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Thomson Healthcare Micromedex

To thrive and deliver optimal value, healthcare enterprises must address both the quality and businessdimensions of performance.

Rising consumerism coupled with falling profit margins has produced a challenging dilemma for healthcare organizations: providing the highest quality care for the lowest possible cost. Today care is a product, payers and patients are customers, healthcare is a business and quality care is more than an ethical concern – it is an economic imperative.

And while hospitals, clinicians, health plans and purchasers have struggled to improve the quality of care and reduce medical errors following alarming reports from the Institute of Medicine and others, their “customers” don’t see adequate change for the better. Indeed, roughly 78 percent of people say the quality of healthcare has stayed the same or gotten worse[1] – for good reason according to recent studies:

• In a study of 700 medical groups, only 75 (– 11 percent) scored in the top quartile on at least four out of six overall performance dimensions (e.g., care management, health promotion, disease prevention, physician turnover, use of electronic health records and financial viability).[2]
• More than 20 percent of patients admitted to intensive care units at Boston’s Brigham and Women’s Hospital experienced an adverse event, such as receiving the wrong dose of a medication. Twenty-four percent of these events were fatal, life threatening or potentially life threatening. About 45 percent of these errors were preventable.[3]

In addition, poor quality care also has a significant economic cost:

• A Food and Drug Administration study of hospital adverse drug events (ADEs) found medication error rates ranging from 2.4 percent to 6.5 percent per facility, resulting in an average cost of $2,257 per event.[4]
• Hospitals spend an average of $9,705 per 100 admissions in treating the effects of ADEs. A facility averaging 20 daily admissions could incur $708,100 in annual expenses.[5]
• The Managed Care Institute estimated as many as 28 percent of all hospitalizations, at a cost of $50 billion per year, are attributed to drug-related morbidity.[6]
• An Agency for Healthcare Research and Quality (AHRQ) study concluded that length of stay, charges and mortality resulting from adverse events (based on sampling 20 percent of U.S. hospitals) has significant financial impact.[7] Extrapolating the data to all U.S. hospitals suggests that 18 different types of medical injuries may add 2.4 million days of hospitalization and $9.3 billion in excess charges to the industry.

Clearly medical errors and poor quality care are expensive both in terms of human life and healthcare costs. As a result, organizations ranging from the federal government to the Institute for Healthcare Improvement, AHRQ, the Joint Commission for Accreditation of Hospital Organizations and the Leapfrog Group have made improving care safety and quality an imperative.

In response, many healthcare organizations are working hard to improve clinical performance by aggressively investing in such tools and practices as evidence-based protocols and guidelines, clinical decision support (CDS), quality assurance programs, patient safety initiatives, compliance measures and business decision support.

Increasingly healthcare organizations are making substantial investments in clinical information systems, in part to support these performance improvement efforts. Is this an effective strategy? The answer depends on how systems are selected and implemented.

The (Potential) Value of Clinical Information Systems

Clinical information systems, particularly when enriched with decision support functionality, play a decisive role in improving business and clinical performance, the obvious benefits of which are better patient outcomes and decreased costs. Mounting evidence confirms this:

• Computerized medication administration decreases medication errors by 81 percent, and integrated pharmacy and clinical information systems decrease preventable drug reactions by 78 percent.[8]
• BlueCross BlueShield of Tennessee reported a $2.3 million average annual savings from health informatics programs in the three-year ROI study period. The number of its catastrophic cases decreased from 17,000 to 10,000. The number of cases per case manager per month dropped from 103 to 76. The average monthly savings per case manager increased from $116,000 to $291,000.[9]
• At CareGroup Health System, which operates several Bostonarea hospitals, a computerized physician order entry (CPOE) system deployed in its Beth Israel Deaconess Medical Center has reduced drug errors by more than 50 percent.[10]
• Boston Medical Center’s CPOE system reduced prescribing errors by 37 percent.[11]

Less obvious, but equally important, are other business benefits of clinical performance improvement enabled through information technology:

• Productivity: Reduced resource consumption (staff efficiencies, equipment, supplies) and streamlined daily workflows.
• Risk management: Targeted quality improvement initiatives ease exposure to legal liability and regulatory scrutiny.
• Patients’ perspectives: Higher quality care translates into brand preference, which boosts a hospital’s patient volume.
• Industry image: Demonstrable clinical excellence produces competitive advantage in terms of marketing, partnerships, staff recruitment and retention.

The sidebar summarizes the business benefits associated with the clinical decision support components of performance improvement efforts.

Value Not Fully Realized

Many organizations don’t optimally address the symbiotic nature of business and clinical performance, or the enabling role that information systems can play in improving both these dimensions. For example, despite demonstrated successes, nearly 30 percent of electronic medical record/CPOE technology implementations fail, according to the Office of the National Coordinator for Health Information Technology.[12]

Many other organizations don’t achieve anticipated benefits from information systems because of problems in the strategic, cultural, management or technical dimensions of their performance improvement efforts. For example, information for clinicians or patients that is intended to support clinical decision making may be unhelpful, inconsistent, delivered at inappropriate times or through a sub-optimal channel. Besides missing opportunities to help, financial consequences of poor decision support can include wasted time, money and staff or patient good will.

A Model for Effective Performance Improvement

A systematic approach to defining and achieving performance targets is essential.[13] A four-step process that utilizes sophisticated measurement and decision support tools in a continuous improvement loop can help ensure that organizations achieve their priority clinical and business goals.

Step 1: Identify

You cannot improve what you cannot identify and measure.While this seems obvious, many attempts to improve clinical and financial performance fail for lack of a solid understanding of the problem, including quantifiable metrics. Healthcare organizations should develop a consolidated and carefully developed working list of their clinical performance improvement targets and parse each into more specific and measurable clinical goals and objectives.

For example, a strategic patient safety organizational goal might be to decrease ADEs. Performance targets would include decreasing severe drug interactions, as well as the costs of associated complications. However, without solid, quantifiable numbers, success in hitting those targets remains a subjective measure.

Data such as medical claims and encounters, market intelligence, demographics and financial information are all critical to pinpointing the underlying causes of an organization’s quality problems and related financial implications. Understanding what is happening is not enough; an organization must also understand why a problem occurs to address it most effectively.

Step 2: Measure

Once an organization articulates measurable clinical objectives, business decision support tools can help determine performance against defined benchmarks, identify where breakdowns are occurring, help track progress and document where there is value and where opportunities remain.

These tools include financial analysis, utilization analysis and measurement, quality and clinical performance measurement, action lists, risk adjustment and episode methodologies. In the ADE example preceding, root cause analysis tools driven by anonymous ADE reporting can pinpoint exactly where severe drug interactions are occurring most often.

Performance measurement reports can compare the total number of patients with a complication of care for a certain disease class or ADE and the cost of care for that patient population against national or regional averages. Cost savings or opportunity costs (e.g., relative to readmissions, extended length of stay, denied Medicare claims, underpayments, capacity and productivity issues) illustrate the potential financial impact of identifying and eliminating quality deficiencies.

Similarly, sophisticated performance measurement and analytic tools can provide accessible and actionable information to drive vital strategic and tactical business decisions related to growth planning, marketing, reimbursement, costs, return on investment and other financial performance metrics.

Step 3: Empower

After an organization has clearly defined and measured performance issues, CDS embedded appropriately throughout clinical workflow can be a powerful corrective force. Broadly defined, CDS is providing clinicians or patients with clinical knowledge and patient-related information to enhance patient care. It includes a variety of approaches, ranging from alerts and reminders about potential commission or omission errors, to organizing and presenting key clinical data about individuals or populations.

For example, Partners Healthcare in Boston recently took a step forward in helping its staff address clinical questions at the point of care by providing patientand context-specific medication and patient education information at the click of a button. Doctors, nurses and pharmacists can query the EMR application to get consistent, on-demand, point-of-care prescribing guidelines and other recommendations. Statistics from initial deployment indicate Partner Healthcare’s clinicians are answering clinical questions more frequently and accurately with access to the right content, in the right format and at the right point in time. Current deployment reports demonstrate more than 400 lookups occurring daily without any employee training.

On the other hand, clinical information systems without carefully selected and implemented CDS are limited in their effectiveness. For example, a study at the VA Hospital in Salt Lake City showed continued high rates of ADEs after implementing a CPOE system lacking CDS specifically focused on drug selection, dosing and monitoring.[14]

To achieve desired outcomes from CDS, it is essential to select CDS interventions appropriate for particular objectives and deliver them through the right channel, in the proper format, to an appropriate individual at a point in workflow where the information will be most useful. CPOE is a powerful tool for performance improvement, but as the VA study emphasizes, these implementation factors must be carefully addressed.When properly deployed, CDS integrated into clinical information systems can support a variety of strategic goals such as ensuring that clinicians are aware of and are appropriately implementing evidence-based best practices for promoting health and managing disease, reducing dangerous medication errors and empowering patients to participate effectively in their care.

An approach for incorporating medical evidence into healthcare on a national basis is likely to be studied in 2006 under a contract the Office of the National Coordinator for Healthcare Information Technology is planning.[15]

Step 4: Improve

Building upon the knowledge gained from measurement and intervention, organizations can adopt process, workflow and culture changes that make performance improvement an automatic outcome of daily operations and clinician workflow.

Implementation services that include intervention testing, staff training and communication about enhanced CDS-enabled practices can help ensure the new approaches fully achieve their targeted improvements. In addition, expert consultation from business decision support providers can help organizations understand the performance data gathered during the improvement cycle and use it in a manner that yields ongoing optimal returns.

Quality: A Clinical and Business Imperative

Healthcare customers are increasingly demanding demonstrable value from care providers. Rising to this challenge in the complex healthcare business is difficult, but robust clinical and business decision support tools, augmented by sophisticated clinical information systems, can be of substantial help.

However, achieving these goals requires a systematic approach that simultaneously addresses both clinical and business performance management, and judiciously applies information technology to achieve targeted objectives. Such an approach offers the best opportunity for health systems to remain financially strong while meeting the ever-growing expectations of healthcare’s purchasers and consumers for safer, cost-effective, high quality care.

Endnotes

1. Kaiser Family Foundation / Agency for Healthcare Research and Quality/Harvard School of Public Health National Survey on Consumers’ Experiences with Patient Safety and Quality Information, November 2004 (Conducted July 7 – Sept. 5, 2004).
2. Yang S., Nationwide survey of medical groups defines high and low performers. UC Berkeley press release. www.berkeley.edu/news/media/releases/2005/08/25_medicalgroup. shtml.
3. Rothschild J, Landrigan C, Cronin J, Kaushal R, Lockley S, Elisabeth MS, Stone P, Lilly C, Katz J, Czeisler C, Bates D., The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive care. Critical Care Medicine. 33(8):1694-1700, Aug. 2005.
4. Bar Code Label Requirement for Human Drug Products and Biological Products. U.S. Environmental Protection Agency. Federal Register: Feb. 26, 2004. Volume 69, Number 38.
5. It’s All in the Wrist: Improving Patient Safety with Bar Code Wristbands, Application White Paper, Zebra Technologies, Vernon Hills, IL, 2004.
6. An Economic Prescription for America. 2000. The Managed Care Institute, Samford University, Birmingham, AL. Sept., 2000: p. 9.
7. Zhan C, Miller M., Excess Length of Stay, Charges, and Mortality Attributable to Medical Injuries During Hospitalization. JAMA. 2003;290:1868-1874.
8. Leape L, Berwick D, Five Years After To Err Is Human: What Have We Learned? JAMA, May 18, 2005; 293: 2384–2390.
9. Enrado P., Health informatics programs provide savings, efficiency for payer. Healthcare IT News. June 9, 2005.
10. McGee MK. Computerized Systems Can Cause New Medical Mistakes, Study Says. InformationWeek, March 9, 2005. www.informationweek.com/story/showArticle.jhtml?articleID= 159400302.
11. Ibid.
12. Gater L., CPOE Uncertainty. For The Record. May 9, 2005. Vol. 17 No. 10 P. 25. www.fortherecordmag.com/archives/ ftr_050905p25.shtml
13. Osheroff JA, et al: Improving Outcomes with Clinical Decision Support: An Implementer’s Guide. Chicago: HIMSS, 2005. Used by permission.
14. Nebeker J, Hoffman J, Weir C, Bennett C, Hurdle J. High Rates of Adverse Drug Events in a Highly Computerized Hospital. Arch Intern Med. 2005;165:1111-1116.
15. www.healthcareitnews/NewsArticleView.aspx?ContentID=3312