Zynx CEO Weingarten on ACOs, decision support, meaningful use (transcript)

This is the transcript of my recent podcast interview with Dr. Scott Weingarten of Zynx Health.

David E. Williams:            This is David Williams, co-founder of MedPharma Partners and author of the Health Business Blog.  I’m speaking today with Dr. Scott Weingarten, he is CEO of Zynx Health.  Scott thanks for your time today.

Dr. Scott Weingarten:            Thank you very much David.

Williams:            Let’s talk a little bit about Accountable Care Organizations (ACOs).  What is an ACO and is there any connection with Meaningful Use and clinical decision support?

Weingarten:            In ACOs, physicians, other health care providers and hospitals align and are accountable for quality and cost outcomes across some period of time for a population of patients.

Many of the details of the structure and financing of ACOs are yet to be defined. We expect to hear more from CMS regarding those details in the near future, but regardless of how those details emerge you see hospitals and physicians aligning and preparing to demonstrate the best quality outcomes at an affordable cost.

The ARRA/HITECH legislation is closely aligned with the ACO language in the Patient Protection and Accountable Care Act. Meanwhile Meaningful Use requires deploying health care information technology and creating the health care information technology infrastructure. As you start looking at draft definitions for Stage Two and Stage Three it’s clear that organizations will need to simultaneously improve their clinical processes and their clinical and financial outcomes.

I believe that Meaningful Use and ARRA really lay the foundation for succeeding in a reformed health care system, succeeding as an ACO, and being prepared for value based purchasing, Medicare shared savings and even bundled payments.

Clinical decision support is also tightly aligned with the requirements for demonstrating Meaningful Use and for becoming an ACO.

Clinical decision support is prominently featured in the draft definitions of Stage Two Meaningful Use criteria and to a lesser degree in the Stage One criteria that have already been published in final form. The Patient Protection and Affordable Care Act requires the practice of evidence based medicine. If you look at the language related to Patient Centered Medical Homes it requires what they call evidence informed medicine.

Clinical decision support is absolutely essential if you’re going to take a large organization of aligned physicians and hospitals and other health care providers and practice evidence based or evidence informed medicine while demonstrating improved clinical and financial outcomes. Deploying health care information technology without clinical decision support is unlikely to demonstrate significant either benefits.

Williams:            As you mentioned the ACO rules haven’t been completely laid out yet, but you do see this alignment that’s going on with hospitals and IDN’s with other affiliated organizations.  What are some of the challenges that they encounter when they’re working with these affiliations or alignments especially if they aren’t directly controlled? It seems like it would be that much harder when you’re actually trying to align with other entities.

Weingarten:            It is challenging.  We’ve seen some steps towards alignment with clinical integration initiatives that have been going on for some years. Aligning the clinical care between physicians in their office setting with the care in the hospital setting is certainly one challenge, but let me give you an example related to alignment through clinical decision support.

If you take a chronic illness such as heart failure, one day the patient may be seen in his physician’s office and then a week later it’s possible for this patient’s condition to worsen and require hospitalization. Hopefully the patient gets better quickly in the hospital and is discharged. Then two weeks after discharge the patient is seen back in his physician’s office.

If you look at Stage Two, the draft requirements include evidence based order sets.  You would like the evidence based order sets to be consistent between the ambulatory setting and the hospital setting.  It would be very confusing and potentially adversely impact patient care if the order sets for heart failure in the ambulatory setting and drug recommendations were significantly different than the recommendations in the hospital, and certainly the discharge order sets.

Williams:            You remind me of an article that I just read recently in Today’s Hospitalist. It reported on some research about difficulty coordinating inpatient and outpatient care for heart failure. When the patients come into the hospital, the doctors typically stop whatever medications they’ve been taking.  They put them on something else –often after a delay. When they’re discharged they’re not necessarily taking anything until they see their ambulatory physician, whenever that may be. Some of these issues could be resolved with consistent order sets, but you won’t have the whole picture until there are other kinds of alignment and coordination.

Weingarten:            That’s a wonderful example. Certainly as an ACO you’re going to be very focused on strategies to safely reduce hospital readmissions.  So care coordination and ensuring patients get the best possible care during transitions is absolutely essential. Everyone that’s familiar with the data on the very high rate of readmissions for heart failure can see that ensuring this consistency of care is critical, not only for succeeding as an ACO but more importantly for the patients. Certainly the last thing patients want is to be readmitted to the hospital because their condition worsens.

Williams:            The first draft of Meaningful Use requirements for Stage One included a fair amount on clinical decision support, but quite a bit of that has been pushed back now into Stage Two.  I’ve been reading recently that both hospitals and physicians are struggling just to get to Stage One of Meaningful Use. What’s your perspective? Do you think organizations are soon going to start giving up when they find out they’re not going to qualify for some of the incentive payments that perhaps they were hoping for?

Weingarten:            Good question. I believe there will be some organizations that are unable to demonstrate Meaningful Use in the required time frame. But I believe that a substantial number will be able to demonstrate Meaningful Use.

In fact I believe a larger number of providers than I originally envisioned will be able to demonstrate compliance with Stage One Meaningful Use criteria. So I am somewhat optimistic that a substantial number of hospitals and physicians will demonstrate compliance with Stage One in the necessary time frames. Certainly when I look at surveys in the field, many hospitals and physician groups are devoting substantial resources and attention to be able to demonstrate Meaningful Use. Many organizations are increasingly optimistic that they will succeed.

Williams:            Are there specific things that Zynx is doing to help your customers move along the path towards Meaningful Use and development of ACO’s?

Weingarten:            Yes. First, on Meaningful Use, Zynx has been very focused on clinical decision support, whether it’s alerts in Stage One or evidence based order sets for Stage Two as well as care plans and care coordination.  Zynx has quite focused for several years on components of clinical decision support that ended up in the Meaningful Use criteria.

As it relates to ACOs, Zynx has focused on the clinical processes that will improve quality and cost outcomes since the inception of Zynx in 1996. We’re highlighting those clinical processes that have been proven, based on the scientific literature, where you’re more likely to get physician, nursing and other health care provider acceptance to reduce mortality, to reduce readmissions, to safely reduce cost and to safely reduce length of stay.  I believe that improving all four of those outcomes will be absolutely essential as organizations prepare to become ACOs.

Furthermore we’re providing an assessment for an increasing number of our clients who have asked us to review their clinical decision support. That could be order sets, it could be plans of care, it could be alerts, it could be structured documentation to make sure they have fully baked in all of the clinical processes that will impact key outcomes.

Williams:            How are the Zynx order sets and clinical decision support rules developed? To what extent are they really evidence based?

Weingarten:            We carefully review the literature and have a systematic, reproducible process with a defined methodology that is similar to the evidence based practice centers of the Agency for Health Care Research and Quality. There is a systematic approach to including and excluding articles, grading the articles and expressing the information in the article.  This is a key part of Zynx clinical decision support, which has been refined based on feedback over the last 14 years. But with that being said not all of medicine is can be evidence based.

There are things that we do in health care that are more experience based.  An example might be for treating patients with community acquired pneumonia. There’s very good evidence related to which antibiotics will lead to the best outcomes but the evidence is not strong regarding whether the blood test, for example, should be ordered upon initial hospitalization.  Should a complete blood count be ordered?  What about electrolytes?  What about liver function tests?

There really isn’t good evidence to point a clinician one way or another.  We have client customized order sets and plans of care, in fact about 140,000 of them. We can review this information in an aggregate format and identify the best experiences related to those elements of care that cannot be evidence based.

Many of our order sets and plans of care may be on their 20th iteration, 30th iteration, 35th iteration based on this assessment and evaluation of the information.  When an order sentence in an order set is evidence based we note it as being evidence based and include an evidence link to allow clinicians to rapidly access the evidence. When an item is informed by evidence we include the link but when it’s experience based we indicate that as well by not having an evidence link.

Williams:            Is it possible for your clients to calculate an actual return on investment for what you provide? If so –or even if not– as payment reform comes in and as ACOs are established will that become easier to do? Will the basis for the calculation change?

Weingarten:            There are a number of ways that our clients assess return on investment.  The first way is that we have these forecasters to calculate financial and clinical return on investment.

A hospital or physician organization looks at existing practice. Often they subscribe to a comparative clinical database; virtually all hospitals subscribe to one or another.  The information resides in those comparative clinical databases and then our customers plug in the information if certain improvements in care are made.

For example in patients with heart failure, if more patients were treated with certain medications –it might be ACE inhibitors, it might be ARBs, it might be beta blockers, it might be aldosterone antagonist– how many lives could be saved, how many readmissions could be avoided and how much cost could be saved? That’s one way that organizations project a clinical and financial return.

Another way is Zynx Measurement, a measurement framework where clients look at cost and quality outcome information before deploying certain order sets or plans of care or alerts and then afterwards. They look at differences and benefits. Many will compare that to a control population to try to isolate the impact of the clinical decision support versus any secular trends that might have been going on in the hospital. We’ve had a number of clients publish those findings in the peer reviewed medical literature. We also have a conference each year.  Last year we had over 300 attendees and a number of them report the impact on quality and clinical outcomes.

Williams:            I’ve been speaking today with Dr. Scott Weingarten, CEO of Zynx Health.  Scott thanks very much.

Weingarten:            Thank you David.

December 22, 2010

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