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The Envelope Please

June 1, 1998
by Lisa Paul
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No matter how you look at it, managed care is affecting the creation of new information technology products. Many of the buzz words in this new era of healthcare--outcomes, case management, disease management--are coming together as new clinical information systems hit the market. For payors, this convergence means lower costs and less risk; for providers, it means better care and improved outcomes.

One of the biggest challenges to healthcare administrators and IT executives is getting the most for their money. To help solve this problem, a number of healthcare organizations are teaming up with software vendors to create new tools for the healthcare IT marketplace. The Henry Ford Health System, Detroit, started the Healthcare Innovations in Technology Systems (HITS) Partnership in Technology Award program several years ago in an effort to recognize and commend these unique business arrangements. Last year, judges chose a winner and runner-up from three different categories: home healthcare, clinical information systems and telemedicine. This article profiles the clinical information systems category.

The Henry Ford Health System, the National Managed Health Care Congress (NMHCC) and InfoCare(former sister publication to Healthcare Informatics) sponsored the competition.

HITS winner:

Clinical pathways have been on many nurses’ must-have lists for years. Today, some case managers create clinical pathways manually; and some don’t use them at all. Still others fall into the same trap as many physicians--seeing pathways as the next best thing to "cookbook medicine."

In addition to the systematic approach to providing care that some nurses and doctors oppose, another roadblock to clinical pathways has been the different terminology used to describe different episodes or patterns of care. PROGNOSYS, Phoenix, formed in 1992 with a goal of creating a clinical vocabulary for setting clinical pathways in the inpatient hospital setting. With the creation of Pediatrax--winner of the 1997 HITS Award for clinical information systems--and with help from five pediatric hospitals and one community hospital, the PROGNOSYS clinical vocabulary database debuted to the public in 1997.

According to Adam Zauder, the company’s president and CEO, the complexity of illnesses of hospitalized children is one of the reasons pediatric nurses and case managers in inpatient settings often desire a useful system for setting and tracking clinical pathways. "Kids in children’s hospitals tend to be much, much sicker than adults in regular hospitals," Zauder says. "It’s almost like 100 or 200 beds [in a pediatric hospital] would be ICU patients in an adult hospital."

For the consortium of six healthcare organizations that helped develop Pediatrax, three of the most attractive elements to this project were:

  • All of the participating hospitals develop their pathways with the same clinical vocabulary. PROGNOSYS maintains that database of terminology and updates and amends it as the users dictate.
  • The pathways’ formats are flexible. They can be customized for individual patients in individual situations.
  • The data collected are clinical--not financial. Thus, the information is based on real patient encounters--not on information used for billing purposes.

Case managers and nurses at the different healthcare organizations use different methods to create their clinical pathways. At Miami Children’s Hospital in Florida, for example, Linda Marzano, director of patient and family services, explains that nurses collect data for clinical pathways manually at the patients’ bedsides. After seeing the patients, nurses input the data into the Pediatrax system. Once the data are in the system, they are available via Internet-based technology to anyone in the consortium. For security reasons, the data are available only in aggregate form for comparisons outside the originating hospital.

Marzano was one of the people involved in the PROGNOSYS partnership. For her, the challenge of getting buy-in from her organization on clinical pathway usage also was her motivation. Though winning the HITS Award has brought attention to the product and to Miami Children’s, Marzano says it did not have the impact she was hoping for. "I was hoping for more support in the use of the product and the whole concept of clinical pathways." However, she maintains hope that the concept will catch on. "I think the whole process of clinical pathways typically takes a couple of years to come to fruition."

Besides Marzano, the consortium Zauder put together includes representatives from: Children’s Memorial Hospital, Chicago; Columbus Children’s Hospital, Ohio; Egleston Children’s Hospital, Atlanta; Le Bonheur Children’s Medical Center, Memphis, Tenn.; and AtlantiCare Medical Center, Lynn, Mass. These case managers, nurses, administrators and systems specialists joined forces nearly three years ago to crank out a universal clinical vocabulary to help manage patients and compare clinical processes across the continuum of care.

Each of the hospitals participating in the project uses and manages its own clinical pathways. On an organization-by-organization basis, it seems the product is working great. "We use coordinated care plans," explains Del Joiner, senior vice president for quality and patient services at AtlantiCare. "We put those coordinated care plans into the system and our case managers can see what should be happening to a patient’s care on any given day."

The next step in the PROGNOSYS plan--an Internet-based national database for clinical comparison and benchmarking--is just beginning to get under way. "Down the road, we’d love to be able to tap into a national database, but I don’t believe that body of data has been prepared at this point," Joiner says. However, he says that as different members of the consortium contribute to the database, it will become much more valuable. The more data the system receives, the more benchmarking consortium members can do.

Thus, users can collect data and do internal comparisons when they first begin using the system. "Everybody else develops the software applications and says to the hospitals, ’the first thing you have to do is build your database,’" Zauder says. "Every hospital ends up with a unique set of data tables that makes it very difficult to do comparisons."

Case managers and nurses from each of the participating hospitals now are using one of the two products that resulted from two intense years of partnership and development. "We would leave the meetings brain-dead," Marzano says. "It was a challenge because we all had our own ideas. Thinking outside of the box was the hardest part."

She continues: "We all came together knowing what we did in our organizations, and then listening to other people and the way they did it, the terms they used and what [they thought] should be data elements. Just learning to work together as a team to develop this product that would work for all the hospitals was a big challenge."

Miami Children’s and the rest of the pediatric hospitals are using Pediatrax--a clinical pathways development tool specifically for pediatrics. AtlantiCare is using Maketrax--an adult version of the product.

HITS runner-up:

In 1994, MEDai, Inc., and Florida Hospital, both located in Orlando, Fla., won one of the first HITS awards for their partnership in the development of the MI-Predictor--a device used to determine whether or not a patient was suffering from a heart attack. In 1996, these two organizations continued working together and began developing another product based on artificial intelligence. For their efforts, these partners and the product--Chronic Disease Predictor--were chosen as runners up for the 1997 HITS Award for clinical information systems.

The Chronic Disease Predictor uses the same modeling technology as the MI-Predictor. According to Steve Epstein, MEDai’s president and co-founder, this product uses a hospital’s or a health plan’s existing data to pinpoint patients currently suffering from chronic diseases or likely to suffer from such illnesses in the future. "If you can identify individuals that have a propensity of heart disease [for example] you can use certain drugs and interventions to prevent problems and help avert the use of more expensive procedures," Epstein says.

In addition to the obvious cost savings of such a strategy, the Chronic Disease Predictor also can help improve outcomes and patient care. "That’s the whole purpose of this," explains Ed Reifsnyder, an independent consultant for Florida Hospital. "We’re trying to get away from the ’wait-and-see’ attitude. We’re trying to be more proactive [with patient care]."

The Chronic Disease Predictor is based on billing and claims data. Florida Hospital provides the information to MEDai which acts as an outsourcing partner. "We operate like a service bureau," Epstein says. "They give us the information and we do the predicting and data analysis. We also give them a tool that helps them slice it and dice it."

But the most innovative aspect of this product (and the technology that puts the "ai" in MEDai) is the system’s artificial intelligence. The Chronic Disease Predictor takes a patient’s data and puts it in a warehouse where it develops a longitudinal patient record. With the artificial intelligence, the system is able to learn what the profile of a future chronic disease sufferer looks like.

By running periodical--usually monthly--reports generated by the hospital’s billing data as well as data collected from members’ voluntary health risk assessments, medical directors and disease managers can track patient outcomes and create stratification into risk levels. According to Reifsnyder, this stratification helps Florida Hospital determine the amount of risk it is taking on at a given time.

Currently, medical directors and disease managers at Florida Hospital are using the product for their managed care members. "We’re letting the market’s needs focus us," Epstein explains.

Reifsnyder says the Chronic Disease Predictor has helped the hospital avoid a number of costly procedures and inpatient stays. "It’s early," he states," but the early statistics are fairly impressive."

He continues: "I think it’s important to create an infrastructure that helps [healthcare professionals] do a better job of population health management. There’s been precious little in the way of technology that’s been made to do this."


Lisa Paul is senior editor at Healthcare Informatics.



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