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How to Choose Wisely: Researchers Confirm the Value of Clinical Decision Support

September 3, 2018
by Mark Hagland
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A recent study provides nuanced insights into the complexity of clinical decision support—while affirming its advantages

When physicians follow computer alerts embedded in electronic health records, their hospitalized patients experience fewer complications and lower costs, leave the hospital sooner, and are less likely to be readmitted, according to a study of inpatient care released on Aug. 15. by researchers affiliated with the Cedars-Sinai health system in Los Angeles and with Optum, an Eden Prairie, Minn.-based information- and technology-enabled services company (though the division of Optum that had been the Advisory Board Company).

As the press released published on that day noted, “The research examined alerts that popped up on physician computer screens when their care instructions deviated from evidence-based guidelines. The alerts were based on an initiative called Choosing Wisely, which identifies common tests and procedures that may not have clear benefit for patients and should sometimes be avoided. For example, an alert might pop up on the screen if a physician orders a CT scan when it’s unnecessary and likely won’t improve the patient’s outcome. The alert would serve as a reminder that the order could expose the patient to unnecessary radiation and costs.  The Choosing Wisely alerts were backed by the American Board of Internal Medicine Foundation and created by various physician subspecialty societies.”

Speaking of the study, Scott Weingarten, M.D., M.P.H., chief clinical transformation officer at Cedars-Sinai and a senior author of the study, said in a statement quoted in the August. 15 press release, “Sometimes the best care for certain patient conditions means doing less. We have seen that real-time aids for clinical decision-making can potentially help physicians reduce low-value care and improve patient outcomes while lowering costs.”

The release went on to note that “Many leaders in the healthcare industry have targeted unnecessary care as a means of improving patient safety while cutting wasteful spending. One 2010 estimate from the Institute of Medicine found that “unnecessary services” contribute to about $210 billion in wasteful healthcare spending in the United States each year. The study, conducted by investigators from Cedars-Sinai and Optum Advisory Services, was published in The American Journal of Managed Care. It examined data from inpatient visits at Cedars-Sinai Medical Center from October 2013 to July 2016 in which one or more of the 18 most frequent alerts was triggered.”

What’s more, the release noted about the study, “For 26,424 of the inpatient visits studied, the treating physician followed either all or none of the Choosing Wisely guidance. In 6 percent of visits, physicians in the “treatment group” followed all triggered alerts; in the remaining 94 percent of visits, physicians in the “control group” followed none of the triggered alerts. An alert was triggered, for example, if a physician tried ordering a sedative for a sleepless older patient or an appetite stimulant for an older patient who was ill and losing weight. Sedatives can put seniors at risk for falls, bone fractures and car accidents, and appetite stimulants can put seniors at risk of fluid retention, stroke and death.”


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Further, “The authors found a significant difference in health outcomes and costs between the two groups. For patients whose physicians did not follow the alerts, the odds of complications increased by 29 percent compared to the group whose physicians followed the alerts. Likewise, the odds of hospital readmissions within 30 days of the patients’ original visits was 14 percent higher in the group whose physicians did not follow the alerts. Patients of these physicians also saw a 6.2 percent increase in their length of stay and an additional 7.3 percent – or $944 per patient – in costs, after adjusting for differences in patient illness severity and case complexity.”

And the release quoted Harry C. Sax, M.D., executive vice chair of surgery at Cedars-Sinai and a senior author of the study, as stating that “Sometimes doctors order tests that they think are in the patient’s best interest, when research doesn’t show that to be the case. Unnecessary testing can lead to interventions that can cause harm. This work is about giving the right care that patients truly need.”

Shortly after the public release of the study, Anne Wellington, managing director of the Cedars-Sinai Accelerator—which, according to its website, is “is transforming healthcare quality, efficiency, and care delivery by helping entrepreneurs bring their innovative technology products to market”—and who was a coauthor of the study, spoke with Healthcare Informatics Editor-in-Chief Mark Hagland about the study’s results, and its implications for healthcare leaders. Below are excerpts from that interview.

Tell me a little bit about the group that came together to embark on this study?

There was a group of us working from three organizations—Cedars-Sinai, where we had a lot of the patients in the study and the physicians; Stanson Health, where I was working at the time, which had been providing the alerts; and the Advisory Board Company, now Optum, and that included Andy Heekin. Stanson Health—Scott Weingarten was one of the founders, and we had had the foundation of the EMR-embedded clinical decision support, though the solution from Zynx [the Los Angeles-based Zynx Health]. We also had support from Stanson Health.

Anne Wellington

What was the origin of the study?

We had created a library of alerts based on the Choosing Wisely Initiative from the ABIM that was targeting low-value care, in order to advise physicians about tests and treatments commonly overused. We translated those into alerts and a decision support program. We wanted to evaluate the use of those guidelines and alerts, so we created the content to essentially scan the patient chart, and when there was a match between the guideline and the situation, and the provider was about to potentially violate that guideline, we could give them information on the fact that some specialty society had a guideline around that situation. When we looked at some of the inpatient stays, we saw that in stays where the physicians followed those guidelines, the patients had fewer complications, lower costs while admitted; shorter lengths of stay, and a lowered likelihood of readmission.

Can you explain a bit about the mechanics of the study?

We had introduced the Choosing Wisely Alerts into the system in October 2013, and they’ve been live in the system since then. Stanson and some of the physicians at Cedars have been monitoring them; they’re still active today. From October 2013 through the end of July 2016, we examined all the patient encounters where the patients were admitted and the providers had experienced one or more alerts. We looked at 18 high-volume alerts, and looked at Choosing Wisely as a full concept. And for those patient encounters where the providers might have seen multiple alerts, what was the overall impact of those alerts?

Can you speak to the results? Particularly the four metrics around the 7.3-percent reduction in cost of care, 6.2-percent decrease in length of stay, the 29-percent improvement in terms of complications, and the 14-percent reduction in readmissions?

Right, so we compared inpatient encounters, for those four metrics, where providers agreed with and followed the recommendations through the CDS, compared with where providers ignored or overrode those recommendations.

What are your thoughts on the qualitative significance of those results?

I think one sort of fine point to put on this that we want to be careful about is that there’s a group of physicians practicing within Choosing Wisely guidelines, who didn’t see alerts, because we would trigger alerts if a provider was about to fall outside the guidelines, so there were some who always practiced within the guidelines. So it was about adhering to the alerts rather than overriding them—not so much always practicing within them or not. That’s a nuance. Indeed, we focused on encounters in which physicians followed all of the alerts, or followed none of them. We also looked at any physician who followed a patient. So all the physicians involved in the encounter had to follow all the alerts, or none.

So they adhered to the guidelines across all the alerts, or none?

Yes, those were the two categories we analyzed. Where it was mixed, we excluded those from our analysis.

Is there anything to say about the mixed situations, in which physicians followed some, but not all, of the alerts provided to them?

We looked at nearly 30,000 overall encounters, a small percentage, 1,400, fell into that mixed group, and I don’t have any specific explanation for those.

What is your view of the Choosing Wisely program specifically, in this context? How effectively do guidelines work, in practice?

I think this is exciting, because when we look at guidelines generally, they are rapidly evolving forward. And simply publishing guidelines and releasing them out into the world, doesn’t necessarily help those who need them. So clinical IT can form a bridge between all those who work within the EHR (electronic health record) and all those who are preparing these guidelines. This provides good research on the best way to provide high-quality care to patients.

What are your qualitative thoughts on why physicians might reject use of the guidelines? What it might mean?

I have two thoughts. The Choosing Wisely initiative itself, the guidelines they issue, they’re pretty clear that they want to foster further conversation between providers and patients, so when they recommend against certain tests and treatments, they want to engage with providers about things that are commonly overused, but they don’t go so far as to say, this is never appropriate for this type of patient or population. On the technical side, we can assess a patient based on the data in the HER and offer a technical recommendation. But the person closest to the patient and who can see the reality and not just the data captured, is the physician. So sometimes, based on the specific recommendation in the chart, they may opt to continue with the treatment.

And of course, clearly, the Choosing Widely program isn’t attempting to substitute for clinical judgment?

That’s correct. The comparison Scott likes to make is that you’re sort of trying to use this as a kind of blind spot monitor. It’s not a substitute for judgment; it’s just something that can help alert you to something that might be worth further consideration.

What would you say to CIOs, CMIOs, and other healthcare IT leaders, about what’s been learned here?

The study shows that clinical decision support that’s carefully concepted and deployed, can reduce low-value care, when we look at the metrics around the cost and value of care measured in the study. And looking at the deployment of it, making sure the decision support is monitored and evaluated—to understand that it’s being adhered to and valued and is helpful to providers, is part of the key to having those positive impacts.

These guidelines should theoretically work in any decent EHR, correct?

It’s hard to put a definition on decent EHR. So that’s a little bit challenging to answer. But I would say that using data elements available in most EHRs, it’s possible to embed similar guidelines, in most EHRs.

Is there anything you’d like to add?

I think the study has been really exciting. Personally, I love to see applications where technology can fill in and do what computers do best—evaluate a lot of information and do it in a very quick and efficient manner. So it’s exciting to pair the power of these technology solutions, with the insight and care of the physician, and see positive outcomes for the patient.



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Gazing Into the Crystal Ball with LRVHealth’s Keith Figlioli

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2019 Predictions on Value-Based Care, Digital Startups, EHR Trends

Here’s a confession: I am much better at writing end-of-year review stories than I am at looking into the crystal ball for preview pieces at the beginning of the year. I might be able to make educated guesses about which issues we will be writing about in the coming year, but I prefer leave predictions about what is actually going to happen to others.

Luckily, people braver and more knowledgeable than I am are willing to weigh in. For instance, Dave Levin, M.D., chief medical officer of Sansoro Health recently shared his predictions for 2019 with Healthcare Informatics. One of his predictions is that “the excitement around new health IT players like Apple and Amazon will fade in late 2019. We need fresh ideas, but in the short-term, expect disappointments and missteps. Health IT (and healthcare in general) is much harder than it looks and the winners in the long-run will master the mash-up of the best of old and new. Health IT history is littered with companies like these that underestimate this challenge.” Good point!

Dave’s company, Sansoro Health, provides a set of APIs that read and write to EHRs. One of its investors is Boston-based LRVHealth, and one of LRVHealth’s general partners is Keith Figlioli, who served as senior vice president of healthcare informatics at Premier Inc. for nearly a decade. In December I spoke with Keith about some of his predictions for 2019.

One is that capital will be less abundant for digital health startups in 2019. I asked him why he thought that would be the case. “There already is a tremendous amount of capital in this space, including capital coming from other industries. The threat is that capital could be less abundant,” Figlioli said. “We are starting to see earlier stage companies have a little harder time raising capital. What that signals to us is that the greater market is pushing capital to later stages. Because capital can be harder to get in earlier rounds, valuations tend to float down a bit. The other thing is that the greater macro economy does feel like things are shifting a bit and that will also have an effect. I think 2019 may be a peaking year for valuations. I don’t think we are going to go much higher than we are right now.”

While Dave Levin had predicted that the enthusiasm about outside disruption from Big Tech might fade by the end of 2019, Figlioli predicted that these emerging entrants will start showing their cards. “Some of these guys are fairly secretive in their moves, but Apple has been hiring in healthcare and Amazon acquired PillPack. My sense is that we are going to know more about the ones that have been secretive,” he said. Now that the CVS/Aetna deal is done they will start to reveal more, he added. “We are going to see more announcements from these players over the course of 2019. People will be able to start deciphering what their plans are, at least out of the gate.” With its leadership in place, the Amazon/Berkshire Hathaway/JP Morgan entity will reveal an initiative, he predicted.

He also noted that Walgreens made some strategic announcements in 2018. “I call them the sleeping giant now, because CVS and Aetna made all the noise with their purchase deal. But Walgreens is making some very calculated moves with the incumbent players.”

Figlioli predicts that in 2019 the pace will pick up again on value-based care activity. “At LRVHealth, we have a saying that value-based care is inevitable but it is gradual,” he said. “I think we are finally going to get back up on the hamster wheel with things that really matter, because it feels like we have basically been at a dead stop since Trump took office.” He expects to see a handful of new mandatory and voluntary programs across cancer, cardiac and new bundled payment models. “When [HHS Secretary] Azar came in, it revved the engine back up and he is talking very publicly about ramping up mandatory programs. I think another signal is him talking more about CMMI [the Center for Medicare & Medicaid Innovation] and what may come out of it in terms of social determinants of health. I think we will see one or two CMMI pilots in 2019 dedicated to social determinants.”

In a related prediction, he said we should expect to see community programs such as local food banks become more closely affiliated with healthcare providers and payers. And just as there have been startups in the transportation area of social determinants, expect to see a few food-as-medicine related startups emerge in 2019, he added.

Figlioli’s final prediction touches on something I have written about a few times, the new “app store” approach to EHR add-ons. With open APIs gradually becoming the norm, he said, more CIOs who will become comfortable layering best-of-breed applications on top.

“There has been this lure in the CIO suite to say that the EHR vendor is going to do everything.  But because of what Cerner and Epic are doing and what athena has done all along, we are finally getting to a place where the average CIO is going to going to be OK going back to more of a hybrid model.” He stressed that the core EHR is not going anywhere. “You can think about them the same way you do about ERP systems. Over the last five years there has been a proliferation of overlays on top of them. And I feel like we are finally going to get to that with the EHR. It is not going to be clean or easy. There are going to be issues. It is going to be a pretty messy situation depending on how FHIR gets implemented. But it will become more of a cultural norm that Epic and Cerner don’t have to do everything. CIOs will say, ‘we are OK with them being our core workflow tool, but now we are allowing an overlay to take place.’”




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Research: Physician Burnout is a Public Health Crisis; Improving EHR Usability is Critical

January 18, 2019
by Heather Landi, Associate Editor
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Physician burnout is a public health crisis and addressing the problem requires improving electronic health record (EHR) standards with a strong focus on usability and open application programming interfaces (APIs), according to a new report from leading healthcare researchers.

The report is a “call to action,” the researchers wrote, “to begin to turn the tide before the consequences grow still more severe.” The researchers also recommend “systemic and institutional reforms” that are critical to mitigating the prevalence of burnout.

The result of collaboration between researchers with the Massachusetts Medical Society, the Massachusetts Health and Hospital Association, the Harvard T. H. Chan School of Public Health, and the Harvard Global Health Institute, the report's aim is to inform and enable physicians and health care leaders to assess the magnitude of the challenge presented by physician burnout in their work and organizations, and to take appropriate measures to address the challenge, the researchers say.

The report also offers recommended actions for healthcare leaders to take, which the researchers acknowledge are not exhaustive, but “represent short-, medium-, and long-term interventions with the potential for significant impact as standalone interventions.”

The authors of the report include Ashish K. Jha, M.D., the K.T. Li Professor of International Health at the Harvard T. H. Chan School of Public Health, and director of the Harvard Global Health Institute; Andrew Iliff, lead writer and program manager, Harvard Global Health Institute; Alain Chaoui, M.D., president of the Massachusetts Medical Society; Steven Defossez, M.D., vice president, clinical integration, Massachusetts Health and Hospital Association; Maryanne Bombaugh, M.D., president-elect, Massachusetts Medical Society; and Yael Miller, director, practice solutions and medical economics, Massachusetts Medical Society.

In a 2018 survey conducted by Merritt-Hawkins, 78 percent of physicians surveyed said they experience some symptoms of professional burnout. Burnout is a syndrome involving one or more of emotional exhaustion, depersonalization and diminished sense of personal accomplishment. Physicians experiencing burnout are more likely than their peers to reduce their work hours or exit their profession, according to the report.

By 2025, the U.S. Department of Health and Human Services predicts that there will be a nationwide shortage of nearly 90,000 physicians, many driven away from medicine or out of practice because of the effects of burnout.  Further complicating matters is the cost an employer must incur to recruit and replace a physician, estimated at between $500,000-$1,000.000. 

“The growth in poorly designed digital health records and quality metrics has required that physicians spend more and more time on tasks that don’t directly benefit patients, contributing to a growing epidemic of physician burnout,” Dr. Jha, a VA physician and Harvard faculty member, said in a statement in a press release accompanying the report. “There is simply no way to achieve the goal of improving healthcare while those on the front lines – our physicians – are experiencing an epidemic of burnout due to the conflicting demands of their work. We need to identify and share innovative best practices to support doctors in fulfilling their mission to care for patients.”

The beginning of the physician burnout crisis can be traced back to several events, according to the researchers, including the “meaningful use” of electronic health records, “which transformed the practice of many physicians, and was mandated as part of the 2009 American Reinvestment and Recovery Act.” Going back further, the 1999 publication of the Institute of Medicine’s “To Err is Human” highlighted the prevalence of medical errors, brought new attention to quality improvement and the value of physician reporting and accountability, the report states.

The researchers note that the primary impact of burnout is on physicians’ mental health, “but it is clear that one can’t have a high performing health care system if physicians working within it are not well. Therefore, the true impact of burnout is the impact it will have on the health and well-being of the American public,” the researchers wrote.

The researchers note, “If we do not immediately take effective steps to reduce burnout, not only will physicians’ work experience continue to worsen, but also the negative consequences for health care provision across the board will be severe.”

And, while individual physicians can take steps to better cope with work stress and hold at bay the symptoms of burnout, “meaningful steps to address the crisis and its root causes must be taken at a systemic and institutional level,” the researchers wrote.

According to the researchers, the primary drivers of physician burnout are structural features of current medical practice. “Only structural solutions — those that better align the work of physicians with their mission — will have significant and durable impact,” the researchers wrote in the report.

To that end, the researchers’ immediate recommendation is for healthcare institutions to improve access to and expand health services for physicians, including mental health services.

In the medium term, technology can play a large role. Addressing physician burnout will require “significant” changes to the usability of EHRs, the researchers wrote, including reform of certification standards by the federal government; improved interoperability; the use of application programming interfaces (APIs) by vendors; dramatically increased physician engagement in the design, implementation and customization of EHRs; and an ongoing commitment to reducing the burden of documentation and measurement placed on physicians by payers and health care organizations.

New EHR standards from the Office of the National Coordinator for Health IT (ONC) that address the usability and workflow concerns of physicians are long overdue, the researchers state. One promising solution would be to permit software developers to develop a range of apps that can operate with most, if not all, certified EHR systems, according to the report. The 21st Century Cures Act of 2016 mandates the use of open APIs, which standardize programming interactions, allowing third parties to develop apps that can work with any EHR with “no special effort.” There already have been efforts on this front, such as Epic’s “App Orchard,” the researchers note, but more work remains to be done.

To expedite this critical process of improvement, the report recommends physicians, practices, and larger health care delivery organizations, when seeking to purchase or renew contracts for health IT, adopt common RFP language specifying and requiring inclusion of a uniform health care API.

The researchers also say that artificial intelligence (AI) can play a promising role as AI technologies can support clinical documentation and quality measurement activities.

Long term, healthcare institutions need to appoint executive-level chief wellness officers who will be tasked with studying and assessing physician burnout. Chief wellness officers also can consult physicians to design, implement and continually improve interventions to reduce burnout, the researchers wrote.

“The fundamental challenge issued in this report is to health care institutions of all sizes to take action on physician burnout. The three recommendations advanced here should all be implemented as a matter of urgency and will yield benefits in the short, medium, and long term,” Jha and the research team wrote.


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GAO Report: Patient Matching Efforts Can Be Significantly Improved

January 17, 2019
by Rajiv Leventhal, Managing Editor
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The report did conclude that no single effort would solve the challenge of patient record matching

There is a lot that can be done—such as implementing common standards for recording demographic data—to improve patient matching, according to a new Government Accountability Office (GAO) report that closely examined the issue.

The 21st Century Cures Act included a provision for GAO to study patient record matching, and in this report, GAO describes (1) stakeholders' patient record matching approaches and related challenges; and (2) efforts to improve patient record matching identified by stakeholders.

The 37 stakeholders that GAO interviewed, including representatives from physician practices and hospitals, described their approaches for matching patients' records—comparing patient information in different health records to determine if the records refer to the same patient.

The respondents explained that when exchanging health information with other providers, they match patients' medical records using demographic information, such as the patient's name, date of birth, or sex. This record matching can be done manually or automatically. For example, several provider representatives said that they rely on software that automatically matches records based on the records' demographic information when receiving medical records electronically.

Stakeholders further said that software can also identify potential matches, which staff then manually review to determine whether the records correspond to the same patient. They said that inaccurate, incomplete, or inconsistently formatted demographic information in patients' records can pose challenges to accurate matching. For example, records don't always contain correct information (e.g., a patient may provide a nickname rather than a legal name) and that health IT systems and providers use different formats for key information such as names that contain hyphens.

Those who GAO interviewed identified recent or ongoing efforts to improve the data and methods used in patient record matching, such as the following:

  • ·         Several stakeholders told GAO they worked to improve the consistency with which they format demographic data in their electronic health records (EHR). In 2017, 23 providers in Texas implemented standards for how staff record patients' names, addresses, and other data. Representatives from three hospitals said this increased their ability to match patients' medical records automatically. For example, one hospital's representatives said they had seen a significant decrease in the need to manually review records that do not match automatically.
  • ·         Stakeholders also described efforts to assess and improve the effectiveness of methods used to match patient records. For example, in 2017 the Office of the National Coordinator for Health Information Technology (ONC) hosted a competition for participants to create an algorithm that most accurately matched patient records. ONC selected six winning submissions and plans to report on their analysis of the competition's data.

Those who were interviewed said more could be done to improve patient record matching, and identified several efforts that could improve matching. For example, some said that implementing common standards for recording demographic data; sharing best practices and other resources; and developing a public-private collaboration effort could each improve matching.

Stakeholders' views varied on the roles ONC and others should play in these efforts and the extent to which the efforts would improve matching. For example, some said that ONC could require demographic data standards as part of its responsibility for certifying EHR systems, while other stakeholders said that ONC could facilitate the voluntary adoption of such standards. Multiple stakeholders emphasized that no single effort would solve the challenge of patient record matching.

To this end, a recent report from the Pew Charitable Trusts outlined several key themes related to patient matching, while also suggesting recommendations to improve matching and the infrastructure needed for more robust progress in the medium and long term.

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