How better clinical decision-making can optimize patient care and reduce healthcare costs

1. Changes in healthcare roles brought on by or accelerated by the pandemic:

Clinicians working outside of their specialty to assist with increased patient loads
Physician assistants and advanced nurse practitioners taking on more physician duties
Care teams required to do more with less due to staffing shortages
Clinicians adapting to digital models of interacting with patients and delivering care

Drive behaviors that lead to evidence-based decisions

Medical practices continually evolve and change due to the amount of new information and research as well as advances in medicine and technology. It’s impossible for clinicians to know everything. Keeping up with the newest evidence can be a burden for clinicians who are already pressed for time. Even if they find the time, medical literature is complex, often difficult to interpret, may span multiple specialties, and not typically collected in one location.

Juggling time constraints and other competing demands, clinicians may sometimes rely on outdated approaches to care, falling back on their formal education and the subconscious, subjective evaluation of their own practice experience over time. Although the experience of an individual clinician is valuable, it cannot substitute for the collective and objective knowledge reflected in the medical literature.

Since clinical decision-making is rooted in a series of behaviors that can be difficult to change — even when clinicians want to do the right thing — medical leaders can play an important role in championing clinician behaviors that adhere to the best evidence and practice guidelines. Raising awareness of unwarranted variation (and its negative effects on patient outcomes and costs) can help reduce it where it often begins — at start of the decision-making process.

Furthermore, as clinicians move into new roles and adopt new practices and ways of delivering healthcare, they may find themselves having to make clinical decisions in uncharted territory. Evidence-based guidance can help clinicians optimize patient care and safety in the “new normal.”

2 Clinicians frequently raise questions about patient care in their practice. Although they are effective at finding answers to questions they do pursue, roughly half of the questions are never pursued.

Minutes matter — Empower clinicians with the answers they need quickly

Searching for answers takes time. Not finding answers needed at the point of care can be frustrating. Even worse is finding conflicting information without a clear course of action. This puts undue stress on your clinicians who are already over-committed and facing increasingly complex decisions in busy clinical settings.

A systematic review of clinical questions raised by clinicians at the point of care found that physicians have approximately nine clinical questions a day, but at least six questions go unanswered because of limited time and/or information resources. Most questions are about symptoms, physical findings, test results, or drug treatment. Lack of time was noted as the top barrier to pursuing clinical questions.

At worst, each unanswered question could compromise patient safety. The danger posed by knowledge gaps should be considered, including delay or errors in diagnosis, ineffective or harmful treatments, and errors in drug dosing or monitoring. At best, each unanswered question is a lost learning opportunity.

The frequency with which answers to clinical questions are not pursued and the potential for concomitant medical errors suggest the need for interventions that ensure timely and accurate answers. Even small time savings can mean the difference between a clinician making a decision based on knowledge that may be out of date and making one that is supported by the latest evidence.

Reliable and comprehensive resources that distill the best available evidence and guidance and summarize the benefits and risks of a decision are critical for getting answers to clinicians quickly. Having these resources readily accessible in the workflow (via EHRs/EMRs) further saves time at the point of care so clinicians can spend more time with their patients.

3. “When all the clinicians in the hospital provide care based on a common, trusted information source, unwanted care variability is reduced. Unnecessary costs due to escalations, unnecessary tests, and medical errors can be avoided. Doctors spend more time with patients. Productivity increases.”

Encourage collaboration to break down silos

Practicing medicine and delivering quality patient care involves constant collaboration among clinicians and across medical disciplines throughout the care continuum. When decisions are made in silos, unwarranted variation in care is more likely to occur, impacting patient outcomes and driving up healthcare costs.

To support your clinicians in practicing evidence-based medicine and making the best care decisions for their patients, you may have created committees to establish care guidelines. However, establishing these guidelines can be challenging, requiring substantial time and buy-in from multiple stakeholders within an organization.

Once created, guidelines can be difficult and costly to maintain. Ideally, they should be updated whenever there is new evidence that warrants a change in clinical practice; otherwise, your clinicians may be making decisions based on incomplete or outdated knowledge. Guidelines must also be in a location where they can be easily found and followed. Bottom line, if your clinicians can’t find them, they won’t adopt them.

To deliver more effective care, reduce unwarranted variation, and rein in costs, decision-making must be aligned and coordinated across the entire care team with everyone working from a single source of trusted, evidence-based clinical information. The most efficient solution is to use existing evidence-based guidelines, then tailor these to your organization’s care setting (e.g., your formulary or referral patterns). A study published in the Journal highlights the gaps in patient care that occurs when care teams are not aligned, in this case, pharmacists and dermatologists. The dermatologists in the study used current research and patient experience to inform their beliefs and counseling, while the pharmacists relied on drug reference textbooks, websites, and medication package inserts. This gap highlights the need for coordinated care and decision-making across care teams to reduce unwarranted clinical variation.9

4.“ We’re constantly asked to make decisions, not in the bright light, where the decisions and the choices are certain, but in twilight, where imperfect options, incomplete information, and competing factors, including patient preference, and, increasingly, costs have to be translated into actions.”

Champion standardized approaches to reduce unwarranted variability

All clinicians want to do the right thing for their patients. However, determining the right course of action can be challenging when clinical information is constantly expanding and patients are presenting with more complex conditions over time. Clinicians must treat the patient’s condition and account for all the other factors going on with the patient
The main aim of clinical pathways is to align clinical practice with guideline recommendations in order to provide high-quality care within an organization.

Clinical pathways can help organizations adhere to quality measures and guidelines for common conditions in which treatment often varies from optimal standards of care. They may also serve as tools to reduce variations in clinical practice, thereby maximizing patient outcomes and clinical efficiency. The use of clinical pathways helps guide clinicians as they navigate critical, complex decision points based on the clinical characteristics of each patient.

Some of the most common clinical areas where using pathways can help reduce unwarranted variation in care include:

→CARDIAC CARE

The danger of atrial fibrillation (AF) is that not all patients with AF are symptomatic, yet serious health complications can arise that lead to stroke and heart failure.

Mitigating the risk of stroke is one of the most important management considerations for clinicians treating patients with AF, and the long-term use of oral anticoagulants is the most effective means of reducing risk of stroke. However, the risk of stroke must be weighed against the risk of bleeding from anticoagulants.

To reduce unwarranted variations and improve patient care, pathways can help clinicians determine a patient’s risk of stroke or bleeding and the appropriate anticoagulant and dose for that individual patient. Along with cardiovascular risk factor and comorbid disease assessment and management, getting a patient on the appropriate anticoagulant may help reduce adverse cardiovascular events and hospitalizations, while being cost saving for healthcare systems.

Adults with food insecurity may be at high risk for having undiagnosed diabetes. Evidence from the Study of Aging suggests that focusing on people from lower socioeconomic groups may help early diagnosis of diabetes for older adults.

→DIABETES

Type 2 diabetes is one of the fastest growing health challenges of the 21st century, with obesity, poor diet, and inactivity contributing to the upsurge. Early diagnosis and treatment of type 2 diabetes is important to reduce damage from higher-than-normal blood sugar levels and prevent or delay serious complications.

Once diagnosed, clinicians must develop a treatment plan and prescribe a medication, or medications, based on the latest evidence and unique patient considerations, such comorbidities, patient lifestyle, preferences, and compliance. For example:

Does the patient have comorbidities such as heart disease, heart failure, or chronic kidney disease that would make one medication preferable over another? Choosing the wrong medication misses the opportunity to manage the patient’s diabetes and improve outcomes for comorbid illnesses.

Would insulin offer better blood glucose control compared to oral medications? What if the patient is resistant to injections? Non-compliance would result in poorly managed glucose levels and potentially increased risk for complications.

Is the patient prone to low blood sugars? The wrong medication and/or medication dose could increase the risk of low blood glucose.

Clinical pathways have a firm place in diabetes care by helping clinicians evaluate a patient’s clinical presentation and risk factors, choosing appropriate behavioral modifications and medications, and determining a timeline for monitoring. Since good glycemic control can also reduce the risks of serious complications — including cardiovascular disease, blindness, kidney failure, lower limb amputation, and stroke — and their associated costs, improving diabetes care has far reaching-benefits for patients and healthcare organizations.

Diagnostic errors cause patients to suffer from unnecessary harm from tests and treatments, but misdiagnosed patients might also suffer from a true underlying disease, which is delayed or completely missed, causing harm or earlier death.

Establishing a correct diagnosis of chronic obstructive pulmonary disease (COPD) is highly important because appropriate management can decrease symptoms, reduce the frequency and severity of exacerbations, improve health status, improve exercise capacity, and prolong survival.

→CHRONIC OBSTRUCTIVE PULMONARY DISEASE

However, correctly diagnosing COPD can be challenging due to several factors:

Current and former smokers are also at risk for other medical conditions for which treatment is very different than for COPD. Multiple COPD subtypes (emphysema, chronic bronchitis, and chronic obstructive asthma) can complicate making the correct diagnosis. The differential diagnosis of COPD is broad and includes heart failure, interstitial lung disease, neuromuscular disease, anemia, and obesity.

Studies have shown that up to 90 percent of patients with misdiagnosed COPD regularly receive COPD treatments, which can cause adverse events and add costs to the health care system. Additionally, some researchers have estimated that between 5% and 62% of patients with COPD have received a misdiagnosis.

Since COPD is a condition fraught with complexity for both diagnosis and treatment, and therefore unwarranted variation, clinical pathways can support clinicians in making a correct diagnosis, determining the appropriate therapy, and minimizing patient harm and risks due to misdiagnosis.

Examples of common high-volume tests for which clinicians often need further information to determine appropriate next steps include:

Abnormal liver panel: high alkaline phosphatase and high conjugated bilirubin in adults
Abnormal lipid profile: high total cholesterol, low HDL cholesterol, high LDL cholesterol, or high triglycerides in adults
Abnormal iron profile: low ferritin or low iron in adults
Platelet count: high or low count in adults
High skeletal
→LAB RESULTS AND APPROPRIATE NEXT STEPS

Laboratory testing is standard practice in clinical medicine. The number and complexity of clinical lab tests makes it challenging for clinicians to accurately order and interpret these tests. Clinicians who receive a test result outside of the reference range will typically investigate further and likely order more tests for their patient.

Over-utilization, tests ordered but not appropriate, causes undue patient discomfort, overloads diagnostic services, risks generating false positives, and is associated with other inefficiencies in healthcare delivery, which undermines the quality of health services.19 Under-utilization, tests that are appropriate but not ordered, can cause patient harm by failing to detect, diagnose, and treat an illness.

A study concluded that the real impact of inappropriateness as it relates to over-utilization of lab tests is difficult to assess but the generated costs for patients, hospitals and health systems are certainly high and not negligible.

In situations where clinicians are covering patients with whom they are not familiar (particularly during overnight and weekends shifts) and clinicians covering specialists outside of their practice (and therefore interpreting lab tests outside of their specialty), appropriateness of lab tests can be difficult to determine.

Along with regular auditing of laboratory tests and educating clinicians about over-utilization, use of lab interpretation monographs can help clinicians interpret abnormal lab results and determine appropriate next steps based on individual patient needs. These measures can help reduce inappropriate testing and associated costs and improve the quality of care provided to patients.

Solving unwarranted variation in care begins with clinical decision-making

Despite widespread attention and organizational efforts to reduce unwarranted clinical variations, it continues to be a persistent problem affecting healthcare organizations around the world.
A new approach is needed. One in which reducing unwarranted variability is considered at every decision point — diagnosis, treatment, and prescribing — along the care continuum.

By identifying and addressing the key clinical areas where inefficient use of resources and gaps in best practices occur the most, medical leaders can begin to reduce unwarranted variations in care at the start of the decision-making process. Meaningful use and application of technology is critical in demanding healthcare environments. Finding ways to reduce clinician workload is proven to be one of the four keys of engaging physicians to reduce unwarranted variations in care.

When you consider and address unwarranted variations from the specific function of clinical decision-making, rather than an over-arching organizational task, you can consistently make small but meaningful adjustments that have an aggregate and measurable impact on patient outcomes, patient safety and satisfaction, and healthcare costs.

Tackling unwarranted variations from a new perspective
“Knowledge and technology alone cannot improve the quality of costs of healthcare. They must be implemented artfully, in ways that are compelling to users and achieve

Despite widespread attention and organizational efforts to reduce unwarranted clinical variations, it continues to be a persistent problem affecting healthcare organizations around the world.

A new approach is needed. One in which reducing unwarranted variability is considered at every decision point — diagnosis, treatment, and prescribing — along the care continuum.

By identifying and addressing the key clinical areas where inefficient use of resources and gaps in best practices occur the most, medical leaders can begin to reduce unwarranted variations in care at the start of the decision-making process.

Meaningful use and application of technology is critical in demanding healthcare environments. Finding ways to reduce clinician workload is proven to be one of the four keys of engaging physicians to reduce unwarranted variations in care.

When you consider and address unwarranted variations from the specific function of clinical decision-making, rather than an over-arching organizational task, you can consistently make small but meaningful adjustments that have an aggregate and measurable impact on patient outcomes, patient safety and satisfaction, and healthcare costs.

Health
Common information sources help health system streamline workflow and align decisions

Elevates staff, and patient experiences with consistent, current decision support

The task of streamlining workflow for teams, and subsequently elevating the patient experience, became a little easier years ago when its decision makers asked: What if we could find all our decision support in one place?

A long-time user of drug data and evidence-based treatment recommendations, drug reference and integrated custom formulary database service all drawing from ours source of evidence-based information. Since then, the health system has realized all it can achieve with aligned information resources delivering consistent and trusted evidence.

Medication utilization coordinator at our Center for Medication Utilization, originally chose to switch to after evaluating multiple competitors “to streamline integration,” as well as because of “the depth of the databases.” By using a full suite of solutions by our system has been able to consolidate many products and services, not only creating efficiencies for team work streams, but value at the bottom line.

The suite is developed by a multidisciplinary editorial team at our EHR division that harmonizes content between solutions. “Whenever you’re in a large health system, you’re trying to align information and resources,”. “It’s nice to have the same systems talking to each other for consistency of information.”

“We definitely view that as a benefit,” adds maintains the integration within the health system’s EMR system. “We like being able to rely on the information coming from the same source.”

Features:

The nursing staff “absolutely loves” the EHR Division’s system, which provides the questions asked in the nationally required Hospital Consumer Assessment of Healthcare Providers and Systems patient satisfaction survey.

Staff members have been vocal about the many language options for medication education patient handouts being a vast improvement over its previous provider.

Within the interface, healthcare professionals can also access in-depth database when needed.

We add-on module provides multinational all the information to help clinicians treat our EHT Divison’s large national population.

2 Streamlining workflow

Using the system and Up-To-Date together gives the ability to link directly from disease topics in Up-To-Date to the related drug therapy information in or to access Up-To-Date searches from the tool bar atop every page of system This accessibility, along with harmonized content within both tools, creates a holistic view of clinical decision support, aligning care teams and providing them with greater clinical insights and context to inform their decision-making process.

HER Division has observed another advantage, reports: collaboration. The ability to easily “toggle back and forth between both” solutions has helped pharmacists connect to disease knowledge and physicians and allied health staff to delve deeper into pharmacology. This has enhanced communication between the hospital and the pharmacy, and helping to unite care team members and enabling them to operate from a common care playbook

Aligning care decisions

When comparing drug information databases, we saw several clear advantages to choosing over previous resource. “The depth of knowledge, timely updates, and how concise it is. All of these factors definitely make our link a high-quality resource. Plus, we saw a huge in cost savings, which made it a great value and fiscally more responsible.”

Reducing care variability and improving clinician satisfaction

The database was also not accessible on the multitude of platforms accessed by clinical staff across the enterprise.“It helps us promote proper therapeutic use of medications that translate into fiscally responsible medication spend.”

With our link create its own customized database within, allowing clinicians to instantly ascertain from a single search whether a medication is on the health system’s formulary and to access valuable dosing and administration information, precautions, and customized internal medication use information. it enables to include its hospital policies, guidelines, historical P&T tracking, and links to hospital intranet resources within drug monographs, fully integrated with drug information.

“Whenever you’re in a large health system, you’re trying to align information and resources. It’s nice to have the same systems talking to each other.”

Integration increases access to information

Effinland IP has taken advantage of the strong relationship between Allopathic and Ayurvedic, using drug data as the backbone of its EMR clinical screening functions and integrating direct links to our syatem drug reference content in its Medication Administration Record (MAR) and Computerized Prescriber Order Entry (CPOE). “The volume of information– if we had to put that in manually, it would be an unbelievable undertaking,” pharmacy informatics specialist.

In addition to data, having links to integrate in EMR system has made reaching valuable drug content “. “We use links from the patient MAR directly to what we need in the system. That wasn’t always the case with [other drug references]. We used to have to go out to a database and look up a drug.”

HER Division linking “was extremely easy to implement,” and. “It was simple to set up, and the support was great. We had several direct contacts we could email or call, and the response was quick.”
Overall, the implementation of this full solution suite has assisted in achieving several important goals. “It’s a platform to improve transparency and accessibility of information that has enabled us to streamline access to point-of-care guidance and improve safe medication practice.”

Information is the best medicine

Information is at the heart of every clinical decision, treatment plan and patient experience. With consistent access to a common source of trusted, current evidence from its suite of clinical decision support solutions, we effectively been able to streamline workflow, align care decisions, reduce care variability, elevate user satisfaction with their formulary, and enhance access to information through smart integration

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