At iHT2-Beverly Hills, Scott Weingarten, M.D. Explains How Cedars-Sinai MDs Successfully Adopted Evidence-Based Alerts | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

At iHT2-Beverly Hills, Scott Weingarten, M.D. Explains How Cedars-Sinai MDs Successfully Adopted Evidence-Based Alerts

November 5, 2014
by Mark Hagland
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Cedars-Sinai’s Dr. Scott Weingarten offers iHT2-Beverly Hills attendees a robust case study in successful CDS implementation

In his presentation on Nov. 5 to attendees participating in the Health IT Summit in Beverly Hills, Scott Weingarten, M.D., M.P.H., senior vice president and chief clinical transformation officer at Cedars-Sinai Health System in Los Angeles, shared with his audience the results of his hospital organization’s participation in a nationwide program to improve patient care outcomes and control cost, one that holds broad implications for the entire U.S. healthcare system.

Weingarten, in his presentation, which was the closing keynote address at the Summit, sponsored by the Institute for Health Technology Transformation (iHT2; a sister organization with Healthcare Informatics under the corporate umbrella of the Vendome Group), and being held at the Sofitel Los Angeles at Beverly Hills, spoke of the gains being made through participation in the Choosing Widely® initiative.

Scott Weingarten, M.D., M.P.H.

An initiative of the ABIM Foundation, the research arm of the American Board of Internal Medicine, Choosing Widely, as its website explains, “is working to spark conversations between providers and patients to ensure the right care is delivered at the right time. Participating organizations have created lists of “Things Providers and Patients Should Question” which include evidence-based recommendations that should be discussed to help make wise decisions about the most appropriate care based on a patients’ individual situation.”

What’s more, since more than 60 medical specialty societies have joined the Choosing Widely campaign since its inception in 2012, the initiate has very broad support across the U.S. medical world.

As the initiative’s website further explains, “Choosing Widely® is part of a multi-year effort of the ABIM Foundation, along with its partners, to help physicians be better stewards of finite health care resources. It continues the principles and commitments of promoting justice in the health care system through a fair distribution of resources set forth in Medical Professionalism in the New Millennium: A Physician Charter, which states: ‘While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources.’ Since 1999,” the website goes on to state, “the ABIM Foundation has worked toward its mission of advancing medical professionalism into clinical policy and practice. Our work is an ongoing, collaborative process, engaging the health care community—including physicians and physician leaders, medical trainees, consumer organizations and patients, delivery system leaders, payers and policy makers—to build a shared understanding of professionalism and actively advance the tenets of professionalism in practice.”

At its essence, the initiative, originally conceived by the National Physicians Alliance seeks to support physicians in avoiding making medical orders, particularly of diagnostic tests, that are not supported by evidence; that are duplicative of other tests or procedures already performed; could cause patients harm; or are clinically unnecessary.

For Weingarten, leading the implementation of Choosing Widely-facilitated order sets at Cedars-Sinai Health System is the culmination of work he has been involved in for years. He served as director of health services research at what was then called Cedars-Sinai Medical Center, from July 1991 through January 2009. During the period of July 1996 through December 2012, overlapping with that tenure, he became co-founder and CEO of Zynx Health, the Los Angeles-based provider of evidence-based order sets. And then he returned full-time to Cedars-Sinai in January 2013.

As Weingarten told his audience on Wednesday, referring to physician order sets generally, “Order sets are checklists, and they’re wonderful checklists, and they remind you of things that are important to do; and they may or may not reduce cost and improve care. But many of our patients in our hospitals today are pretty sick, and have a lot of conditions and situations. So order sets and care plans can be helpful, but may not be able to create plans that account for all the co-morbid conditions,” he noted. “And many patients are outpatients. And what type of information can we provide clinicians in the workflow, to keep these patients as healthy as possible?”

Helping physicians optimize their ordering has become more and more crucial over time, Weingarten said. In that context, he said, “Choosing Widely, I think, is one of the most important physician-led initiatives of the last 20-30 years. Initiated by the American Board of Internal Medicine, the initiative has gathered support and involvement from 60 of the nation’s subspecialist groups, representing 500,000 practicing physicians nationwide.”

Choosing Widely’s evidence-based alerts embedded in physician workflow at Cedars-Sinai. As a result, Weingarten told his audience, “When a physician is doing something not consistent with Choosing Widely recommendations, an alert pops up. That sounds annoying, right, in the context of alert fatigue? But it works well.” And he cited three areas in which research has confirmed the value of such alerts for physicians and for their patients. As Weingarten recounted it, “A long, long time ago, I was a primary care physician at Kaiser Permanente. I used to order CT scans for patients with chronic isolated headache; and they were all coming back negative. And I went to the Kaiser Permanente leaders and said, we’ve got to study this, they let me apply for a grant to study.”

What he and his fellow researchers found was striking: within a study cohort of 100,800 patients, not a single CT scan for chronic isolated headache led to actionable results, after a follow-up period of 15 to 27 months of physician observation of those patients. “In fact,” Weingarten noted, “not only did no CT scans for chronic isolated headache yield new or important information; there were a number of false positives, including the case of one patient who underwent an unnecessary brain biopsy. And honestly,” he added, “if there’s a biopsy for a single part of your body that you don’t want to have performed unnecessarily, it’s a brain biopsy. What’s more,” he added, “a study from the National Research Council found that we physicians could actually potentially be causing 4,000 additional cases of brain cancer per year in the United States from unnecessary brain radiation exposure.”

So whenever a physician at Cedars-Sinai clicks to order a CT scan for chronic isolated headache, she or he now receives an alert explaining the evidence from the literature and advising her or him not to order that scan. Of course, the physician is always empowered with the clinical authority to override that alert, but at that point, s/he is made fully aware of the evidence from the clinical literature. What’s more, the system provides that doctor with consumer-level information that can be given to the patient explaining why a CT scan is not called for in that situation. The strength of the system, Weingarten noted, is that it “gives physicians feedback on their ordering patterns, and information comparing their actions to those of their peers.”

Weingarten cited several other examples as being particularly significant. One is the alert that urges physicians away from ordering antipsychotics as a first choice to treat the behavioral and physician symptoms of dementia; another advises physicians not to use benzodiazepines or other sedative-hypnotics to treat insomnia (those medications significantly increase the risk of patient falls); and another advises against using opioids or butabital to treat headaches. All of those are examples in which the clinical evidence has been robustly documented in the medical literature, he noted.

Weingarten also cited a recent example in which “One doctor at Cedars had ordered six Lyme disease tests in three days. The fact is,” he said, “that we don’t really have Lyme disease here in Southern California. There’s only been one confirmed case in the past year, according to public health authorities, of a patient who had not left Los Angeles County, who was diagnosed with Lyme.” So the excessive ordering of that test in that local community is another example of testing that would not be helpful.

With regard to insomnia medications, Weingarten noted that “Prescribing benzodiazepines and other sedative-hypnotics in older adults for insomnia, agitation, or delirium increases the risk of falls, hip fractures, and motor vehicle accidents. So in that case, what we did was to provide that alert, and we catalogued within the alert the reasons physicians might override it, and gave them links to information they can give to their patients in that area.” Based on implementing that alert, he reported, “We conducted a randomized study of 10 physicians, and found a very wide range of variability there—a 30-percent of prescribing benzodiazepines to older patients. Then, we projected the impact of reductions in such prescribing over one year, and we found that potentially, such reductions could prevent 22 fall-related injuries, six ED visits, three hospitalizations, and two deaths from falls. That’s very significant,” he noted.

With regard to the rollout of the Choosing Widely set of alerts, Weingarten recounted a conversation he had had with Darren Dworkin, senior vice president and CIO at Cedars-Sinai (and a panelist in Wednesday’s discussion of population health and information systems at the Summit). “We ended up going with a ‘big bang approach,’ going live with nearly 180 new alerts in a very short time,” Weingarten noted. “I give credit to Darren Dworkin. He knew that I would take any flak from the doctors, and that I had to sell it, but he said we really needed to go live at once. I told him he was crazy! But I listened to his advice, and it turns out he was right. The physicians did not need to individually customize this clinical decision support program to meet their needs; the Choosing Widely program is a great brand.” What’s more, he noted, since then, “We’ve migrated from ‘soft stops’ to ‘medium stops’”—alerts that put a bit more challenge into overriding them on the part of physicians—“with improvements in patient outcomes quality and reductions in cost.”

For Weingarten, who has spent decades as a pioneer in the evidence-based clinical decision support sphere, everything that has happened so far in his recent tenure at Cedars-Sinai has vindicated his dedication to the concept of evidence-based CDS for practicing physicians. And, at a time when medical practice is evolving quickly under a wide variety of external pressures, programs like Choosing Widely are going to provide vehicles for improving clinical outcomes while improving resource utilization profiles at patient care organizations nationwide, he told his audience. “Healthcare is changing rapidly, very rapidly,” he said. “We have to adapt to it. If we don’t adapt to it, the market will punish us, and patients will go elsewhere. But we’ve also been investing a lot of money, and will continue to do so, in IT. We now need to optimize this large investment to deliver on quality and cost,” he said.

Weingarten ended his presentation by quoting a line from the 1992 movie “A League of Their Own,” in which Tom Hanks’s character, Jimmy Dugan, the manager of a women’s baseball team that is struggling for recognition and support during World War II, tells his players, “Of course it’s hard. It’s supposed to be hard. If it were easy, everybody would do it. Hard is what makes it great.” That, Weingarten told the iHT2-Beverly Hills audience, is exactly how medical informaticists, clinician executives and other healthcare leaders should view the path forward towards eliminating unnecessary and harmful care and embracing evidence-based best practices in today’s medical practice.

 

 


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