How Smile’s Clinical Reasoning Expertise and Capabilities Contributed to a $10 M Operational Benefit
Executive Summary
Client: A large US payer and healthcare delivery organization
Summary: Smile Digital Health (Smile) authored Clinical Practice Guidelines (CPGs) and contributed to Clinical Decision Support (CDS) and Clinical Reasoning (CR) services for the client. Healthcare analytics and data-driven care delivery and quality metrics are a core competency of the organization. The first implemented set of solutions contributed an operational benefit of $10M within a single surgical unit. In continued efforts, these clinical guideline driven, real-time CDS recommendation solutions were expanded for chronic condition management and are still being used at the point-of-the-care today.
Objectives:
- Standardizing data inputs and outputs on FHIR® across all divisions with real-time connections to EHRs.
- To produce better, more efficient clinical recommendations and cognitive support, seamlessly integrated with the clinical workflow.
- To reduce inefficiencies, errors, delays, cost and time burdens in their manual and disjointed CDS processes.
- To adopt emerging best-practice clinical guidance early and enhance patient outcomes.
- To create a sustainable market share and new revenue streams in the CDS market.
The Challenge
Clinical data comes in a variety of formats and has a complex structure (structured, unstructured and semi-structured) depending on which proprietary EHR format it has been collected and stored in. When it comes to data exchange and interoperability, standardization of data has been a major road-block for the entire industry. Disparate data sources in a variety of unstandardized formats make it difficult (in terms of time, cost and manual burden) to achieve high quality data that can be used to provide high quality care across all points of care.
Through the years 2018 and 2019, the client acquired a number of primary and specialist clinics across the US, all of which utilized different proprietary EHR systems. As such, they inherited fragmented and inconsistent CDS solutions—specifications had different clinical definitions, fields, values and contexts making them unstandardized and not interoperable. The process of researching a variety of specifications, processing them and then making a clinical decision was entirely manual. This created both a clinical and business need to provide consistent, reliable, high fidelity CDS across the points of care delivery and breadth of care.
As a leading and innovative healthcare organization, the client saw the need to ensure consistent application of high quality care—applying a standards-based approach with evidence-based CPGs to patient care, across all points-of-care. In order to achieve better patient outcomes and enhance operational efficiency, the client needed to elevate their Clinical Reasoning (CR) and CDS technologies. They had to decide whether to build it completely in-house or buy the solution. They decided on a model, where Smile’s team would author CPGs and augment their codebase with fully integrated clinical capabilities. They chose this model because they had limited expertise and technical resources to build high-quality computable CPGs.
Smile’s task was highly nuanced and complex: to author re-usable CPGs into a standardized format, that would make relevant and efficient recommendations to clinicians; thereby supporting consistently available CDS to all points-of-care. The recommendations would then have to be implemented in a way that integrated with any EMR to reduce clinical burden and achieve efficient high quality treatment for patients with an overall lowered cost of care.
Expertise and Solution
Smile Digital Health is an award-winning company and a subject matter expert in FHIR, CQL and CR. Smile is the maintainer of HAPI FHIR—the world’s prevailing open source reference implementation—and custodian of CQF (Clinical Quality Framework) Ruler—a decision support service that runs quality measures on clinical reasoning. Smile directs and contributes to several IGs (Implementation Guides). These include, but are not limited to US Core CPG, CDS Hooks, CPG and QM. Smile is also the primary contributor to establishing the CDS standardization process into FHIR. Smile has over 160 real-world data transformation and modernization implementations around the globe.
The client was aware of the limited technical expertise in the field of health standards, in terms of both understanding, and applying them into clinical practice guidelines. In order to build the foundation, and grow their library of reusable and scalable CPGs, they needed Smile’s knowledge authoring expertise to augment their CDS process.
To this end, Smile Digital Health authored a set of CPGs as computable code to run and use along with CDS services. These reusable CPGs continue to work with the client’s common computable enterprise-level platform that tightly integrates the unified open standard data framework (FHIR) with a clinical logic standard, CQL.
In contrast with other CPG recommendation solutions, Smile takes specifications created by expert agencies—like ADA (American Diabetes Association), AHA (American Health Association) and NCI (National Cancer Institute)—and faithfully represents those established treatment guidelines using CPG logic. The resulting CPGs were then made available in near real-time at all points-of-care in the client’s network. Since CPGs are not locked into proprietary authorship, the client can scale them across clinics, regardless of which EHR system is being used.
The client analyzed the benefits of Smile’s expertise in authoring CPGs, and compared that with using their own in-house teams to build them from scratch. Given the depth of expertise and requirement of high-quality consistent CDS across clinics, they chose Smile knowledge authoring expertise to augment their CDS processes.
Technical Components of the Solution
Smile’s solution is integrates two key technical components:
- FHIR® is the dominant interoperability standard for health data exchange. It is a widely adopted open standard that provides unified specifications for how to describe health data. In the context of the quality improvement landscape and lifecycle, a FHIR-based solution enables the interoperability, availability and seamless exchange of clinical data.
- CQL (Clinical Quality Language) is a standardized authoring language that enhances the expressiveness and human readability of CDS and quality measures content. It is executable by a machine and enables consistent interoperability of clinical logic.
Together FHIR and CQL, eliminate systemic inconsistencies by providing semantic accuracy, reusability and system interoperability. FHIR resources are the foundational data elements for quality measurement, providing a standardized representation of clinical data. CQL, in turn, enables the expression of complex logic and criteria using these FHIR resources. This integration is the engine that powers the ingestion and normalization of data in an easily searchable language that runs fast, time-saving queries and analytics for CDS. Computable CPG can seamlessly integrate with any EMR at all points-of-care and then recommends best practices to support CDS.
Results of Implementing Smile’s Solution
Smile’s authored CPGs—built from established industry best practices for colorectal cancer post-surgical care—were consistently applied to a patient group of 3,000 patients under a team of 8 surgeons. A combination of multiple CPGs were used together in this setting.
The care team had access to real-time CDS and could compare it to a patient’s current state of recovery. This resulted in:
- An average 33% (1 day) reduction in length of patient stay. This reduction enabled the care team to complete more patient visits, better manage the clinic’s workflow and increase revenue.
- A 50% drop in post-operative risk complications. This improved patient satisfaction and reduced costs in the clinic as fewer additional procedures and corrective surgeries had to be performed—services that were often not reimbursable.
Prior to utilizing Smile’s authored CPGs, clinician staff started their shifts ~1 hour earlier in order to forage necessary data from paper and electronic records. At times, extra funding was required to hire additional administrative staff. Once the CPGs were implemented, there was a 95% reduction in time (and cost) spent doing administrative tasks like navigating records for information.
Combined, this resulted in a $10M operational benefit.
Additional mid and long term benefits the client is enjoying, as an early adopter of Smile’s cutting edge technology are:
- Rich CPG libraries—which combine healthcare specific language and established expert treatment plans with clinical logic, vocabulary and content—that form the basis for high-value AI generated analytics.
- De-risking the health ecosystem, as quality measures can be run on the same data as the CPG specification.
How Smile is Leading the Way
The adoption and application of standards—common methods, guides and measures—in an industry creates the foundation for how large-scale problems are solved in the real world. For example, when ISO (International Standards Organization) came into existence in 1947, several nations adopted common standards in an effort to rebuild infrastructure after the war. The standardization of processes, materials and components, along with management and quality guidelines, enabled specialization of skill, efficient utilization of resources (time, funds and labor) and provided the ability to drive progress across industries, including healthcare. Today organizations such as HL7 (Health Level Seven International) create open interoperable standards—like HAPI FHIR—to create new foundations for global health IT infrastructure.
Smile’s solution suite is a commercially viable, enterprise-level solution that integrates these foundations with clinical logic (CQL) into a robust architecture, which no other vendor in the marketplace currently offers. The solution architecture allows for more advanced capabilities like Multi-threaded Processing—the ability to have multiple concurrent users of a program without duplicating it. This is an essential requirement to ensure organizations have high-performance solutions that are robust, secure, scalable and supported by technology experts.
Even with well-established CPGs, the lack of standardization and interoperability results in inconsistent application. Adherence to CPGs for colorectal surgery can be as low as 29%, which creates gaps in care. Smile’s solution suite can be leveraged for predictive assessment of care gaps and clinical recommendations to close the gaps before they ever occur. By choosing Smile as a vendor for digital transformation and innovation for any one part of the CQI lifecycle, the technology implementation will solutionize the entire cycle—be it CPG, CDS, CQM or dQM.
Historically, CDS and Clinical Quality Measures (CQM) were developed in silos and were not interoperable; even though they are both a part of the Quality Improvement cycle. A meaningful and continuously evolving CQI (Clinical Quality Improvement) cycle requires harmony and exchange between these two specifications, so that improvements can be assessed, implemented and measured. Integrating FHIR and CQL brings needed technological revolution to harmonize the entire lifecycle of CQI, including but not limited to CDS, CQMs and dQMs (digital quality measures).
The work to unify the quality lifecycle solution has taken almost a decade. The standards and cutting edge technology—FHIR, CPG and CQL based solutions—now exist. The next steps are to capitalize on this work and invest in the innovative Clinical Quality solution suite within the Smile Health Data Platform (HDP) to generate sustainable improvements in revenue, operations, patient care and care quality.