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Cedars-Sinai uses electronic records to spur improved, lower cost care

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Last week, I told you about Sutter Health's efforts to orient its doctors toward more cost-conscious, high-quality care.

As you might remember, the Northern California health system is gathering doctors and, using data culled from electronic health records, comparing individual doctors' practice patterns. It's an attempt to get doctors to change their behavior by exposing them to their peers' success at providing high quality care at a lower cost. 

Today, I have another cool model to share!

Cedars-Sinai Health System in Los Angeles has chosen another route toward higher-quality, lower-cost care: It's incorporated a set of best-practice guidelines into its electronic health system. Essentially, the system alerts physicians when they attempt to order a procedure or medication that could be unnecessary or harmful. This often spurs them to reconsider their decisions, according to Cedars officials.

Choosing tests, treatments wisely

Cedars' efforts are based on guidelines developed as part of the Choosing Wisely campaign, designed by the American Board of Internal Medicine, Consumer Reports and national medical specialty societies. The guidelines detail a number of tests and treatments that could be wasteful, unnecessary or harmful. 

When he heard about the guidelines, Dr. Scott Weingarten, chief clinical transformation officer at Cedars, says he thought to himself: "This is really important information that could both improve quality of care and also safely reduce the cost of care."

Cedars interated the Choosing Wisely recommendations into its electronic health record in 2013, making it the first and only health system in the country to do so, according to Weingarten. Under the system, if providers order a test or treatment that is in conflict with one of about 180 Choosing Wisely guidelines, a message will instantly pop up on their computer informing them.

"That might prompt them to consider whether it is the most appropriate test or treatment for their individual patient," Weingarten says, "and to have a conversation with their patient about whether it is advisable or inadvisable to proceed with that test or treatment."

'It served as a reminder'

Cedars' efforts to incorporate these recommendations into the electronic health system has quickly yielded results, Weingarten maintains. He says physicians are changing their recommendations to be in line with Choosing Wisely guidelines, leading to improvements in quality of care.

That's spurred an annual reduction of more than $4 million in health care costs so far, he says. As Cedars incorporates more recommendations into its electronic health records, Weingarten expects to see more improvements in quality of care and greater reductions in cost.

Weingarten offers this example of the program's effectiveness: According to the guidelines, physicians should avoid prescribing benzodiazepines - a class of drugs including Valium, Ambien and Ativan - as insomnia treatments to people over age 65. The drugs can cause older patients to fall and break a hip or get into car accidents, he says.

Cedars incorporated this recommendation into the electronic health system and "almost immediately we found a 30 percent reduction in physicians prescribing benzodiazepines to older patients," says Weingarten. He notes that there was no change in the amount prescribed to younger patients, who can more safely take these drugs.

Following this reduction, Weingarten says he calculated the overall impact for patients. He concluded that based on scientific models, the reduction should lead to significantly fewer people suffering hip fractures, being hospitalized and subsequently dying.

Dr. Daniel Stone, medical director for the Cedars-Sinai Medical Group, shares his own experience using this system: He was in the process of ordering a bone density test for a patient when an alert popped up on his electronic health system. It reminded him that the Choosing Wisely guidelines generally recommend bone density tests for women when they’re 65, unless there's a specific reason she needs one earlier.

"I had forgotten she wasn't over 65," Stone says. The alert reminded him that he could wait a few years to do the test; he then explained his change of plan to the patient.

"There's an expense, and there's a small amount of radiation, and it wasn't necessary," he says of the bone density test. "If I had just through about it, I would've done it that way in the first place, but it served as a reminder."

Generally, the problem with unnecessary tests and studies, he adds, is they, "sometimes lead into a cascade of testing that takes the patient in the wrong direction... so oftentimes, if that can of worms isn't opened, it's best for the patient."

Some doctors are still conflicted

Stone's experience with the bone density test is a great example of why Cedars' system has proven successful: The electronic health record prompts doctors to reconsider decisions that are in conflict with the Choosing Wisely guidelines at the moment they're making those decisions. 

While Stone was grateful for the reminder and is an advocate for the system, he says other doctors are more conflicted.

Some believe their patients will want that unnecessary x-ray or test and won't budge until they get it, he notes. Stone's response is that it's worth at least a discussion, and "Choosing Wisely prompts us to have those conversations - it reminds us to have those conversations."

Others, he says, worry the electronic medical record is encroaching on the time and energy they'd rather share with their patients. But the medical field is evolving, Stone replies, and "we have to make an effort to maintain that personal contact even when we are dealing with that third entity, which is that electronic record."

Weingarten says such concerns aren't unexpected, since the movement to improve quality while lowering costs is still in its early stages. 

This post has been updated.