Dr Peter Edelstein, Chief Medical Officer, Elsevier Clinical Solutions, gives an overview of how the healthcare scenario in India can be improved by implementing clinical decison support solutions which are broadly classified into ‘Pull CDS’ and ‘Push CDS’ solutions
“Health and healthcare are changing across the world.” I’ve not only repeatedly heard it, but have also witnessed it. My journeys across the globe have allowed me to meet with healthcare thought leaders, government officials, and hospital administrators, all seeking to address the significant quality and cost-efficiency challenges that are inherent in healthcare delivery. Many countries are experiencing a shift in the definition of healthcare, moving away from the traditional focus on ‘the doctor-patient relationship’ towards a broader goal of ‘Population Health.’
India, being the most diversified country, in terms of culture, language, and health, holding nearly one-fifth of the entire world’s population is predicted to become the most populous by the early 2020s. Adding to these demographics, the growth in medical malpractice litigation as well as the financial realities associated with maintaining such a nation, and the significant dangers posed by poor quality, high cost healthcare becomes very clear.
So what does it mean for India to drive towards ‘Population Health?’ It means implementing sweeping changes in operations and, more importantly, in the perspective of doctors, patients, and government leaders to force a dramatic shift away from reactive, acute, primarily inpatient care to proactive, out-of-hospital, preventative care and health maintenance. It requires abandoning the belief that physicians and the Indian government are primarily responsible for individual Indians’ health; that is, Indian patients themselves must accept responsibility for owning their health and participating in healthcare decisions and activities. It means a significantly greater dependence on nurses and other non-physician providers to support preventative health and health maintenance across the nation.
What I am proposing is truly radical change. And India, with its entrepreneurial spirit and democratic principles, is among the few nations with the potential to successfully execute such difficult changes now and in the future.
But real healthcare reform cannot be a wedding; it must be a marriage. That is, changing the Indian population’s perception of responsibility for health and healthcare is not a one-time event. Rather, meaningful healthcare reform represents a commitment to continuous improvement and maintenance of the health of all of India’s varied populations, to consistently and sustainably deliver high quality, cost efficient care at all points across this vast nation.
Of course, such seismic change requires investment. But just as important as how much a nation spends on the health and healthcare of its people is how wisely it spends its money. India’s current healthcare spending (as a percentage of GDP) has been criticised as being too low; while that may be true, it is most important that how India spends its healthcare dollars offers the greatest return-on-investment. Fortunately for India (and the rest of the world), the basic economics of healthcare are opposite those of other industries. In non-healthcare sectors, better quality costs more. If you want a nicer car, home, dinner, you must pay more for the better quality. But not so in healthcare. In healthcare, better quality costs less. Thus, patients who undergo cancer screening and are diagnosed with early stage malignancies have better outcomes at lower costs. Heart failure patients who weigh themselves daily avoid emergency hospitalisations, better quality for the patients and less expense for the system. Prevention of millions of preventable errors annually will dramatically improve the lives of Indian patients while saving hundreds of billions of rupees. Thus, wisely investing will not only improve the health of the Indian people, it will ultimately reduce the cost of healthcare.
And the goal of investment is simple: reduce variability.
Why do you take the same train to work each morning? Why must pilots complete a check-list before every flight? Because in virtually all aspects of our lives, variability is damaging. If you take a different train to work, you’re more likely to be late. If we leave it up to each individual pilot to decide if a plane is safe for flight, planes will crash and people will die. And in healthcare, variability leads to patient injury, patient death, and significant wasted resources and money. Even within the same hospital, the variability provided by two orthopedic surgeons in treating identical patients leads to different clinical outcomes and costs of care. A surgical nurse assigned for one shift to care for cancer patients likely provides care of lower value (quality divided by cost) than the care provided by an experienced oncology nurse. A recent nursing school graduate may waste resources or provide poorer quality care as a result of inexperience. Nor are patients immune from the damage caused by variability: A majority of Indians are unaware about the preventive measures of cancer and type-II diabetes.
To implement reforms, India must commit to invest in two major areas: information and people.
While approaching reforms, information is often confused with technology. In India, people believe that implementing electronic health records (EHRs) will dramatically improve health and the value of delivered care. While it is true that EHRs reduce some dangerous variability (for example, medication orders are clearly entered and presented for all to see), in reality, EHRs serve only as a vehicle to deliver the powerful solution to dangerous variability: current, credible, evidence-based information. It is knowledge of best practices that reduces variability, improves clinical outcomes, and drives down costs. Whether delivered most efficiently via EHR, read off of a smart phone, or provided in ink on a piece of paper, current, credible, evidence-based information is what can reduce preventable medical deaths and injuries and increase the cost – efficiency of healthcare. Such information, broadly defined as Clinical Decision Support (CDS), is the most impactful answer to the vast and destructive problem of variability, whether due to variability in physician, nurse, or patient knowledge.
While there are many types of CDS solutions, they fall broadly into two categories. The first category I call ‘Pull CDS Solutions.’ Reference solutions are an example of a Pull CDS Solutions. Like the seatbelt in your car, which is enormously helpful in reducing the risk of death or injury when driving, but only when buckled, Pull CDS Solutions are very beneficial in reducing risk and cost by providing current, credible, evidence-based information, but only if they are used. Don’t buckle your seatbelt, and the seatbelt can’t protect you. Don’t actively access a reference or other Pull CDS Solution, and it can’t protect the patient. The challenge of such Pull CDS Solutions is that physicians, nurses, and patients often “don’t know what they don’t know.” Because they don’t realise that they have a knowledge gap, they are unable to actively search for information on a Pull CDS Solution. So again similar to your car, there are airbag analogs:
Push CDS Solutions. Order sets are one example. Push CDS Solutions (like your airbag) automatically provide protection whether or not the target of the push realises they have a knowledge gap. Thus even when a physician fails to appreciate that a cancer patient should undergo blood testing for a genetic syndrome, an order set can push this evidence-based suggestion to the physician. Best practices can be pushed to nurses to drive quality and cost efficient care regardless of the nurse’s experience (or lack thereof). Health screening, medication, and other credible preventative and care maintenance information can be pushed to patients and their loved ones.
And the best value? A combination of seatbelts and airbags; that is both Push and Pull CDS Solutions.
Thus, an early major Indian investment should be in a combination of Push and Pull Clinical Decision Support Solutions which deliver current, credible, evidence – based information to doctors, nurses, other traditional providers, and patients. India should not wait until EHRs are widely in use; rather, powerful CDS solutions can immediately improve the quality and cost of healthcare across India via EHRs, the internet, or even through print. Why should patient care suffer just because an EHR is not available when the answer is information? CDS solutions can be added in a modular fashion (particularly if purchased through one or a limited number of vendor partners). Order sets, reference solutions, care plans, drug information, nursing skills, patient engagement and education. There are many Push and Pull CDS Solutions to implement and add based on the specific needs and strategies of individual population health providers.
The second area for India to initially invest in is human capital; that is, people. It is unrealistic for India to rely solely on its limited number of physicians to drive impactful healthcare reform. After all, virtually all of every Indian patient’s time is spent away from a doctor. India’s greatest potential to improve the quality and cost efficiency of healthcare is by empowering two critical non-physician provider groups: nurses and patients. Unlike the U.S. and some other countries, India’s nurses are limited in education, in responsibilities, and, most importantly, in perceived value to impact population health. But given that there are many more nurses than doctors, and given that with advanced practice training, Indian nurses could mimic their American counterparts in providing safe, high quality, cost efficient basic care activities currently delegated to physicians. Educating and empowering nurses can significantly and favorably shift the Indian healthcare value curve. Indian nurses (both with and without advanced training) supported by nurse-specific Push and Pull CDS Solutions would dramatically improve health and healthcare across the country.
And to truly reform, India must commit to an even more challenging “people investment”: patients themselves. It is critical that India begin the long process of radically altering the entire population’s view (including that of physicians and governmental health authorities) as to who truly owns health and healthcare: the patient. As individual adults, we are responsible for our debts; our children’s safety, education, and care; showing up for work and doing our jobs; our behavior; virtually every aspect of our lives. Yet when it comes to health, Indians join hundreds of millions of others around the world (including millions of Americans) who somehow feel that their health and healthcare are the responsibility of others (physicians, the government). Until Indian patients truly begin to own their health, healthcare reform cannot realize its full potential. Such a monumental change in perspective requires investments in public education (such as via public awareness campaigns for sub – populations) and Push and Pull CDS Solutions geared specifically to engage and educate patients and their families about preventative and maintenance healthcare.
The challenges and obstacles posed by radical healthcare reform are indeed great. But the reality is that particularly for densely populated India, the danger of waiting to initiate and invest in meaningful reform activities is much greater, as without real change, both the quality of life for Indians and the ultimate cost of healthcare will become unacceptable.
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