Beyond EHRs: Positioning hospitals for the pay-for-performance era

By Steve Riddle
09:52 AM
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Fierce competition ahead. That’s what hospitals can expect in the pay-for-performance landscape that is already unfolding on the national regulatory scene. Medicare’s Value-Based Purchasing (VBP) and Readmissions Reduction programs officially began on October 1, while the Hospital-Acquired Conditions program will follow in a few short years. Similar programs are already being launched by commercial payers.

Collectively these initiatives have the potential to impact hospital revenue in a significant way, and rising to the top of the heap will require constant improvement. Yesterday’s industry leaders can easily become today’s poor performers as hospitals are judged relative to one another across a broad array of quality and cost measures.

Data on current quality measures reveal that a small performance gap or missed opportunity may dramatically impact a hospital’s ranking and payment. The current VBP process of care measures are an excellent illustration. National averages published by the Centers for Medicare and Medicaid Services (CMS) indicate that many hospitals have measure compliance rates at or very near 100 percent, and more than half of hospitals report scores that are above 93 percent compliant. When numerous competing hospitals have performance scores separated by hundredths of a percentage point, there is not much room for error.

To effectively compete under pay-for-performance models, hospitals will need to implement flexible IT infrastructures that provide the tools necessary to drive improvements in patient outcomes and clinical intelligence reporting. From standardization of care based on evidence-based practices and proactive medication management to identifying complications and adverse events in real time, hospitals need to consider how automation and clinical decision support (CDS) can enhance their efforts to come out on top of the competition.

[Feature: VBP -- can you get there on today's IT?]

Such automation goes a step beyond the basic electronic health record (EMR) and ensures that hospitals are able to truly tap the potential of initial IT investments. While EHR technology provides a collective repository for valuable data, it is simply not capable of providing robust functionality, such as real-time surveillance and reporting. This was demonstrated in a 2010 study by Health Services Research, which found that while EHRs streamline workflows, there was no connection between using them and taking evidence-based practices to the next level to improve quality.

Healthcare executives need to consider that EHRs are just the beginning of the health IT era. What is needed is a long-term technology strategy that is built upon an EHR foundation but that also generates actionable information to drive quality improvement.

CDS to drive evidence-based practices
Of the applications currently available on the market, electronic evidence-based order sets and care plans provided at the point of care through an EHR have been singled out as powerful tools in helping healthcare organizations increase momentum with evidence-based medicine (EBM). A recent KLAS report found that providers cited electronic order sets and care plans most often when identifying the CDS technology that has greatest impact on standardizing care within their organization, while disease and drug reference tools ranked high for their impact on individual clinical decisions.

And it’s no wonder. Physicians simply do not have the time or resources available to stay abreast of the massive volume of scientific research published annually. Hospitals that expect to take EBM to the next level have to provide assistance to clinicians to stay current.

[See also: 3 keys to viable value-based purchasing.]

A 2008 study published in the Annals of Internal Medicine found that out of 148 random trials evaluated, both commercially and locally developed CDS systems improved healthcare process measures related to performing preventive services, ordering clinical studies, and prescribing therapies. While this study takes a broad look at CDS, there are many other diagnosis-specific studies that have demonstrated the positive impact of CDS tools on outcomes.

At one 172-bed hospital in Illinois, electronic order sets were deployed as its foundation for adoption of best practices. Order sets helped standardize care by providing physicians with a checklist to guide care decisions and direct access to the latest medical evidence. The end result was notable quality measure improvements within just six months in such areas as acute myocardial infarction (AMI), heart failure, pneumonia, mortality and outpatient surgical compliance.

The ability to access intuitive CDS through order sets and care plans at the point of care is an all-important component of maximizing these tools’ benefits. In its most basic form, the technology should offer links to supporting evidence, but a more significant impact can be achieved by offering a robust infrastructure of clinical rules and intelligent alerts that draw attention to key care protocols. CDS can also be expanded to guide physicians to properly record care decisions that are outside of best practices, as well as require an explanation when critical alerts are overridden. Other enhancements to current CDS strategies would include providing reminders and cross-reference checking.

A necessary balance of appropriate and relevant alerts will have to be achieved, though, to avoid overwhelming clinicians. This was outlined in another KLAS report conducted in 2012, revealing that while providers express optimism about the future of CDS tools, many cite workflow integration and alert fatigue as areas in need of improvement.

With this concern in mind, the healthcare industry is challenged to find ways to aggregate and mine data in real time from a number of disparate systems and leverage mobile technology to deliver informed alerts regarding a patient’s condition.

The challenge of big data
The existence of data is not the problem. The healthcare industry is rich with uncovered repositories of data that have the potential to transform patient care, improve antiquated processes and save lives.

The problem that currently exists is twofold and has vexed the healthcare industry for years: a lack of consistent data standardization to take reporting and analytics to the next level and a lack of technological infrastructures that are capable of managing large amounts of data in a meaningful way to drive quality improvement.

In their current form, EHRs can be effective for streamlining workflow and processing transactions that work with small amounts of data. To support the future workflow and infrastructure needs of system and enterprise reporting, however, health systems will need to deploy applications that can aggregate and analyze large amounts of data from disparate systems in real time.

[See also: Northrop Grumann steering big data analytics toward health agencies.]

Advanced surveillance technology deployed over cloud-based platforms has shown promise in this area. In particular, applications hosted on Web-based platforms enable real-time information sharing, creating proactive rather than reactive responses to patient care.

Consider how CDS addresses medication management in its current form. Typically a physician will enter an order for an antibiotic and if there is a potential issue, such as an allergy, based on the patient information available, an alert will appear.

CDS on this level is a good first step, but patient care is dynamic. A patient’s condition could change to negate the need for a particular antibiotic or cause the medication to become ineffective or dangerous. To truly take quality patient care to the next level, smart systems need to follow a patient’s care and provide warnings and information, such as local antibiogram reports, to the care providers relative to a patient’s current status.

Advanced surveillance technology to heighten CDS effectiveness
While CDS technology allows hospitals to fully leverage their EMR investments, surveillance technology provides the foundation to make CDS more effective and intuitive.

By leveraging smart logic and a rules-based approach to CDS, surveillance technology can provide 24/7 monitoring of targeted performance areas within a hospital’s care delivery systems. For example, this technology has proven to be effective at improving quality outcomes related to medication management and infection prevention, two primary focal points of upcoming pay-for-performance initiatives.

A 2011 KLAS report found that, when compared to other CDS applications, surveillance technology was found to have the greatest impact on quality outcomes when rated against the performance of a variety of decision-support tools, including care plans, diagnostic tools, disease reference tools, drug databases, drug reference tools and order sets.

The impact can also be seen through a number of real-time success stories. A 531-bed acute-care hospital in Florida recently deployed surveillance technology to address such areas as venous thrombo-embolism (VTE) management via anticoagulation therapy, antimicrobial stewardship and medication dose optimization using renal dose adjustment monitoring through a specific rules-based approach. Instead of trying to address medication intervention and management by manual, paper-based processes that are often outdated by the time information gets in the hands of clinicians, the surveillance technology is providing relevant information and alerts to staff in real time.

The outcomes have been notable. Not only have care interventions by pharmacists increased by more than 100 percent to circumvent the potential for error and improve patient care, but the hospital is achieving cost savings equating to $6,300 per month for renal-related interventions and $11,800 for antimicrobial management activities.

[See also: Value-based purchasing elicits favor, concern among healthcare execs.]

Another 200-bed hospital in Central Florida has developed 50 clinical rules within its surveillance technology for targeted medication monitoring. This has resulted in a total cost savings of more than $5.7 million in 2011 alone via improvements in care and avoidance of adverse outcomes. The organization has also been able to more effectively manage its antimicrobial stewardship program, as reflected by its 29,000 interventions in 2011. The daily monitoring and intervention activity also addresses regulatory and accreditation compliance requirements related to the Joint Commission’s National Patient Safety Goals.

Conclusion
The new pay-for-performance healthcare environment will require an IT infrastructure that goes beyond a hospital’s initial EHR investment. Hospitals that expect to succeed will need to have the best technological infrastructure in place to address the full continuum of care. Real-time surveillance that supports aggressive continuous quality improvement, expert systems that ensure accurate clinical documentation and care coordination, and delivery of evidence-based care conducted on patient needs, are examples of critical technology capabilities that will help healthcare systems compete and excel.

Steve Riddle, PharmD, BCPS, FASHP, is vice president of clinical affairs with Pharmacy OneSource, part of Wolters Kluwer Health.