The Mother Of Invention

Aug. 1, 2007

A physician-owned medical group builds its own clinical decision support tool and brings it to the open market.

Tom Hastings, M.D., sits with his patient, a 67-year-old woman who was diagnosed with Type II diabetes several months earlier. She has been unable to control her diet and exercise. Having been visited recently from the Glaxo drug representative, Hastings recalls the rep touting Avandia’s proven ability to lower A1C levels among diabetic patients. While writing the prescription for Avandia, using his electronic prescribing software, he notices a message on the screen reminding him of a recent study regarding the increased risk of ischemic heart disease in patients taking Avandia. Reviewing the information further, and noting the higher cost for Avandia and potential adverse side effects, he looks at the alternatives the software presents. Based on the latest ADA recommendations for this patient’s diagnosis, Hastings concludes Metformin would be the safer and more economical first-line drug therapy for his patient.

A physician-owned medical group builds its own clinical decision support tool and brings it to the open market.

Tom Hastings, M.D., sits with his patient, a 67-year-old woman who was diagnosed with Type II diabetes several months earlier. She has been unable to control her diet and exercise. Having been visited recently from the Glaxo drug representative, Hastings recalls the rep touting Avandia’s proven ability to lower A1C levels among diabetic patients. While writing the prescription for Avandia, using his electronic prescribing software, he notices a message on the screen reminding him of a recent study regarding the increased risk of ischemic heart disease in patients taking Avandia. Reviewing the information further, and noting the higher cost for Avandia and potential adverse side effects, he looks at the alternatives the software presents. Based on the latest ADA recommendations for this patient’s diagnosis, Hastings concludes Metformin would be the safer and more economical first-line drug therapy for his patient.

 Hastings is one of 60 primary care physicians within Esse Health, a progressive physician-owned medical group in St. Louis. Our group of forward-looking physicians is constantly searching for, and creating, new ways to challenge the status quo related to patient care, cost and physician reimbursement. However, we started out like every other medical practice, experiencing the issues of time pressures, shrinking reimbursement and information overload universal to the majority of primary care physician groups.

Time Famine

 There has long been a romantic notion that each doctor is some sort of self-contained scientific institute. That physicians have the time to read all the latest medical journal articles, scrutinize the data, use the tools of evidence-based medicine to assess the validity of each study, and then integrate the new information with everything that has ever been published on the topic so that they can make correct decisions months later when they see a patient who actually needs the information.

 The truth is that doctors are struggling with time famine, as payers have shifted their administrative burden onto physicians while saddling them with rationing through inconvenience. Due to decreasing incomes, primary care physicians are being forced to see more patients, ultimately spending less time with each. The opportunity to keep apprised of the latest medical evidence has become a luxury the typical physician cannot afford. These factors particularly apply to the small and medium-sized practice groups, who deliver 70 percent of healthcare in America.

 Not surprisingly, these pressures on doctors can contribute to unnecessary medical errors. According to a 2005 Harvard Business Review study, medical errors account for between $19 to $31 billion dollars annually.

 Physicians are directing 70 to 90 percent of the spending in the $2 trillion healthcare sector. This means that many doctors have up to $2 million in annual spending authority. If viewing these doctors as healthcare purchasing agents, it is hard to imagine how they can possibly be their most successful when they don’t have timely access to comparative quality information and don’t know the cost of the alternatives that they are considering selecting for their patients.

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Turning the Tide

 In the case of Esse Health, our group began turning the tide back in 1996, when Tom Doerr, M.D., a practicing internist at Esse Health, became frustrated by his inadequate understanding of the relative risks and cost/quality tradeoffs when he was making prescribing decisions. As a busy physician, he found he had little time to keep apprised of the latest information on various medications, their efficacy and how much they actually cost.

 To address this information deficit he created a paper-based prescribing guide for his own personal use, patterned after Consumer Reports magazine, which could fit inside his coat pocket. The guide compared costs, efficacy, adverse effects and short- and long-term outcomes of treatment strategies for common problems in pharmacotherapy. The guide soon became a popular tool with other physicians at Esse Health, and by 1998, had grown to include more than 140 pages with chapters written by 10 other physicians and a pharmacist.

Esse Health felt strongly that [Purkinje] must be an advocate for the physician. Our goal was not to have this company viewed as just another vendor, but a partner to physicians to make a difference in their lives and the lives of their patients.

 In 1999, the largest managed care payer for Esse Health, United HealthCare of the Midwest, rated the practice as “one of the top two performing medical groups in the U.S.” This recognition was based on UHC’s measures for quality of care, patient satisfaction and cost-effectiveness in their Medicare HMO plan. We suddenly realized this little guide was making a much bigger impact on patient care then we ever imagined.

Adding Technology

 Clinical decision support technology is considered a potential tool to get useful clinical information into the hands of busy doctors; however, it is a term that has been often misused. Simply presenting guidelines with no validation, or offering links to online textbooks is unlikely to improve healthcare outcomes. Meaningful clinical decision support must be based on unbiased and validated medical evidence and must be presented within context of medical decision making without slowing down busy physicians. For example, HEDIS (Health Plan Employer Data and Information Set) rewards the lowering of blood pressure, but does not distinguish between a calcium channel blocker that may worsen the patient’s 5-year mortality, an expensive new drug with no 5-year outcomes data, or a thiazide diuretic that clearly improves 5-year mortality.

 The little paper-based prescribing guide Esse Health had created was clearly a useful clinical tool for physicians. However, as we added more information it became increasingly inefficient and difficult to use in the clinical setting. We finally decided that adding a layer of technology to the guide was the answer to increasing ease-of-use.

 At first we started looking at incorporating the prescribing information we had already created with an existing electronic prescribing software package. However, we quickly realized the available software did not even consider the diagnosis that clinicians were treating. Most software simply automates existing paper-based processes. What good does it do to automate the process of creating prescriptions that never should have been written in the first place?

Taking Action

 We decided if we wanted a product that provided physicians with the best-published evidence at the point of care, we were going to have to build it ourselves. So in 1999, Doerr and I decided to build the ultimate decision support solution for our doctors. “By doctors for doctors” was our mantra.

 We employed six pharmacists from a leading medical center to help enhance our existing decision support content. The original 140-page book quickly blossomed into more than 5,000 pages of information. We then designed the electronic prescribing software to be diagnosis-driven, allowing all relevant clinical content to be presented each and every time a physician prescribes. The decision support content also was extended to address non-pharmacy issues, such as diagnostic testing strategies and advance directives, as well as pharmacotherapy—again, all tied to diagnosis.

 Esse Health’s doctors understood well the challenges and rewards of software, and our goals for our clinical decision support effort were clear. We wanted to provide superior patient care through better clinical decision making, save time for physicians by organizing and displaying key patient information and provide evidence-based treatment alternatives at the point of care. From a business perspective, we saw that evidence-based clinical decision support can create new revenue for physicians through better performance in risk contracts, quality bonuses based on improved patient outcomes and modest income from in-office dispensing.

 Editorial objectivity was a major concern for us. Therefore, we enforced a strict policy prohibiting the acceptance of any money from pharmaceutical companies looking to influence physician decision-making.

 Once completed, the software contained evidence-based decision support and prewritten prescriptions for almost 4,000 common diagnoses based on efficacy and cost, along with extensive patient education materials that present a balanced view of drug therapy options and promote self-care. In order to facilitate the contextual decision support aspect, the system enabled the storage and management of patient problem lists. In addition, an interface to the Esse Health practice management system was constructed to avoid re-keying of patient data.

Beyond the Hippocratic Oath

 Upon implementing our new software into the physician workflow, Esse Health quickly began seeing positive results. In fact, one of our doctors claimed the system had taught him many drug-to-drug interactions and even saved him from harming patients. Another doctor told the story of an elderly patient that kissed him for saving her $1,800 per year on her medications. Office staff appreciated the reduction in pharmacy phone calls and the fact that multiple refills are much faster. Nobody forces Esse physicians to use clinical decision support; they use it because it works for them and their patients.

 Looking at the implications of evidence-based clinical decision support at Esse Health, which certainly apply to most practices, we found that motivated physicians armed with decision support and appropriate incentives can dramatically lower the costs of healthcare, while increasing quality and improving patient satisfaction.

 Seeing how passionate our doctors had become about this new clinical decision support software, and hearing how much it was helping with patient care, we decided to commission a study to determine the actual impact the software had on patient care, safety and cost.

 Having seen the quality of care and financial benefits of our Web-based solution, we decided to sell this clinical decision support product to our colleagues nationwide. Esse Health founded a separate company to handle the sales, marketing and support of the technology to other physician groups. In undertaking this unusual step, Esse Health felt strongly that the company must be an advocate for the physician. Our goal was not to have this company viewed as just another vendor, but a partner to physicians to make a difference in their lives and the lives of their patients. Today, this organization is known as Purkinje, named after renowned Czech physiologist Jan Evangelista Purkinje.

Empirical Evidence

 In peer-reviewed studies published in the Annals of Family Medicine and the Journal of Managed Care Pharmacy, our clinical decision support solution showed a significant impact on the cost and quality of patient care. The studies demonstrated a 12 percent savings in the costs of new prescriptions and refills, compared to contemporaneous control groups. The participating payer, Affinity Health Systems, enjoyed ongoing savings of $1,270 per doctor per month relative to the contemporaneous control group, in pharmacy costs. In fact, there was remarkable consistency among the largest groups using the software. Their generic prescribing rates had all climbed to about 75 percent.

 Another third-party study performed in Maine by Anthem found a savings of $3.55 per prescription, which amounted to $470 per physician per month. Because Anthem was the payer for approximately 30 percent of patients in Maine, the total savings for all payers could be estimated to be more than $1,500 per physician per month in one quarter alone.

 We also saw that clinical decision support integrated with evidence driven data can make a major impact on patient safety. Often the FDA approves drugs that are appropriate for a small number of patients. Then, as we all know, direct-to-consumer advertising creates artificial demand for the medication. Earlier this decade the majority of prescriptions—61 percent—for nonsteroid anti-inflammatory drugs (NSAIDS) were for the newer COX-2 inhibitors such as Vioxx and Bextra. We had been messaging our patients and physician-customers via our e-prescribing software about the risks and limitations of these drugs since the CLASS and VIGOR studies came out in 2000. We then tracked the prescribing patterns of doctors using our software and found that 25 percent of all prescriptions for NSAIDs were for COX-2 inhibitors.

 As we know, in September 2004, Vioxx was withdrawn from the market because it quadrupled the risk of heart attacks. In April 2005, Bextra was withdrawn from the market because it doubled the risk of heart attacks and strokes. Many of the existing e-prescribing companies took pride in being able to rapidly notify physicians when these drugs were withdrawn from the market and/or enable them to quickly message their patients to stop taking these medications. Both these items are good things, however, we felt we were taking it a step further by scouring the medical evidence and seamlessly incorporating it into physician workflow at the point of medical decision making. We knew our formula for incorporating clinical decision support at the point of thought really could make a measurable impact on patient safety.

Form Follows Function

 Following our “by doctors, for doctors” mantra in establishing this new company, we gathered feedback from colleagues and the field on how a clinical decision support solution could work best for physicians. What we heard was not uncommon, especially today. First, a clinical decision support solution should eliminate the cost barrier. Second, workflow must not be disrupted; evidence-driven clinical support must be infused into the physician workflow in an intuitive manner. Third, eliminate the risk factors by making evaluation transparent, Web-based and convenient. Fourth, achieve rapid and non-disruptive implementation. A recent report by the Office of the National Coordinator for Health Information Technology echoes this sentiments, identifying “access to the best knowledge available,” widespread adoption and continuous improvement of knowledge as key factors in making clinical decision support a nationwide reality.

 With this in mind, we needed to determine ways to eliminate the hassle and expense of implementing and operating the software. Few medical groups have the in-house expertise to install, update and maintain software and prefer not to have to go to the expense of hiring resources to do so. Hosting the software on behalf of each practice would be the best approach. This way each practice would not have to make significant upfront investments in hardware, add an IT resource to their payroll, or worry about the security or integrity of their patient’s data. As an added bonus we could also deliver software updates and the latest medical evidence and content to our customers in real time.

 We wanted to provide superior patient care through better clinical decision making, save time for physicians by organizing and displaying key patient information and provide evidence-based treatment alternatives at the point of care.

Financial Success

 As the software continued to gain traction with medical groups nationwide, many exciting things also began happening for our own medical practice as a result of the clinical decision support embedded in our e-prescribing software.

 Most medical groups that were involved in risk contracting in the mid 1990’s abandoned these efforts around the turn of the millennium. A common criticism was that payers under-funded the global risk contracts. However, it was also true that many medical groups had information systems that did not enable them to seamlessly integrate evidence-based best practices into the workflow of their clinicians. In addition, the health plan information systems did not provide data with adequate visibility into the clinical and financial performance of their clinicians, or the economic consequences of their decisions.

 Esse Health’s fortunes ran contrary to this trend, as clinical decision support helped us flourish in our risk contracts. Esse repeatedly observed that its medical malpractice claims were less than 20 percent of their premiums. With this low claims history, and with the confidence that our software usage would continue to minimize errors, Esse Health formed its own professional liability carrier. We began to self-insure for professional liability on July 1, 2003, and our subsequent years of experience as a medical liability carrier were even better than the preceding years. Recouping 80 percent of malpractice premiums translates to savings of about $12,000 per doctor per year in primary care.

 The financial success that clinical decision support enabled also made it possible for Esse Health to undertake an exciting venture in 2004. Esse Health launched our own Medicare Advantage health plan called Essence Healthcare. Starting with only 45 primary care physicians, the plan was at financial break-even only 45 months later, boasting 4,200 members. From inception, the Essence plan offered the most generous benefits of any Medicare Advantage plan in Missouri.

 In September 2006, the latest CAHPS survey of membership was published by CMS. Essence had the top rated plan in Missouri for overall member satisfaction, as well as numerous other metrics. Membership blossomed and currently stands at about 13,000 members, with 110 primary care physicians and 700 contracting specialists. The Essence health plan is now expanding into other regions outside the St. Louis area. Most importantly, in a recent comparison with industry benchmarks, Esse Health noted its physicians have incomes twice the industry average.

 Good things not only came to our medical group and the physician-owned health plan we formed, but also to the clinical decision support company we created around our original paper-based prescribing guide. From its humble beginnings, Purkinje has grown to 350 employees and recently launched CareSeries, the company’s Web-based practice management and electronic health record solution. CareSeries includes an updated version of the original e-prescribing system and the electronic health record module incorporates the same formula for integrating evidence driven decision support into physician workflow. Even more satisfying are the millions of patients whose healthcare we have positively impacted.

 Esse Health’s experience clearly illustrates the clinical and financial benefits of evidence-driven clinical decision support. Such technology is a critical factor in the success of regional health information networks, as well as a larger national health information infrastructure. Physicians prepared and supported in this manner can shift their focus from reacting to acute illness, toward using data to proactively manage patients with chronic disease, as well as populations with specific diseases. Our leaders at CMS, and in the federal and state governments, should promote more aggressive reimbursement reform that rewards fiscally responsible, evidence-based care. Such reform provides financial incentive for doctors and saves money for payers, representing a win-win proposition for physicians, payers and patients that makes clinical decision support a must-have, not a nice-to-have, in today’s healthcare system.

Dr. Charles Willey is CEO
of Esse Health and a co-founder of Purkinje.
Contact him at
[email protected].

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