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 question and answer was conducted on May 5, 2022. Discussion has been edited for length and clarity.
Skilled Nursing News: I’m here with Dr. Phil Jacobson who is the company’s senior medical director. He will share with you a little 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 staff time. I have an extensive background in academic and clinical practice in managing respiratory viruses, as well as in quality improvement, including designing sepsis alert tools and things that use technology to enhance patient care.
What is clinical decision support and how did it develop?
Historically, I believe that clinical decision support as clinical pathways or clinical protocols for specific disease entities, which can standardize care, and those pathways when properly established, lead to better outcomes, as well as significant cost savings. What we’ve done in BASE10 is to develop some of these pathways in a way that uses consensus-based guidelines from authoritative entities such as AMDA, CDC, the American Infectious Diseases Society, and the American Thoracic Society.
They come from the best experts in the world with these agreed-upon methods for diagnosing and managing these things. I will focus my comments today mostly on the infectious disease management aspect of this. Now, the way it’s evolved, you’ve gone beyond just saying to providers and nurses, this is a pathway, and here’s an algorithm, find out how your patient fits into this.
Now, what we’ve been able to do in BASE10 is create a program that actually reads the electronic chart and uses relevant data from the patient, and identifies the algorithm area for that patient, so that you get very thoughtful recommendations about diagnosis and management from the software we offer.
What pathways and tools have been successful in long-term care settings, and are they widely used?
The tracks are used throughout hospitals and some long-term care facilities. There is some interesting recent literature on the pathways, most notably that by University of Missouri investigators. They developed the Missouri Quality of Health Initiative. What these investigators did was they searched 11 facilities in the St. Louis area, and they created clinical pathways for specific entities such as bacterial pneumonia, urinary tract infection, and influenza.
What they did was they planted practice nurses every day in each of those facilities, as well as creating these clinical pathways. Then what they found was that by using clinical pathways and nurse practitioners, they were able to obtain early detection and early treatment of these infectious disease entities, thereby reducing disease severity and, ultimately, reducing hospitalizations significantly over a six-year period. They demonstrated a significant reduction in hospitalizations by improving care and early detection and saving nearly $35 million.
Now, the problem becomes how do you implement this on a large scale, having a practitioner on site every day in this environment that may not be that simple? The second best thing we think is to have this technical answer, software that can actually read a patient’s chart and have the relevant data available to off-site providers so they can better manage patients without them being physically present. We think this could be something really important.
There is another very important study conducted in Ontario, Canada. This did not include nurse practitioners, but did include 22 facilities specifically looking at the management of bacterial pneumonia to see if they could prevent hospitalization using clinical pathways. The clinical route they used was one way they put intravenous antibiotic fluids, pulse oximetry, and supplemental oxygen, if needed. Half of the patients were on the clinical track and the other half had just started on standard operating procedures.
In some cases they have used standing orders to enable nursing staff to establish the path only when the diagnosis is made, or providers will say, OK, we got the diagnosis, go ahead and establish the path without giving specific explanations of what to do. What they found is that they again were able to get earlier detection, early treatment for bacterial pneumonia, and they had a significant improvement over the controls in terms of the hospitalization rate for the pathway group, so obviously they improved care, but also so much that they saved an average of 1,000 Dollars per patient for each pneumonia diagnosis. Again, another demonstration of how to enhance paths or protocols, and this one didn’t even use the technology I was talking about or the software that reads the schematic.
What are the implications of clinical decision support for quality and medication management which is something we hear in the nurse space all the time right now?
The three primary things this can achieve are improved care, cost savings, and time savings for employees. All the things you heard during today’s activities topic. In terms of the paths themselves and keeping up with the consensus guidelines, that’s one of the things we do. We take experts in the fields from all those trusted entities. We are able to provide the best possible practices for these pathways and update them constantly.
Now, some things are consistent but if you think about the pandemic how much it has changed in terms of recommendations, monoclonal antibodies not working well, etc. We are able to stay updated regarding the type of treatment guidelines and what are the diagnostic guidelines of these entities.
In addition, it allows capturing these disparate points of data from a patient specifically in a way that is useful for patient management. Instead of providers and nurses walking around the chart, looking for data like allergies, past infections, kidney function, or things that really matter, the software is able to succinctly provide that in front of the face and provide associated recommendations.
Our software even uses data from antibiotics so you can see patterns of resistance within specific facilities. Up until this time, I had been emphasizing early detection and early diagnosis to prevent hospitalization, to get better treatment, and to reduce the severity of the disease, but a very important aspect of infection management is preventing overdiagnosis and overtreatment, and there is a strong public health initiative around antibiotic stewardship.
We don’t want to overuse antibiotics. What happens when we use too many antibiotics? For one thing, antibiotics have side effects like any other drug. If you’re considering residents in long-term care, there are likely already plenty of other medications, and the potential for drug-drug interactions to be antagonistic is significant. This is one place where there is a problem.
Using antibiotics can create an environment for an infection called Clostridium difficile to thrive. Clostridium difficile It can cause acute gastroenteritis that can be life-threatening and, in fact, kills many patients each year. Perhaps the most common and worst of all, problems associated with overuse of antibiotics are the compounding of drug resistance. The more antibiotics we use, the more pathogens evolve, becoming resistant. When a true infection occurs, these antibiotics are not available for us to use to treat that infection. This is a major public health problem in which thousands upon thousands of people die each year due to multidrug resistance.
For these reasons, we have to find a way with technology to accurately identify, thread the needle to catch the infection early, treat it while preventing overdiagnosis and overtreatment of all these causes.
Can you tell me what are the cost benefits? What cost benefits can be seen by implementing a successful clinical decision support system?
There are direct and indirect cost benefits, direct cost benefits are things like preventing hospitalization, exposure to less severe illnesses, and on the flip side of that, prescribing a lot of medication and a lot of lab testing is very expensive. There are some direct and measurable cost benefits associated with using appropriate infectious disease management, 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 a nurse spends administering medication sounds fairly straightforward, but what does the nurse have to do? They have to find the medicine wherever it is stored, whether it is a refrigerator or a small cupboard. They have to open it up. They have to use the scanning tool. They should check for the right medication, the right patient, and the right dose.
They have to come and administer the medication. If the medication is orally, they may have to bring in some water. Then, of course, there’s making sure the patient is able to take the medication as well as the chart that goes with it.
Every seemingly simple task has a lot of small tasks associated with it and it takes a lot of time. If you think about scheduled medication, well, that can really knock out the workflow. These are the types of time indirect costs that can be associated with this problem. We estimated at BASE10 that just for infectious disease management alone, we believe up to 75% are based on reports from the Centers for Disease Control and Prevention and other people that about 75% of antibiotics prescribed are inappropriate or overused. That’s a lot, so just supervising the antibiotics can be a really important thing.
Additionally, we estimate that the savings, with the direct costs of managing infectious diseases appropriate for that facility of approximately 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 can see that there are a lot of different things that can be done to save time and money.
Another thing BASE10 does to help installations is reporting. We’re talking about infectious diseases now. There is a great deal of responsibility for state and government reporting. As many of you know during the pandemic, reporting COVID has been a huge burden on facilities, very time consuming, and very difficult. Fifty-seven percent of facilities incurred citations due to inappropriate or non-reporting of COVID, these citations come with heavy fines, and we’ve built a way with our technology to deliver the service and take on the reporting burden.
In addition, customers were very pleased with the amount of time saved by the staff who did not bear the burden of this burden. In short, I think we’ve heard a lot about lobbying and doing things with government, but at BASE10 we’re focused on creative solutions for how to take better care of patients, how to do it at lower costs, and how to do it while reducing the time burden that’s obviously on shortened facilities.
BASE10 Genetics brings hope to the lives of at-risk patients by helping them access the latest precision medicine technologies through our disease management platform. To find out more, visit www.base10genetics.com.