• Simulations Train Clinicians in Value-Based Decision Making

    Oct 23, 2012

    Web-based clinical simulations allow clinicians to see how their medical decisions will likely impact care quality and cost-critical information as fee-for-service healthcare models are replaced by value-based models.

    By Bob Yayac

    Healthcare payment is changing. Fee-for-service revenue based solely on volume and admissions is shifting to value-based models, such as accountable care organizations (ACOs) and patient-centered medical homes. Healthcare leaders now find themselves squarely in the middle of the big three of healthcare reform: a better patient experience (including quality and satisfaction), better health for populations, and reduced per-capita costs. Achieving the Institute for Healthcare Improvement's Triple Aim depends, in large part, on patient and provider behavior.

    Hospitals and health systems will not meet their objectives without first changing the long-entrenched behaviors of clinicians trained to optimize their decisions in the fee-for-service model. Physicians and other clinical staff need to be trained and given time to practice making decisions that will not only enhance clinical outcomes, but also reduce costs and improve the patient experience. To this end, web-based clinical simulation platforms offer a safe environment for assessing specific skills and providing personalized feedback.

    Using Simulation for Training

    Most healthcare providers are familiar with traditional forms of patient simulations, including mannequins, task trainers, and actors posing as patients. Although valuable for certain applications, these types of simulations are limited in their ability to enhance or assess clinical decision making. In contrast, web-based clinical simulation platforms?which enable clinicians to work with virtual patients?replicate the complex challenges healthcare providers face daily.

    An interactive clinical simulation platform presents a patient's story and background information and offers healthcare providers multiple decision paths, showing the impact of their decisions without the risk of actually treating patients. Simulations that use a branched narrative structure offer scenarios and variations that evolve in real time in response to a clinician's decisions. Unlike lectures, text-based training, or other traditional medical education formats, simulations show the immediate consequences of each decision just as they would play out in real life. For example, a physician can see the cost differences and risks between various tests for a patient with suspected colon disease. The simulation screen offers the following choices:

    • A simple $100 X-ray of the abdomen
    • A more detailed $350 computed tomography (CT) scan with its associated higher radiation exposure 
    • A colonoscopy, which has better sensitivity and therapeutic capability but also poses higher risks and costs about $1,000

    Clinicians' schedules are busy, so training time is a valuable and limited resource, and it must be used effectively. Interactive patient simulation platforms promote deliberate practice that engages clinicians: They don't simply ask clinicians to go through the motions of a training exercise. In addition to receiving a score for the simulation exercise, clinicians receive other feedback on their performance, including the costs and patient satisfaction levels that result from their decisions. Their performance can be measured against experts or their peers, as shown in the following computer screen shot.


    Applying Clinical Simulation: Three Examples

    Healthcare organizations can use clinical interactive simulation in a variety of ways, including to:

    • Assess a clinician's current decision making
    • Allow clinicians to actively practice applying new clinical guidelines or knowledge
    • Evaluate a clinician's competency
    • Reinforce a clinician's understanding of new procedures and approaches

    For example, the Veterans Health Administration (VHA) is using clinical simulation in its SimLEARN program, which is helping to improve the quality and consistency of care for veterans. Early projects are focusing on addressing the needs of women veterans, who make up an increasing percentage of the VHA's patient population. Through simulation, clinicians are being trained to correctly diagnose and treat female veterans to improve outcomes and increase satisfaction rates.

    In another example, one leading medical school in Canada is currently investigating the use of interactive patient simulation to help improve care continuity by training physician residents in effective patient handoffs. Residents will practice their documentation and workflows with simulations to ensure that the next resident or attending physician can understand the notes and appropriately follow the care plan.

    The MedStar National Rehabilitation Hospital (NRH) in Washington, D.C., is using an interactive patient simulation platform for a somewhat similar continuity initiative: It is being used to train community health workers who aid recently discharged stroke patients in an effort to improve their outcomes and avoid readmissions. NRH trainers designed virtual cases depicting common ethical dilemmas that arise while working within the community. Some cases advance what a lay person might reasonably think is an ethical response, while others illustrate the truly correct ethical response from a research perspective.

    Changing Behavior: The 4 R's

    Changing personal behavior is a challenging process that typically involves four R's: recognize, remediate, reassess, and reinforce. Here's how a clinical simulation platform tackles each step.

    Recognize. Gaps and variances in decision making are identified by assessing clinicians on a simulation platform using common patient scenarios. During a typical simulation training session, a clinician is presented with several types of encounters, or cases. Each case presents the clinician with different levels of complexity and different levels of cost and quality consequences for each decision.

    The simulation not only records each clinical decision, but also provides the opportunity to query the clinician as to why each decision was made. For example, if a healthcare organization wants to curb the use of high-cost imaging, it could present physicians with cases of patients who require an imaging study, and ask the physicians to select from a variety of imaging studies of varying costs-and then measure which ones clinicians select.

    Remediate. Once a clinician's decision-making process is understood, the simulation platform can be used to run through similar cases, but this time providing educational feedback along the way. The platform can reinforce a correct decision or, when a clinician makes an incorrect choice, it can offer information about the correct evidence-based protocols or lower-cost alternatives. Using the imaging example, a simulation could present evidence about imaging best practices and their cost impacts. Continued practice with related cases can help ensure that clinicians transfer these decisions into daily practice.

    Reassess. After a clinician completes the cases described above, the simulation platform can present new, yet similar, patient encounter scenarios to reassess the clinician's decision-making. If the provider still has not changed his or her behavior, then the remediation phase can begin again. Not all of these phases need to be completed in one session. One significant value of a web-based training environment is that clinicians can resume training at their convenience wherever they left off.

    Reinforce. Without reinforcement, any skill eventually atrophies. For this reason, clinicians will need to reassess and reinforce decision-making skills periodically to ensure long-term success in value-based payment models.

    Sharpening decision-making skills is a continuous process, and clinical simulations are a cost-effective approach to meet that need. Furthermore, a simulation platform's reporting tools provide verifiable documentation showing that clinicians have been trained to follow the best evidence-based protocols. These data are an important component of a risk-management strategy and may offer healthcare executives leverage during payer or ACO negotiations.

    Tracking the Impact

    Given the challenges of changing care models, the need to continually sharpen clinical decision making has become a vital component of all healthcare education and training. Web-based clinical simulations offer hands-on, interactive training in a safe environment. With the ability to track key financial metrics and performance indicators in the simulated cases, clinicians can see how their decisions likely would impact care quality and cost. In the new payment environment, these data translate directly to the physician's compensation and a hospital's bottom line.

    Bob Yayac is the president and co-founder, Decision Simulation LLC, Chadds Ford, Pa. (bobyayac@decisionsimulation.com).