Guest post by Diane D. Homan, MD and Adam Lokeh, MD.
As the healthcare industry unwraps the next phase of population health management (PHM), providers are increasingly embracing its promise to drive success with healthcare’s triple aim of improving population health, enhancing patient experiences and reducing costs. It’s a 180-degree shift in thinking for many providers who have been conditioned to long-standing fee-for-service models, one that will require a coordinated care effort and an advanced technological infrastructure to support decision-making based on the latest industry evidence.
As regulatory initiatives, such as meaningful use and value-based purchasing converge to up the ante on improved outcomes, the proactive premise of PHM will be critical to success. A foundational component to effective implementation of a PHM model is a clinical decision support (CDS) strategy that drives standardization of care based on best practices.
For Rush-Copley Medical Center, the first step in this process was deployment of evidence-based order sets and a complete clinical content management solution— ProVation Order Sets, powered by UpToDate Decision Support. The decision to leverage evidence-based order sets at the point of care has proven advantageous on many fronts, from supporting recent responses to public health crises to raising the bar on outcomes improvement and laying a foundation of accountability across the continuum.
Reducing Variation for Improved Response
Getting clinicians on the same page and helping them to adopt industry best practices in their day-to-day workflows is certainly a key element in bending the quality curve, but ensuring that variations are minimized in a public health crisis is absolutely critical to success.
A 210-bed hospital serving the greater Fox Valley region of Illinois, including the state’s second largest city, Aurora, Rush-Copley uncovered an outbreak of tuberculosis (TB) in late 2009 following two admissions over the course of two months. In cooperation with the Kane County Health Department, an investigation traced the outbreak back to a homeless shelter, which, in turn, presented a considerable challenge to containing the outbreak as the population was highly transient.
With evidence-based order sets and an advanced clinical content management solution already deployed to address standardization of care, the clinical team was able to quickly deploy a point-of-care strategy for identifying at-risk patients, apply isolation management tactics and develop collaborative efforts throughout the community to minimize exposure. The strategy was three-fold: 1) contain the epidemic, 2) provide highest quality treatment based on industry best practices and 3) avoid duplication of services.
Within the clinical content management system, order sets were customized and built with guidelines that ensured the same screening protocols would be used to identify at-risk patients and proactively move those affected through the most appropriate levels of care. By adding pre-checked diagnostic testing and focused guidance into the order sets, the clinical team was able to achieve full compliance with recommended guidelines. The order sets also ensured the accurate capture of data in the EHR to track screenings and eliminate the potential for duplication of services that could result in higher costs.
Similarly, Rush-Copley was able to leverage a point-of-care strategy to respond to an outbreak of pertussis in recent years by adjusting order sets to include appropriate screenings and treatment. This past winter, the organization also leveraged order sets to eliminate a bottleneck within the emergency department associated with a rapid influx of influenza patients.
Armed with one screening tool for influenza that required a two-hour turn-around, the clinical team quickly researched other options and identified a tool that would require only 20 minutes. Within a half hour, the team confirmed availability of the product and adjusted order sets to include the additional option. The lengthier screening tool would be used for patients exhibiting high-level symptoms of influenza, while the 20-minute tool would be used where the condition simply needed to be ruled out.
In the case of each of these responses, the existence of the right technological foundation alongside proper governance ensured success.
Managing Care along the Continuum
As PHM initiatives evolve, adoption and standardization of best practices will need to be extended across the continuum, both inside and outside the walls of an institution. Strategies will also need to be regional in nature, as populations and disease are best defined locally. The ability to engage patients and families in care, exchange data in real-time and share clinical information throughout the healthcare community is the broader goal of the PHM movement.
In the case of the TB outbreak, Rush-Copley was able to identify and leverage information from the Centers for Disease Control (CDC) along with state and local health departments to ensure that order sets and guidelines aligned with regional requirements and needs. This information was then used to update the applicable order sets, alerting clinicians when TB screening tests were appropriate and guiding them toward appropriate treatment based on whether an identified patient had active or latent phase TB.
As PHM efforts continue to mature, order sets will become most effective when they are built to correspond with risk-stratified patients based on the severity of disease and condition. It is at this level that the most appropriate level of care is provided and costs are minimized.
Healthcare organizations will also need to consider that broader industry best practices may not correspond to the needs of a particular region. Often, best practices will need to be adjusted and order sets and other clinical decision support tools built with more population-specific evidence coming out of a defined territory.
Creating a Culture of Accountability
When point-of-care technology strategies and appropriate governance are working in tandem to drive adoption of the latest industry evidence, the end-result is a foundation of accountability throughout a healthcare community. By creating an infrastructure for transparency into performance, Rush-Copley has achieved highly-successful responses to public health crises as well as improved outcomes and quality metrics. For example, the organization has eliminated the occurrence of surgical site infections for the past two years.
As the healthcare industry continues to build consensus about common clinical pathways and develop accountability for upholding quality standards, the potential for PHM efforts to truly transform care delivery becomes elevated.
Diane D. Homan, M.D., is vice president of clinical innovation and CMIO at Rush-Copley Medical Center.
Adam Lokeh, M.D. is a practicing plastic surgeon at Children’s Hospitals and Clinics of Minnesota and vice president of clinical development and informatics with Wolters Kluwer Health.