Build­ing pro­to­cols into EHRs can help cut waste­ful care

Modern Healthcare - - NEWS - By Me­lanie Evans

MRIs, CT scans and X-rays for low back pain pa­tients dropped by half last year at the UPMC health sys­tem in Pittsburgh af­ter doc­tors started see­ing re­minders in the elec­tronic health record that such tests can be un­nec­es­sary.

UPMC in­cor­po­rated the re­minders into its EHR, draw­ing from the Choos­ing Wisely rec­om­men­da­tions from the Amer­i­can Academy of Fam­ily Physi­cians and two neu­ro­log­i­cal sur­gi­cal so­ci­eties to avoid spine imag­ing for “non­spe­cific acute low back pain and with­out red flags.” The path­way di­rects these pa­tients to rest or phys­i­cal ther­apy first, said Dr. Steven Shapiro, UPMC ex­ec­u­tive vice pres­i­dent and chief med­i­cal and sci­en­tific of­fi­cer.

Use of CT scans, MRIs and X-rays at UPMC dropped 52% in 2014 com­pared with 2012. Spend­ing on imag­ing dropped $2.8 mil­lion and spine surgery fell by 5%.

More than 70 med­i­cal so­ci­eties have rec­om­mended more ju­di­cious use of roughly 430 med­i­cal tests and in­ter­ven­tions since the Amer­i­can Board of In­ter­nal Medicine Foun­da­tion launched its Choos­ing Wisely cam­paign in 2012. The cam­paign first fo­cused its ef­forts on public ed­u­ca­tion, but it will in­creas­ingly push to change the prac­tice of medicine, said Daniel Wolf­son, the foun­da­tion’s ex­ec­u­tive vice pres­i­dent.

But track­ing un­nec­es­sary care and get­ting clin­i­cians to change their be­hav­ior has proven dif­fi­cult. Track­ing overuse has been ham­pered by un­even use of EHRs, which hold the most de­tailed in­for­ma­tion about med­i­cal history and symp­toms. That de­tail is valu­able to iden­tify which pa­tients are not likely to ben­e­fit from cer­tain treat­ment. Claims data of­fer less in­for­ma­tion. In­cen­tives to re­duce overuse re­main weak with­out well-de­vel­oped mea­sures of per­for­mance.

“Mea­sur­ing these ser­vices in claims is dif­fi­cult and im­pre­cise,” said Car­rie Colla, an as­sis­tant pro­fes­sor at the Dart­mouth In­sti­tute for Health Pol­icy and Clin­i­cal Prac­tice.

Even at hos­pi­tals and med­i­cal groups with so­phis­ti­cated health IT sys­tems, iden­ti­fy­ing un­nec­es­sary ser­vices is com­pli­cated by the dif­fi­culty of fig­ur­ing out which pa­tients might ben­e­fit from those ser­vices in at least some cases. And once un­nec­es­sary care is defini­tively iden­ti­fied, no one is sure how best to change physi­cian be­hav­ior or pa­tients’ ex­pec­ta­tions to re­duce use.

Health sys­tems are us­ing var­i­ous strate­gies to try to change physi­cian be­hav­ior once overuse is iden­ti­fied. These in­clude pay-for-per­for­mance, qual­ity mea­sure­ment and re­port­ing, and elec­tronic de­ci­sion sup­port. But ev­i­dence for each method is weak, Colla said.

Re­cent es­ti­mates of overuse of med­i­cal ser­vices in the U.S. have ranged widely. The In­sti­tute of Medicine es­ti­mated that waste ac­counted for $765 bil­lion, or about 30% of the na­tion’s $2.5 tril­lion healthcare tab in 2009. Of the wasted spend­ing, the IOM said, $210 bil­lion con­sisted of un­nec­es­sary care. Last year, an ar­ti­cle in JAMA In­ter­nal Medicine es­ti­mated from 9.1 mil­lion to 21.9 mil­lion cases of overused ser­vices for Medi­care pa­tients in 2009. A sep­a­rate anal­y­sis us­ing 2012 Medi­care data found be­tween $1.9 bil­lion and $5.8 bil­lion in spend­ing be­cause of overuse of 26 ser­vices, in­clud­ing imag­ing for low back pain.

Some health sys­tems, such as UPMC, have started track­ing overuse and de­vis­ing strate­gies to stop it. The ABIM Foun­da­tion awarded seven grants this year to test use of some Choos­ing Wisely rec­om­men­da­tions by doc­tors and hos­pi­tals. The seven groups will work to re­duce use of an­tibi­otics to treat viruses, along with tar­get­ing at least two other ar­eas of overuse. Wolf­son said the grants pro­vide sup­port for chang­ing the be­hav­ior or doc­tors and pa­tients.

But the num­ber of Choos­ing Wisely rec­om­men­da­tions that providers have tack­led through data an­a­lyt­ics, prac­tice guide­lines and fi­nan­cial in­cen­tives has been lim­ited so far. Re­searchers and physi­cians are grap­pling with how to trans­form “well-in­ten­tioned state­ments” from the Choos­ing Wisely pro­gram into use­ful mea­sures, said Dr. Thomas Seq­uist, chief qual­ity and safety of­fi­cer for Part­ners HealthCare in Bos­ton.

For ex­am­ple, one Choos­ing Wisely rec­om­men­da­tion urges doc­tors not to per­form a stress test on pa­tients with sta­ble heart dis­ease. Pa­tients who are low risk and asymp­to­matic don’t need the test, Seq­uist said. But which pa­tients are low risk and what symp­toms should trig­ger stress test­ing? Dizzi­ness? Chest pain? With­out greater clar­ity, doc­tors could make the wrong rec­om­men­da­tions and ei­ther fail to curb overuse or deny needed care, he cau­tioned.

At UPMC, it helps that the sys­tem owns a health plan and pays doc­tors based partly on how closely they stick to pro­to­cols, which in­clude some Choos­ing Wisely rec­om­men­da­tions. One-quar­ter of physi­cian in­cen­tives are re­lated to qual­ity, and ad­her­ence to pro­to­cols is one mea­sure of per­for­mance, Shapiro said. Too of­ten, healthcare fails to fol­low strong ev­i­dence for good care, where such ev­i­dence ex­ists. “That’s not ac­cept­able,” he said.

To avoid un­nec­es­sary spine imag­ing, UPMC added re­minders to its elec­tronic health record for low back pain based on guide­lines from Choos­ing Wisely and two neu­ro­log­i­cal so­ci­eties, Dr. Steven Shapiro said.

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