Reducing clinical variation: Does it limit or enable patient care?

Reducing clinical variation continues to be a hot topic in health care. However, it’s the idea of reducing or eliminating variation that makes many physicians who may not like the idea of standardization take pause. As a physician myself, I understand the concern and have had the opportunity to see how evidence-based medicine can be done effectively and efficiently to enable hospitals and clinicians to deliver better outcomes — and at a lower cost.

What is clinical variation and why is it important?

Unwarranted clinical variation is the differences in care that cannot be explained by type or severity of illness or patient preference. This variation is one of the root causes of preventable harm and poor outcomes, and is responsible for over 30 percent of health care costs.1 Reducing care variation provides a significant opportunity to take costs out of the system and improve clinical outcomes.

Reducing clinical care variation helps take costs out and improve outcomes

Cedars-Sinai and Optum® Advisory Services conducted an observational study about whether the utilization of clinical decision support is correlated with improved patient clinical and financial outcomes. The findings, published in the American Journal of Managed Care, from 26,424 inpatient visits, showed that adherence to a real-time clinical decision-support system embedded in the electronic health record at Cedars-Sinai was associated with cost savings of almost $1,000 per patient and a statistically significant improvement in both 30-day readmissions and probability of complications, compared to non-adherent encounters.

Winning physician buy-in critical to reducing clinical care variation

Physicians influence 80 to 90 percent2 of health care costs, so it is critical to get their buy-in. I like to think about four pillars of success for moving the engagement dial with doctors: hearts, minds, wallets and watches. It’s kind of corny, but it makes sense.

  • Hearts: You have to appeal to what attracted people to enter into the health care profession. They have a sincere desire to be healers.
  • Minds: A provider is at his or her core a scientist. You have to be able to demonstrate that you are helping them follow and deliver evidence-based care for their patients.
  • Wallets: You have to figure out how to provide compliant financial incentives for providers.
  • Watches: This is critical. You’ve got to be more efficient than the workflows clinicians are following today. The more personal time you can give back to physicians the more they will be open to adapt to change.

How do electronic health records and clinical decision support work together?

People often get confused between information systems and clinical decision support. You need both, but the two are not the same. The challenge is that many electronic health record (EHR) systems have clunky workflows. Content usually is not aggregated by EHRs, nor coordinated, which can lead to potential conflicting guidance and alerts that can lead to false positives (fatiguing providers). Clinical decision support provides curated evidence-based guidance embedded into an EHR to help reduce clinical variation with actionable, well-supported interventions consistently throughout the organization.

How Optum is delivering patient-specific care pathways

The dominant approach for health systems adopting EHR enabled care pathways is a “do-it-yourself” process. Execution of a single care pathway requires significant in-house resources be dedicated and sustained. Once complete, this work is difficult to scale and replicate across multiple conditions and throughout a health system. Optum works with providers to efficiently deploy patient-specific, multidisciplinary care pathways driven by behind-the-scenes logic, integrated seamlessly into a familiar but optimized EHR workflow. Using cloud-based technology, we provide a scalable approach to knowledge management and pathway execution that enables us to efficiently and effectively deliver and maintain pathway guidance at the point-of-care across multiple conditions.

Looking into the future

We still live in a fairly paternalistic health care environment where physicians and provider organizations wield most of the power because they hold the clinical knowledge and the patient data. Now, with the National Coordinator for Health Information Technology (ONC) and Centers for Medicare and Medicaid Services (CMS) proposed regulations requiring providers and payers to free up data access, patients will be more informed. And potentially disruptive entrants into health care, such as Amazon and Apple, will be more empowered to help reduce clinical variation and associated costs.

Given the move to a more consumer-centric health care environment and nontraditional entrants into the health care market, solving the riddle of clinical variation and care efficiency with technology will continue to play a vital role in helping create a sustainable, high-quality U.S. health system.

About the author

Kontor_John_blog article.050715_pptJohn Kontor, MD
Practice Leader, Provider Technology Services and
SVP, Optum Advisory Services

John Kontor, MD, serves as senior vice president, where he plays a pivotal role in leading electronic health record (EHR) implementation, EHR optimization and population health/value-based operations efforts.

1Berwick DM, et al. JAMA. 2012;307:1513–6.

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