People who know me know that there’s one thing I hate at work – duplication of efforts. I’m not talking about working on a problem in a coordinated fashion. I’m talking about two or more people doing the same work, to answer the same question. Without coordination, there will be some combination of waste and confusion based on having two sets of results.

Why do we have duplicative diagnostic testing?

In the past several years, the medical community has focused on duplicative diagnostic testing. Why? Because of the negative effect of additional radiation on overall health, combined with these tests’ prevalence and costs.  A study presented at the 2011 American Academy of Orthopedic Surgeons (AAOS) conference showed the top reason for “over-testing” patients is defensive medicine; while peer review, financial incentives, and lack of information-sharing are also contributors.

• Defensive medicine. Physicians are afraid of being sued because they didn’t order a test. In fact, 19 percent of tests, accounting for more than 35 percent of imaging costs, were done purely for defensive purposes.
• M&M conferences. Not surprisingly, physicians aren’t motivated to “confess” to their peers because they don’t want to present their mistakes at Morbidity & Mortality conferences. According to the AAOS survey, physicians are actually more likely to order more tests for minor symptoms – if they’ve had a previous negative experience that went through this peer review process.
• Financial incentives. The current fee-for-service model provides little penalty for duplication of tests, and doesn’t align with medical necessity.
• Lack of information sharing. When a single physician or group is taking care of an individual’s medical condition, they typically have access to all of your relevant tests and clinical data. But most procedures require a team of providers – including physicians, surgeons, anesthesiologists, therapists, and others – along with batteries of tests for both diagnosis and recovery. More often than not, these providers work under more than one roof, or will at least have different EHR and billing systems. Sharing clinical details across a procedure’s entire episode of care is difficult, at best. In fact, the mere mention of the topic raises the blood pressure of HIPAA Privacy and Security Officers everywhere.

Stopping the duplication…

So how can this change? Unless you’ve been living under a rock for the last few years, you’ve likely heard of the payment reform currently underway for Medicare, and have seen its influence on private plans throughout the US. Basically, the goal is to eventually pay for a procedure like a knee replacement with a single, lump sum payment. This payment would cover all work required to diagnose, treat and complete care for the patient’s medical condition. The individual test, procedure and post-operative work would all be bundled together into a single payment to be shared. The result will be that providers will have to figure out the best way to diagnose and treat patients, including omission of anything unnecessary and costly.

Looking at the episodes of care concept from this duplicative efforts perspective has been like turning on a light for me. In particular, the alignment of financial incentives and information sharing in these models has great promise to reduce duplicative efforts. I can see a future where:

• Providers are able to focus on standards of care and medical necessity, and can have more confidence when following these standards, rather than being consumed by malpractice and peer review fears.
• Providers and payers can share the financial risk of caring for the most complex patients, because of a strong financial model that supports care delivery for an entire episode of care.
• Providers can share relevant information to all providers involved in the entire episode of care, with confidence in the underlying security models and data governance. And a combined standard of care spans the episode and drives sharing of test results.

Levels of understanding and confidence are raised through being able to understand all components, services and complications stemming from all providers involved in a patient’s episode.

Analyzing episodes of care

SAS has built a solution - SAS^® Episode Analytics – that can help organizations not just understand the services and components that comprise an episode of care, but also bring light to both potentially avoidable complications and variations in care – even within the care delivery process itself. The insights that can be gained by looking at patient care data from this approach can transform how physicians practice medicine.