Bringing up the bottom line: Using surveillance and guidance to streamline efficiency and standardize care

The American Medical Association (AMA) reports that physicians are spending up to six hours a day working with their electronic health record (EHR) to comply with documentation mandates. This is contributing to record-high levels of physician burnout and dissatisfaction with the practice of medicine.

While this has been a topic of conversation that has grown over the last few years, it shouldn't surprise anyone. EHRs are transactional systems that were designed for regulatory purposes, not for easing workflow. They "check a box" and review and manage tasks to ensure your institution is compliant with meaningful use. They were never meant to be about care, rather they were intended to reduce billing-related headaches.

Another issue that has arisen relates to the emergency of antibiotic-resistant illnesses. According to the Centers for Disease Control and Prevention, antibiotic resistance is one of the biggest health challenges of our time. More than two million people get an antibiotic-resistant infection each year. This results in the death of more than 20,000. It's time that providers have the ability to leverage their EHR to serve as part of the solution to this challenging problem.

It's increasingly important that hospitals and health systems help their clinicians sort through the noise and find high-value, actionable opportunities more efficiently. To achieve this goal, healthcare administrators are forced to balance justifying their EHR investment with the delivery of clinical care. This requires technology that's complementary to the EHR, aligned to diverse clinical workflows and wrapped with analytics, resulting in a unique clinical lens that can identify opportunities to improve care and reduce costs. Clinical efficiencies and standardization can only be achieved with focused technologies coupled with the clinical expertise to implement and guide best practices.

Enter Premier® — the enabler of clinical excellence for hospitals and health systems, ensuring that their technology and infrastructure create efficiencies and support standardization to guarantee the best possible patient care and protect the bottom line.

Avoiding Sinking Margins and Justifying EHR Investment

Premier has a direct line of sight into the innerworkings of hospitals and health systems from both clinical and financial vantage points. Due to the sheer amount of data Premier sits on, the company's experts can articulate what works in organizations, provide an enterprise view of clinical performance along with perspective on how they compare, and identify opportunity — all without disrupting workflow. The lens into the innerworkings of your organization that Premier provides includes:

  • Helping administrators see the broader context of opportunities and associated risk simultaneously
  • Helping clinical teams act immediately using real-time surveillance across patient populations to protect patients and the organization's bottom line
  • Supporting organizations as they address methods to effectively change provider behavior at the point of order for the best care at the lowest price

Under the new reality of value-based care, efficiencies and standardization are key to not only thriving, but simply surviving. Read on to see examples of how Premier has impacted organizations through efficiencies and standardized care.

Case Study — No Change Management Required

In 2017, AdventHealth of Florida decided to tackle the way care was being delivered across its 45+ hospital enterprise. In its goal to become a high reliability organization, this meant removing unwarranted care variation to provide exceptional care for all patients.

After assessing its level of readiness to implement care transformation, AdventHealth set out to better manage patients across facilities and ensure patients were always receiving the right care, which is easier said than done. To this end, AdventHealth leaders had a significant interest in advanced, or "intelligent" clinical decision support (CDS) that would take identified opportunities to reduce care variation and make them actionable for providers within the workflow — at the point of care. The EHRs, which had been implemented across the board, needed to be optimized.

AdventHealth had been working extensively with Premier to reduce expenses related to labor, supply chain and drug formulary. They had also identified opportunities to reduce care variation and costs across the system. It was determined that the next area to address was intervention at the point of decision-making, driving real change in the way patients received care. Medical errors — both acts of omission and commission — were of concern, and intelligent CDS was identified as the solve.

It was here that Premier connected AdventHealth with the recently-acquired Stanson Health team who had developed a CDS technology with an intelligent approach to delivering guidance that fosters behavior change. Key to the CDS technology is an evidence-based clinical content and alert library that are seamlessly integrated into the clinical workflow/EHR.

Alerts are triggered based on an array of data points existing within the EHR. Once fired, the alert contains three pieces of information for the physician:

  • The advice — this is the "why" behind the alert
  • A link for more information on the advice — this tells the user what else they need to know
  • An option to accept, ignore or override — this puts the ultimate decision squarely in the hands of the clinician

Starting with Florida Hospital, AdventHealth's flagship, the governance team rolled out 10 specific rules in the inpatient EHR. Initially the team intended to have the rules run silently in the background, see how often they were firing and begin a physician education program based on the results.

However, by accident, the rules were turned on for providers — without change management or training. Surprisingly, the physician leaders at AdventHealth found that even without education, training or change management, behaviors were being modified. By the end of 2018, AdventHealth's new CDS installation was live systemwide in both its inpatient and ambulatory EHRs.

Case Study — 40% Antibiotic Intervention Rate

Suboptimal use of antibiotics, leading to a rise in antimicrobial resistance, is a growing concern. In response, there is an increased effort to reduce or refine antibiotic use in hospitals across the U.S. However, most antimicrobial prescriptions originate in outpatient settings, with almost half thought to be inappropriate. This includes unnecessary antibiotic use, as well as unsuitable selection, dosing and duration.

King's Daughters Medical Center (KDMC) in Ashland, Kentucky — a 455-bed general medical and surgical hospital — began using the TheraDoc® technology in early 2012 to support and enhance their antimicrobial stewardship program (ASP). They chose the TheraDoc clinical surveillance solution because it provided antimicrobial stewardship (AMS) pharmacists with the real-time clinical insights and user-customizable tools to help identify and act on potential interventions and recognize opportunities to optimize drug therapy.

Initially, the AMS pharmacy team at KDMC used TheraDoc for inpatient initiatives. As the team expanded their scope outside of the hospital they had a challenge. Outpatients were not necessarily in the EHR and were frequently seen by multiple providers, with various times between appointments. This created delays in the review of cultures and adjusting therapies. To create efficiencies and a population view, the team decided to extend their use of TheraDoc so that they could have a single location for individual patient data, medication information, lab results and physician notes.

Starting in early 2015, KDMC pharmacists turned to TheraDoc to conduct a medication-use evaluation in the IV infusion center, which revealed an opportunity for potential antibiotic streamlining. Based on this insight, the ASP team stepped into action. By setting up an IV therapy review though the TheraDoc reporting tool, the team began reviewing all IV outpatients weekly. They also started tracking use of antimicrobials and dosing regimens.

In November of 2015, after seeing the benefits in the infusion center, the AMS team expanded their lens to the wound care center with the creation of a Wound Care Center Review section in TheraDoc. This allowed pharmacists to monitor patients and follow up on all positive culture results.

The expansion of the TheraDoc solution to outpatient facilities helped KDMC pharmacists increase drug interventions, deescalate therapy for more patients and reduce time to appropriate therapy. Interventions increased by 22 percent in the IV infusion center and 40 percent in the wound care center.

Case Study — 286 Percent Improvement in Antibiotic Prescribing

Ellis Medicine in New York had policies and procedures in place for monitoring and dosing several antibiotics but didn't have an antimicrobial stewardship program. In early 2016, recommendations from the New York State Department of Health and new Joint Commission requirements prompted the hospital to develop a program. To help meet these regulatory standards, Ellis Medicine turned to Premier's clinical surveillance solution, powered by TheraDoc.

In establishing its antibiotic stewardship program, Ellis Medicine pharmacists found they couldn't easily identify duplication of therapy and opportunities for de-escalation or discontinuation of therapy using time-consuming and labor-intensive methods.

The Premier technology Ellis Medicine adopted helped streamline and automate the process. It was implemented for general pharmacy use and was tailored for antimicrobial stewardship using alerts customized by clinicians focused on multiple activities, including de-escalation and discontinuation and duplication of therapy.

Ellis Medicine pharmacists initially focused on two antibiotics: vancomycin and meropenem. With surveillance automated, improved coordination between shifts was realized. Interventions and cost savings were tracked, and pharmacists began presenting results at monthly and quarterly meetings.

Cost savings for de-escalation and discontinuation of antibiotics were calculated. From May 2016 to May 2017, there was a 286 percent improvement in appropriate prescription of meropenem within five months of stewardship recommendation. An analysis of intervention types revealed that:

  • 23 percent were for antibiotic de-escalation
  • 11 percent were for discontinuation
  • 6 percent were for therapy adjustment
  • 4 percent were for initiation or escalation of therapy
  • 1 percent were for dose/interval adjustment
  • 1 percent recommended culture draw
  • 1 percent recommended therapeutic drug monitoring
  • 53 percent of cases reviewed by the stewardship team required monitoring only

From January 2017 to May 2017, the percent of vancomycin courses de-escalated and discontinued rose from 20 to 25 percent and courses of meropenem de-escalated and discontinued rose from 15 to 43 percent.

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