The 65-year-old patient has arthritis, diabetes and congestive heart failure. He is homebound and smokes half a pack of cigarettes a day. He is also overdue for a routine colonoscopy.

Would the invasive test qualify as high value health care?

That was the question Nancy Schoenborn, a Johns Hopkins associate professor of geriatric medicine, posed during her presentation at the national Architecture of High Value Health Care Conference, sponsored by the Johns Hopkins University School of Medicine and held Nov. 15–17, 2019 at the Baltimore Convention Center.

Schoenborn, like others at the conference, shared research and insights on how to improve patient care by eliminating unnecessary tests, treatments or procedures.

“The standard approach is to think about the degree of potential benefit and harm,” she said. “On top of that, in the geriatric population, we’re also thinking about when that harm and the benefit might occur.”

In the case of her unhealthy 65-year-old patient, she said, a colonoscopy could cause immediate harm, but the potential benefit would be negligible because, without better management of other health issues, he would be more likely to die of something other than colon cancer. Her advice: Urge the patient to skip the colonoscopy, and focus on other health priorities instead.

The third annual Architecture of High Value Health Care Conference, a partnership between the High Value Practice Academic Alliance (HVPAA) and the American Hospital Association, attracted more than 300 participants — its largest gathering so far — representing some 80 academic medical centers from across the U.S. and as far away as Norway.

The three-day event featured roughly 200 abstract presentations, 50 lectures, 12 workshops and 15 panel discussions on high value health care for adult and pediatric patients in inpatient, outpatient and emergency settings.

Sponsored by the Johns Hopkins University School of Medicine, the conference is the flagship event for the High Value Practice Academic Alliance (HVPAA). The alliance, launched in 2016, is a group of 100 academic medical centers that provides a national forum for institutions to collaborate on performance improvement, education and research related to high value health care.

HVPAA’s founders are Pamela Johnson, vice chair of quality and safety in the Department of Radiology and Radiological Science at the Johns Hopkins University School of Medicine, and physician lead on the Johns Hopkins Department of Medicine High Value Care Committee; and Roy Ziegelstein, vice dean for education at the Johns Hopkins University School of Medicine.

In the conference’s keynote speech, Allen Kachalia, senior vice president of safety and quality at Johns Hopkins Medicine, reviewed some of the barriers to providing high value care. They include fear of litigation, a desire for answers even if test results won’t change treatment, inertia (doing something the way it’s always been done) and just being “safe” by ordering more tests.

“Clinical leadership to change how we do things is mandatory,” said Kachalia, who is also director of the Armstrong Institute for Patient Safety and Quality. “Be explicit about what you’re trying to improve when you talk about improving value. It’s about reducing waste and improving quality of care for patients.”

Here are some suggestions for improvement discussed at the event.

Use a stethoscope with artificial intelligence to reduce referrals for pediatric heart murmurs. A study conducted by Reid Thompson, associate professor of pediatrics at the Johns Hopkins University School of Medicine, and graduate student Christine Kuryla, is reducing referrals to cardiologists for children with harmless heart murmurs. For the study, pediatricians use stethoscopes that record heart sounds, which are then uploaded through an app that uses artificial intelligence to analyze whether the murmur requires further evaluation.

Use data in electronic medical records to identify and help patients who are struggling with medication adherence. Johns Hopkins pharmacists Alona Crowder and Jessica Merrey use an adherence tool in the electronic medical record system to check if patients are taking their medications or taking less than recommended. If cost is the reason, the pharmacists can recommend solutions including less expensive medications, discounts from manufacturers or copay cards.

Reduce unnecessary abdominal ultrasounds. Johns Hopkins radiology fellow Nebiyu Adenaw and radiologist Pamela Johnson created an intervention to decrease unnecessary imaging for hospitalized patients. The radiologists developed an alert in the Epic electronic medical records system that lets physicians know that an additional abdominal scan within 72 hours of a previous one likely will not yield useful information. As a result, 16% of scan orders were canceled over a six-month period, with no evidence of compromised care.

 

 

 

Published in DOME NOVEMBER/DECEMBER 2019