'Better care costs less': Texas Children's Hospital's clinical standards journey

BOSTON—Pediatric medicine has about half the scientific research of the adult world, said Charles Macias, director of the Evidence Based Outcomes Center at Texas Children’s Hospital, speaking at the Big Data & Healthcare Analytics Forum.

That lack of research is one reason for the wide variability in treatment, he said. Citing a study of 16 hospitals that treated children for bronchiolitis, Macias said there was variability in both the management and diagnosis of the condition as well as variability within institutions. Without a common language for the way clinicians should provide care, it’s difficult for their institutions to support labs, process discharges and conduct all the other business related to delivering care.

The Pediatric Health Information System Database tracks measures from 21 member hospitals and Macias said that variability results in significant financial impact. Most importantly, increased costs were not associated with lower admission rates or 3-day ED revisit rates. “It’s actually more expensive to delivery poor quality care.”

Macias’ center wanted to put patients and clinicians at the center of this work where the care model is constantly in communication with the integrated system. Clinical standards and evidence-based guidelines give Macias and his team recommendations to assist practitioners with very specific conditions to help reduce complexity.

The Evidence Based Outcomes Center is geared for the systematic development of clinical standards. Texas Children’s Hospital (TCH) has reduced mortality from septic shock by 30 percent thanks to the center’s work. They built in best practice alerts, and the high rate of success led to spreading the tools to other hospitals through the American Academy of Pediatrics.

Macias and TCH also use population health approaches such as permanent teams to drive PDSA cycles. “We created a matrix model where every intersect has some component of IS that addresses it.” Analytics were built and feed back to the care process teams.

“One cannot define high quality without knowing what outcomes are defining it,” he added. Outcomes go well beyond patient outcomes to utilization metrics, financials and understanding the interplay of all of this. That informs their next strategy.

TCH is in the process of changing its culture because most physicians associated lower cost care with poorer care quality. “It’s almost the opposite. We want to provide a better understanding of finance in our operational analytics so that clinicians understand how improvements in care lead to reductions in the cost of care.”

Macias shared TCH’s experience with its asthma care process team. They have 19,000 asthmatics and built evidence-based guidelines into their EMR. They went from a $662 loss per patient with asthma to almost revenue neutral. They also improved efficiency and measured better outcomes. “It’s simply a better way to deliver care.”

The crosslink of system integration drives clinical operations and financials in every activity, Macias said. “We had to deliver sophisticated models for understanding the return on investment in our care process teams. It’s very challenging.” They’ve aggregated the return across 13 care process teams to prove that they are “a very effective way of improving outcomes and reducing costs.”

TCH has several lessons learned to share. Wide variations in practice can be minimized with systematically developed clinical standards. This provides “a common way to converse with clinicians, administrators, operations people, these are the processes and this is the equipment we need to have in place.”

The systematic use of tools will help standardize approaches to the integrity of clinical standards. Guidelines shouldn’t be based on people’s opinions, Macias said “You need a very refined method.”

Governance and a systems integration strategy are critical to effective uptake. Get information services, revenue cycle and other departments on the same page, he said.

The evaluation of outcomes through analytics allows for guided implementation and transparency of outcomes. “Giving those outcomes to providers inspires them to understand the interplay of it all.

“When you tackle best practice guidelines in this model, when clinicians can understand how we affect all asthmatics, you can truly begin to take a population health approach for the triple aim.”