Translang (cost-‐eﬀecve) evidence into pracce in the EMR era Andrew D. Auerbach MD MPH Professor of Medicine UCSF Department of Medicine Chair, UCSF Apex Clinical Content Oversight CommiKee
Overview • Translaon and implementaon of evidence • Where to get evidence for those who want (need) to implement – Translaonal issues in EMR’s – Evidence Acquision, implementaon • Costs, value, and cost-‐eﬀecveness
The Translaonal pathwayascade Improved Bench/ Bench to Clinical Comparative Comparative Implement population health,Biomedical bedside efficacy effectiveness effectiveness practices ImprovedResearch translation knowledge research knowledge effectively healthcare value Determine how patient, provider, and delivery Determine causal Determine associations system changes influence outcomes pathways between treatments and outcomes - Health system redesign Outcomes and health services - Scaling and dissemination of delivery system changes Clinical efficacy trials research - Research in redesign and dissemination
It takes a long me to translate… • On average, it takes 16 years to move a biomedical innovaon from bench to bedside • It is unknown how long it takes to have a pracce used eﬀecvely
Why so long? • Unaware of a Cons of changing outweigh the pros at the top Precontemplaon problem, not intending to make a of this cascade change • Recognion of Contemplaon problem, beginning to look at pros and cons of change • People ready to take Preparaon acon, may require assistance • People have Acon modiﬁed behaviors to address problem • People able to sustain acon, The pros surpass the cons for later stages Maintenance working to prevent relapse ..But backsliding can always take place
Factors which speed adopon • Consciousness-‐Raising – Increasing awareness via informaon, educaon, and personal feedback. • Changing social norms: – What makes the new behavior cool and the old one uncool? – Is the preferred behavior an important part of who we are and want to be? – Does the old behavior aﬀect others negavely? – Are people generally supporve of change? • Counter-‐Condioning – Substung healthy ways of acng and thinking for unhealthy ways – Provide rewards for the new behavior, and eliminate rewards related to old ways • Self-‐Eﬃcacy – Believing in one’s ability to change and making commitments to act on that belief • System change: – Make the new behavior easier to carry out than the old one – Provide reminders and cues that encourage the new behavior
Where to get evidence • Local experts – Advantages: Local champion, may represent local priories, may have a ‘how to’ component – Disadvantages: May not be truly evidence-‐based o • Latest NEJM (or pick your journal) – Advantages: High face validity – Disadvantage: no ‘how to’, always another study on the way
Where to get evidence • Cochrane database of systemac reviews – hKp://www.cochrane.org/cochrane-‐reviews – Advantage: Comprehensive synthesis of evidence, explanaon of where evidence is clear/unclear – Disadvantage: No clear recommendaons for how to use the evidence • Professional sociees – Advantages: Clear recommendaons – Disadvantages: Potenal COI, variaon across compeng sociees
Clinical pracce guidelines • A speciﬁc subset of evidence – Considered a ‘standard’ source of pracce evidence – Recent controversies (mammography, PSA, CT Angio, etc) prompt discussion regarding what comprises a ‘trustworthy’ clinical pracce guideline (CPG)
Which guidelines should you choose? • To be trustworthy, guidelines should: – Be based on an explicit and transparent process that minimizes distorons, biases, and conﬂicts of interest; – Be based on a systemac review of the exisng evidence; – Be developed by a knowledgeable, muldisciplinary panel of experts and representaves from key aﬀected groups;
Which guidelines should you choose? • To be trustworthy, guidelines should: – Consider important paent subgroups and paent preferences, as appropriate; – Provide a clear explanaon of the logical relaonships between alternave care opons and health outcomes, and provide rangs of both the quality of evidence and the strength of recommendaons; and – Be reconsidered and revised as appropriate when important new evidence warrants modiﬁcaons of recommendaons.
What should recommendaons include • For each recommendaon, the following should be provided: • Explanaon of reasoning underlying the recommendaon, including: • Descripon of potenal beneﬁts and harms. • Summary of available evidence (and gaps), descripon of the quality (including applicability), quanty (including completeness), and consistency of evidence. • An explanaon of the part played by values, opinion, theory, and clinical experience in deriving the recommendaon.
What should the recommendaons include • For each recommendaon, the following should be provided: • A rang of the level of conﬁdence in (certainty regarding) the evidence underpinning the recommendaon. • A rang of the strength of the recommendaon . • A descripon and explanaon of any diﬀerences of opinion regarding the recommendaon.
What the IOM did not talk about • How to translate guidelines into EMR decision support or ordersets – LiKle informaon on how to implement CPG’s in a way that is concordant with core recommendaons • Most likely aﬀects complex algorithmic decision support, such as early warning systems – ‘Atomizaon’ of evidence/decision making in EMR’s • The workﬂow in EMR’s is usually fundamentally diﬀerent than that envisioned by a CPG.
EMR’s provide the needed connecons All these connecons can be made by the EMR, but are selected by people
Humbling evidence • EMR’s for improving health quality: – Small to moderate sized improvement in acute care process measures, no impact on outcomes in 36 published studies* (Sahota, Implementaon Science 2011) – Heterogeneous impact on management/screening of chronic condions (Roshanov, Implementaon Science 2011) *Don’t feel badly, most of QI is in the same boat
Costs Value– the next froner • To increase value you must tackle costs – “Approval driven” approaches • P&T CommiKees, anmicrobial stewardship – System redesign • Six Sigma/Lean Sigma – Some quesons for the future
50,000 Some diseases have goKen more costly faster 45,000 40,000 35,000 MIHospital Charges ($) 30,000 CHF CAP 25,000 COPD UTI CVA 20,000 Sepsis 15,000 10,000 5,000 0 1993 1995 1997 1999 2001 2003 Year Rothberg M, Health Aﬀ (Millwood). 2010 Aug;29(8):1523-‐31.
20% What are we gerng for our money? 18% 16% 14%In Hospital Mortality 12% MI CHF CAP 10% COPD UTI CVA 8% Sepsis 6% 4% 2% 0% 1993 1995 1997 1999 2001 2003 Year Rothberg M, Health Aﬀ (Millwood). 2010 Aug;29(8):1523-‐31.
Where are the cost reducon opportunies? Missed Prev Opps, Prices That Are Fraud, $55 Too High, $105 $75 Ineﬃciently Delivered Services, $130 Excessive Administrave Costs, $190 Unnecessary Services, $210 Non-‐Wasteful Spending, $1,735 Low hanging fruit of ineﬃcient and wasteful care are present, but larger beneﬁt may be elsewhere
Cost types in healthcare • Fixed costs – Costs that do not vary over ranges of output. • Buildings/Equipment – Paid for once • Salaried personnel – paying for anyway – For example: • A PET scanner is expensive, but it is paid for once • The cost of upkeep, space, and the PET technician don’t vary substanally as more people use it
Point of clariﬁcaon • Where do guidelines/pathways ﬁt in this talk? – Lots of studies on guidelines, pathways – Minority report costs as an outcome – Few used guidelines/pathways with the aim of reducing costs/ulizaon (and few succeeded).
Cost types in healthcare • Variable costs – Costs that change as the volume of services increases • Some medicaons, material costs – For example: • Reducing the number of CT scans may reduce the amount of contrast purchased and used.
Cost types in healthcare • Marginal costs – Elsewhere in the world: • Costs to produce an addional product decrease with each addional unit – In healthcare: Not usually the case • Cost per unit output ﬁxed (See Fixed costs) unl maximal capacity reached • Addional PET scanner or PET scan not priced lower than the ﬁrst one. • Replacement opons generally not of lower cost (think Xa inhibitor vs. warfarin)
Why is Econ 101 in an EMR talk? • Vast majority, 70-‐80% -‐ maybe as high as 84% of costs in health care are ﬁxed costs – Building upkeep, equipment, personnel occupy bulk of costs – Variable salaries and discreonary items (e.g. drugs, materials) represent a small proporon – EMR’s • Implicaons over the short term: – Reducing variably costed items will have limited impact – Eﬀorts to reduce ulizaon of costly items oxen oﬀset by compensatory eﬀorts to maintain revenue to subsidize ﬁxed costs – Goal will need to focus on reducing ﬁxed and variable costs in tandem Roberts R JAMA, February 17, 1999—Vol 281, No. 7
Why is Econ 101 in an EMR talk? • Implicaons over the longer term: – EMR’s used to automate human tasks – EMR’s used to eliminate need for ﬁxed cost items – Must provide clear cost and ulizaon data – Overcome barriers or innovate on old models • Physician awareness • Health technology acquision commiKees • P&T • Anmicrobial stewardship cmte • Pathways Roberts R JAMA, February 17, 1999—Vol 281, No. 7
Physician-‐targeted cost reducon eﬀorts • Speaker’s prerogave – High level summary: -‐ A reasonable number studies of physician-‐ targeted intervenons cost and ulizaon exist. -‐ Example: -‐ Provision of cost informaon for common primary care medicaons increased the likelihood that lower cost alternaves would be chosen (Frazier LM, Ann Intern Med 1991;115:116-‐21.) -‐ Recent arcle suggests we add a ‘check out’ cart for what we order (Brook, JAMA 2012)
Physician-‐targeted cost reducon eﬀorts -‐ In general: -‐ Educaonal in nature -‐ Slight decrease in ulizaon paKerns, eﬀect did not diﬀer whether IT-‐based or not -‐ No informaon as to whether appropriateness increased -‐ Limited persistence of intervenon eﬀect -‐ Focus on variable costs (e.g. lab, some drug tests)
Health systems • Health Technology Assessment CommiKees • P&T • Anmicrobial stewardship • Pathways
Health Technology Assessment CommiKees • Similar to pharmacy and therapeucs commiKee – In existence for at least 20 years – Limited data on their prevalence, but appear most common in integrated health systems • General characteriscs – Broad based membership, includes C-‐suite – Physician led and championed – Most commonly focus on surgical technologies, capital expenditures – not implants, etc. Fine A Healthc Financ Manage. 2003 May;57(5):84-‐7
Health Technology Assessment CommiKees • Few (?No?) data on their eﬀecveness in constraining costs – In general, capital/technology expenditures represent marketplace diﬀerenators and are hard to deny • UCSF HTAC – In existence since 2006 – 24 approvals, 13 provisional approvals, 4 declined Gutowski C Health Technology Assessment at the University of California–San Francisco. Journal of Healthcare Management 56:1 January/February 2011
P&T and cost • A closed formulary may produce lower pharmacy costs – Not clear whether it slows pharmacy cost rises – More restricve formulary pracces may have adverse eﬀects (Horn SD, Formulary limitaons and the elderly: Results from the Managed Care Outcomes Project AJMC 1198: 4; 1105-‐1113) • No data on whether speciﬁc P&T structures or acvies are more eﬀecve than others at restraining cost. • No data on the ‘return on investment’ of P&T
Anmicrobial stewardship • Subtype of P&T • Generally narrower focus on selected set of medicaons • Able to link choice of medicaons to speciﬁc clinical situaons (and microbes) – Oxen include clear clinical guidelines – Pre-‐approval via consultaon in many programs
Anmicrobial stewardship • Highly eﬀecve at increasing appropriateness of anmicrobial use – Can produce both reducons in direct costs of medicaons and reduced downstream events – Most eﬀecve programs include physician outreach/ approval component with ered approach • Limited data on their cost to beneﬁt rao – One study esmated 1M/year direct cost savings – No esmates of the program cost Standiford HC. Anmicrobial stewardship at a large terary care academic medical center: cost analysis before, during, and axer a 7-‐year program. Infect Control Hosp Epidemiol 2012;33:338-‐45.
Health systems • Anmicrobial stewardship models include concepts that may be useful elsewhere – Physician detailing – Tiered restricon process – Understanding that restricng anmicrobials has real beneﬁts • ASM’s also – target acute care medicaons.
Pathways • Where do guidelines/pathways ﬁt in this talk? – Lots of studies on guidelines, pathways – Minority report costs as an outcome – Few used guidelines/pathways with the aim of reducing costs/ulizaon (and few succeeded).
How can EMR’s innovate over old models • HTAC, P&T, AMS, and Pathways – Can provide decision support over paper models. – Flexibly catch people ‘oﬀ path’ – Set ﬁrm(ish) guardrails around unwanted pracces – Actually measure what the pathway is doing and give clear feedback
Queson 1: Can physicians embrace limitaons stewardship as a professional standard?
We have to • Growing recognion that costs are important • EMR’s can help reinforce posive behavior, discourage unwanted behavior
Queson 2: Will physicians allow themselves to be stewarded by EMR’s (or anyone)?
The pizalls of greater choice Physicians want this The future needs this
Find ‘Model T’ systems • What would your company look like if it produced just one product? – 1908 Ford Model T – Single model from which others arose • More modern examples: – Starbucks: Medium Coﬀee – In And Out Burger: Cheeseburger + fries – Bank of America: Base checking account
Translate this to healthcare workﬂows • Potenal examples of Model T workﬂows – Inpaent Model T: What if all we did as an instuon was treat pneumonia? – Ambulatory Model T: What if all we did was see paents for hypertension? • Use these models to deﬁne workﬂows, clinic visit structure, etc. for most common paent ﬂows – Add ‘modules’ on to allow customizaon around core funcons. – Can then create single entry points an economies of scale – Can EMR’s do this?
Translate to therapeuc choices • Complexity in treatment choices – Within these groups, what 20% of drugs account for 80% of paents • What 20% of devices account for 80% of paents? • Can we make those the defaults? • Can this approach the be used to set ers of ‘approval’ or decision support? – Top 80% easily available – Next 10% require aKestaon as to choice – Next 10% require more in-‐depth approval?
Queson 3: Can health IT really solve everything (including costs)?
Health informaon systems and cost reducon • HIT is thought to be a key route reducing costs – Reduced redundancy through sharing of informaon – Ability to provide decision support – Few studies have demonstrated cost reducons* • Maybe cost increases??
Health IT • Why it might be old wine in new boKles – Using Health IT as…. • A more eﬃcient way to warehouse as broad a selecon of treatments/algorithms as possible. • A more eﬃcient way to present all possible treatment/ tesng choices – We don’t improve on exisng systems and organizaonal structures to help deﬁne appropriate choices • P&T, Anmicrobial “Culture eats technology for lunch”
Health IT • Why it can get us to the place we want to be – IT does force workﬂow standardizaon – More sophiscated use of formulary materials limits • Decision support • Automated ‘academic detailing’ – Data about producon processes
Conclusions • Translang evidence into pracce is hard, but crical – EMR’s can help by providing easy access to the best therapies and tests • Reducing costs in EMR’s is a crical goal – Automate and smooth workﬂows to target ﬁxed costs – Innovate and partner with exisng organizaonal funcons to speed adopon
Conclusions • Can we ﬁnd answers to the key quesons? – The culture of healthcare is changing – Perhaps instead of culture eang technology for lunch (at least insofar as cost and quality is concerned), culture can make the meal more appealing.