At NYU Langone Health, “Value-Based Medicine” Takes Center Stage

March 28, 2018
For the project, the organization’s finance department collaborated with VBM physician champions to identify variations in care both internally and compared externally to benchmarked external institutions.

It wasn’t too long ago when clinical, operational and IT leaders at the New York City-based NYU Langone Health realized that the skyrocketing costs of U.S. healthcare were having a ripple effect at the consumer level—even beyond patients not being able to afford their care.

As Frank Volpicelli, M.D., chief of medicine, NYU Langone Hospital-Brooklyn—one of the health system’s inpatient hospitals—puts it, it is those out-of-pocket healthcare costs that have been a leading cause of bankruptcy in the U.S. As such, he says, the rise of healthcare costs is a “national problem, an individual patient financial problem, and also a patient quality of care problem. We are one of only countries in the developed world where patients skip routine care due to out-of-pocket costs, and down the road this leads to more problems and even higher costs,” he says.

Striving to be a healthcare leader with the aim to solve this problem, at least on a regional level, Dr. Volpicelli and others, including Jonathan Austrian, M.D., medical director, inpatient clinical informatics at NYU Langone Health, launched an initiative called “Value-Based Medicine (VBM),” with the goal to leverage health IT and its related workflows to improve the value of inpatient care. For the project, the organization’s finance department collaborated with VBM physician champions to identify variations in care both internally and compared externally to benchmarked external institutions. The VBM physician champions also collaborated with IT physician informaticists and IT project teams to design interventions to both reduce cost and improve clinical care.

The health system’s work was recognized with semifinalist status in Healthcare Informatics’ 2018 Innovator Awards Program, and in a recent interview with Healthcare Informatics, Dr. Austrian notes that from a health IT standpoint, the organization first “needed to define the problem.” As such, working with members of their finance department and others, Austrian’s team used analytics and dashboards to understand in which areas were NYU Langone Health’s costs not in line—such as the appropriate use of blood products, for example. “And we noticed that for some of our clinical care, there was not a standard, and we thought we can do better by standardizing our care and ensuring that all of our patients are getting the best practice in care for certain conditions,” he says, offering heart failure, colon surgery and pneumonia as three core conditions that applied for this project.

As Volpicelli—who was the clinical lead for the VBM initiative—contends, “It’s a matter of optimizing utilization. VBM, at its core, is about bringing the right call to the right patient at the right time, and IT is at the heart of that,” he says. With blood transfusions, for instance, over the years the data has shown that giving people red blood cells—outside of very specific indications—causes negative health outcomes such as increased infections, increased heart attacks, strokes, an increased death, Volpicelli explains.

“So we put the institutional guidelines for blood transfusions right in the order and made it transparent, but we also showed you the patient’s last blood count. Essentially, we gave the provider ‘just-in-time’ education about the patient who is front of you, with information about what the NYU Langone Health standard [of care] is. And if you think you should deviate from that [standard], tell us why. And then on the back-end with reporting, we could take an aggregate look at [when providers agreed with the standard and when they didn’t],” Volpicelli says.

As Austrian puts it, the VBM team is “using analytics to help define the problem, then providing decision support via the electronic medical record (EMR) at the point of care, and then retrospectively reviewing the outcomes and using analytics to give audited feedback when there is deviation from the NYU Langone Health standard.” Volpicelli and Austrian also point out that the information is available right in the EMR, “off-the-shelf,” meaning there is no need to purchase extra technology or modules.

In all, the project’s suite of interventions included: electronic clinical pathways; blood protocols; intravenous (IV) to oral (PO) medication changes; and lab ordering enhancements. Electronic pathways were created for heart failure, colon surgery, and pneumonia, and blood ordering clinical decision support and analytics were built. These projects realized significant two-year savings, including: electronic clinical pathways: $12.9 million; lab modifications: $3 million; blood utilization: $2.9 million; and IV to PO: $2.2 million, the organization’s officials stated.

Austrian notes one other key to the project’s success: having operational leaders to support the adoption and frame the interventions as a value implementation rather than an IT one. An example, he says, is when the team needed to do change management with the clinicians. “For some projects we needed someone in IT to demonstrate [to the clinicians] how to do the workflows,” he says. “But you don’t get buy-in that way because it’s the IT department doing the [demonstration], and of course they [know how] to do that IT work. But [Dr. Volpicelli] and his team were comfortable in demonstrating the workflows themselves—such as the appropriate ordering of blood and electronic clinical pathways—and that made it legit. It [proved] that operational leaders are doing this work, so we can do it, too.”

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