Healthcare systems around the world are recognising the need to move from fee-for-service to value-based healthcare. This requires a focus on raising the quality of care as the driver towards value rather than pure cost reduction, as well as engaging the patient. It requires a shift in understanding that patient engagement is no longer the thing to do after the patient has visited the hospital, but should be implemented from the very beginning, before they visit the hospital, and even taking it further back to managing population health.
Healthcare systems around the world are recognising the shift from reactive, acute care, to proactive and preventive care. This comes at a time when countries are facing the challenges of an ageing population, which in turn has an impact on the healthcare system with potentially unsustainable rise in healthcare spending. Japan, Korea, Australia and Singapore are some of the fastest ageing nations in Asia, and these countries are also experiencing a transformation from fee-for-service to value-based healthcare.
Ensuring that healthcare systems continue to be sustainable, would inevitably require better quality and more cost-efficient healthcare services. As patient expectations rise, accessing and coordinating care in an appropriate and timely manner for the best outcome for patients is becoming more complex and difficult every day. This requires a focus on raising the quality of care as the driver towards value rather than pure cost reduction, as well as engaging patients. It also requires a shift in understanding that patient engagement is no longer the thing to do after the patient has visited the hospital, but should be implemented from the very beginning, before they visit the hospital, and even taking it further back to managing population health.
It is not only the cost of healthcare that we must consider – today’s healthcare challenge is also the changing nature of illness, with the disease burden shifting from infectious to chronic diseases. The World Health Organization (WHO) estimates that 50 per cent of the global burden of disease is chronic illness. Chronic disease is also a significant concern for countries in Asia, such as Singapore. One in nine Singaporeans have diabetes, and the numbers are expected to grow due to a rising obesity levels, and a lack of physical activity and a healthy diet. For similar reasons, China is experiencing a growing burden of cardiovascular disease, a chronic disease that has been on the rise for the last 20 years and now the leading cause of death in the country.
Chronic diseases require a different approach that factors in the complexity of the illness and frequent requirements for proactive and planned integrated care within a system that patients can navigate. If unmanaged, such chronic conditions frequently lead to poor patient outcomes and hospitalisations that are key drivers of costs to healthcare systems.
Increasingly, patients too are demanding more clarity and information from their healthcare providers regarding medical diagnosis and treatment, as well as or from the Internet of Health Things (IoHT), to allow them greater control on their health and wellbeing.
Another obstacle to delivering value-based care is the overwhelming magnitude of medical information and the ability to process all the knowledge into actionable steps for better patient outcomes. By 2020, medical information is expected to double every 73 days. If physicians were to read everything of possible biomedical relevance, they would potentially need to read around 6,000 articles a day.
The burden of information overload and the expectation from providers to rapidly incorporate all relevant evidence into practice is likely to negatively impact the quality of care and result in poor and even catastrophic outcomes for patients.
Standing in the way of high value care is variability. Variability in care delivery means that a subset of patients (often a large subset) experience poorer clinical outcomes while paying the same healthcare expenses. Variability in care delivery also leads to spending with reduced benefit. Variability in healthcare takes many forms, but it can be segregated broadly into knowledge and operational variability.
Knowledge variability poses the greatest threat to the quality and cost efficiency of health and healthcare delivery, and is more challenging to identify and address. With an explosion in the rate of medical information growth coupled with the slow adoption of research findings into clinical practice, more often than not physicians don’t know what they don’t know.
Operational variability is when healthcare systems, physicians, nurses and other clinicians deliver care differently and, as a result, experience variations in outcomes. Variability arises, for example, when a physician’s handwriting results in the nurse or pharmacist misreading the prescription and compromising the patient’s safety.
The complexity of today’s healthcare system means that not all operational variability is so easily countered. As healthcare reform drives us from acute, reactive care toward proactive, preventative care, operational variability-and the clinical and financial risk it generates-is prone to metastasising. One of the primary reasons is the care itself is rapidly moving out of traditional settings, such as hospitals and physician offices, to large retail pharmacy chains, and patient homes. The roles and responsibilities of providers are also expanding, with greater clinical care responsibilities shifting to nurses and to patients themselves. Such a rapidly changing, multiple-provider system creates room for operational variability and subsequent patient risk and cost inefficiency.
Fortunately, today’s technologies represent a great leap forward in accessing high-value care information and guidance at all points of care. Within traditional care settings, integrated Electronic Health Records (EHR) systems can reduce some operational variability. But in reality, EHRs serve only as a vehicle to deliver current, credible, evidence-based information. In order to truly address new challenges appearing as our entire healthcare delivery model evolves, Clinical Decision Support (CDS) is the most impactful answer to the vast and destructive problem of variability in care delivery.
CDS solutions deliver evidence-based and current information specific to the patient’s clinical history to the physician, enabling him or her to make the best decision. One such example is clinical pathways. While definitions and approaches to development are numerous, a commonly shared goal of clinical pathways is the longitudinal reduction of operational variability as patients move from care setting to care setting and from provider to provider.
The majority of today’s CDS are ‘pull’ solutions (clinical reference and diagnostic reference), requiring providers to interrupt their workflow to research answers to their clinical questions.
On the other hand, ‘push’ solutions feed current, credible, evidence-based information specific to the patient’s clinical history and current clinical status directly to the physician at the point of care. Elsevier’s Order Sets for Physicians and Care Plans for Nurses are powerful forms of ‘push’ CDS solutions, designed not only to answer questions that physicians and nurses usually ask, but also to answer critical questions that they don’t know they should be asking. For instance, even when a physician fails to appreciate that a cancer patient should undergo blood testing for a genetic syndrome, an order set can push this evidence-based suggestion to the physician. Best practices can be pushed to nurses to drive quality and cost efficient care regardless of the nurse’s experience (or lack thereof). Health screening, medication, and other credible preventative and care maintenance information can be pushed to patients, their family, and even their care taker.
A combination of ‘pull’ and ‘push’ CDS offers the greatest opportunity to empower physicians, nurses and other providers to provide the safest, highest quality, most cost-efficient healthcare. There are many ‘push’ and ‘pull’ CDS solutions to implement and add based on the specific needs and strategies of individual population health providers. They can be added in a modular fashion – order sets, reference solutions, care plans, drug information, and nursing skills.
Even with the best physicians, nurses and ‘push’ and ‘pull’ CDS solutions in place, if patients are not engaged and invested in making decisions about the care they receive, then the cost of care is still going to increase. Discharged patients who do not take their medications, do their physiotherapy, will be readmitted. This can have a multiplying effect on costs, hospital beds and mortality.
It is important to transfer that awareness of care consistency to patients as well, standardising their approach and letting them understand the care that they should be given.
There are many ways to educate and engage patients. There are interactive and ‘entertaining’ online tools, which use videos and cartoons to make boring information interesting to read or watch. One such example is Health Nuts Media’s “Huff & Puff: The Asthma App”, which has improved the paediatric pulmonology patient experience at University of California, Los Angeles (UCLA). Appropriate educational opportunities for patients and their families are now readily available on television, tablets, computers and mobile devices. The videos have also significantly reduced the amount of time that clinicians and nurses spend on patient and caregiver education, including post-visit phone calls.
In order to improve the health of our populations and reduce the costs of care, we must make a 180-degree philosophical and cultural shift away from reactive, acute, inpatient care to proactive, outpatient, preventative and maintenance care. Additionally, when we measure value-based care, we not only need to be measuring the cost of care in our hospitals, we need to be looking at long-term care of patients outside hospital walls and measuring that as well.
Patient engagement, no longer is a nice to have. It is no longer just a clinical follow up after a patient has visited a hospital. Patient engagement should start from pre-hospital visits; it should be educating patients before they arrive and actually taking it even further back to population health. It is about managing health and well-being before people become ill rather than having to worry about patients being discharged from the hospital. Only then will we truly see improved outcomes at a population health level.
