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Data Doc: The Case for Standardization (and How It Can Ease Your Drug Shortage)

Salgia, Anup, DO

doi: 10.1097/01.EEM.0000533645.98281.98
Data Doc

Dr. Salgiais a physician executive at Cerner Corporation and an assistant professor of emergency medicine at Northeast Ohio College of Medicine. He holds several patents related to medical devices, and is the founder of a medical device company. He also serves as a spokesperson for the American College of Emergency Physicians, and was previously a commissioned officer in the U.S. Navy and a medical officer with the 2nd Marine Division, primarily in U.S. Marine Special Operations.

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Electronic medical records have created a number of opportunities to move health care forward, with one being standardization of the delivery of care. Physicians have historically viewed standardization as cookbook medicine, not allowing physicians to use their problem-solving skills and stifling the art of medicine. This could not be further from the truth.

The modern EMR permits physicians to standardize certain aspects of care like medication regimens, ancillary treatment orders, and treatment protocols. These offer predictability and the ability to decrease the cost of care while reducing errors and increasing the quality of care.

Treating certain conditions such as community-acquired pneumonia in the ED or inpatient ward in a standardized manner is important. The EMR offers order-sets that are easily accessible in a menu format. You all use these standard order-sets mainly for the sake of convenience, but the advantages run deeper than this. The insurance companies know that Community Hospital X provides appropriate, optimal-outcome, evidence-based, cost-effective care for, let's say, 85 percent of their patients with pneumonia with a low degree of variability. They are so good at providing care that the hospital has won accolades from insurers, governing bodies, and the like. This gives hospitals leverage in negotiating payor contracts. Taking it a step further, standardization gives hospital systems predictability in their revenue cycle operations. The cost of care is as predictable as the reimbursement for care. The physicians who order tests, medications, and imaging studies off the menu will eventually be considered outliers and will need to be more accountable for their ordering habits. The physician who orders from the menu, however, would be considered a good steward of the patient. Obviously, we are talking about uncomplicated, routine care. This example does not necessarily pertain to the complicated patient, though insights can certainly be derived from them as well.

The hospital system that orders the standard regimen of medications for the majority of their patients based on an EMR protocol or order-set for certain conditions has the advantage of buying power for those medications or supplies. This organization can save on costs because it is a high-volume user of certain medications, lowering the cost of care. By contrast, a hospital system that does not set a policy, loosely enforces medication usage, or does not utilize order-sets to standardize care becomes like the Wild West, leading to high variability in care. This not only can place patients at risk, but can also lead to an unpredictable revenue stream and unpredictable costs.

Consider this example: Amid all of the various crises in health care, medication shortages has emerged as a new one. Recently, a community hospital depleted its cache of intravenous controlled pain medications to the point that it had to stop performing elective surgeries at that institution. They are unable to obtain more due to market forces and distribution of medications by drug manufacturers, among other factors. It is likely that they would not be in this situation if they had a standardized strategy in place where patients in the hospital would receive oral instead of IV pain medications. Elective surgeries can be a great service to the community and also a source of steady revenue.

Leveraging data from the EMR, it would have been possible to cross-reference patients who are not NPO with patients who are receiving parenteral pain medications. This example shows how EMRs can help hospital administrators give oral pain medications to patients who are able to take medications orally rather than intravenously. This would allow the hospital to save their IV medications for those profitable elective surgeries.

Taking a common sense approach to effective, cost-efficient, evidence-based care can be accomplished by deriving insights that the electronic medical record can help derive.

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