The power of information Featured

8:00pm EDT April 25, 2008

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 Shanahan-RichardsW@aetna.com.