognized as visionary but also productive," Health System Chief Medical Officer and Chief Quality Officer David Shulkin said. So far, the program has written protocols for 23 diseases -- including diabetes, asthma, hypertension and osteoporosis -- that supporters say have improved care while lowering costs. David Bernard, the director of the Health and Disease Management Program, said disease management programs were sparked by information that has accumulated in recent years showing that physicians and other care providers practice medicine very differently, which is "sometimes appropriate and OK, but sometimes it is not." "Many people believe, as I do, that this variation is responsible for relatively uncontrolled costs of care and erratic outcomes of care," he said. And while lowering cost was not a primary goal of the Disease Management program, Shulkin said that it has been a benefit that has come with more efficient medical treatment. Still, the program does have its detractors in the Penn Health System, though no doctors would disparage it on the record. Penn Health Care Management Professor Mark Pauly said disease management could in the end prove helpful to doctors, but he also noted that "the verdict still isn't in if this is the way people will want care to be organized." Teamwork In the first step toward the creation of a new protocol, Bernard brings together teams of experts -- including physicians, nurses, social workers and therapists -- on specific conditions. To formulate the guidelines, the committee members -- headed by a leader in each specific field -- work together to develop the best way to clinically manage the specific condition. The resulting protocol is then piloted in three primary care offices, intensively studied and modified by the committee and then made available to all Health System doctors over a system-wide Intranet. The protocols are updated monthly to reflect ever-changing medical opinions and options. "This is a hugely valuable way of making sure that all new advances are quickly implemented into clinical practice," Bernard said. "Implementation is critical" But developing the protocol is the easy part. Officials must train doctors to use the guidelines rather than sticking to what individual training programs tell them. "It's all very well to sit in a room and come up with a series of guidelines and algorithms," Bernard said. "It's another thing to have them used by the physicians." To encourage use, the Disease Management program gathers primary care physicians for informal meetings to discuss the protocols and their usefulness. "We've really put into place all the pieces that are necessary, not only to develop what the best practices are, but to support their use throughout the Health System," Shulkin said. And many Penn doctors have successfully been using the new guidelines in their practices. "It seems to work quite well," said Internal Medicine Professor Michael Cirigliano, who regularly uses the asthma, diabetes and lower back pain protocols. Other physicians, though, are saying privately that the programs take away some of their own initiative in treating patients by implicitly forcing them to adopt certain practices. Jack Ende, chief of medicine at Penn's Presbyterian Hospital, said that when the protocols were first introduced he was concerned about using them because "it's another set of rules." He said, though, that he now realizes his view was an "unsophisticated" way of looking at things. "We all make decisions," he said. "You might as well have the best evidence behind it so you can be sure that you made the right ones." Shulkin also emphasized that the protocols do not take away from physicians' individual thinking. Instead, he said, doctors who follow the protocols make their own decisions -- based on the "best-practice" method -- for each individual patient. And Shulkin said critics who call disease management a "one-size-fits-all" approach to medicine "reflect a lack of understanding of what this field is all about." Striking Gold Peers from across the nation have recognized Penn's Disease Management program as an innovative approach to medicine. Al Lewis, president of the Disease Management Association of America, said Penn's program is "easily the most advanced disease management program of any provider organization in the eastern U.S.," partly due to the fact that it is an academic medical center with immediate access to medical developments. And besides the agreement to use the protocols in other hospitals, Penn also won three major awards. "We're quite proud that we were able to be recognized by all three groups," Shulkin said, referring to the accomplishment known as the nation's "triple crown" in health care. Officials attribute Penn's acquisition of both the National Quality Health Care Award and the Excellence in Healthcare Risk Management Award to the Disease Management program. And to top it all off, the Hospital of the University of Pennsylvania -- at the heart of the Health System -- received the coveted Ernest A. Codman Award in November for improving patient satisfaction and clinical outcomes through the Disease Management program.