Putting health records to work

By John Moore
01:00 AM
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As regional health information organizations struggle to find their place in the health care market, one group in the central Appalachians has tapped an emerging technology for help: clinical decision-support systems.

The CareSpark RHIO operates in a region that encompasses 17 counties in southwestern Virginia and northeastern Tennessee, including the cities of Bristol, Kingsport and Johnson City. Provider partners in the network include the Veterans Affairs Department's James H. Quillen VA Medical Center, the Virginia Department of Health's Cumberland Plateau Health District and several private hospitals.

In April, the two-year-old RHIO began offering a clinical decision-support service through ActiveHealth Management, a New York-based company. ActiveHealth's CareEngine technology compares patients' medical, pharmacy and laboratory claims against established standards of care. It then notifies a physician if it finds an opportunity to improve a patient's treatment.

Liesa Jenkins, CareSpark's executive director, said the RHIO plans to have employers and other payers cover the costs of the clinical decision-support system. CareSpark recently signed its first employer: Eastman Chemical. Employees participating in Eastman's health care plan will be enrolled in CareSpark's Care Considerations program, which will send bulletins to physicians regarding opportunities to improve care.

"This is something the employers and payers are willing to pay for and subsidize," Jenkins said, adding that many RHIOs have had a difficult time identifying services people will pay to obtain.

Incentives for participating in clinical decision support stem from the opportunity to boost the quality of care and reduce expenses. In Jenkins' view, well-informed decisions improve outcomes and reduce unnecessary costs.

For example, CareEngine can alert physicians to potential adverse drug interactions, overlooked lab tests or the availability of beneficial drugs, according to ActiveHealth.

The company said its system saves $8.07 per month per health plan member, citing a study in the American Journal of Managed Care.

Clinical evolution
The decision-support technology CareSpark and other organizations now deploy traces its roots to the 1980s, when university researchers began applying artificial intelligence to the practice of medicine.

The goal was to create software that would capture medical knowledge and assist physicians in diagnosing ailments.

"The early work was decision support to help a doctor make a diagnosis," said Dr. Don Detmer, president and chief executive officer of the American Medical Informatics Association. "But, generally speaking, clinicians do that pretty well. Where they really need help is remembering things they already know."

To that end, clinical decision support has shifted its focus from diagnosis to the "drudgery aspects of care"¦where we typically fall down," Detmer added.

He said he believes clinical decision support can have the greatest impact by flagging drug interactions and other factors that can affect prescription decisions.

The potential for payback in that area is considerable. The Institute of Medicine reported last year that drug-related errors affect at least 1.5 million people every year, and drug-related injuries in hospitals drive up medical costs by at least $3.5 billion annually.

Accordingly, the current crop of clinical decision-support technology emphasizes areas such as drug interactions. One vendor, TheraDoc, targets medicine and patient safety. Its decision-support tool also helps hospitals survey patient data, investigate infections and implement control
efforts.

Scott Walker, TheraDoc's vice president of strategic development, said infection control has the potential for huge savings. Hospital-acquired infections add anywhere from $2,000 to $80,000 to the cost of a hospital stay " or about $15,000 on average.

ActiveHealth also seeks to offer measures to improve patient care and safety. The American Journal of Managed Care's study of a managed care plan in the Midwest found that most of the alerts issued through ActiveHealth's clinical decision-support system involved suggesting a test or procedure; 790 clinical recommendations fell into that category. The system issued 395 recommendations to start a patient on a particular medication and 150 recommendations to stop a medication.

In those situations, clinical decision support "converts raw data into actionable information," said Dr. Lonny Reisman, ActiveHealth's founder and CEO.

Reisman said clinical decision support is particularly beneficial for RHIOs. Those organizations aim to exchange clinical data, he said, but they have not focused enough on turning that data into information a doctor can act on.

Clinical decision support, he added, will move RHIOs "closer to making the business case."

Software as a service
The CareSpark RHIO's use of clinical decision support is just getting under way and will evolve in the coming months.

The system's deployment follows the software-as-a-service model. ActiveHealth hosts the system, which is based on its CareEngine technology. The rules-based artificial intelligence system analyzes an array of data and generates clinical recommendations.

CareEngine gathers clinical information from patients' medical claims, pharmacy claims and laboratory results, among other sources. The system then analyzes that data against evidence-based clinical guidelines that are rooted in the medical literature. The system identifies deviations from the guidelines and flags errors in care.

Such deviations trigger alerts that CareSpark refers to as care considerations. Physicians receive those alerts via phone or fax. A sample care consideration on the CareSpark Web site alerts a physician to the absence of statin therapy for a patient whose claims data suggests evidence of vascular disease. The notice cites relevant medical studies and provides references.

Jenkins said physicians benefit from the ability to compare their decisions against evidence-based guidelines. The technology also offers physicians a safeguard against "making an inadvertent error that results in malpractice suits or a poor outcome that they have to report and deal with and pay for," she added.

Until recently, the system conducted analyses in batches, and it took about a day to notify physicians. However, the latest iteration of CareEngine provides real-time decision support. The technology can also integrate with electronic medical records (EMRs). Reisman said the company will release the real-time capability this summer.

That approach will allow physicians and patients to jointly make treatment decisions at the point of care, she added. Physicians will be able to access care considerations via their EMR systems or a Web portal. Jenkins said CareSpark has not yet chosen a portal vendor.

When fully operational, the decision-support system will supplement a physician's experience and knowledge in evaluating treatment alternatives. Physicians have traditionally relied on what they remember from medical school, journal articles or drug company representatives, Jenkins said.

Clinical decision support will deliver care information that's concise and targeted to a patient's condition, "so the physician doesn't have to depend on memory," she added.

Clinical decision support caveatsDespite its promise, clinical decision support faces some major hurdles on the path to widespread adoption.

One issue is the lack of technical readiness. Dr. Don Detmer, president and chief executive officer of the American Medical Informatics Association, cited the low use of electronic health record systems, particularly i