Hospital executives across the U.S. are becoming increasingly focused on reducing clinical variation as a key goal in 2019. According to Advisory Board’s Annual Health Care CEO Survey that was released in June—inclusive of 90 C-suite industry leaders—“minimizing unwarranted clinical variation” ranked second on the priority list for healthcare executives, behind only “improving ambulatory access.”
As noted by Advisory Board researchers, “Minimizing unwarranted clinical variation refers to reducing the utilization of treatments that do not improve patient outcomes.” More often now, patient care organization leaders are realizing that millions of dollars could potentially be saved by identifying and acting on unwarranted variations in clinical care. After analyzing care variation in 468 hospitals, Advisory Board found that a typical facility could save up to $29 million annually by delivering care in line with cost benchmarks for high-quality hospitals.
Indeed, as healthcare shifts from a fee-for-service payment landscape to one in which value-based care and population health will be prioritized, hospitals and health system executives are spending the time and effort needed to uncover variation and standardize care practices.
A key health technology company in this space is Wolters Kluwer, whose UpToDate Advanced solution contains clinical pathways that target common medical conditions with unwarranted variability in care, aiming to help clinicians meet national and international quality measures. UpToDate Pathways are interactive decision-making tools that are built upon the evidence and graded recommendations found in UpToDate, a clinical decision support resource. Thousands of clinical topics, medical calculators and graphics from UpToDate were used to develop the pathways, according to Wolters Kluwer officials.
Providers use UpToDate Advanced for its recommendations tailored for specific patients. For example, it helps clinicians reduce inappropriate testing and treatments, and provides guidance on when and which antibiotics should be prescribed.
In the Upper Midwest, the Sioux Falls-based Sanford Health is one of the largest healthcare delivery systems in the U.S., with hospitals and clinics in nine states, as well as senior care centers and skilled nursing facilities in several more. As such, it became quite challenging for organizational leaders to think about how to spread best practices and reduce clinical variation across all its care sites. “With our vast footprint of hospitals, clinics and senior living facilities across 26 states, reducing variations in care is a critical part of our efforts to improve outcomes and increase patient safety,” says Heidi Twedt, M.D., chief medical information officer (CMIO) at Sanford Health.
As such, Twedt felt that “turning to an expert source of information” for reducing unwarranted variation and standardizing care practices would provide great assistance to Sanford Health clinicians. Historically, the health system had developed its own clinical practice guidelines and standard treatment regimens, but “the idea of developing those for the vast number of conditions that patients can present with is a daunting task—both to develop them in the first place, but also to keep them up-to-date with current practices as new evidence comes out,” Twedt acknowledges.
But now, by leveraging UpToDate Advanced—with some of its top clinical pathways clinicians turn to including atrial fibrillation, hyponatremia, hypertension and Type 2 diabetes mellitus—Twedt says that Sanford Health plans to discontinue the process of generating its own standard treatment regimens and clinical practice guidelines. Rather, it plans to turn to the UpToDate Advanced content to be its “source of truth for the best practice.”
Twedt notes that if there are clinical guidelines that come up for review, and there are UpToDate Advanced pathways with the same content, “we will retire our own and point our users to that pathway. We are just doing our first batch of those this month,” she says.
Clinicians Buying In
Physicians, of course, want to do the right thing for their patients, but some could be concerned that reducing variation means limiting their ability to make critical decisions for care since their own expertise could be called into question. But at Sanford Health, Twedt says this has not been an issue whatsoever. “Our physicians want to make sure they are doing the best and right thing, and it’s very difficult to keep up with the literature for all the disease states that might walk in the door,” she says.
What’s also helped is the fact that Sanford Health clinicians have been using some version of UpToDate for years as the tool they turn to for learning best practices. “The pathway [in UpToDate] just puts it in a more step-by-step, protocol driven [process],” she says. “So I think the reassurance that the pathways bring to them is a benefit. And we never stop them from customizing it to a certain patient, if there’s a reason why that patient needs to be different.”
Twedt brings up an anecdote of a younger physician, fresh out of residency, who uses UpToDate to reinforce what she believes she should be doing anyway. “It’s helping her gain the confidence that she’s on the right path in her [early] years.”
What’s more, Twedt says that UpToDate integrates well with the health system’s Epic electronic health record (EHR). For example, a user can easily move into a topic from a problem that’s on the patient’s problem list, or he or she can quickly access UpToDate via the EHR to search any clinical topic.
“We plan to have links out to specific pathways that more embedded in clinicians’ workflows as we move forward,” she explains. “So, maybe from an order set, there would be a link out to the right pathway. And perhaps that’s where you will choose your antibiotic—through the pathway rather than have it native in the order set. Delivering the content right to the workflow—rather than something you have to look for and search out—will be a way we plan to [evolve].”
