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

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.

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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)

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

Slide 3

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.

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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.

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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 & Costs

Slide 7

Results—Activities & Costs

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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.

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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).

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Results—Personnel Time & Costs

Slide 11

Results—Activities & Costs

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Special Issues in Development Costs

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

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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.

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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.

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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!

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Results

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

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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.

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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.

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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).

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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.

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Results

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

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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.

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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!