In medicine, the greatest challenges often emerge not from what healthcare organizations fail to do, but from the variations in how they do it. At MultiCare Health System, a 13-hospital network spanning the Pacific Northwest, this manifested in the variations of clinical resource utilization across its facilities.
THE CHALLENGE
The data told a compelling story. When comparing hospital costs against other multi-hospital health systems in the Northwest with comparable case mix indices, three areas emerged as particular concerns: medications, imaging and laboratory testing. Closer analysis revealed anti-infective medications and chemistry tests demonstrated the largest amount of variability in the health system.
“The COVID-19 pandemic cast this challenge into sharp relief,” said Dr. Arun Mathews, chief medical officer at Auburn and Covington Medical Centers, part of MultiCare Health System. “The health system faced unprecedented drug shortages and supply chain disruptions, while simultaneously managing a surge in hospitalizations that drove up the total cost of care. It was a perfect storm that demanded a systematic response to resource utilization.”
PROPOSAL
The proposed solution to the challenge, Mathews said, was rooted in the principle that has driven medical progress for centuries: evidence-based decision making. The technology company MultiCare chose proposed a clinical decision-support system that would be quietly present at the moment of clinical decision making, offering evidence-based options when appropriate.
“One of the technology’s salient features was that it combined qualitative benefit and the true cost of an order while algorithmically suggesting higher value options,” he explained. “Should the alternative be accepted, the technology would calculate the concurrent cost savings with each change in order.
“The system’s architecture is built on a foundation of authoritative medical evidence, drawing from multiple sources that any clinical researcher would recognize: the ABIM Foundation’s Choosing Wisely database, ARUP Laboratories guidelines, UpToDate, DynaMedex, national guidelines, societal guidelines and other evidence-based resources,” he continued.
The content in these alerts is unique as it includes the health system cost of the order, the median savings when this order was changed historically, the clinical synopsis, and a link to the most relevant publication, he added. The system is structured to provide information without forcing decisions, respecting the autonomy of the treating physician, he said.
“Taking a methodological approach to pre-implementation, the system began by analyzing baseline data, identifying specific areas of opportunity within specialties and resource classes,” Mathews noted. “The data revealed that the hospitalist specialty, responsible for more than 80% of inpatient orders, represented the largest opportunity for impact.”
MEETING THE CHALLENGE
The implementation followed a carefully structured approach. Phase One began with a soft launch to assess the system’s integration with physician workflow. The system was integrated directly into the electronic health record, appearing as an overlay that physicians could access during their regular clinical work.
“The clinical waste rules were validated by pharmacy, laboratory and other clinical teams,” Mathews explained. “The technical integration involved HL7 interoperability data feeds, creating a real-time feedback loop between clinical decisions and evidence-based guidelines. When the system detected an order pattern that diverged from best practices, it would present this information through non-intrusive alerts.
“The system’s adoption faced initial resistance, similar to the early days of many medical innovations,” he continued. “A workflow analysis revealed the cognitive load of processing alerts and adjusting clinical decisions was not negligible. This led to a crucial adaptation: the development of a shared savings quality performance metric for clinical stewardship, aligning performance-based quality incentives with evidence-based practice.”
Patients and health would benefit from these efforts, he added.
“Why should clinicians not also be formally aligned in this program?” he commented. “A literature review was conducted in the design of this approach, revealing multiple precedents, which was then vetted by our legal and compliance colleagues. We also placed countermeasures – readmissions and patient experience metrics – to monitor for any unintended consequences during the pilot.”
RESULTS
The new technology achieved a 7.46% total cost-of-care reduction in its first year, translating to an estimated $2.6 million in healthcare waste reduction. Additionally, recent data since go-live now suggests an 11% healthcare waste reduction, $81 per admission waste reduction, and greater than $10 million dollar savings cumulatively.
“As I stated, the implementation included careful monitoring of potential adverse effects,” Mathews noted. “Patient experience scores remained stable after accounting for seasonal variations, and readmission rates showed no significant changes. The data validated that cost reduction was achieved without compromising quality of care.
“Part of our deep strategic partnership involved responding to the feedback we received from our teams about the end-user experience of interacting with the Clinical Stewardship Decision Support (CSDS) alerts,” he added.
Providers wanted to address the alert by either stopping an order or starting a new one. As part of the next iteration of these alerts, the technology vendors deployed a functionality that excites staff – “CDS Hooks.” In essence, built into the substance of the alert, is the functionality to complete orders in the background pertaining to the alert.
“This additional functionality already has been shown to spare our clinicians valuable time navigating to separate order screens and is being seen as a human factors/user experience win for our clinicians,” Mathews reported.
ADVICE FOR OTHERS
For healthcare organizations considering clinical decision support technology, Mathews offers four pieces of guidance, drawn from both the successes and challenges of the MultiCare implementation.
“First, approach the implementation in a phased manner,” he said. “Begin with careful baseline measurements, implement with clear phases, and monitor multiple endpoints. Pay particular attention to the human factors – the cognitive load on clinicians, the workflow integration and the incentive structures that will drive adoption.
“Second, establish robust monitoring systems for unintended consequences,” he continued. “Track not just the primary endpoint of cost reduction but also quality metrics, patient satisfaction and clinical outcomes. Remember that in medicine, as in all complex systems, interventions can have far-reaching effects beyond their intended targets. We found no harm and in fact found benefits for the patient and the health system given lower costs for both via reduction in low value care.”
Third, consider carefully the change management aspects of implementation, he added. Like any new treatment protocol, success depends not just on the intervention itself, but on how it is introduced and integrated into existing practice patterns, he said. Build consensus, provide education and create aligned incentives that acknowledge the additional work required of clinicians, he advised. MultiCare strives to limit nudges to less than 60 seconds per day for the hospitalists.
“Finally, remember the goal is not simply to reduce costs/waste, but to create a more evidence-based, efficient health system,” Mathews said. “The goal is to reduce the cost associated with low-value care. Like the evolution of medical practice itself, this is a journey of continuous improvement, guided by data but always centered on the fundamental mission of providing optimal patient care.
“Our health system considers wasteful care and the financial consequences for our patients an iatrogenic harm,” he concluded. “Our thoughtful collaboration with our technology platform vendor and hospitalists highlighted to us the value of building deep, strategic partnerships that continue to evolve.”
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