NEXT, Extend Value Based Healthcare in Erasmus MC
By the Erasmus MC VBHC-team
Value Based Healthcare in Erasmus MC Rotterdam
Value Based Healthcare (VBHC) in Erasmus MC means: Working together with patients to deliver better care and improve patient outcomes at the lowest possible cost.” Since 2013, 24 diagnosis teams successfully implemented VBHC in our hospital. These teams incorporated routine outcome measurement using both generic and disease specific questionnaires. The outcomes are discussed with patients using tailored dashboards to support shared-decision making. We use aggregate outcome data to evaluate the quality of care on a higher level.
Evaluation of diagnosis-specific approach and extend implementation
In line with the goal of the Dutch Ministry of Health, Welfare and Sport to make outcome information available, Erasmus MC aims to provide insight for both patients and healthcare providers in outcome information for at least 50% of our patient population by 2023. This requires both acceleration and upscaling. Therefore, we critically evaluated our diagnosis-specific implementation approach. Although this approach has led to promising results, it is very time-consuming and not cost effective. For instance, the development and maintenance of tailored dashboards requires dedicated IT support. Moreover, Erasmus MC is a University Hospital mainly delivering tertiary care, we consult many patients with rare diseases and multi morbidities. As these patients are often enrolled in several care pathways, they have to complete multiple, diagnosis-specific questionnaires, which is highly burdensome. Consequently, we critically reviewed the questionnaires that we already use in our hospital. We found that most diagnosis-specific questionnaires include generic questions that can be used for multiple patient populations. Secondly, many of the diagnosis-specific questionnaires appear to cover constructs or domains that are applicable to most patients regardless of the diagnosis, for instance anxiety, depression, pain and engagement in social activities. Our findings confirm the strategy of The International Consortium for Health Outcome Measurement (ICHOM) to develop overall health sets and the NIH-funded initiative Patient-Reported Outcomes Measurement Information System (PROMIS) to develop a large amount of domain specific questionnaires and item banks, which are validated across different patient populations.
Considering the drawbacks of a diagnosis-based approach, we decided to change our strategy. Mid 2020 we started the implementation of a generic, global health questionnaire: the PROMIS-10. Since this is validated for adult patients, for our pediatric population, we selected the PROMIS-GH 7+2 patient and parent-proxy versions. We are aware that in some cases disease-specific outcomes are needed to deliver the best possible care. Therefore, we will have room for inclusion of diagnosis-specific items in the near future. This new strategy is in accordance with the recommendation of the Dutch Linnean Initiative to measure “generic where possible, specific where needed”.
IT as keyplayer
Reviewing our former diagnosis-specific approach also resulted in a different position of our business intelligence department. While they were hired by consultation in the past, they are now part of our VBHC team. Our first conjoined goal was to create a technical sound fundament. As Erasmus MC prefers having patient data in an all-in-one place system, the electronic health record (EHR) was selected to be the storage of all data. This required close cooperation with Erasmus MC staff responsible for the maintenance of our EHR developers. The combination of our VBHC team, business intelligence department and EHR staff enabled us to move forward fast. Patients now automatically receive an invitation to complete the PROMIS-10 a week prior to their outpatient appointment, including telephone and video consulting, triggered by a specific appointment code. Patients can complete the questionnaire via their personal portal, which is only accessible with a highly secured personal login. In this same environment, they have access to their EHR. Although patients fill out the questionnaire preferably at home, it is also possible to complete it in several waiting rooms in Erasmus MC. If patients completed their questionnaires, a dashboard with summed scores is available in the EHR, enabling our health care workers to discuss the results with their patients.
Although we are very proud of the accomplishments of our team so far, we have encountered several difficulties due to restrictions of the EHR. For example, healthcare professionals prefer to see instantly whether a questionnaire has been completed. If there is no data available, there is no need to visit the dashboard, saving them time. Despite numerous efforts, this option has not been realized yet.
We strongly recommend hospitals or departments that start with the implementation of VBHC or set the goal to scale up VBHC, to incorporate business intelligence and EHR developers in their team.
Secondly, the current characteristics of EHRs sometimes restrict user friendliness, which has a negative impact on implementation. The potential to alter and simplify these characteristics to make EHRs more user friendly should be higher placed on the strategic agenda of EHR companies.