By Diane D. Homan, M.D.
It’s a unique time in healthcare. Public and private initiatives are aligning and are working synergistically toward the transformation of the healthcare system through improved care access, quality and cost. Part of this movement is a paradigm shift away volume-based, fee-for-service care toward a system where quality is the foundational aspect of all clinical and administrative operations—a healthcare system incentivized by a performance-based regulatory and reimbursement environment to provide proactive, patient-centered care.
Effective population health management (PHM) strategies have been identified as critical to success under this new quality-focused, value driven healthcare model. The goal of PHM is to gain a clear understanding of health trends within the patient populations organizations served, and then take proactive action to achieve the best outcomes.
When PHM strategies drive care delivery, performance metrics fall into place. Healthier patients naturally drive improvements in outcomes and minimize the need for higher-cost interventions such as emergency department visits, inpatient hospitalizations and surgical procedures.
While simplistic in theory, achieving success with PHM requires an advanced technological infrastructure to support standardized care practices and provide access to clinical decision support (CDS) at the point of care. In particular, CDS tools that deliver to physicians the latest industry evidence and guide them toward appropriate treatment protocols and management, have quickly become important elements of hospitals’ strategies to enhance care delivery and quality for improved patient outcomes and overall population health.
The value CDS brings to PHM—in particular advanced evidence-based order set solutions— is demonstrated by Rush-Copley Medical Center’s highly effective and successful response to a local tuberculosis (TB) outbreak.
Already deployed to address standardization of care practices, we leveraged Minneapolis-based ProVation Order Sets, powered by UpToDate Decision Support, to quickly deploy a point-of-care strategy for identifying at-risk patients. This in turn enabled the rapid application of effective isolation management strategies and development of a collaborative community effort to coordinate ongoing care and avoid a broader public health epidemic.
Containing an Emerging Public Health Crisis
Rush-Copley Medical Center is a 210-bed hospital providing state-of-the-art health and wellness services to the greater Fox Valley region of Illinois, including the state’s second largest city, Aurora. The first sign of a potential TB outbreak occurred in late 2009, when a homeless person presented to the emergency department. A second admission a few months later led our infection prevention manager to reach out to the Kane County Health Department regarding the suspected outbreak. This trigged a joint investigation that ultimately led to ground zero—the homeless shelter frequented by both patients.
Two factors contributed to the successful identification and containment of this outbreak. First was the collaborative effort of our emergency department personnel, infection prevention professionals and the county health department. Second was having in place CDS tools to support rapid diagnosis and appropriate treatment.
Successful PHM requires overcoming the unique challenges presented by impacted often vulnerable populations, in this case the homeless, which tends to be transient in nature. Failure to quickly identify and contain the outbreak could have resulted in a rapid escalation as the broader population became exposed including the high-traffic public locations such as malls and libraries frequented by the homeless when shelters are closed during the day.
Another key challenge to PHM is avoiding provision of unnecessary services. In the case of the TB outbreak, this necessitated developing a method to identify which patients should be tested when they presented to our facility, and which had already been screened. Such an approach is not feasible without the help of the right technological infrastructure. There simply are not enough providers and care managers in today’s lean healthcare climate to effectively address this type of large-scale PHM initiative without the support of advanced health IT.
Automation and a structure of clinical evidence that established what is applicable to all exposed patients 100 percent of the time would provide a foundational starting point. Building upon this was the need for flexibility to institute modifications that effectively addressed our own unique workflows and patient population. Finally, we needed a system in place that ensured accurate capture of information in the electronic medical record on every patient who presented to track screenings over time and avoid any duplication of service, which would only add to the cost.
Simply put, we needed a CDS solution to standardize treatment protocols based on industry best practices that was flexible enough to be altered in response to specific community needs, all while maintaining our priority focus on quality and safety. Fortunately, ProVation Order Sets—the tool we already had in place—had everything needed to effectively address the full picture.
Leveraging Evidence-Based Order Sets to Circumvent Risk
At Rush-Copley, we turned to our order sets to form the foundation for a standardized approach to addressing the TB outbreak. We implemented guidelines that ensured the same screening protocols would be used to identify at-risk patients, and that the next steps always addressed the highest-quality care delivery to contain risk and produce the best outcomes.
This was accomplished by altering emergency department order sets to address specific diagnostic and treatment protocols. Specifically, we used information provided by Centers for Disease Control (CDC), and state and local health departments to identify specific treatment procedures and processes that aligned with regional requirements and needs. This information was then used to update the applicable order set, alerting clinicians when TB screening tests were appropriate and guiding them toward appropriate treatment based on whether an identified patient had active or latent phase TB.
The addition of pre-checked diagnostic testing in evidence based order sets ensured that our team was fully compliant with the recommended guidelines for patients who exhibited nonspecific symptoms. Isolation management strategies were immediately employed for all high-risk patients to keep exposure to a minimum during the diagnostic testing.
As of mid-June 2013, we were managing 45 active TB patients and 350 latent phase patients. This long-term treatment effort—something that is often impossible with the transient homeless population—is possible thanks to a collaborative effort under the coordination of the Kane County Health Department, Illinois Department of Public Health and the CDC. Since the outbreak began, the CDC has made site visits to Kane County on two occasions, providing oversight to ensure that regulatory guidelines are being met and industry best practices followed.
It took a collaborative effort to address the long-term PHM aspects of the TB outbreak, but it was the availability of evidence-based order sets that drove the point-of-care actions needed to identify and treat infected patients and bring down the risk of broader contamination both within the hospital and across the community at large.
Conclusion
The federal government is taking action to address inefficiencies and the need for higher quality in healthcare. CDS technology provided at the point of care has been identified as a critical component to meeting these goals.
Of six major focus areas identified by the government that attribute to significant losses in healthcare, three—accounting for 50 percent of total losses—can effectively be addressed with evidence-based order sets at the point of care:
Rush-Copley was able to address all three of these areas and deploy an effective PHM strategy during the recent TB outbreak through use of ProVation Order Sets. It is a clear demonstration of the critical role point-of-care strategies play in addressing the deficiencies that exist in the healthcare system.
Diane Homan, M.D. is the Vice President of Quality and Patient Safety Officer with Rush-Copley Medical Center.