This article is sponsored by BASE10 Genetics. This article is based on a Q&A discussion that took place during the Clinical Conference, with Dr. Phil Jacobson, Senior Medical Director at Base10 Genetics. The Q&A took place on May 5, 2022. The discussion has been edited for length and clarity.
Skilled Nursing News: I’m here with Dr. Phil Jacobson who’s the senior medical director of the company. He’ll share with you a little bit about himself and what they do.
Dr. Phil Jacobson: BASE10 provides data-driven technology platforms and software solutions to help improve patient care, as well as reduce costs and reduce the time burden for staff. I have an extensive background in academic and clinical practice in managing respiratory viruses, as well as with quality improvement, including designing sepsis alert tools and things that use technology to enhance patient care.
What is clinical decision support and how has it evolved?
Historically, clinical decision support I think of as clinical pathways or clinical protocols for specific disease entities, which can standardize care, and those pathways when they’re instituted correctly, they resulted in improved outcomes, as well as considerable cost savings. What we’ve done at BASE10 is develop some of these pathways in a way that uses consensus-based guidelines from authoritative entities such as AMDA, CDC, Infectious Diseases Society of America, and American Thoracic Society.
They come from the best experts in the world with these consensus ways of diagnosing and managing these things. I’m going to focus my comments today mostly on the infectious disease management aspect of this. Now, the way it’s evolved though, it’s gone beyond just saying to the providers and the nurses, here’s a pathway, here’s an algorithm, figure out how your patient fits into this.
Now, what we’ve been able to do at BASE10 is create software that actually reads the electronic chart and uses pertinent data from the patient, and pinpoints the area of the algorithm which is specific for that patient, so that you get very pointed recommendations about diagnosis and management from the software that we provide.
What pathways and tools have worked in the long-term care settings, and are they widely used?
Pathways are used throughout hospitals and some long-term care facilities. There’s some very interesting recent literature on pathways, most notably the one from the University of Missouri investigators. They developed the Missouri Health Quality Initiative. What these investigators did was they looked at 11 facilities in the St. Louis area, and they instituted clinical pathways for specific entities such as bacterial pneumonia, urinary tract infection, and influenza.
What they did was they planted nurse practitioners every day in each of those facilities, in addition to instituting these clinical pathways. Then what they found was that by using the clinical pathways and the nurse practitioners, they were able to get earlier detection and earlier treatment for these infectious disease entities, thereby reducing the severity of illness, and ultimately, considerably reducing hospitalizations over a six-year period. They demonstrated a considerable reduction in hospitalizations with improved care, early detection, and a savings of approximately $35 million.
Now, the issue becomes how do you implement this at scale, having a practitioner on site every single day in this environment that may not be so simple? The next best thing we think is to have this technology answer, the software that can actually read the patient chart and have the pertinent data available to providers who are offsite so that they can better manage the patients without being physically present. We think that that could be something that’s really important.
There’s another very important study done out of Ontario, Canada. This one didn’t involve nurse practitioners, but it involved 22 facilities looking specifically at the management of bacterial pneumonia to see if they could prevent hospitalizations by using clinical pathways. The clinical pathway they used was one where they instituted antibiotics IV fluids, pulse oximetry, and supplemental oxygen, if necessary. Half the patients were on the clinical pathway track and the other half just went about with standard operating procedures.
In some cases, they used standing orders to empower the nursing staff to just institute the pathway when the diagnosis was made, or the providers would be saying, okay, we got the diagnosis, go ahead and institute the pathway without giving specific explanations of what to do. What they found was once again they were able to get earlier detection, and earlier treatment of bacterial pneumonia, and they had marked improvement over the controls in terms of hospitalization rate for the pathway group so obviously improved care, but so much so also that they saved on average $1,000 per patient per diagnosis of pneumonia. Once again, another demonstration of how pathways or protocols can enhance, and this one didn’t even use the technology that I was talking about or the software reading the chart.
What are the implications of clinical decision support on quality and medication management which is something we hear in the nurse space all the time right now?
The three basic things that this can accomplish are improved care, cost savings, and time savings for the staff. All things that I’ve heard throughout the theme of today’s activities. In terms of the pathways themselves and keeping up to date with consensus guidelines, that’s one of the things that we’re doing. We’re taking the experts in the fields from all those authoritative entities. We’re able to give the best possible practice of these pathways and keep them up to date.
Now, some things are static but if you think about the pandemic how much has changed in terms of what the recommendations are, the monoclonal antibodies aren’t working very well, etc. We’re able to stay up to date about what the treatment guidelines are and what the diagnostic guidelines are from these entities.
In addition to that, it allows for these disparate points of data from the patient specifically to be captured in a way that’s useful for the management of the patient. Instead of the providers and the nurses scrounging around the chart, looking for data such as allergies or previous infection or renal function, or things that are really important, the software is able to provide this in a nutshell right in front of the face and provide recommendations associated with it.
Our software even uses data from antibiograms so that you can know what the resistance patterns are within the particular facilities. Up until this time, I’ve been emphasizing early detection and early diagnosis to prevent hospitalizations, to get better treatment, to have decreased severity of illness, but a very important aspect of infection management is preventing overdiagnosis and overtreatment, and there’s a strong public health initiative about antibiotic stewardship.
We don’t want to overuse antibiotics. What happens when we use antibiotics too much? For one thing, antibiotics have side effects just like any other drug. If you think about long-term care residents, there are already potentially a lot of other drugs, and the potential for drug-drug interactions which are adversarial is considerable. That’s one place where it’s a problem.
The use of antibiotics can create an environment that’s ripe for an infection called Clostridium difficile to thrive. Clostridium difficile can cause severe gastroenteritis which can be life-threatening, and in fact, does kill many patients every year. Maybe the most common and worst of all, the problems associated with the overuse of antibiotics is a multiple of drug resistance. The more we use antibiotics, the more pathogens evolve, so that they become resistant. When true infections occur, these antibiotics aren’t available to us to use, to treat these infections. This is a major public health problem in which thousands and thousands of people die every year because of multiple drug resistance.
For these reasons, we have to find a way with technology to pinpoint, to thread the needle of catching infections early, and get them treated while preventing overdiagnosis and overtreatment for all of these reasons.
Can you tell me what the cost benefits are? What cost benefits can be seen by implementing a successful clinical decision support system?
There are direct and indirect cost benefits, and the direct cost benefits are things like prevention of hospitalization, getting less severe ailments, and on the other side of that, prescribing too many drugs and too many lab tests are also very costly. There are some very direct, measurable cost benefits associated with using appropriate infectious disease management, and threading that needle as I mentioned about not underdiagnosing but not overdiagnosing. Then there are a number of indirect costs associated with it.
If you think about the time that a nurse spends just administering the drug seems fairly simple, but what does a nurse have to do? They have to find the drug wherever it’s stored, whether it’s a refrigerator or some compartment closet. They have to get that open. They have to use a scanning tool. They have to check the right drug, the right patient, and the right dose.
They have to come and administer the drug. If it’s an oral drug, they may have to bring some water. Then, of course, there’s making sure the patient’s able to take the drug plus the charting that goes along with it.
Every seemingly simple task has a lot of micro-tasks associated with it and is time-consuming. If you think about the scheduled drug, well, that can really throw off workflows. These are the types of indirect time-related costs that could be associated with this problem. We estimated at BASE10 that just for infectious disease management alone, we believe that up to 75% based on CDC reports and other people that about 75% of antibiotics prescribed, are inappropriate or overused. That’s a lot, and so just having this antibiotic stewardship can be something really important.
In addition to that, we estimate that savings, with appropriate infectious disease management direct costs of that facility of about 100 residents, could save about $80,000 per year just by getting this right, and from indirect cost and time, about 80 hours per year per 100-bed facility. We could see that there’s a lot of different things that could be done to save time and to save money.
Another thing that BASE10 does to help facilities is reporting. We’re talking about infectious diseases right now. There’s a lot of responsibility for state and government reporting. As many of you know during the pandemic, COVID reporting was a major burden on facilities, very time-consuming, and very difficult. Fifty-seven percent of facilities incurred citations for inappropriate or underreporting of COVID, and these citations come with hefty fines, and we’ve instituted a way with our technology to offer the service and take on the burden of reporting.
Additionally, the clients have been extremely pleased with the amount of time that was saved from the staff not being burdened with this. In short, I think that we’ve heard a lot about lobbying and doing things with the government, but we at BASE10 are focusing on creative solutions to how to take better care of the patients, how to do it at lower costs, and how to do it with reducing the burden of time that’s obviously on the shorthanded facilities.
BASE10 Genetics brings hope to the lives of vulnerable patients by helping them access the latest in precision medicine technologies through our disease management platform. To learn more, visit www.base10genetics.com.
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