Session Objectives 11/27/2013

Transcription

1 Workshop A3 and B3 This presenter has nothing to disclose Clinical and Cost Improvement for Population Health Scott Weingarten, MD Senior Vice President and Chief Clinical Transformation Officer Cedars-Sinai Health System David Classen, MD Senior Partner and Chief Medical Information Officer Pascal Metrics December 10, :30am-10:45am and 11:15am-12:30pm Session Objectives P2 Identify the potential of evidence-based clinical decision support for improving cost and quality outcomes across the continuum of care Describe the potential role of clinical decision support in the creation of Accountable Care Organizations (ACOs) and Medical Homes 1

2 3 Disruption by Employers Employer s Perspective It s not personal. It s business Everything I Needed to Know About Health Care Reform I Learned in Middle School 4 2

3 Cedars-Sinai Health System 5 Cedars-Sinai Health System Cedars-Sinai Medical Center Cedars-Sinai Medical Group Cedars-Sinai Health Associates - IPA MSSP ACO Health plan chronic care ACO The Role of the Academic Medical Center 6 Charting our course under the current economic pressures won t be easy. But our AMCs have built their reputations by addressing society s most pressing health care challenges, and today s central challenge is the rising cost of health care. Fortunately, AMCs specialize in innovation. We must now apply that capability not just to scientific aspects of medical care but also to the systems delivering it. Partners Healthcare, Massachusetts General, Brigham and Women s Hospital N EnglJ Med 369;11 NEJM.org 994 September 12,

4 Results to Date 7 Best Practices Clinical Decision Support Engagement Delivery Model Redesign Greater than 10% reduction in LOS index over 2 years 22% reduction in duplicate lab testing 13% reduction in duplicate head imaging with CDS 31% reduction in median initial antibiotic time to administration for sepsis. 56% reduction in inpatient orders for Gastric Emptying studies 75% decrease in Chest Physiotherapy 5% reduction in lab test per patient Web Portal (MyCSLink) has been available since December 2013 and there are approximately 25,000 active accounts Roll-out of Advance Directive efforts and a 25% reduction in patients dying in the ICU with chronic, terminal illness. For managed populations have achieved: 7% reduction in ED Admissions/1,000 12% reduction in Inpatient Admissions/1,000 Achieved 75% compliance with generic drug utilization Next Generation CDS 4

5 Next Generation CDS Next Generation CDS VTEP order set use 51% to 58%, p<0.001 Patients with potential harm from VTEP had greatest increase OR 1.58 (95% CI 1.12, 2.22) JGIM 2011;27:

6 Next Generation CDS P11 Accident Avoidance Systems 12 Lowered accident claims Mercedes 16% Acura 15% 6

7 13 Blind spot monitor vs. Learning about blind spots in drivers education Predictors of Success Automatic provision of decision support as part of workflow Provision of decision support at the time and location of decision making Adjusted OR Provision of recommendation rather than just an assessment 7 Computer-based generation of decision support Source: Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ Apr 2;330(7494):765. PMID: Choosing Wisely 120 tests that do not benefit patients 150 more over next 9 months 35 subspecialty societies Representing >500,000 physicians Integrating into CS-Link Cedars-Sinai might be first in the country Source: JAMA. 2013;310(4): doi: /jama

8 15 Benefits of reducing inappropriate utilization* Up to 19-times greater false-positive rate than truepositive rate CT may increase incidence of cancer by 24% Elimination of 5 of 90 Choosing Wisely -type tests would reduce costs by $5 billion per year** *JAMA Intern Med. Published online February 25, doi: /jamainternmed **Arch Intern Med. 2011;171(20): JAMA Intern Med. 2013;173(6): BMJ 2013; 346 doi: (Published 21 May 2013) Cite this as: BMJ 2013;346:f Don t do imaging studies for chronic isolated headache Kaiser Permanente Woodland Hills 1990, 100,800 adults 15 to 27 month follow-up period No CT scans for chronic isolated headache yielded new and important information False positives, one led to unnecessary brain biopsy. CT brain radiation exposure may cause 4,000 additional cases of cancer per year in US Model based on National Research Council s Biological Effects of Ionizing Radiation Weingarten, et al. Archives of Internal Medicine 1992;152(12): Arch Intern Med Dec 14;169(22):

9 Benzodiazepines in the Elderly 17 Increased risk of falls (57% for benzos, 97% for Valium) Increased risk of MVAs Increased risk of hip fractures Arch Intern Med. 2009;169(21): J Am Geriatr Soc 59: , Impact of Blind Spot Monitor Prescriptions of Benzodiazepines to Elderly Patients 18 Change in number of prescriptions from baseline with active alert* Age >=65 years Age <65 years Pilot MD offices -20.9% 3.6% Control MD offices 10.6% 3.5% Difference -31.5% +0.01% *Comparison periods 7/13/13 to 8/6/13 and 8/7/13 to 8/31/13 9

10 Over-riding the Blind Spot Monitor 19 Benzodiazepine Over-rides By Patients >65 Years Early Data projected reductions over 1year 31.5% reduction in benzodiazepine use 22 fall related injuries 6 ED visits 3 hospitalizations potential impact 2 deaths from falls Woolcott et al. JAGS 2009, CDC. MMWR Weekly 2008, Schiller et al., Adv Data No. 392 (CDC) 2007, Pariente et al, Drugs Aging

11 optimizing interventions passive reminder pop-up alert no action required pop-up alert action required intervention intensity low impact medium impact high impact hemoglobin A1c in diabetic patients > 65 years old The Next 100 Years of Medicine 22 "Complex but empirically validated algorithms will be embedded in EHR systems as decision support tools to assist in everyday patient care. Those management algorithms will evolve and be modified continuously in accordance with inputs from ongoing clinical observations and from new research. Clinical decision support algorithms will be derived entirely from data, not expert opinion, market incentives, or committee consensus. New England Journal of Medicine December 27,

12 Innovations in Healthcare Delivery 23 Ruth 83 year-old History of pituitary abscess, hypopituitarism, parkinsonism Minor insults (e.g., UTIs, viral illness) cause altered mental status I do not like being in the hospital Innovations in Healthcare Delivery 24 Ruth Hospital at Home 93% acceptance rate Caregivers without medical background Higher patient satisfaction 90.7 Hospital at Home v 83.9 hospital Lower mortality 0.93% Hospital at Home v 3.4% hospital Meta-analysis of published trials (RCTs) 21% reduction in mortality NNT =50 24% reduction in readmissions Ann Intern Med. 143: , J Am Geriatr Soc. 54: , J Am Geriatr Soc. 2008;56(1): Am J Manag Care. 15:49-56, J Am Geriatr Soc. 2009;57(2): Medical Care, 47(9):979-85, 2009.; Health Affairs 2012; June 31(6);

13 Closing Thoughts 25 Health care has been disrupted Most health care purchasing decisions will be determined by cost and quality Disruption will lead to health system and physician winners and losers Winners will provide excellent quality of care at an affordable price Cedars-Sinai has a long history of innovation Cedars-Sinai will innovate to improve the delivery of health care 13