Estimating the ROI for Computerized Clinical Decision Support Systems: Pieces of the Puzzle

Slide Presentation from the AHRQ 2011 Annual Conference

On September 19, 2011, Terry Field made this presentation at the 2011 Annual Conference. Select to access the PowerPoint® presentation (660 KB). Plugin Software Help.

Slide 1

 Estimating the ROI for Computerized Clinical Decision Support Systems: Pieces of the Puzzle

Estimating the Return On Investment (ROI) for Computerized Clinical Decision Support Systems (CDSS): Pieces of the Puzzle

Terry Field, S.Dc.
Meyers Primary Care Institute
University of Massachusetts Medical School,
Fallon Community Health Plan, Fallon Clinic

Slide 2

 Pieces of the Puzzle: Adding CDSS to Existing Electronic Health Record (EHR)

Pieces of the Puzzle Adding CDSS to Existing Electronic Health Record (EHR)

  • Development and implementation costs.
  • Immediate, direct costs and savings.
  • Potential additional savings.

Slide 3

 Development Cost Example 1

Development Cost Example 1

  • Long-term care setting.
  • CDSS to provide prescribers with patient-specific maximum dosing recommendations based on renal function.
  • Added to a commercial EHR with integrated Computerized physician order entry (CPOE) (Meditech).
  • Included 62 drugs; 94 alerts specific to the level of renal insufficiency.

Slide 4

 Tracking Personnel Time and Costs

Tracking Personnel Time & Costs

  • Internal: physicians, pharmacists, informatics project manager, project coordinator, health services researcher weekly reports from each participant with hours by category.
  • External : specialized programmer tracked through bills submitted.

Slide 5

Cost Analysis  

Cost Analysis

  • Reported hours combined with U.S. national average hourly wages for the appropriate personnel categories.
  • Submitted bills from external programmer.

Slide 6

 Results-Personnel Time and Costs

Results—Personnel Time & Costs

CategoryHoursCost ($)% of total time
Physicians41425,90245
Pharmacist—MS1205,30713
Pharmacist—BS601,8146
Informatics Project Manager1224,98713
Project Coordinator801,3159
Researcher185292
Programmer1108,81312
Total92448,668 

Slide 7

Results-Activities and Costs

Results—Activities & Costs

ActivityHoursCost ($)% of total cost
Determining contents48227,45556
Preparing blueprints for programmer511,8694
Programming1108,81318
Testing and implementing793,3227
Informatics project management1224,98710
Project coordination802,2205
Total92448,668 

Slide 8

 Alternative Scenarios

Alternative Scenarios

  1. CPOE system does not require specialized programmer.
    Hours: 924, Cost: $43,268.
  2. Database for renal dosing exists.
    Hours: 657, Cost: $34,201.
  3. CDSS Product exists.
    Hours: 475, Cost: $23,695.

Slide 9

Development Cost Example 2  

Development Cost Example 2

  • Ambulatory setting—large group practice.
  • Automated alert system to provide PCPs with:
    • Notification of hospital and SNF discharges.
    • New drugs added during hospital stay.
    • Recommendations related to dosing and monitoring.
    • Reminders to support staff to schedule follow-up visit.
  • Added to a commercial EHR with CPOE (EpicCare Ambulatory EMR).

Slide 10

 Results-Personnel Time and Costs

Results—Personnel Time & Costs

CategoryHoursCost ($)% of total time
Physicians61455,34047
Operations research analyst37012,56128
Research assistant2023,88516
Registered nurse581,8734
Computer software engineer401,6923
Database administrator175971
Pharmacist73671
Total1,30876,314 

Slide 11

 Results-Activities and Costs

Results—Activities & Costs

ActivityHoursCost ($)% of total cost
Determining content16914,97720
Designing and preparing HIT application33015,84720
Developing blueprints for programming32514,91720
Programming27317,40623
Testing/revising1648,95411
Project management2219833
Maintaining262,2313

Slide 12

 Special Issues in Development Costs

Special Issues in Development Costs

  • Substantial time required from clinical personnel!
    • Determining contents (or reviewing if purchased).
    • Extensive time spent testing.

Slide 13

 Potential Costs and Savings Immediate, Direct Impact

Potential Costs & Savings Immediate, Direct Impact

  • Long-term care setting.
  • Within an randomized controlled trial (RCT) of the renal dosing CDSS described earlier.
  • Randomized by unit within a large long-term care facility.
  • Costs and savings related to drugs and laboratory tests.

Slide 14

 Tracking Costs and Savings

Tracking Costs & Savings

  • Drugs that triggered an alert as prescriber began the order vs. drugs actually ordered.
  • All drug orders for the day of an alert reviewed to identify potential substitutes.
  • Drug costs based on U.S. wholesale price at the time.
  • Serum creatinine tests ordered within 24 hrs of alert of missing lab information—costs based on Medicare allowable payments at the time of the order.

Slide 15

 Analysis

Analysis

  • Within both intervention and control units, we compared costs for initial vs. final submitted drug orders.
  • Adjusted findings from the intervention units by findings in the control units.
    Note: Even in the control units, prescribers changed their minds during an order!

Slide 16

 Results

Results

  • Estimated savings for drug orders: $2,160.
  • Estimated additional costs for lab orders: $769.
  • Total estimated savings: $1,391.

Slide 17

 Potential Additional Savings: Reduced ADEs

Potential Additional Savings: Reduced ADEs

  • Setting: large, multispecialty group practice providing care to >30,000 Medicare enrollees.
  • Case-control study nested in a cohort study that identified adverse drug events from 7/1/1999 to 6/30/2000.
  • Control group—for each subject with an event, we randomly selected a control matched by having an encounter and dispensing in the month prior to the event.

Slide 18

 Determination of Costs

Determination of Costs

  • Outcome measure: costs of medical care from 6 weeks prior to the event through 6 weeks after.
  • In-patient stays, emergency department (ED) visits—national average of cost-to-charge ratios.
  • MD visits, dx tests, therapy, lab, ambulance use, home health, DME—Medicare fee schedules.
  • Pharmaceuticals—average wholesale cost on day dispensed.

Slide 19

 Analysis

Analysis

  • Average total costs for cases and controls calculated and plotted.
  • Estimated surge in costs calculated by subtracting pre-event costs from post-event costs for each individual.
  • MVA with cost surge as outcome and case status as exposure, controlling for confounders.
  • Analyzed for 1225 case/control pairs and 325 pairs for preventable adverse drug events (ADEs).

Slide 20

Results

Results

Image: A graph shows total costs in 2-week periods before and after the ADE. Costs are considerably higher 1-2 days after the ADE.

Slide 21

Results  

Results

Component of costIncrease in costs after
preventable ADE*
(95% confidence interval)
Total1983 (193, 3773)
In-patient stays1222 (-320, 2763)
ED visits111 (17, 205)
Out-patient care571 (227, 915)
Prescribed meds79 (24, 134)

*Controlling for age, gender, Charlson comorbidity index, # scheduled meds, hospitalization in pre-period.

Slide 22

 Extrapolation

Extrapolation

  • 1,000 enrollees age 65+ for 1 year 13.8 preventable ADEs $27,365 (CI $2,663, $52,067) in 2000 dollars.
  • All Medicare enrollees age 65+ in 2000 $887 million for preventable adverse drug events.

Slide 23

 Summary

Summary

  • Development costs are significant.
  • Development (or even implementation) requires extensive time from clinicians.
  • Immediate, direct cost savings may be minor.
  • Savings from reductions in adverse events are likely to be substantial.
  • Complete, detailed tracking of adverse events and their associated costs is a large and expensive task!
Current as of March 2012
Internet Citation: Estimating the ROI for Computerized Clinical Decision Support Systems: Pieces of the Puzzle. March 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2011/field/index.html