Every patient has a unique set of needs and expectations. According to the Institute of Medicine (IOM), there are unprecedented challenges to how we identify and deliver the most appropriate care for individual needs and conditions (IOM, 2011). In part one of this series, we looked at clinical tools that can help us to understand the most vulnerable patients and the care they require. In part two, we will peel back the problem of, “Care that is important is often not delivered. Care that is delivered is often not important (IOM, 2011).”
One of my favorite holidays is the Fourth of July. There is just something about a dark sky, a well-lit punk (fire) and a stockpile of ammunition just waiting to explode. Throw in a few neighbors, good music and a cold beer, and you have just pulled off the best block party in town. I’ve had more fun with family & friends creating our own show than some of the best professional firework shows I have attended. It’s a sort of paradox that the joy we experience from this display is in reality a memorial to the price of our freedom.
Thankfully, most Fourth of July celebrations go off without a hitch and we have a good time, but having worked in the ER, I know it does not always go as planned. Yet, most are willing to take a risk since we typically get good results. On the flip side, many remain risk-adverse when there is a chance of a bad outcome.
Like two sides to a coin, it is not uncommon to ask our patients to consider the benefit of a test or a treatment to minimize a potentially harmful outcome, but we may not be so clear about the exchange of one risk for another or fully consider patient-specific factors such as self-efficacy, genetics or quality of life. So just how effective is that treatment plan? For example, Vinay Prasad and colleagues asks us to consider, “Why cancer screening has never been shown to ‘save lives’---and what we can do about it (Prasad, 2016).”
In the case of thromboembolism (TE) or blood clot management, patients are asked to consider powerful, potentially toxic blood thinning medications such as warfarin to prevent future blood clots that may lead to a stroke. However, we are also asking them to exchange one risk (stroke) for another risk (internal bleeding). Without better feedback about the effectiveness and safe delivery of different treatment options, the resulting uncertainty can lead to the delivery of services that may be unnecessary, unproven, or even harmful.
Adverse Drug Events (ADEs) are sited as “the most common cause of harm (iatrogenic) related to medical treatment” and a common reason for ED visits and hospital readmissions (Shehab, 2016). According to the National Action Plan for Adverse Drug Event Prevention (NAPADEP, 2014), anticoagulant medications are a major player, and management of these medications are labor-intensive and complex. In high-risk medications such as anticoagulants, there are two sides of the coin. We can harness the properties of these drugs to prevent life-threatening blood clots, but because of multiple factors (such as the drugs narrow therapeutic effects, change in renal function, complex dosing, drug transitions for procedures and drug-drug interactions-to name a few), significant adverse events such as bleeding can quickly turn a life-saving solution into a life-threatening problem.
In the tension of clinical paradox, like anticoagulation (AC) management, clinicians should not let contradictions drive them to emphasize a given risk or benefit over another. Rather, we should transparently engage with our patients to live in the midst of it and find a balance. We must also demand data-driven clinical tools that better address these paradoxical questions because balancing the tension is paramount to achieving optimal results.
It is not a surprise then that the National Action Plan for Adverse Drug Event Prevention sited anticoagulant ADEs “…to be common, clinically significant, preventable, and measurable,” and selected as a high-priority target (NAPADEP, 2014). The mandate will require providers to have seamless access to real-time, integrated, linked pharmacy-laboratory data to facilitate and deliver the right care to the right patient at the right time. To accomplish this, we are seeing an alignment of patient safety mandates with improvement, quality, and interoperability measures across CMS value-based reimbursement programs specifically targeting problematic areas and shifting national resources to tackle several high priority initiatives such as ADEs.
AC management is one of the high priority national patient safety initiatives tied to CMS reimbursement across health care systems. Leveraging complementary EHR technology plays a vital role in delivering point of care solutions that facilitate the safe delivery of high-risk, life-saving treatment during critical patient care touch-points. This has opened the door for software companies like Point of Care Decision Support to bridge the data gap and address paradoxical clinical questions, address workflow inefficiencies and meet the challenges of high risk patient populations.
Health care is still struggling to make the leap from volume to value but it may take just a few sparks of innovation to tip the scales. What we know is that we can make a substantial difference in preventable adverse events such as blood clots or internal bleeding when we effectively and efficiently engage patients. Unfortunately, ADE associated with ACs are still common, clinically significant and at a high cost to patients and healthcare systems. The good news is that these events are preventable and measurable. There is a critical need for clinical tools at the point of care that captures comparative effectiveness of treatment options and customizes treatment plans to facilitate a meaningful exchange of risks and benefits between patients and their provider.
How do you communicate and track the risks and benefits of treatment with your patient? How can technology better address these questions in your clinical practice?
IOM (Institute of Medicine). 2011. Digital Infrastructure for the Learning Health System: The Foundation for Continuous Improvement in Health and Health Care: Workshop Series Summary. Washington, DC: The National Academies Press.
National Action Plan for Adverse Drug Event Prevention (NAPADEP). 2014. Washington, DC: U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion.
Prasad V, et al. (2016). Why cancer screening has never been shown to “save lives”—and what we can do about it BMJ; 352 :h6080
Shehab N, et al. (2016) US emergency department visits for outpatient adverse drug events, 2013-2014. JAMA; 316(20): 20015-2121