Transcript Knowledge Management in Clinical Systems: Principles and

Clinical Decision Support
ROI of Knowledge Management
in Healthcare Services
Tonya Hongsermeier, MD, MBA
Partners Healthcare Systems
Corporate Manager
Clinical Knowledge Management and Decision Support
Stats
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Today, with healthcare expenditures at 14%
of GDP, Uncle Sam is paying half of the bill,
this will grow with aging population…
Medicare, Medicaid and Military beneficiaries
Today, there are 4 workers/Medicare
beneficiary, by 2079, 2:1 ratio
Numerous efforts to curb inflation:
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Managed Care : reduced resource consumption without
patient safeguards
DRG-based/case-based reimbursement – Drive-by
Bypass surgeries and Deliveries
Capitation : Capped suppliers without patient safeguards,
Dr’s kept short hours in places without elevator access
All Failed
Simplified US Healthcare System
CMS/TriCare/VA
Employers
Payors
Pharma
Hospitals
Doctors
Consumers
Goals:
1) Give consumers greater
financial responsibility
2) Reduce Hospitalizations and
cost per hospitalization
3) Increase quality
performance
(NCQA/JCAHO)
4) Reduce drug expenditures
5) Reduce imaging study
expenditures
6) Increase wellness/reduced
sick days
Employer initiatives now:
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Leapfrog : reduce unnecessary adverse
events
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CPOE
High Procedure Volume hospitals
Intensivists on site
HEDIS measures/JCAHO core measures:
Value-Based Purchasing
Defined Contribution: Consumer determines
where to spend first $2000
Consumerism cannot drive down the cost of
services unless the value is transparent
Use Case Examples:
ROI of CDS in Healthcare
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Safety and Primary Preventive Care in
Inpatient and Outpatient Setting
Disease Management and Secondary
Prevention – Diabetes, Geriatric
Prescribing
Roche’s challenge: p450, a new
diagnostic test
In the early 90s…
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Little tangible business case for quality
Increased errors  increased resource
consumption  increased
reimbursement for everyone except for
DRG case-based reimbursment
Selling CDS was impossible
Then, the IOM report was published…
Errors Cause Real Harm
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Medical Errors kill between
44,000 and 98,000 people each
year
7.3% of hospital admissions
incur preventable medication
errors
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66% of these were not intercepted
25% resulted in patient harm
360 preventable Adverse Drug Events for a
hospital with 20,000 annual admissions,
almost 1 ADE per day
Outpatient Adverse Drug
Events
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Overall
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25% of outpatients incurred an ADE
39% were preventable
Antidepressants and antihypertensives were largest
contributors
Elderly (over 65)
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Adverse Events in 5% of population per year
28% preventable
New benzodiazepine w/in 30 days doubles risk of hip
fracture
Cardiovascular agents, diuretics, non-opioid analgesics,
hypoglycemics, & anticoagulants were largest contributors
Causing falls, strokes, bleeds, renal failure, dementia, etc…
Gandhi et al, NEJM 2003;348(16):1556-1564
Gurwitz et al, JAMA 2003;289:1107-16
NEJM: Chances of
Receiving Appropriate
Preventive Care is
about 50%
MAKING THE GRADE - Doctors in California were graded
using a weighted scorecard on the following:
Childhood immunizations - Children who turned 2 years old
during the measurement year who received both Chicken
Pox and Measles/Mumps/Rubella vaccinations
Breast-cancer screening - Women age 50 through 69 who
had a mammogram
Cervical-cancer screening - Women age 18 through 64 who
received one or more Pap tests
Asthma - Patients with persistent asthma,in three age
groups,who received at least one dispensed prescription for
inhalers
Coronary-artery disease - Patients age 18 through 75 with
major heart conditions who showed evidence of cholesterol
screening
Diabetes - Patients with childhood and adult-onset diabetes
age 18 through 75 who had evidence of blood-sugar
screening
Note: The above measures account for 50%of the total
score.Other measures include patient experience (40%) and
investment in technology (10%).
Computer-Based Clinical Decision
Support Evidence Shows…
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55-83% decrease in hospital nonintercepted serious ADEs using CPOE
22-78% increased adherence to
preventive health reminders
At Partners, Drug-Drug Interaction
checking intercepts 5% of physician
orders, physicians change their decision
about 33% of time
Kaushal R, et al. Arch Intern Med. 2003
Bates, JAMA 1998
And Unpublished
Hospital Business Case for
Safety and Quality
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Preventable Adverse Drug Events add $4685 to an admission
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Sedation exceeding HCFA guidelines occurred in 20% of elderly
admissions, adding $5200 or 7.3 days per case
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$1.9 to $3.8 million annual excess costs in a hospital with 20,000 annual
admissions
Nosocomial infections add $100s to $10,000s per case
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Failure to wean, falls, hip fractures
$10.4 million annual excess costs for a hospital with 10,000 annual Medicare
admissions
Pressure Ulcers add $1900 to an admission, sites self-report rates of 510%
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$1.7 million annual excess costs in a hospital with 20,000 annual admissions
Numerous studies show sub-standard antibiotic prescribing practices in the
hospital resulting in excess costs and mortality
NEJM study of advanced antibiotic prescribing system showed reduction of
$18,500/case where clinicians accepted advice of system vs cases where advice
was ignored
Failure to meet JCAHO core-measure goals will result in reduced
reimbursement by CMS and Payors in coming years
Most common prescribing error is failure to adjust for renal function…
Renal Dosing Calculates Creatinine Clearance First,
Then Presents Calculated Default Dose –
It’s a 3000 x 4 cell decision table
Geratric Dosing Presents Adjusted Default Dose
A 250-row Decision Table with Multiple
Substitution Recommendations
Employer/Payor business case
for CDS - Diabetes
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Estimated avg $21,000/year per diabetic employee in
absenteeism, disability and medical costs (study of 6
employers with 375,000 employees
Glycemic control is associated with $1000-$2000
medical costs savings/year to payor
Currently, we are “reimbursed” to measure HgA1c
annually (captured claim for test ordered)
Will soon be reimbursed for maintaining control
through test result surveillance, goal is < 7
“Smart Form” = about 300 rules
Composite Decision Support Application: Diabetes Management
Guided Data Review
Guided Observation Capture
Guided Ordering
•Payor contracts withhold
money annually to reward
good HEDIS performance
•This can swing a physician’s
compensation by $10-15K
•We are gathering data
(unpublished) that shows
that clinicians that use CDS
do better than those that
don’t
•Physicians who are not
wired will increasingly find
themselves financially
penalized
The “Genetic Revolution” Begins
Leading the News: Roche Test Promises to Tailor Drugs
to Patients --- Precise Genetic Approach Could Mean
Major Changes In Development, Treatment
June 25, 2003
Roche Holding AG is launching the first gene test able to predict how a person
will react to a large range of commonly prescribed medicines, one of the biggest
forays yet into tailoring drugs to a patient's genetic makeup.
The test is part of an emerging approach to treatment that health experts
expect could lead to big changes in the way drugs are developed, marketed and
prescribed. For all of the advances in medicine, doctors today determine the
best medicine and dose for an ailing patient largely by trial and error. The
fast-growing field of "personalized" medicine hopes to remove such risks and
alter the pharmaceutical industry's more one-size-fits-all approach in making
and selling drugs.
Cytochrome P450 Test
•No data on it’s value
•Worse, no knowledge
base on how to use
the test result
•No titration
algorithms
•No substitution
algorithms
•Test should be almost
as cheap as a
creatinine clearance
ROI is always on shifting
sand…
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Reimbursement policies always change based on
public sentiment, employer/payor maneuvers, and
government policies
Suppliers are always trying to stay ahead of these
policy shifts
Aging, Obesity, Diabetes, CAD, Oncology and
infectious diseases will continue to drive US inflation
Expect new counter-measures if a “magic bullet” is
discovered for type 2 DM and it still costs more than
a life-time of current standard care….