Opinion Article by Robert Dunlop, Clinical Director, Elsevier Clinical Solutions.Good care costs less, the health secretary announced. How much less? According to NHS productivity lead Lord Carter, around £5 billion a year less. That is the amount that the NHS could save if it reduced the amount of unwarranted variation in clinical care.
It is a point echoed by others, such as the King’s Fund’s Better Value in the NHS study, Monitor’s research into elective care pathways, and Sir David Dalton on unacceptable variations in the quality of care in the Dalton Review.
These reports show that the benefits of consistent, high quality care could be felt financially by the application of best practice and national guidelines such as those from the National Institute for Health and Care Excellence (NICE), by keeping people out of hospital when it is not needed, and improving the care they do receive and by preventing complications.
One good example of this can be seen in the early diagnosis of cancer. Research in the British Medical Journal showed early diagnosis and referral could reduce mortality rates and unnecessary referrals to hospital if GPs applied the latest NICE guidance.
But the reality is, a time-poor GP has a few minutes to see a patient and judge whether a patient has any one of several cancers. Implementing the latest NICE guidance can be challenging, and some argue that it may result in over-referrals to busy hospitals as the risk threshold for referral is now lower than previously.
Such pressure on GPs to make the right decisions in the early diagnosis of cancer run alongside wider pressures from increased patient demand, the drive for more integrated care across the patient journey, and the urgent need for efficiency gains. All of these require active GP leadership, and active clinical decision support can help.
Clinical decision helping GPs with the challenges of cancer diagnosis
Taking cancer as an example, active clinical decision support tools such as Elsevier's Arezzo Pathways can help transform rates of early diagnosis and appropriate referral.
GPs require rapid access to high quality, evidence-based clinical information that is tailored to the precise needs of their patients so that they can make the best-informed decisions. Active clinical decision support tools provide recommendations to the clinician based on the most appropriate course of action, so that busy clinicians can exercise their clinical judgement with the best information to hand.
For cancer diagnosis, active clinical decision support technology can help alert doctors to patients at high risk, or those who are in need of ‘safety-netting’ and regular reappraisal of non-specific symptoms. All can help increase the chances of early diagnosis and referral.
The Arezzo technology has been shown to lead to a 35% improvement in the appropriateness of referrals, fewer unnecessary referrals, and very significant improvements in the quality of documentation - all of which can help deliver the ‘better care for better value' ambitions of policy makers.
Clinical decision support starts at home and in the community
The application of evidence-based information to inform clinical decisions is not contained to just primary care. Every stage of a patient’s journey through healthcare can benefit.
As the Five Year Forward View noted, many people wish to be more informed about their own care, which can increase opportunities for supported self-care. Services need to be integrated around the patient, so that the interdisciplinary team for a patient with long term conditions such as cancer, for example, can provide evidence-based support for their physical, mental and social care needs. And these services need to be deployed through emerging models of care that fit with local needs, rather than the top-down approach to care provision that has characterised the NHS to date.
This means multiple challenges for ensuring the consistent delivery of high quality care outside the traditional hospital environment.
For self-care, providing evidence-based advice needs to be available quickly and relate to an individual’s needs. For the mother with a sick child, for example, tools such as health and symptom checkers help them make a decision on the best choice of care by applying relevant guidelines and recommendations to their individual needs. This can then help provide the best care for their child, whilst reducing the burden on health services.
Analysis of the impact of the Arezzo-powered online health and symptom checker on NHS Direct (now on NHS Choices) showed that 1.3 million unnecessary visits to healthcare professionals were avoided in its first year alone.
People also turn to non-emergency telephone triage services for information on their own care, which are seen as a core part of NHS England’s urgent and emergency care review. Again, rapid access to the best advice for an individual’s needs is essential. The Arezzo inference engine used to support telephone triage services such as NHS 24 is providing the right advice to people 24 hours a day seven days a week, and helping to ensure that emergency services are only despatched for those most in need.
Equally, helping those with long term conditions receive the care they need outside of hospital means giving primary care clinicians the tools to help such patients. Matching national and local guidelines to current best practice, and relating this to information entered on the electronic patient record, means GPs are presented with information to help them make the right care choices.
In New Zealand active clinical decision support is in use in over 1,000 primary care practices, and has been shown to have halved the number of hospitalisations for childhood asthma in a country with unusually high prevalence.
Clinical decision support inside the hospital
GPs are central to managing the demands across the health system, acting as ‘gatekeepers' to the rest of the NHS. Active clinical decision support can help them perform this function effectively.
Hospitals and acute care providers can also benefit from effective use of healthcare technology. Enhanced clinical digital maturity in healthcare settings has been linked to improved patient outcomes, and active clinical decision support is featured in stage four and beyond of the seven-stage European EMR Adoption Model (EMRAM) that can be used to assess digital maturity in healthcare IT.
Hospitals can use active clinical decision support tools to provide clinicians with timely access to evidence-based information that is directly related to the needs of individual patients, which can help drive out variation and improve positive outcomes.
Order sets and care plans are examples of such tools. They enable the consistent delivery of high-quality, cost effective care by following the same principles outlined above.
Order sets are condition or procedure-specific standardised processes for caring for patients. They include activities for diagnosis, treatment, monitoring and screening, and are designed to use the most current medical evidence and apply it to an individual patient’s needs.
Often managed in paper form in the UK, electronic order sets can combine information from electronic patient record systems to match best practice with patient data.
Such technology can help reduce preventable complications, medication errors and extended patient stays. A study in a large number of US hospitals showed that such clinical information technology can deliver lower mortality rates and lower costs.
Care plans take the same principles of standardised care and apply them to interdisciplinary teams over multiple care settings, which is vital as health services move to more integrated care models.
Care plans can realise similar care and efficiency benefits as order sets and other clinical decision support tools; one case study showed how care planning helped to reduce pressure ulcers by a third, and falls by 16%. Electronic care plans can also significantly reduce costs currently associated with the in-house management of local guidelines.
Delivering good care that costs less means starting with best practice. Active clinical decision support technology can help everyone make informed decisions about their own care, and those of their patients, with access to a global knowledge base on how to deliver consistent, high quality care.
This care does not start at the hospital door; it starts and ends with the individual receiving that care, and the numerous others involved in delivery. Applying the latest evidence and best practice to an individual’s needs across the patient journey will help realise the vision for better care for better value. Active clinical decision support helps make that vision a reality.