With the launch of the Affordable Care Act (ACA), 41.3 million previously uninsured individuals will now have access to healthcare coverage. This potential surge of new patients – particularly in areas with high concentrations of uninsured individuals – could lead to a shortage of skilled and experienced clinicians. To compensate, healthcare organizations will need to find new ways to support physician efficiency and performance to maintain high levels of service.
Most industries value efficiency, yet there is sometimes a negative perception of efficiency when it comes to healthcare providers. After all, “efficiency” might be the watchword used to emphasize speedy patient encounters rather than thorough examinations and thoughtful care plans.
Thus, it makes sense to look for ways physicians can become more efficient while simultaneously improving the patient experience and the quality of patient care. As is often the case, one solution is data; the ability to use data to assist the clinical reasoning process not only allows providers to work at the highest level, it can also make them exponentially more efficient.
Predictive Analytics vs. Clinical Reasoning
The phrase “predictive analytics” is becoming more commonplace in healthcare. Although often used synonymously with the term “clinical reasoning,” there is actually a slight – but important – difference between the two.
Predictive analytics involves the use of data sets to determine patterns and predict future outcomes and trends with a certain degree of reliability. It is essentially a forecast of what might happen. Predictive analytics employs an algorithm applied to a defined set of data to derive the probability of a distinct outcome. Clinical reasoning, on the other hand, is the process by which a provider gathers information and determines a diagnosis and treatment plan. It’s a cycle consisting of compiling and assessing information, formulating and executing the plan, and reassessing the plan based on the results.
Ideally, clinical reasoning combines clinical training with a provider’s personal knowledge resources. Those resources may include “background information” which consists of details such as how patients with this disease generally present, or what kinds of treatments and tests are available, and “foreground information” which applies these facts to the specific patient and specific condition being evaluated.
To help providers work at the top of their game, clinical reasoning tools can be used to bring analytics to the decision-making process. They help fill the gap between background and foreground information. By bringing evidence-based best practices into play, these tools can effectively raise the bar for all providers, regardless how long they have been practicing or how many times they have treated a particular condition. As mid-level providers increasingly are called upon to treat straightforward clinical conditions because of physician shortages, for instance, assistance from clinical reasoning aids can help ensure a consistent knowledge base is maintained.
Benefits for All
Assisted clinical reasoning delivers a number of benefits to healthcare organizations, individual providers and patients alike, including:
1. Checklists. The algorithms used to create clinical reasoning systems can be easily converted to checklists, which many experts champion as a simple, low-cost way to improve care much in the same way they have helped the aviation industry. All pilots, regardless of how many flights they have flown, use a checklist during each takeoff and landing to address safety standards consistently. While admittedly much more complex, patient care still could benefit in a similar manner.
2. Clinical guidelines. Clinical reasoning tools bridge the divide between background information and foreground information. At a practical level, this puts detailed clinical guidelines at providers’ fingertips, allowing highly experienced providers to confirm diagnosis and treatment options and helping less experienced providers successfully diagnose and treat patients according to standards and best practices.
3. Care quality. Healthcare services are no longer offered solely within the traditional confines of doctors’ offices and hospitals. Especially in physician shortage areas, the rise of retail clinics has made care extremely convenient for busy patients. However, to be effective, retail clinics must adhere to the same quality levels as other healthcare organizations. This can be accomplished by including clinical reasoning tools as part of the foundation of high level care.
From Retail Clinics to In-patient Hospital Wards
In retail clinic settings, clinical reasoning tools can be used to help mid-level providers (e.g., nurse practitioners and physician assistants) become efficient at diagnosing and treating common conditions such as earaches and sore throats. For example, a clinical system could guide them through which questions to ask, exams to perform and diagnostic tests to conduct. Based on the answers and results, the system recommends various treatment options that, according to clinical guidelines and best practices, offer the best chance at achieving desired outcomes.
It’s important to recognize that while these tools augment provider knowledge, they can never replace a provider’s training. That training ensures providers can identify when a patient’s condition falls outside the scope of their care, and merits further testing or a higher level of care because a more serious illness is possible.
In physician practices, clinical reasoning tools often are integrated into existing electronic health records (EHRs) to help providers formulate treatment plans based on best practices. For example, consider a patient who presents with symptoms indicative of community-acquired pneumonia, which is confirmed through a chest X-ray. Based on the diagnosis, the patient’s history, current conditions and medications, embedded clinical reasoning aids will help the provider select a treatment plan based on industry-accepted guidelines that might include antibiotics, inhaler options or even hospitalization.
Some hospitals are even beginning to tie together patient monitoring and clinical reasoning systems to allow a higher patient-to-physician ratio with no downgrade in care. For example, within the in-patient hospital ward, devices can monitor each patient’s major organ systems and transmit the data to dashboards in real time. When combined with clinical reasoning, any time these dashboards can signal that a given organ systems parameters has changed beyond acceptable levels based on clinical standards, an alarm can be triggered and the patient immediately evaluated by a nurse or physician.
In the future, this type of system may be used to monitor patients remotely. The potential exists for one or two highly skilled physicians to monitor a number of patients regardless of location, and direct providers on the ground to follow best practices in response to patients in distress. In rural or other underserved areas, such a scenario presents numerous benefits for patients who otherwise lack access to highly specialized care.
Improving Workflow, Enhancing Care
Despite the benefits technology affords, augmenting provider knowledge with clinical reasoning support should never start with a technology evaluation. Rather, it must begin with a thorough understanding of existing workflows, processes and goals. Providers, organizational leadership and IT experts all must work together to compare their outcomes to those of peer organizations, and target areas for improvement.
The team then should work to uncover the missing or problematic processes that result in poor outcomes. Only after workflows have been thoroughly examined against outcomes should technology be used to help fix identified shortcomings.
Reconsider for a moment the example of the patient who presents with community-acquired pneumonia. Clinical guidelines recommend that patients over age 65 with that diagnosis receive a pneumococcal vaccination. If the providers in an organization already are offering 100 percent of such patients the vaccination, then there is no need for improvement. If this step is not occurring for all such patients, however, the organization might want to adopt a clinical reasoning prompt in the EHR that requires providers to either enter the patient’s vaccination date or order the vaccination.
Whether a workflow assessment is conducted internally or with the assistance of outside experts, it is the first step in effectively evaluating an organization’s improvement opportunities. As the ACA, an aging population and other factors combine to swell the numbers of patients seeking care, it will become increasingly important for organizations to assess how best to support physician efficiency and performance. By expanding provider knowledge, clinical reasoning aids can play a role in efforts to optimize the physician workforce and maintain high levels of patient service.
Viet Nguyen, MD, is Chief Medical Information Officer for Systems Made Simple, Inc. (SMS), a provider of IT systems and services to support critical architecture, data and application challenges in the healthcare industry. Todd Schwartzrock is CIO-SP3 Program Manager at SMS.
