Decision-support software eases information flow

It offers easy way to share financial, clinical data

No more parking the benchmarking notebook on a shelf in the finance department. With decision support software now making integrated financial and clinical data instantly available on personal computers throughout the health care system, benchmarking has moved into the fast lane - and into the hands of clinicians who need it most.

Take Medical Center East, in Birmingham, AL, for example. Clinically adjusted comparative data from HCIA is imported into Trendstar, a decision support system developed by HBOC in Atlanta, says Paul Graham, director of reimbursement and decision support.

With the new system, the six case managers in the outcomes management department receive quarterly benchmarking data on their personal computers. "It's like having the information on a Web site. Case managers can tap in and view charts and graphs, drilling down in a specific DRG to payer, physician, and patient level. They can also see how we vary from the local and national market," he explains.

Previously the benchmarking data came in a huge notebook. "The information was great, but it wasn't in a user-friendly format, and it wasn't easily accessible by those who really needed it," says Mary Beth Briscoe, chief financial officer. "With the new decision support software, all that has changed."

MCE's director of case management Suzanne Holland agrees. "Before, the binders were over in finance, and we were in the hospital," she says. "We had to query for the information, and often we didn't even know what to ask for or how to ask for it."

There also wasn't a good opportunity to integrate clinical and financial data, says Beth Hoffman, decision support manager.

Graham and Holland point out that the real advantage of the system lies not only in its ability to generate detailed instant reports, but also in the synergy it has created between finance and case management departments.

"We have taken responsibility for communicating the financial information, and case management has taken the responsibility for using that information for change," Graham says.

Learn new languages

For example, Graham and other members of the decision support department, along with contract management and utilization review, meet weekly with the case managers to discuss reimbursement issues and challenges. (Representatives from social services, home health, and medical records also attend.)

"We've learned to speak each other's language," Graham says. By providing definitions and examples of the following concepts, clinicians quickly see how their decisions affect the hospital's bottom line:

· direct vs. indirect costs;

· fixed vs. variable costs;

· charges vs. cost;

· reimbursement vs. actual collections.

Education and information

He also explains how capitated rates, fee schedules, and payment under the new Medicare provisions are figured. Rather than giving such information in a straight lecture format, he weaves it into a current case scenario, he says.

A representative who negotiates third-party contracts also attends the meetings. "Any time there is update or new contract, we point it out so clinicians know this patient is on that insurance with a certain rate of reimbursement," Graham says. "The goal is to help clinicians understand the financial ramifications of care."

Close contact with clinicians has given him cost-effective insights his accounting background didn't provide. "For example, if a particular drug is the most advantageous yet expensive, I know when I see its name during a contract negotiation that I may need to carve it out and make provisions for a separate payment," Graham explains.

Share the knowledge

Armed with a good working knowledge of reimbursement and cost structures, case managers take that information to their interdisciplinary practice groups. The groups include clinicians from various disciplines who have expertise in the following areas:

· diabetes;

· renal care;

· respiratory care;

· neurology;

· cardiovascular surgery;

· cardiovascular medicine;

· surgery/urology;

· oncology;

· obstetrics/postpartum care;

· gynecology;

· pediatrics;

· well-baby care;

· newborn intensive care;

· rehabilitation;

· wound care.

The purpose of the practice groups is to develop clinical pathways, monitor outcomes, and recommend practice pattern or care delivery changes, Holland explains. Physicians are responding well to the new system, she notes.

"The data stands on its own," she says. "Instead of forcing [benchmarking and best practices] down their throats, we are telling them, 'We are not the critical pathway police,' and they are coming to us for help."

For example, when a cardiovascular physician asked to evaluate their cost per case, the case manager and decision support team ran a report that compared the costs of performing an outpatient catheterization in which the patient stayed post-procedure on the nursing unit or in the same-day services area. "We found it saved money using same-day service, and the patient still received the same level of care," she says.

This concept of the most appropriate utilization of service is inherent in any practice pattern change, Holland says. Here are the areas that approach has taught her and her case managers to examine when coaching a physician through an opportunity for change or developing a critical path:

1. Type of bed. "Match the appropriate bed to the level of care needed," she says. "Ask yourself, 'Can the patient get the appropriate care in a less resource-intensive setting?'"

2. Pharmacy. "Weigh current drug costs against future benefits," she says. "For example, clot-busting drugs are very expensive, but if we don't spend the dollars now, we may be inviting congestive heart failure later on."

3. Respiratory therapy. "Keep a close watch on oxygen ordered PRN. If patients are giving oxygen to the pillow because they don't need it, that's not efficient use of resources," Holland suggests.

4. Laboratory. "Don't use a shotgun approach. Order studies that will make a difference in the care of the patient; don't order them because you always have."

5. Blood. "If you perform a type and screen instead of a type and cross match; it is less expensive. Only order type and cross match if you need blood on hand," she says.

6. Physical therapy. "The earlier the intervention, the better the outcome," she says.

7. Central supply. "Evaluate whether you need a whole package or just a few," she says.

8. Radiology. "Watch ordering of chest X-rays carefully. Will you make any changes as a result of the X-ray? Can it be done on an outpatient basis? Look at the whole clinical picture before ordering," she says.

For more information, contact:

HCIA Inc., 300 East Lombard St., Baltimore, MD 21202. Telephone: (410) 576-9600 or (800) 568-3282.

HBOC, 301 Perimeter Center North, Atlanta, GA 30346-2403. Telephone: (800) 981-8601. Web site: www.hboc.com.

Suzanne Holland, Medical Center East, 50 Medical Park East Drive, Birmingham, AL 35235. Telephone: (205) 838-3104.