American Health Line's Aly Seidel sat down with John Kontor, executive vice president of Advisory Board's Clinovations, and Stanson Health CMO Jeremy Orr to discuss how clinical decision support can help providers adapt to new payment models implemented under the Medicare Access and CHIP Reauthorization Act (MACRA) and the Protecting Access to Medicare Act (PAMA). The Advisory Board publishes American Health Line.
Question: Health care organizations and regulators have made a big effort in recent years to engage physicians in improving care quality through clinical standardization—but those efforts often haven't yielded major gains. Why do you think that is?
Kontor: First, there's a volume issue: An overwhelming amount of clinical evidence and guidelines accumulates over time. There's also a consistency issue: Even if your providers are familiar with their specialty's guidelines, their daily challenges—including dealing with a large number of patients and an increasingly complex patient mix—makes it easy for individual guidelines to slip through the cracks.
Now, EHRs were supposed to help solve this problem. But many major EHR systems come with relatively little support out of the box, other than medication alerts. So even though EHR systems have fairly sophisticated capabilities, they are typically not set up to efficiently provide evidence-based, standardized guidance for providers. And hospitals often just don't have the clinical teams and infrastructure in place to hardwire evidence-based guidelines into the EHR to help change physician behavior.
That's a resource challenge, but there's a prioritization challenge, too: You could theoretically create alerts for thousands of conditions, but each individual health system has different priorities based on clinical practice patterns. You can't turn every alert on, or else they'd be firing every time a provider touched the mouse.
That said, hospitals can see and have seen big dividends from hardwiring clinical decision support into EHRs when they find ways to tackle those resource and prioritization challenges.
Q: Let's talk a bit further about that. Jeremy, you're the CMO at Stanson Health, which has a lot of experience in this field. Can you touch on some wins that you've seen in your work?
Orr: We've actually seen great progress at Cedars-Sinai Health System. A few years ago, Cedars' leaders decided they were going to reduce imaging utilization across the board.
It's really paid off for Cedars. From just canceled orders due to alerts, the system saved $4.5 million through the end of 2015. When you include the physician learning opportunities that alerts can bring, that number shoots to $6.7 million per year since Stanson has started working with Cedars.
There are other benefits as well. Cedars, like many organizations, has some risk-based contracts. Reducing care variation has enabled them to get major bonuses on these populations. Their HMO and some of their accountable care organizations have received millions in bonuses: One risk population had a 21 percent cost reduction on inpatient care, while another had a 16 percent reduction in prescriptions.
Q: You mentioned that Cedars made this a priority. But what about other hospitals, that do not consider CDS a top-of-mind issue?
Kontor: The problem is, reducing adverse care variation will soon becoming everybody's pressing priority amid the shift away from fee-for-service. Providers will need to take advantage of cost-saving opportunities.
Recent legislation, especially MACRA and PAMA, have also signaled a growing trend toward requiring providers to use advanced clinical decision support tools. PAMA, for example, starting in 2017 will require physicians ordering advanced diagnostic imaging exams to consult government-approved, evidence-based appropriate-use criteria through a clinical decision support system as a condition of reimbursement. So it's clear where regulators are going, and providers need to be prepared.
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Orr: We're at an interesting place. There's a saying: Health care is now 80 percent digitized, but only 8 percent optimized. We have the basic infrastructure in place, but we're still refining how to get the safety and savings benefits from it. To succeed under MACRA, to succeed under bundled payments, you need to narrow the gap between what physicians are supposed to do and what they're actually doing. Clinical decision support can bridge that gap.
It's great to adopt clinical decision support principles, but unless you make it easy for physicians and incorporate it into their workflow every day, it really won't create any day-to-day change. We need to hardwire these evidence-based changes into the workflow, so it's easy for the physician do to the right thing, at the right time, every time.
Q: What do you think the future holds for clinical decision support?
Orr: We're likely to see more legislation that requires clinical decision support, because it's too beneficial from a cost and quality perspective not to take advantage of. The government and large payers want to see a return on the $30 billion plus invested in EHRs.
In the long term, the future of clinical decision support is even more interesting for practicing providers. For example, if you're an oncologist seeing a patient with breast cancer, you have lots of factors to consider: the patient's tumor grade, whether he or she has local spread or metastatic spread, genotype factors, certain receptor factors, and so on. Then, you have to reconcile that with literally hundreds of relevant clinical trials that try to point the way to the best treatment plan.
Without clinical decision support, that's not sustainable. To practice good medicine in the future, doctors are going to need a system that aggregates the evidence and points the way to the most high-value treatment plan. Effective medicine 20 years from now is just going to have to include a computer.