Cedars-Sinai reduces unnecessary care using EHR alerts

Physicians receive automated recommendations, based on Choosing Wisely suggestions, during patient visits to help them make better treatment choices.

Cedars-Sinai Medical Center in Los Angeles has decreased inappropriate or unnecessary care by integrating recommendations from the national Choosing Wisely initiative into its electronic health record system.

Because of the integration, EHR alerts pop up on physicians’ computer screens during patient visits at the 886-bed hospital and multi-specialty academic health science center, advising whether specific care choices are necessary because of patients’ specific medical conditions and medications.

Launched in 2012 by the American Board of Internal Medicine Foundation and Consumer Reports, the Choosing Wisely initiative is based on guidance from dozens of medical specialty societies and has identified nearly 500 common diagnostic tests and procedures that may not have clear benefit for patients and sometimes should be avoided.

According to Scott Weingarten, MD, chief clinical transformation officer, Cedars-Sinai began integrating Choosing Wisely recommendations into its Epic EHR in October 2013, giving doctors real-time information and sparking important conversations with patients about the appropriateness of certain tests and treatments.

“The learning effect or educational effect is that when physicians learn Choosing Wisely recommendations, they usually do not re-order the unnecessary test or treatment and then cancel, but rather they do not order to begin with, once they recognize it is not necessary,” says Weingarten.

To date, almost 100 Choosing Wisely recommendations have been added to Cedars-Sinai’s EHR system, he notes, with patients of physicians who followed all the alerts experiencing fewer medical complications and leaving the hospital sooner.

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“After decades of discussion and debate, physicians, nurses and others responsible for delivering care at the bedside are demonstrating that we can address this problem of inappropriate care where the harms exceed the benefits,” says Weingarten. “By empowering patients and doctors, we can deliver higher quality care more efficiently, increasing the value of healthcare for those who need it most.”

Weingarten adds that when physicians fully adhered to all the EHR alerts, costs at Cedars-Sinai dropped by hundreds of dollars per patient encounter. Overall, the health system avoided $6 million in healthcare spending in the first full year of Choosing Wisely implementation.

“The past year, Cedars-Sinai Health System achieved $1.63 million in savings from cancelled orders alone, where physicians did not re-order the unnecessary test or treatment or substitute another unnecessary test or treatment,” according to Weingarten. “This does not include additional savings from orders not placed, reduced labor costs such as nursing time associated with inappropriate blood transfusions, or the cost associated with harm.”

Among the Choosing Wisely recommendations adopted by doctors at Cedars-Sinai is to avoid prescribing benzodiazepines, such as Ambien and Valium, in the elderly. “They can cause elderly patients to have falls and hip fractures,” says Weingarten.

Harry Sax, MD, professor and executive vice chair of surgery, refers to a forthcoming study of inpatient care at Cedars-Sinai conducted with Advisory Board, a healthcare consulting and research firm.

“Our study suggests that patients of physicians who follow clinical decision support Choosing Wisely guidelines have fewer complications, lower costs and a shorter length of stay,” contends Sax, who advises doctors on best medical practices at Cedars-Sinai. “Future work will focus on the characteristics of these physicians and which alerts have the greatest effects.”

Going forward, Weingarten says Cedars-Sinai will continue to leverage such clinical decision support to improve the quality, safety and value of care at the health system.

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