Providers are still feeling their way around clinical decision support – and figuring out how best to integrate it with business intelligence to survive in an era of accountable care.
Data warehousing and decision support aren't exactly new. "Hospitals have had data warehouses for a long time," says Mary Griskewicz, senior director of health information systems at HIMSS. "I was working at a hospital 15 years ago, and we had one."
What is new these days is the ways clinical and business decision support are being used, and how they intertwine. And how the stakes are higher than ever for making them work.
Simply put, as the inexorable push for value in healthcare continues, "we cannot afford to keep performing the way we're performing," says Griskewicz. In this new landscape, "it all boils dow to the CIOs and the executives saying, 'We need to be more effective and efficient.' The best way to do that is to look at the data, and understand it."
James Gaston, senior director of clinical and business intelligence at HIMSS, agrees. "Fee-for-service is not going to be around for very much longer," regardless of how the Supreme Court rules on the Affordable Care Act, he says. "Payers and self-insured large businesses are all pushing to get value. And for a healthcare organization to respond to that, they need clinical intelligence. We're going to see more organizations dip their feet in this pool and figure our how they can effectively implement it in their culture and their structure."
Business analytics is well-established, but the shift in importance toward clinical intelligence is relatively recent. But both must work in tandem to gauge and deliver quality.
"Ten to 12 years ago, a lot of the larger hospitals all had data warehouses, that was the cool thing to do," said Griskewicz. "They had a lot of data, but they were using it basically for the C-suite, more on the financial management side – for your supply management, your inventory control. There was not a lot of emphasis to look at clinical informatics unless you were in more of an academic research facility."
Nowadays, not only is CDS coming much more to the fore, but "you're starting to see that cohesion" of both strains of intelligence, says Griskewicz. "We need to align the clinical informatics with the business informatics, because the business is that of healthcare."
From large academic medical centers to small community hospitals, the need to understand "how many 'Xs' I'm doing, and what are the clinical outcomes," is more acute then ever, she says.
"Because we're now going to be measured not only by CMS and the Medicare and Medicaid programs, but the larger insurers are basically saying, through value-based purchasing, 'If you meet the basic requirements the government is putting in front of you, we'll give you X amount of additional dollars as an incentive.'"
With patient-centered medical home models setting the stage for ACOs, the new approach is much "more team-driven – it's working together to make sure they can get to those outcomes. That's very, very different from a managed care model. In order for providers to effectively do any of this, they have to understand the data in their systems."
That said, not all doctors are convinced just yet. "There's a lot of skeptics on the street right now," says Griskewicz. "Physicians are struggling with a lot of things," and to many, CDS systems are just another new and potentially burdensome responsibility.
Key to bringing docs into the fold, and getting the most out of these systems, is smart planning and proactive communication.
Gaston mentions a CIO who "spent a lot of money to implement a really sophisticated electronic medical record and hospital information system – but there was absolutely zero cultural integration and training with that system. He could put up a pretty pie chart with a lot of number, but none of his staff knew how to integrate that and work it into their care process."
It's crucial to determine "when information is needed, what information is needed and how do you use that information to deliver better care," he says, "as opposed to just throwing it in the face of the care provider."
Because the answers to those questions can vary widely from facility to facility. "There is no standard industry model," says Gaston. "Even if you put in a clinical data warehouse, you still have to manually exercise opportunities to leverage it."
So far, he says, vendors have been doing their jobs on that front. "They've been asked by the market to deliver a product that is extremely flexible and accommodating for any number of healthcare delivery environments, and they've done that."
The challenge, though, is that it's "not a standard package." Meaningful use offers specific requirements on data collection and gathering in the process of delivering care, and those government mandates are "a good first-step toward normalizing and helping people begin to use the same information and definitions around clinical data management. But it's still got a long way to go."
Not to mention, "it's expensive," says Griskewicz. "First of all, you have to have a framework. You have to have a plan. Just like any program or project, you have to have the project manager, the engineer, the architect."
So before making that investment it's crucial to ask – "five times," she says – a very important question: "Why are we doing it? What is it that we hope to accomplish?"
The most successful deployments of CDS don't come because the market pressures or federal mandates have forced the issue, says Gaston. "The ones that stand out right now, they're driven to stand out because of their mission or vision of delivering the absolute best care they can, and not necessarily because of a government mandate, or a financial or business mandate."
Nonetheless, a new era of value-based care means that sooner or later, market competition will have something to say about the situation. Some clinicians may be skeptical, but the C-suite recognizes that "due the competitive marketplace, and for financial reasons – we want to keep our doors open for goodness sake – we need to provide the best care to our patients.
"We're already seeing more and more need for understanding the data to run the business of healthcare – understanding it, managing it, analyzing it and looking to improve the healthcare system," she says. I have not met one clinician or healthcare executive who is not on that path."
