Four benchmark institutions have demonstrated the efficacy of health information technologies in improving quality and efficiency. Whether and how other institutions can achieve similar benefits, and at what costs, are unclear.

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M any experts argue that addressing the burgeoning problems of the health care system requires a fundamental redesign, a transformation in which existing modalities are replaced by new paradigms for care delivery. 1,2 As the Institute of Medicine has stated, simply "trying harder" to make the existing system work better will not be enough. 3 However, while the need for fundamental redesign is generally agreed upon, less agreement exists for how those changes should be made and what that new health care system should look like. Expanding the use of information technology has emerged as one of the most widely supported aspects to health care system redesign. [4][5][6][7][8] Health information technologies designed to improve clinical decision making are particularly attractive for their potential to address the growing information overload clinicians face and to provide a platform for integrating evidence-based medicine into care delivery. 9,10 However, despite the theoretical and intuitive benefits of such technologies, the existing literature has demonstrated mixed empirical results. 11,12 Additional work in understanding adoption of computerized decision support is critical. In this issue of the Journal of General Internal Medicine, studies by Agostini et al. and Graber and Mathew, respectively, examine decision support systems focused on treatment and diagnosis. 13,14 Together, they illustrate many of the challenges involved with using and evaluating computerized decision support systems.The study by Agostini et al. provides insight into the dynamics of using decision support systems for clinical care and illustrates how quality improvement approaches can be applied to adopting health information technology. The authors qualitatively evaluated physician perceptions of an electronic reminder related to prescribing sedative hypnotics for older hospitalized patients. The reminder was integrated into a health information system that allowed clinical orders to be entered through a computer. It was triggered when a physician attempted to order diphenhydramine or diazepam for insomnia in patients aged 65 or older. The authors used semistructured interviews to evaluate perceptions of the benefits and limitations of the reminder in a cohort of 36 housestaff physicians who ordered a sedative hypnotic despite receiving the reminder.The results suggest that a complex set of factors underlie physician use of computerized reminders. Despite the decision to not follow the recommended action, physician respondents had both positive and negative perceptions of the reminder. These diverse perceptions were technology-specific (positive perception of integrating computers into clinical care), user interface-related (time needed to read reminder), professional (threats to physician autonomy), and health sciences-related (educational value/information content). These findings provide insight into the dynamics of adopting clinical decision support systems. Health information technologies are tools whose value is influenced by how cl...

6635 Background: The Oncology Care Model (OCM) is intended to incentivize physicians to improve the quality and reduce the cost of cancer care. In OCM, providers are accountable for all costs during six month episodes of care relative to target costs (TC) derived from a baseline spending period (BSP; 2013-2015). This accountability is intended to foster care coordination to reduce preventable emergency department visits and hospitalizations (EDH). Benefits of reducing EDH may be diluted when new treatment indications for costly immunotherapies (IO) are introduced into clinical practice after BSP. Methods: We identified all non-small cell lung cancer (NSCLC) and bladder cancer (BC) OCM episodes attributed to Tennessee Oncology (TO), a large community oncology network of over 90 oncologists, during performance period 2 (PP2; the most recent PP with available data). We selected NSCLC and BC because both diseases have IO indications that became standard of care after BSP. Using claims data analytics software, we identified all NSCLC and BC episodes with spending above TC, and found a subset of these above target episodes (ATEs) without any EDH that remained above TC due to IO use. Two medical oncologists reviewed these cases in duplicate to assess guideline concordance of IO. Results: During PP2 there were 2,623 OCM episodes attributed to TO, including 240 NSCLC and 31 BC episodes. Spending was above TC in 118 (49%) and 13 (42%) of NSCLC and BC episodes, respectively. For these NSCLC and BC ATEs, EDH was prevented in 62 (53%) and 5 (38%) of cases, respectively. In NSCLC and BC ATEs without EDH, 43 (69%) and 5 (100%) of episodes included IO, respectively. Clinician review in duplicate (S.M.S.; C.A.W.) found that the use of IO was NCCN guideline concordant in 33 (77%) and 4 (80%) of these NSCLC and BC cases, respectively (K = 0.87). Conclusions: Guideline-concordant use of expensive IO as its treatment indications expand poses substantial challenges to meeting cost targets in OCM, even when practices prevent EDH. [Table: see text]

Most cancer centers are ill-equipped to pursue value-based payment (VBP) because of limited information on their population's cost of care. Herein, we outline the stepwise approach used by Smilow Cancer Hospital at Yale-New Haven in our pursuit of better value care. First, we addressed institutional barriers. A move toward value required demonstration to Yale-New Haven Health System leadership that OCM would improve patient care, fund new infrastructure, and provide the opportunity to gain experience with VBP without a major threat to the financial stability of the health system. We evaluated patterns of care and found that of patients presenting to the emergency department (ED), 88% were admitted, 62% arrived during the workday, and 50% could have been stabilized with urgent care services. Within 30 days of death, 27% were admitted to the intensive care unit, 38% presented to the ED, and 52% were admitted. To quantify total cost of care, we accessed the 5% Medicare Limited Data Set to map out total cost of care for patients receiving chemotherapy at Smilow Cancer Hospital. Costs increased as patients moved through 6-month episodes, used the ED (patients with two or more visits were twice as expensive as those with one or fewer), or died during an episode (costs were twice as high as episodes in which the patient lived). To determine strategic interventions to improve value, we targeted investments in urgent care to reduce ED utilization, care management to prevent hospital admissions, and referral to palliative care for clarification of goals of care and avoidance of costly futile treatment. Developing internal metrics to evaluate success will require monitoring our interventions by having utilization measures for each site of care and individual provider.

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3 Background: Cancer centers across the country are largely unprepared to move toward value-based payment. Total cost of care data is not readily available and centers do not know how much of their patients’ care is received at other hospitals, when in the trajectory of illness greatest cost is incurred, or the elements of care that present the greatest opportunity for savings. A previous examination of practice patterns Smilow Cancer Hospital (SCH) demonstrated that our patients had high rates of ED visits, hospital admissions and ICU use in their last month of life. While this data is consistent with other large academic cancer centers (AMCs), there is a clear opportunity to improve our end-of-life planning and reduce futile care. Cost data supplemented the overutilization analysis, informing the infrastructure investments to prepare us for value-based payment models. Methods: We accessed the 5% Medicare Limited Dataset (2012-2013) to map out cost of care in 6-month episodes for all Medicare patients receiving chemotherapy. Patients who had received chemotherapy at a SCH site were flagged and the analysis included all cost of care, regardless of the site of service or type of professional delivering the service. Results: On average, a first episode of care at SCH cost $26,500, a second episode $38,000 and a third $45,600. Our analysis demonstrated important associations between increases in spending and ED utilization. Patients who had 1 or fewer ED visits during an episode, averaged $21,000 vs. $49,000 for those with 2 or more. Patients who died during an episode cost $53,000 compared to $25,600 for patients who lived. SCH episodes were significantly more expensive than CT, and slightly more than a comparable east coast Academic Medical Center. Conclusions: The above demonstrates that aggressive treatments, ED visits and hospital admissions at the end-of-life are major cost drivers. We used the analysis to target infrastructure investments in Urgent Care to reduce ED utilization, Care Management to prevent hospital admissions/readmissions and early referral to Palliative Care for clarification of goals of care. We believe these investments will lead to significant cost reductions.

Clinical pathways are intended to promote consistent evidence-based care in an increasingly dynamic treatment landscape. This implies a critical role for pathways to improve quality treatment selection as we advance into an era of precision medicine. 1 In addition to improving quality, studies in the past focusing on the treatment of non-small-cell lung cancer (NSCLC) have suggested that treatment pathways may also be a lever to reduce cancer spending by driving appropriate utilization of high-value treatments. 2,3 As such, there is an implicit belief that inappropriate drug utilization is a key contributor to rising drug costs, leading to the inclusion of drug spend in many oncology value-based care models such as the Center for Medicare and Medicaid Innovation's Oncology Care Model. 4