How providers can benefit from more study of CDS benefits

Results of a study analyzing the benefits from clinical decision support systems shows promise at Cedars-Sinai.

Amid healthcare’s complexities, many providers are trying to streamline their core business, delivering quality patient care at sustainable margins. The objective sounds deceptively simple: Serve the organizational mission by reducing services that provide little value to patients—and can occasionally cause harm. But providers have long sought effective strategies for reaching that elusive goal and continue to do so.

A new study shows how technology can help. Pop-up alerts can aid physicians in treating patients so they experience fewer complications and lower costs, leave the hospital sooner and are less likely to be readmitted. Patients realize these benefits when physicians adhere to alerts in EHRs with care instructions based on evidence-based guidelines, according to the study that was a collaboration between Cedars-Sinai and Optum.

Specifically, the study showed that when physicians follow all clinical decision support (CDS) alerts, their care correlated to significantly better outcomes than for physicians who did not follow all alerts:
  • Costs of care reduced by $944 from a median-cost hospital encounter—an improvement of more than 7 percent, after adjusting for differences in patient illness severity and case complexity.
  • Patients’ average length of hospital stay decreased by 6.2 percent.
  • The odds of complications improved by 29 percent.
  • The odds of hospital readmissions within 30 days of the patients’ original visits shrank by 14 percent.

The American Journal of Managed Care, a peer-reviewed journal, first published the observational study and noted in an editorial, “This study adds to promising evidence that [clinical decision support] assists clinicians in making value-based clinical decisions and reducing the use of care that is not clinically indicated.”

The study examined data from 26,424 inpatient visits at Cedars-Sinai Medical Center from October 2013 to July 2016 in which one or more of the 18 most frequent alerts was triggered.

In 6 percent of visits, physicians in the treatment group followed all triggered alerts. In the remaining 94 percent of visits, physicians in the control group followed none of the triggered alerts. These findings are both clinically and statistically significant, demonstrating that guidelines are most useful when presented to the clinician during the decision-making process.

The alerts were based on an initiative called Choosing Wisely, which identifies common tests and procedures that may not have clear benefit for patients and should sometimes be avoided. The Choosing Wisely alerts were backed by the American Board of Internal Medicine Foundation and created by various physician subspecialty societies. Other evidence-based guidelines have been applied to CDS initiatives- we used Choosing Wisely because its primary aims include addressing both quality and cost containment.

As the healthcare system shifts toward value-based payment, helping to minimize low-value care is becoming an important priority for health systems.

Clinical standardization is the single largest source of cost savings recognized by health system CFOs, according to a recent Advisory Board survey. This aligns with broader provider strategy: In the latest Annual Health Care CEO Survey, C-level health system executives told Advisory Board that their No. 1 concern for 2018 is preparing the enterprise for sustainable cost control and No. 2 is innovative approaches to expense reduction.

Savings from reducing unnecessary care variation could exceed millions of dollars annually for most hospitals. The value is even greater when accounting for savings to all healthcare stakeholders.

For healthcare leaders, understanding how to empower providers to reduce lower-value care is critical.

Despite the publication of myriad evidence-based guidelines, providers continue to order tests, procedures, and medications for patients that may be not only inappropriate, but also lead to worse health outcomes and higher costs for patients and third-party payers, such as employers, insurance carriers, Medicare and Medicaid.

Our research and experience has led us to conclude that embedding care standards effectively within the provider workflow is at the heart of scalable, sustained care variation reduction efforts. Embedding such care standards is only possible through the use of carefully curated CDS.

Although health system executives acknowledge the theoretical impact that CDS could have on care decisions, peer-reviewed research had yet not definitively established the relationship between commercially available CDS adherence and outcomes. To our knowledge, the Cedars-Sinai-Optum study is the first analysis to examine outcomes associated with the implementation of several Choosing Wisely recommendations via CDS.

This builds on previous studies showing the benefits of a single alert and our study provides new evidence of the effect that a more comprehensive collection of alerts has on high-level patient and financial outcomes. Others should continue to study the impact of CDS through approaches such as formal prospective cohort studies and randomized CDS intervention trials, perhaps randomizing providers assigned to receive CDS interventions.

Such intensive work could conclusively determine the cause of the association between CDS interventions and improved clinical and financial outcomes—and could greatly help in guiding future provider strategies toward reducing low-value care. Although this new study is encouraging, there is still much work ahead in our shared mission of unlocking the value in EHRs and CDS to benefit patients and manage costs.

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