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Posts Tagged ‘clinical decision support’

A healthcare treasure map leading to a single data warehouse

I’ve waited 20 years for my Treasure Map.  Yes, a map with hidden passages, remote islands and an “X” to mark the spot.  As kids, some of us hunted in our yards looking for buried treasures.  Kids today use smart phone apps for activities like “Geocaching” to explore public and urban spaces.  What do we use in Healthcare?

The single place to put a healthcareMany of us desire a chest full of clinical outcomes, protocol conformity, activity based costing, provider scorecard, genomic studies, Pharmacogenomic markers, Adverse Event analysis, and coordination of care analytics.

But lately, we have been lost – adrift at sea, hopping from one raft to another, and from one stranded island to the next more barren island.  We’ve bought point solutions that offered the holy grail for a niche activity, all while knowing the vendor or the quick fix would evaporate before we had achieved broad-based adoption.

Oh, I’ve been there – tasked with implementing the pet project for a clinical director or department chair.  I’ve no sooner got the data in and one cycle of analysis out, than the provider champion would change their focus and the solution implemented didn’t transfer to the next project. (Sigh.) Read the rest of this post »

5 Reasons Big Data Improves Personalization of Medicine

I enjoyed an article today in IT Business Edge about the ways that Big Data is improving outcomes. We hear that all the time, right? But what does it really mean? Why does more (and better) patient data lead to improved healthcare for all? When business intelligence is leveraged properly to deliver insights to healthcare providers, we see the following:

  1. 5_waysLearning what we never knew before: 

    “Allowing for previously unknown factors involved in disease to be discovered and utilized as drug targets or disease biomarkers.”

  2. Comparing data points from various sources to individualize treatment plans, improving outcomes. 

    “We are able to align and compare multiple data points from various sources, tailoring individualized treatment plans for each patient.”

  3. A move from subjective interpretation to objective diagnosis.A coworker of mine said to me yesterday, “Can you imagine when our kids are older? They’ll be laughing at our stories of how doctors once said to us, ‘Based on your symptoms, I think you have [X disease].'”

    She’s right. Diagnoses vary from physician to physician based on his or her background and experience. Not any more! As this article states, we’re facing a “datafication” of patient samples.

    “A vast quantity of knowledge that can be statistically analyzed and quickly reviewed by multiple clinicians for solid diagnosis”

  4. Better – and faster – decisions about treatment as a result of more and better patient data
    “Clinicians can systematically extract more information from each patient without requiring multiple rounds of testing.”
  5.  More accurate diagnosis and more appropriate spending on treatments due to reproducible testing”Consistently reproducible test results are possible between clinicians and doctors for more accurate diagnosis and appropriate spending on therapy options.”

CDS Tools: Should we pile them on?

A 2008 study on CDS (clinical decision support) tools found that while the benefits of CDS technologies are widely understood and accepted by providers, there is still a lack of proactivity in its adoption. An article summarizing the study stated: “For example, Chang said that while CPOE with CDS is now already widely accepted, it is rarely used appropriately.” Physicians complain that too many inappropriate alerts pop up on the computer screen, and as a result, providers begin to ignore the alerts, negating the reason why they were set up in the first place. Chang also cited a general lack of technology adoption and steep financial investment as high barriers to adoption. “If Facebook is able to predict who an individual might be friends with based on who he/she is already friends with, why shouldn’t CDS be able to determine what diagnosis patients may have based on their health information?” she asked.”[1]

The problem with this analysis is that Facebook cannot be sued if members become friends with the wrong people but physicians can be sued for malpractice if a patient is incorrectly diagnosed and treated, especially if that treatment turns seriously negative for the patient. Medical practice and treatment should not be subjected to as simple a comparison. Even if a CDS tool can be accurately set up to flawlessly diagnose patient symptoms, it cannot replicate the personal touches of a physician who can answer patient’s questions while performing a check-up. For example, a patient can go to a podiatrist for a foot problem and also be able to get a prescription for eczema cream without having to see two doctors at two different times and pay two different co-payments. The patient can speak to the doctor about his/her eczema or other minor ailments while the doctor is checking his/her foot. If the point of new technologies is to ultimately improve healthcare, then how will a CDS tool that diagnoses patients without seeing a doctor help in this commonly occurring situation? If the patient can still see and speak directly with a physician, why should he/she spend time on a CDS tool as well?

Read the rest of this post »

EHRs + Clinical Decision Support = Better Healthcare

We all know that the healthcare delivery system in the United States is decentralized.  Patient information is in multiple sources and often times not even accurate or complete. This fragmented system leads to large gaps in care, contributing to poor quality, patient safety issues and increased costs. A nationwide audit assessing 439 quality indicators found that US adults receive only about half of the recommended care, and the US Institute of Medicine has estimated that up to 98,000 US residents die each year as the result of preventable medical errors,1 all of which could have been avoided if the right information was available at the right time.

The federal government has recognized this problem and has incentivized healthcare providers to implement and meaningfully use electronic health records (EHRs) as a way to improve overall healthcare delivery. There is no doubt that systems, such as EHRs, have the ability to transform healthcare. However, it is unlikely any national or organizational goal of improving healthcare can be accomplished without the thoughtful and widespread adoption and proper use of a clinical decision support system2 (CDS).

What is Clinical Decision Support (CDS)

A CDS is an interactive system that provides clinicians, staff and other individuals a process for enhancing health-related decisions and actions with pertinent, organized clinical knowledge and patient specific information to improve health and healthcare delivery3.  According to John Glaser, it encompasses a variety of tools and interventions, such as computerized alerts and reminders, clinical guidelines, order sets, patient data reports and dashboards, documentation templates, diagnostic support, and clinical workflow tool to assist clinicians at the point of care2.

Benefits of a CDS

A CDS can positively influence medical decisions at point of care, which in turn can have substantial benefits.  Here are just a few simple examples:

Improved Quality: Prevention is vital to improving healthcare.   Through various decision support tools and timely alerts, a CDS can help with prevention by scanning patient records for risk factors and by recommending appropriate preventive services, such as routine screenings4, informing the physician that immunizations are not up to date and addressing any additional gaps in care.  This is especially useful for patients with certain chronic conditions that require frequent tests and check-ups. A RAND study indicated that roughly 15,000-27,000 deaths could be avoided simply by being vaccinated for pneumonia.  Routine screenings and preventative medicine can easily decrease the amount of deaths, such as these, in this country. CDS can also improve quality of care by providing educational information that can be passed along to the patient to encourage proper disease management and assist with compliance to plans of care.

Patient Safety: Every year, millions are hurt or killed by medication errors that could have been prevented.  The infamous Institute of Medicine (IOM) report indicated that medication errors account for approximately 1 out of 131 outpatient and 1 out of 854 inpatient deaths. Medication errors can drastically be reduced through CDS.  According to Gina Moore, “decision support in the form of evidence-based clinical knowledge delivered in the right format to the right person at the right time can help providers enhance their medication reconciliation strategies by taking steps to ensure patients receive the correct medication, the accurate dosage, avoid drug to drug interactions, check for potential medication allergies, as well as, alert a clinician to reassess the need for medications such as antibiotics that appear to be used for longer than indicated”5.

Cost Savings: Duplicative and/or unnecessary tests can be very costly.  For example, physicians who refer patients to a hospital for imaging tests, such as MRI or CT scans, sometimes order tests that are duplicative or not the most appropriate.  CDS would prevent inappropriate orders by providing the referring physician with evidence at the point of order6. The evidence could be displayed from the use of the American College of Radiology guidelines, as well as criteria created by the organization within the CDS toolset, to guide physicians to the most cost-efficient and effective imaging test for each patient, saving the hospital and patient hundreds of dollars6.

Barriers to adoption

Despite the promise of CDS systems, numerous barriers to their development and implementation exist.  Of these barriers the two most common are physician resistance and cost.

Physician resistance: Physicians resist the use of CDS tools for a variety of reasons, but the main reason is the belief that the use of CDS tools will decrease clinical productivity and impact financial reimbursement7. Usability issues, such as ease of use, speed, as well as its lack of integration into the clinical workflow, concerns about autonomy, and the legal and ethical ramifications of adhering to or overriding recommendations made by the CDS system8 also make physician leery.  Other reasons range from not wanting a computer system to infringe on their decision making to something known as “alert fatigue8.

Cost7: The initial cost of purchasing an EHR with CDS system is compounded by the implementation costs. Once the system is implemented, hospitals incur ongoing costs related to maintaining the system as well as keeping current the evidence-based clinical knowledge that is accessed by the CDS tools. In addition, all of the people using the system require extensive training, further affecting the productivity of the provider and in turn impacting reimbursements.

______

A CDS holds great potential to overcome the quality, patient safety and cost challenges facing healthcare today.  Though there are barriers to its adoption, improvements in these key areas will occur only when physicians can make timely, accurate, evidence-based decisions at the point of care, and from the looks of it a CDS embedded within an EHR may just be what the doctor ordered!

Resources for this blog post:

  1. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC555881/
  2. http://findarticles.com/p/articles/mi_m3257/is_7_62/ai_n28092995/
  3. http://staging.himss.org/himssstage/ASP/topics_clinicalDecision.asp
  4. http://www.rand.org/pubs/research_briefs/RB9136/index1.html
  5. http://www.psqh.com/novdec06/reconciliation.html
  6. http://www.beckershospitalreview.com/healthcare-information-technology/improving-cost-efficiency-safety-in-hospitals-via-imaging-clinical-decision-support.html
  7. http://www.healthcaretownhall.com/?p=1458
  8. http://www.e-healthcaremarketing.com/archives/3319

Member-centric Care: Not without Business & Architectural RoadMap

If I had a dollar every time an Enterprise Architect said, “I have a Road Map,” and handed me the future state IT architecture (which is 5 years out) and proceeded to verbalize current to future IT while I madly wrote every word down in preparation for a Business Transformation Session to prioritize/re-prioritize initiatives, well you get the general thought here.  Not the way to be doing things.

The whole industry is going through business and IT transformation; however, Road Maps are never complete, unless someone is accountable for these deliverables (See http://blogs.perficient.com/healthcare/blog/2009/12/15/the-value-of-business-and-architecture-roadmaps/).

How can the business prioritize initiatives without a road map for understanding the IT implications… better yet, how can the business reprioritize initiatives without understanding the IT impacts? This has always baffled me.  Has it bothered you?

Visions have to be documented in many forms and various levels of details for the appropriate audience.  One size future state IT architecture does not fit all.

What are your thoughts?

Member-centric Care: Open source to the rescue?

A must read from my colleague, Martin Sizemore, entitled, “Is it time for open source in healthcare?”

Wow! This Business/Process with system enablement person, me, can understand this architecture stack.  Yes, now more than ever we need open source.

Prototyping Open Source for testing ICD-9 to ICD-10 with on the fly remediation before going to production in a collaborative environment with Payer and Provider.  There’s an interesting thought.  What are your thoughts?  It is ok to let me know that I have exceeded my knowledge on this one.  That is, I have gone too much into IT and need to stick to the Business side of things.  Glad to have Martin as the expert.

ICD-10 Revenue Neutrality Will Drive Collaborative Testing

I was reading my collegue Mike Berard’s blog, on ICD-10 Revenue Neutrality: A Strategic ApproachWe have discussed the importance of testing before production between Payer and Provider (e.g., Physicians and facilities). In his 2nd to last paragraph Mike proposes the following:

“The reality is that Revenue Neutrality verification is still subject to the availability of a Claims and Benefits test environment that will mirror production but accommodate GEMs and reimbursement schedule refinement on the fly. Does this mean that organizations will be subject to an infrastructure investment that also mirrors production? And will the test environment be subject to the same change control rigor of the production environment? I wonder if we have enough “maintenance widows” to support the number of changes to Claims and Benefits systems’ application logic before we know what changes to make the GEMs and reimbursement schedules…”

Based on my experience, I am not seeing Payer’s Business and IT departments addressing testing environments for Revenue Neutrality.  What is your experience?

I can see that Revenue Neutrality is being considered the end of the process so not much attention is being placed on it at this time.  Everyone is in ID and Stratification Mode.  However, as a process person, the end of the process is what drives the beginning of the process.  All critical information is gathered and tested at the beginning of the process to ensure the end-of-process can be completed and successfully reported.  If we are not testing ICD-9 to ICD-10 all the way through the process for Payer, Provider, and Member neutrality before we go to production, we must take a step back and revisit our Strategic Approach.

Mike concludes with the following:

“Revenue Neutrality may have an initial focus on billing and reimbursement based on clinical accuracy in procedural coding, but will ultimately depend upon remediation of information systems and close collaboration between the payer and provider for ongoing refinement of reimbursement contracts.” These are hand in hand with a Member’s benefits and out-of-pocket expenses for ICD-9 to ICD-10.  This should be tested and certified for our patients/members prior to production.  Otherwise, we are not member-centric.

Payers and Providers need to reengineer their processes to ensure remediation on the fly after going into production for Member-centric care with ICD-9 – ICD-10. Michael Hammer would not be very pleased with our reengineering efforts for member-centric care without remediation processes once in production.

What are your thoughts?

ACO – A Brave New Enterprise: Are you ready?

Racing towards an ACO and Population Management this year is a huge challenge.  A new enterprise platform is a must for an ACO to coordinate the changing of Provider and Payer processes and behavior not to mention the Shared Savings contracts which require new measurements and reporting: a shared dashboard.  Check out Martin Sizemore’s take and solution for this Brave New Enterprise.  Also, how are you going to leverage Cloud Technology?

During my years in consulting I have had the opportunity to work at a large local telecommunications carrier who wanted to get into long distance; thus, they had to open up their systems and serve competitive local exchange carriers.  Just 15 years ago the telecommunications industry faced a Brave New Enterprise.  Just as a local carrier had to go through third-party review and regulatory oversight, we now have a similar situation facing the ACOs.

The partners of the ACO need to start now on formal Enterprise User Group.  Yes, we are talking establishing weekly status meetings with all parties and a formal change request management process for the ACO.

What if multiple Providers want to change the flow and/or data extraction from/to the Brave New Enterprise?  This should be discussed by all users of the enterprise and prioritized in the appropriate release.

Changes will need to be fast and the ACO will need to follow an Agile w/iRise BPM.

Do you find it exciting to think of the Brave New Enterprise without the chains of a traditional SDLC?  Think of the mobile applications that can be put in place.  This white paper can help you to learn more.

The ACO BPM needs to be established.

Change requests will not be for just the Brave New Enterprise system, but will include process as well.  Think big.  The Telecom industry had to do so and it took years and lots of lessons learned. Avoid repeating the same mistakes since we do not have the time to re-invent the wheel.  Leverage whatever you can.  For example, Lesson Learned:  Start sooner rather than later….build with anticipation to manage changes to processes and systems in a formal consensus building environment.

What are your lessons learned from building and managing a Brave New Enterprise with parties that have to transition to a Brave New Relationship?  Do you have other industry comparisons to the Healthcare industry of today?

Member-Centric Care: Have we over turned every rock?

In my previous posts about the Member-Centric Care team, I posed several questions and gave my opinions to support them. Here is a review of what was discussed, as well as new thoughts:

  • Have we over turned every rock (e.g., process, operation, and IT enablement) to allow for member-centric care?
  • Let us assume that you have gone as far up stream in BPM…all the way to Marketing/Sales and Insurance Brokers/Agents, then Yesyou have overturned every rock for the Payer and Provider to collaborate.
    • Health Insurance Agents are the first individuals to touch a potential new employer and member and support existing employers and members.
    • Health Insurance Agents are paid through commissions to educate their clients for Consumer-Driven Health Care and Member-Centric Care.
    • Health Insurance Agents have a responsibility regarding plan, eligibility & benefits, and assisting with claims.

Are Academic Medical Centers the next big Clinical Trial players?

One thing I have been wondering about recently is to what extent consulting firms are exploring the clinical trial sector of academic medical centers (AMCs). While conducting an assessment of just one (small) department within an AMC in a previous consulting engagement, I learned how weary everyone around me was of the academic bureaucracy and lacked any faith that a change can come about. During our assessment, my teammates and I learned about two types of organizations that can be set up inside an AMC to boost its competitiveness in the clinical trial landscape.

Organization Types

One is a Site Management Organization (SMO) that helps sponsors manage multiple sites for clinical trials, including private sites in the AMC’s own vicinity. An SMO can help an academic medical center not only boost clinical trial revenues with more sites under its belt but also cut costs on research and resources by sharing them with its sites. The only drawback is that a SMO cannot conduct its own Quality Assurance, which would be resolved if the AMC can use its university’s Institutional Review Board (local IRB) to gain approval for all its clinical trial sites. However, the fact that local IRBs can take somewhere from two to six months to approve one study, as they are often underfunded and understaffed, really means that by the time a study gets approved it is over. Other clinical trial sites have picked up patients, reaching the maximum goal set by the sponsor. Thus, an SMO within an AMC has no choice but to contract with an independent IRB (central IRB) or partner with a Contract Research Organization (CRO) to keep up the pace. While the former partnership is necessary to gain fast approval for clinical trials (within one business week), the latter is not in an AMC’s best interest because a CRO is a direct competitor who can manage clinical trial sites, conduct Quality Assurance, and compile the findings to meet sponsors’ requirements. In a partnership with a CRO and a sponsor, the AMC SMO would be just another, bigger, clinical trial site.

AMC Advantages

One very crucial thing that an AMC has going for it, and that a CRO cannot boast, is the research minds and expertise of its world-renowned physicians as well as the research funding and resources that come with being part of a large state university. Sponsors like to see more AMCs in their clinical trials because results from these sites provide the credibility that a CRO cannot provide by simply compiling the results. Further, from our research, my teammates and I found that sponsors WANT to work directly with AMCs instead of going through a CRO. However, CROs have become a major force in the clinical trial landscape as the main “middlemen” between sponsors and sites because they can manage an entire clinical trial for sponsors on one budget from start to finish. This may offer convenience but may be not always provide the best expertise or the best product for the price.

Now, if you combine the competitiveness of a CRO with the resources that come with being an AMC, you can build a very strong clinical trial competitor who can do more just conduct a lot of clinical trials. An AMC CRO can work directly with sponsors on clinical trials and medical research to improve the healthcare that is provided not only in the AMC’s immediate area but also to patients worldwide by backing up the findings with the expertise of world-renowned physicians who are trusted for their opinions and experience. This will benefit the AMC by attracting the best medical talent there is, meaning the best residents who want to train and the best physicians who want to be researchers, and also by improving its outreach in its immediate community.

I wonder why I don’t see more and more consulting firms working with AMCs on reaching these heights by helping them become major sources of clinical research as well as the best medical care that members can get no matter what their healthcare affordability. I am hoping to gain insight from healthcare consulting experts through my blog. 

Healthcare Business Intelligence – Success vs. Biting off More than You Can Chew

The healthcare industry is ecstatic about the opportunity to apply business intelligence (BI) to improve healthcare quality, cost and outcomes. Providers are using BI to address process issues that limit operational efficiencies. BI is “the solution” to successfully overcoming short-comings and creating provider bottom-line benefits, patient time and efficiency benefits and overall social equity. IBM stated that “(f)orward-thinking healthcare organizations realize that data – and, thus, business intelligence – is at the center of informed and precise decision-making that will improve patient and service outcomes in addition to ensuring their organizations’ future.” However, these benefits are only revealed if a BI initiative meets its goal.

To meet a goal, a BI project must be clearly defined. For example, the goal of a BI project is not a dashboard. Instead, the goal is getting the right information about an area of opportunity to the right people. Therefore, the value of healthcare BI projects comes from a thorough analysis of the opportunity. This leads us to the first point: Get different perspectives.

Combining knowledge from throughout an organization allows those involved in the project to identify themes and examine the problem from different perspectives. This is invaluable as the outcome of a BI project must provide the right information to the right people to be successful.

Next, as BI projects are introduced to an organization, each person’s perspective may lead the project down a different path. For example, some perspectives may suggest different data is necessary to provide valuable analytics about an issue. To ensure that a project stays on track, moves forward and remains a manageable size, a project’s scope and goal must be clearly defined. Setting a firm definition will ensure that the initiative meets its goal.

Finally, staying on track and limiting scope can be frustrating, but it provides an opportunity to look forward at how one initiative overlaps with future initiatives. Success on Project A may lend itself to Project B and Project B to Project C – together these projects may paint an invaluable view to members of an organization and allow each employee to address an issue from their perspective.  Don’t bite off more than you can chew. Divide a project up into manageable pieces.

Acknowledge that each issue has its own set of players and each player has its own solution. Remember that the healthcare sector is biting at the bit for ways to address their operational efficiencies. Organizations expect BI to live up to its promise – and it can, if the projects are approached from multiple perspectives, remain goal-driven and are divided up into manageable pieces.

Using Core Measures to Jump-Start Enterprise Analytics

Today I spoke in a webinar entitled “Using Core Measures to Jump-Start Enterprise Analytics”.  During this presentation I covered a number of topics around business intelligence in healthcare and specifically around an approach called targeted analytics. I reviewed some of the options available today to healthcare organizations and provided an example of building an enterprise BI platform using core measures analytics as the foundational application.

You can view the slides below.  You can also view a recast of the webinar here: http://www.perficient.com/webinars/

Let me know what you think!

See this slideshow on SlideShare.