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Advisory Panel: Physician Order Cost Tools

August 8, 2013 Advisory Panel No Comments

The HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news developments and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a hospital or practice, you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

This question this time: What IT tools do you use to help physicians make cost-effective decisions as they are creating patient orders?

Although our system allows us to create rules that would give the provider options for less expensive selections, we do not use that feature. The pharmacy already has an aggressive substitution policy and the thought of more alerts makes us concerned. I’d love to hear how others are approaching this.

Not as much as we should. We try to build our order sets in a way that makes it easy to make cost-effective decisions. In particular, we try to make it easy to use best practices and make it difficult to order unnecessary tests and therapies. But we haven’t taken the path (yet) of displaying costs next to drug orders, for example.

We have not been very effective in bringing utilization management to the physician ordering workflow. We’ve tried with mixed success to incorporate best practices embedded in Zynx order sets into the standard content, but our physicians have many workarounds to avoid using condition-specific order sets. 

We embedded a link and query tool in Cerner PowerChart to our charge master that allows physicians to review costs of medications, tests, procedures, DME, etc., with their patients in the exam room. In our organization, the charge master reflects our actual charges and reimbursements from the national insurance company. In the course of re-competing our Cerner contract, I asked the EMR vendors to build a prototype equivalent of the Amazon shopping cart in the EMR. That is, as a physician completes the order, the total cost of the order accumulates in the upper right corner of the EMR.  RazorInsights developed a prototype demo that was very slick. None of the other vendors could do it in the timeframe of the re-compete. Of course, because of the laughable situation of the charge master in the US market, it’s not a very easy thing to pull off in a real setting. But at least we could have the functionality in the EMR, waiting for the industry to catch up.

None at the present.

Rank diagnostics and medication choices in increasing order of cost.

Right now, only thing I can say is they can use UpToDate to help make the right choice. We are looking into the option of displaying price and/or cost-effectiveness indicators in the ordering panels. And as we start improving our analytics capabilities so we can better understand variance, I assume we will start using more protocols/pathways to help ensure the right test is ordered for a specific condition.

Having the cost of the ordered test may help…duplicate tests alerts on CPOE, trend value of labs viewable in the clinical summary tile.

[From a vendor member] As a revenue cycle management company, we use various reports to show physicians where they are adequately being paid for the services they render and where there are gaps in the way they bill claims.  We do this retrospectively and not real time as coding is a matter of physician choice.

Our primary interventions to help physicians make cost-effective, appropriate decisions for patient care are actually 1) our actual hospital formularies themselves 2) antibiotic stewardship clinical decision support embedded in electronic orders for antibiotics at some facilities 3) evidence based order sets standardized by diagnosis at the facility level that are designed with high quality, high safety, high reliability and cost effectiveness in mind. Not overly fancy interventions, but they have been successful and really these are truly the basics that everyone should be doing in every hospital in the world (even laggard facilities out there that are still stuck on paper based provider ordering can be making an impact in all three of these areas).

None, yet. We’ve looked at a tool from Nuance for imaging orders–I can’t recall the name. We’re planning a rebuilding of order sets (and I’ll sleep when I’m dead) with fewer options and more guardrails to make it harder for practitioners to deviate from best evidence based practice when available.

Mainly the lab flow from the EHRs and the imaging studies from the  EHRs to avoid duplication of tests already performed.

There are efforts to incorporate the cost of various medications and treatments in the drop down menus. These also include the efficacy of the various treatments. In study after study, we find that the order of the options in the menus is significantly influential in determining the selection. At least if options were listed by least expensive to most expensive (and include efficacy) they would be useful guides to choices

We have been live with CPOE for several years and took the traditional approach of using various third party content providers to provide some insight into the clinicians thinking as they were attempting to build their own content. This helped us move along but didn’t assist in aligning cost to outcomes during their ordering process. We looked at opportunities prior to live hypothesizing on how CPOE would reduce re-tests but didn’t have much support to evaluate post live to assess any benefits realization. For us I think it is a matter of how much time do we have to spend looking back vs. focusing on the road ahead. Perhaps a good example of the unintended consequences of the things that you don’t do given other various obligations (MU2, I10, Bundle Payments, etc.).

There is little support to physicians to ensure / suggest more cost-effective treatments via the EHR / CPOE process. We do provide order sets that have some element of cost consciousness in them, but that it somewhat limited in scope.

Standard order sets. Descriptive information on order screens showing relative cost "$", "$$", or "$$$".

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