One of the most pressing issues facing the U.S. and nearly every country is the trajectory of healthcare costs. Healthcare spending in the U.S. grew 5.8% in 2015, reaching $3.2 trillion, or $9,990 per person. As a share of the nation’s Gross Domestic Product, healthcare spending accounted for 17.8%.1 At this rate, if the industry doesn’t change this trajectory, eventually healthcare costs will surpass the American GDP. Clearly, this is not sustainable.
Further complicating matters in the U.S. is an aging baby boomer population, consisting of about 76.4 million Americans.2 In addition, the life expectancy of Americans is higher than ever before, currently standing at 78.8 years - eight years longer than it was in 1970.3 The elderly require more healthcare resources than other age groups and will need them for an extended period of time.
Additionally, of the more than $3 trillion we are spending on healthcare in the U.S. each year, about a third of it is considered to be wasted.4 Part of that waste is related to the clinical choices that patients and providers make that aren’t justified by the available knowledge and experience. This is referred to as the “know-do” gap - the gap between what we know and what is actually done in practice.
At the same time, for the amount it is investing, the U.S. is not deriving optimal value from its healthcare dollars when comparing public health benchmarks to those of other countries. These include metrics on access to care, quality of care, efficiency, healthiness, and equity. Other countries spend far less than we do.
These factors have created an incredibly challenging environment within which healthcare organizations must operate. More than ever, healthcare organizations are under intense pressure to decrease the costs of care while providing more value by improving care, outcomes, and ultimately, clinical effectiveness.
Steps Toward Achieving Clinical Effectiveness
To improve quality while containing costs within the healthcare delivery system, organizations must take steps toward overhauling the actual clinical care being delivered. This requires that providers consistently apply the best knowledge - based on research, evidence-based medicine, and clinical experience - while more deeply engaging patients in their care. It also necessitates a method of continuously defining, monitoring, and optimizing the processes at the heart of care delivery.
Only when our healthcare system commits to achieving clinical effectiveness within broad-scale practice across all institutions, will we begin to make progress on balancing the quality/cost equation. There are four key steps organizations must take today to make this happen.
Reduce Variability of Care
A crucial step towards achieving clinical effectiveness requires tackling variability of care, and doing so at scale. In some cases, specific institutions have had success in addressing variability of care for individual diseases or conditions, but doing that across hundreds of conditions and thousands of institutions is a much bigger challenge.
There are numerous examples of variability of care. For example, one study5 looked at the incidence of appropriate care for patients with atrial fibrillation. Although good data exists on which patients should be anticoagulated and which drugs should be administered, about 30% of patients didn’t receive appropriate care. This affects not just costs, but quality of care and outcomes as well.
Geography is also a factor. For example, a 70-year-old man who has been diagnosed with early-stage prostate cancer has up to four times higher likelihood of having his prostate surgically removed in some regions of the country than in others, where watchful waiting might be recommended.6 Yet, evidence shows that outcomes for the two approaches would be the same.
The care patients receive should not vary based on their healthcare system, the regions of the country in which they reside, or the doctor they see. When there are choices available and we know which approach optimizes outcomes, the treatment plan should not be a matter of chance.
Variability of healthcare has been a topic of discussion since the early 1970s, when studies started highlighting these geographic differences. Nonetheless, current studies still report these inconsistencies. What has changed in the intervening 40 years is that we now have the know-how, the technology, and the sense of urgency to reduce this variability and work toward nationwide standardization of care.
Move the Patient to the Center of Care
A seismic shift is underway, from providers being at the center of the healthcare universe to patients being the center of that continuum. By putting patients at the center of their own care, all providers involved in a patient’s care can function more consistently and seamlessly to enable greater clinical effectiveness.
Thanks to online resources and communities, patients no longer deferentially accept their physician’s recommendations. Many of today’s patients come to appointments armed with questions and information. In turn, clinicians need to fully discuss treatment options and alternatives with patients, since many care decisions are highly dependent on patient preference.
Part of the challenge with patient engagement has been finding effective means to engage patients. Just as technology is penetrating other aspects of medicine, the industry now has tools that encourage behavior modification, helping patients to better follow recommendations, to more closely adhere to standards, to more actively participate in their care, and to understand the benefit of investing their time by measuring outcomes. Deeper patient engagement is a crucial step for improving clinical effectiveness, since studies show that engaged patients have better outcomes.
Coordinate Care Across the Continuum
Another crucial step towards improving clinical effectiveness requires the coordination of care across the many elements of the system with which a patient interacts. In addition to the team at a clinician’s office or clinic, the healthcare continuum encompasses pharmacies, hospitals, short-term rehab clinics, long-term care facilities, home-based care providers, and other entities. Lack of coordination among these many players is often frustrating and confusing for patients and can waste time and resources.
Improved clinical effectiveness will ultimately require a holistic, longitudinal view of the patient, rather than the fragmented view that has been more typical. It will require that healthcare organizations bring many different elements together so that patients and providers are in synch. And it will mean that measurement processes must span the many steps in the continuum of care. This more holistic, patient-centered approach will help patients and providers make the right choices to optimize outcomes.
Leverage Next-Generation Clinical Decision Support
Many facets of the healthcare system must change to make improved clinical effectiveness commonplace in our healthcare system. Since coordinated information is at the heart of this vision, advanced integrated technology and content enablement will be required.
We are making steps in the right direction. With the proliferation of electronic medical record systems and the digitalization of healthcare, most healthcare providers in the U.S. and several other nations are interacting with technology throughout the day. Now health systems must leverage and integrate existing resources and applications to take advantage of the prodigious investments in technology that many have already made. The key is to harness and capitalize on the information being captured to better understand the care dynamics and workflow as clinicians are working with patients.
Traditional decision support has helped providers make progress in many of the areas that are key to optimal clinical effectiveness. Studies show that alerts and reminders from clinical decision support systems at the point of care have resulted in more informed decision making in diagnostics and therapeutics, resulting in positive effects on quality outcomes. The next step is to broaden that impact, and offer better ways for patients and providers to make the right choices.
At Wolters Kluwer, we’ve been working to broaden our impact on healthcare by developing the next generation of advanced clinical decision support solutions (ACDS). Building on our CDS foundation, we are developing an integrated solution comprised of patient engagement, personalized medical education, and measurement capabilities that quantify both impact and quality of care.
ACDS offers a better way for patients and providers to make the right choices by having intuitive and actionable content seamlessly embedded into healthcare portals and professional workflows. Ultimately, ACDS is about taking a more comprehensive approach to decision support, one that will help providers finesse the delicate balancing act of curtailing costs while delivering high quality care.
Conclusion
Thanks to the digitalization of healthcare, several factors are coming together to make the vision of ACDS achievable now. The healthcare industry is shifting to a system centered on the patient, with a focus on wellness. Standards are beginning to emerge for different EMR systems, so we have the ability to deeply embed decision support components within the workflow. Finally, we have the ability to harmonize care and reduce unwanted variability, thus improving quality and consistency while reducing costs.
Patients deserve the best care healthcare organizations can deliver. They deserve to have providers making the best decisions possible, with everyone in the healthcare continuum - whether a therapist developing a physical therapy plan or a pharmacist filling a prescriptionfully harmonized in their goals and actions. With the right tools and technologies in place, enabled by the next generation of clinical decision support resources, the vision of optimal clinical effectiveness is now within our reach.
References
- National Health Expenditures 2015 Highlights. In CMS.gov website. Retrieved from https:// www.cms.gov
- Pollard, K. and Scommegna, P. (n.d.). Just How Many Baby Boomers Are There? Retrieved from http://www.prb.org 3 Bernstein, L. (2016, Dec. 8). U.S. life expectancy declines for the first time since 1993. The Washington Post. Retrieved from https://www.washingtonpost.com
- The price of excess. PricewaterhouseCooper’s Health Research Institute. Retrieved from: http://www.hasnet.us/uploads/PWC_The_Price_of_Excess_Exec_Sum_Exhibit3.pdf
- The price of excess. PricewaterhouseCooper’s Health Research Institute. Retrieved from: http://www.hasnet.us/uploads/PWC_The_Price_of_Excess_Exec_Sum_Exhibit3.pdf
- Hsu, J. C. et al. Aspirin Instead of Oral Anticoagulant Prescription in Atrial Fibrillation Patients at Risk for Stroke, Journal of the American College of Cardiology, Volume 67, 25, 2913-2923, doi: 10.1016/j.jacc.2016.03.581.
- The Dartmouth Atlas of Healthcare. Prostatectomy per 1,000 Male Medicare Enrollees with Prostate Cancer, by Age. Retrieved from: http://www.dartmouthatlas.org/data/map. aspx?ind=319