In its 2003 report, “Patient Safety:
Achieving a New Standard for Care,” the
Institute of Medicine’s Committee on
Quality of Health Care in America found that,
every day, tens of thousands of errors occur
in our nation’s health care system. Some can
have devastating effects, while others — the
“near misses” — slip by virtually unnoticed.
The report suggests that, in order to
improve patient safety, we must build a
health care delivery system that can prevent
errors from happening in the first place.
Additionally, we must establish a way for
health care professionals to obtain and share
information related to error prevention and
quality improvement.
As medical care becomes more complex
and patients are treated by an increasing
number of highly specialized physicians, the
use of computerized systems to identify
opportunities to improve care and prevent
error may be the answer.
“Data are most powerful when they are
integrated and converted to comprehensive
and useful information,” says Dr. Wendy A.
Richards, national medical director for Aetna
Small and Middle Market Business. “Today’s
clinicians are faced with increasing amounts
of data about their patients, and the dilemma
is how to leverage that data to help their
patients improve their health.”
Smart Business spoke with Dr. Richards to
learn how computerized systems are helping
to improve clinical quality and patient safety.
How do these computerized systems manage
patient data?
Computerized systems, or data-analytic
programs, convert member health data comprised of claims history, pharmacy, physician
encounter reports, laboratory results and
patient demographics into practical, usable
information. Information that is self-reported
by members through a health risk assessment tool or in a personal health record can
also be important. For example, many people
use over-the-counter medication or supplements, but some may not tell their physicians. Systems that have the capability to
capture self-reported data provide additional
opportunities to detect potential adverse
events. This gives physicians access to a
broader view of a patient’s clinical profile.
Behind the scenes, these programs are continuously scanning an individual’s health data
against highly respected sources of medical
literature and, when appropriate, alerting
heath care professionals about possible
urgent situations and opportunities to
improve care and patient safety.
Is there a standard of care against which
these data are compared?
With more sophisticated systems, patient
data are regularly compared against thousands of evidence-based care guidelines that
have been adopted within the medical community as the standard of care. The comparison attempts to identify gaps in care, medical
errors and deviations from evidence-based
clinical guidelines. It also can alert a physician when a necessary and prescribed medication has not been filled.
For example, claim data might show that a
patient had a heart attack but has not filled a
prescription for a beta-blocker medication,
which is an accepted best practice to reduce
the risk of a future heart attack. Or, one physician might have ordered lab work that shows
a patient’s deteriorating kidney function,
while a second physician treating the patient for a separate condition might have unknowingly prescribed a medication that could
damage the kidneys further.
With this knowledge, the insurer’s medical
staff can work with health care providers to
ask the right questions, detect related exacerbating conditions and get patients more
comprehensive treatment that can improve
their health and help them stay at work or
return to work more quickly.
Beyond seizing these opportunities, powerful data allow the insurer to gain insights into
potential treatment conflicts that could
escape the attention of the patient’s doctor. In
fact, some insurers offer programs that
proactively alert doctors to potential areas of
concern.
How do these programs differ from pharmacy benefit managers?
While most employers have pharmacy benefit managers in place to monitor drug-to-drug-related clinical situations, data-analytic
programs cover a much broader range of
clinical issues and use more comprehensive
data sources, including medical claims and
lab results. Additionally, these programs
deliver patient-specific, evidence-based treatment guidelines to physicians, who are better
positioned than pharmacies to effect a
change in treatment in a timely manner.
How do employers benefit from offering
these data-enabled health plan approaches?
Computerized systems allow insurers to
provide practical, timely, clinical decision
support to physicians and patients, which
can help to improve patient safety and medical quality, reduce medical costs and
improve employees’ productivity.
If your existing health plan does not include
a data-analytics program with health care
provider notification, you may want to consider upgrading. The choice you make might
take your plan to the next level of effectiveness and quality improvement, empowering
your employees and their doctors with tools
to improve wellness and potentially lowering
your health plan costs in the process.
DR. WENDY A. RICHARDS is national medical director for Aetna Small and Middle Market Business. Reach her at (312) 928-3307
or [email protected].
