Clinicians must promote value-based care, but there is an assumption that one has defined cost and quality. The two can be discordant, in that low-cost and high-quality care are occurring or vice-versa. When low-cost care is providing low value, there is a concordance, and when high-cost care is providing high quality, there again is concordance. The first scenario is the best!
I have always felt that in the inpatient setting, having a personal pharmacist round with a physician on every patient and review medication orders would result in powerful, high-quality clinical outcomes. The use of frivolous antibiotics would be curbed, the incidence of drug-drug interactions would decline as would the use of costly medications. Just ask the pharmacist at the point of care before the order and poof – you have your answer for the dose adjustment or side effect. So one could deliver high-quality care with lower costs. The problem indeed arises because the cost of a “pocket pharmacist” in the hospital for every physician would be high.
Clinical decision support tools are felt at times to be a nuisance because of the impairment of a precious clinical resource – time. CDS tools are purported to save money and lower risks, but they are expensive. What impedes a physician from a detailed history and physical exam, looking up every side effect of a medication along with drug-drug interactions, and then mapping each test to a cost? Time of course – and time is of the essence as clinicians round, make rapid decisions, and wade through a data barrage. The quest for value-based care and maintenance of autonomy over patient care decisions entails providing unique tools that are available at the point of care and save time. Many clinicians have access to web-based tools but they impede workflow, require extra log-ins, and the decision to use them is inconsistent.
I am reminded of a patient I saw years ago. She was a 37-year-old nurse with inflammatory bowel disease. She was diagnosed with Crohns at the age of 33 and was not in remission for she had been treated with multiple prednisone courses. She had presented to multiple different hospitals over the years resulting in 9 computed tomography scans of the abdomen and pelvis. I wanted to perform a value-based care analysis. The 18 scans (9 of each) and a few other test resulted in little improvement in her overall condition as the course of therapy rarely changed – she was either admitted on iv steroids or discharged on oral steroids. The test value was defined as low as she presented each time with diarrhea, abdominal pain, with no peritoneal signs per review of her records. The attributable cost based on Medicare allowable charges was close to $4300.00. This is clearly discordant in our modeling as it is high cost, low-value care. Had I considered all costs though? What about insidious patient risk? Radiation exposure was involved, and this is a metric that is rarely defined. How many clinicians know what a Gray, a rad, or a Sievert is? After a total of 6 hours of data acquisition, risk modeling, and mathematical calculations, I determined she had 235 mSV of radiation, and this translated into an absolute 2.8% cancer risk added to her baseline. Indeed, this care path is the ultimate in low value, high cost to the health system, and high cost to the patient (cancer risk). She received the equivalent effective dose of living 1 mile from Ground Zero at Hiroshima 2.8 times in her life. I wrote this number on a card and told her to flip it over any time another scan was ordered. She has been to the emergency room twice since then and hasn’t received another CT scan.
Imagine a point-of-care system that displays insidious patient risk and cost data at the point of care with no extra login required in the hospital setting. IllumiCare’s novel decision transparency tool presents such information in real-time. We know that time is of the essence. IllumIcare is designed to value physician time, health care cost, and patient risk in unity.
Mukul Mehra, MD is founder and Chief Medical Officer at IllumiCare Inc.