The Healthcare Imperative Lowering Costs and Improving Outcomes: Workshop Series Summary (2010) / Chapter Skim
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8 Knowledge Enhancement
8 Knowledge Enhancement
Pages 257-280
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From page 257... ...
Expanding on these investments in comparative effectiveness research and health information technology, speakers in this session focus on the essential strategies to enable more efficient generation and application of knowledge during the care process. In particular, they highlight tools for generating high quality, consistent treatment, with a focus on the medically complex; timely, independent, and understandable evidence; reliable, sharable, and secure clinical records; protected but accessible data; and patient-centered care.
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From page 258... ...
Savitz illustrates the success of this strategy by discussing outcomes with implementation of the care of febrile infants evidence-based CPM, explaining that infant stays have dropped to an average of 36 hours from 69 hours previously, readmissions have decreased, and adverse events, including preventable bacterial infections, have fallen significantly. While suggesting that Intermountain's protocols could be adopted across different models of care delivery, she additionally discusses the larger challenge of sustainability of savings beyond initial implementation.
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From page 259... ...
Clinical decision support tools can then include all ways in which healthcare 1 The author wishes to give special thanks to Institute for Health Care Delivery Research analysts Erick Henry, Craig Gale, Karen Valentine, Thomas French, and Pascal Briot for providing summary results of clinical program CPMs. The author would also like to thank Brent James, Director of the Institute and Chief Quality Officer at Intermountain Healthcare, for his vision and leadership in providing analytic infrastructure to clinical programs as well as guidance in placing Intermountain Healthcare's quality improvement work on the national agenda.
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From page 260... ...
Bohmer (2009) provides a detailed description of clinical programs and the role of the Institute for Health Care Delivery.2 Five example Intermountain Healthcare evidence-based CPMs are provided in Table 8-1 together with indication of clinical program, cost drivers impacted, observed cost savings, and scope.
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From page 261... ...
usual care at IH including FQHCs NOTE: ALOS = average length of stay; CABG = coronary artery bypass graft; CPM = care process model; FQHCs = federally qualified health centers; ICU = intensive care unit; IH = Intermountain Healthcare; LOS = length of stay; MHI = mental health integration. a Contact corresponding author for more detailed information.
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From page 262... ...
We documented that only 49 percent of febrile infants managed in hospital-based outpatient facilities had both a complete blood count and a urine analysis, as recommended by guidelines. This understanding of the problem led Byington's team to conduct the following analyses: • Reanalyze Rochester Criteria and risk for serious bacterial infection.
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From page 263... ...
Key quality measures used to monitor the process and clinical compliance with the CPM include the following: • Receive core laboratory tests and viral testing as indicated. • Admit patients at high risk for serious bacterial infection as indi cated by CPM threshold.
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From page 264... ...
, Intermountain Healthcare provides: • Supportive infrastructure and culture for improvement; • Commitment from leadership; and • Necessary staff training, education, and feedback. We have also documented the value of clinical decision support tools to accommodate use of evidence-based CPMs across our clinical programs.
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From page 265... ...
These include • Widespread adoption of febrile infant evidence-based CPM at In termountain Healthcare and beyond; • Demonstrated value of evidence-based CPMs leading to application/ modeling in other areas; • Electronic medical record vendors building capacity to integrate clinical decision support for evidence-based CPMs; • Useful outcomes comparisons supported through collaboratives or focused national efforts led by government agencies such as the Centers for Medicare & Medicaid Services (CMS) or AHRQ; and • Documentation of significant national cost savings.
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From page 266... ...
In addition, EHRs have clinical decision support, which are electronic alerts and reminders provided to a physician at the point of care to improve medical decision making. Most EHRs include applications for ordering medications and tests, referred to as computerized physician order entry (CPOE)
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From page 267... ...
Hillestad included further savings projections, estimating an additional $147 billion savings per year from long-term chronic disease prevention and management. Over 15 years, cumulative net hospital efficiency and safety savings could be $371 billion, and physician practice savings could be $142 billion.
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From page 268... ...
A Massachusetts-based report suggested that the average community hospital accrued annual savings of $2.7 million from a CPOE system with robust clinical decision support (Massachusetts Technology Collaborative & New England Healthcare Institute, 2009)
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From page 269... ...
There are significant national investments in interoperable EHRs underway. The American Recovery and Reinvestment Act stipulates a minimum investment of $19 billion (Steinbrook, 2009; U.S.
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From page 270... ...
Supporting interoperability is a significant task unto itself; while many existing EHRs have the technical capacity to be interoperable, very few are actively exchanging data. Successful interoperability will depend on further development of state and federal policies, including those focused on privacy and security, development of community-wide governance for health information exchange, and technical development by vendors.
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From page 271... ...
Instead, and again this is where AHRQ has focused its attention on CER, the agenda was one that included the context and the care delivery interventions necessary to make it feasible for patients and clinicians to use information to drive decisions. AHRQ envisions CER as providing the information needed to drive improvement in clinical care by: • Providing information that can be used on the front lines of treatment; • Helping to make decisions more consistent, transparent, and rational; • Ensuring the effectiveness data is more widely used; and • Promoting an open and collaborative approach to comparative effectiveness.
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From page 272... ...
Consistent with our focus, we will be investing the $300 million appropriated to AHRQ in the American Recovery and Reinvestment Act in evidence synthesis and generation, evidence communication and translation, and continued support for methods, training, and data development. Evidence synthesis and generation We have had standing an • nouncements to researchers for career development and other types of training awards in order to build research capacity.
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From page 273... ...
Yet the medical records that hold the promise for centralizing all of these clinical data fall short of the task, instead bringing together excess information and obscuring other critical information that impedes better care and better research. The current medical record can be likened to a Christmas tree with the data elements being ornaments.
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From page 274... ...
. Three major opportunities for this comprehensive restructuring lie in physician documentation requirements for physician payment; nursing documentation related to hospital and nursing liability claims; and nursing documentation requirements for home healthcare payment.
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From page 275... ...
The onerous nature of the documentation requirements has led to the creation of electronic systems designed to meet these requirements and to the aggregation of meaningless, irrelevant, and inaccurate clinical data. Nursing Documentation to Reduce Vulnerability Liability Claims "If it is not in the medical record, it didn't happen." This quotation is a major driving force determining the clinical data elements recorded by our nation's nursing workforce (Joint Commission, 2005)
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From page 276... ...
. Nursing Documentation to Enable Home Healthcare Payments Another area where the administrative burden of data collection and codification may have significant impact on cost and quality is in home health care with OASIS data.
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From page 277... ...
In its most recent rendition, now proposed for enhancement, there is a 175-page date specification file describing the 375 required data lines (OASIS data specifications, n.d.)
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From page 278... ...
Furthermore, a major reduction in the number of clinical data elements collected is in order, with the requirements tested for clinical relevance and research relevance. All three examples share the common theme that the goals of our expansive bureaucratic regulation are at best misaligned and at worst contrary to effective healthcare delivery.
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From page 279... ...
2003. Nurs- Nurs ing documentation time during implementation of an electronic medical record.
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From page 280... ...
2003. A cost-benefit analysis of electronic medical records in primary care.
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