Pushing Strong Decision Support to the Point of Care

Within the competitive healthcare areas of Colorado, California, Kansas and Montana, SCL Health System has integrated evidence-based decision-making directly in its EMR to support, enhance and speed patient care decisions. One-click, fully integrated access to a clinical point-of-care resource was a must as was a clear implementation strategy and plan to spur physician adoption.

SCL Health System (SCLHS), based in Denver, is a faith-based, nonprofit healthcare organization operating 11 hospitals, four safety net clinics, one children’s mental health treatment center and more than 100 ambulatory service centers in four states--Colorado, California, Kansas and Montana. The $2.7 billion health network was founded by the Sisters of Charity of Leavenworth, who opened their first hospital in 1864.

SCLHS has always been progressive in adopting and deploying leading edge technology, says Joe Heaton, MD, vice president and chief medical information officer. Heaton, who practices hospital medicine in the Denver area, has been additionally focused on IT initiatives for almost a decade. SCLHS deployed its first enterprise EMR in 2004 and expanded it in 2009 to a new Epic system in Denver at Exempla Saint Joseph Hospital and Exempla Lutheran Medical Center, and the following year at Exempla Good Samaritan Medical Center. From November 2011 to November 2012, SCLHS brought seven more hospitals across the health system in Colorado, Montana, and Kansas onto the shared EMR platform. In 2013, the team is focusing on ambulatory implementations across the system. “We needed to learn how to be more efficient and show value while sharing an EMR in a cost-effective way with a system-wide approach,” Heaton says, one that also supported their established clinical point-of-care resource, DynaMed. “Allowing easy access to knowledge-based, medical references at the point of actual care is a priority for all of our facilities. And so are integration and workflow of the whole experience.”

Heaton stresses that an integral part of the EMR are the tools accessed through it. “Decision support tools are part of the value the EMR brings. Good clinical decision [support] is not obstructive, it is integrated at the pointof care, thus being part of care,” he says. “It must be intuitive within the system. In contrast to some alerts and reminders, it needs to be both satisfying and value-added rather than intrusive to the physician making decisions. We have approached it as an integrated, point-of-care knowledge tool imbedded in a nonintrusive and non-obstructive way. It assists with workflow.”

The process for selecting the right decision support

Heaton was part of the team that made the choice to stick with DynaMed when the SCLHS facilities were implementing their EMR. Decision-making was shared with three groups: physicians fluent in informatics, the CMO, medical leaders and key administration and their team of medical librarians. Physician leads from each hospital took part in product demonstrations, had open system access for a couple of months and shared system features with clinician peers. The medical librarians supported DynaMed’s superior methodology and integration capabilities, sharing that insight with physicians, Heaton says. Also lending credibility was a 2011 British Medical Journal study that measured the incidence of research findings relating to potentially eligible newsworthy evidence among DynaMed and four other decision support systems. DynaMed “cited 87% of the sampled reviews, while the other summaries had cited less than 50%. The updating speed of DynaMed clearly led the others,” it stated. (http://www.bmj.com/content/343/bmj.d5856)

The CMO and physician and administrative leaders absorbed the feedback and asked questions focused on efficiency, the need for tight integration with the EMR and cost. They also looked at national product rankings. DynaMed emerged the clear choice “in terms of performance and a serious cost advantage,” Heaton offers.

Once the decision was made, Heaton and his team laid out the strategy for the go-live of the enterprise-wide EMR install that included financial, clinical, ER, OR, Med Surg capabilities as well as decision support at seven hospitals in 12 months.

For a clinical point-of-care resource to be used well, the integration needed to be seamless for clinicians. The SCLHS team introduced easy access to DynaMed via a right mouse click from the problem list. The physician or clinician doesn’t have to leave a specific patient record to see diagnostic and therapeutic references. Take for example Lyme disease, which is quite rare in Colorado. While detailing symptoms of Lyme disease, decision support also prompts the physicians with questions on conditions closely related to Lyme disease to consider in their diagnosis and treatment. “With rapidly changing guidelines and recommendations in all areas of practice, it is hard to rely on recollection,” he says. “Using this tool is especially helpful when it is not something you see often or in your area of specialty.”

 As a physician, the system is easy to use, Heaton offers. “Having it in the workflow is night and day to having to get out of the EMR to access information. It has a consistent look and feel with bulleted information. It’s easy to see what is evidence-based and what is added. Over time, it allows you to move faster in your information gathering and diagnosis. And I would say it’s even preferred.”
Another benefit of DynaMed includes continuing medical education (CME) for the medical staff for each search they conduct. To get CME, once the search has been conducted and evidence utilized, the physician fills out an online evaluation that asks a variety of questions such as: did this search change your practice? The forms are submitted to the CME coordinator at SCLHS who then gives the physician 30 minutes of CME credit for each search and evaluation completed. SCLHS has an ongoing campaign to promote the CME capabilities integrated with decision support which has been very successful, he notes. “CME is a big satisfier.”

Lessons learned

Among the biggest challenges of the decision support integration project was keeping the channels of communication open, Heaton recalls. “You need to make sure your whole team is connected on the target of the project,” he says. “They need to go to meetings. They need to read emails. [Projects] like this are large decisions in terms of people and money. They need diligence and dedication by the whole team.”

An essential piece was the integration with the EMR, which required some work by the SCLHS team as well as their EMR and clinical point-of-care resource vendors. “This is not ‘plug and play,’” Heaton says. “You must have all of your vendors on board. Our [integration] required our EMR vendor, their interface and firewall teams, and a moderate degree of coordination internally and externally to get up and running. Now it runs smoothly without reliance on our resources.”

Physician adoption

Outreach to physicians is important to achieve adoption, too.  “It was important to physicians to know a decision support tool was bundled with the EMR,” says Heaton, stressing that a multidisciplinary approach is the way to go to urge widespread adoption. “Our role is to remind and reinforce so the system is used to its full potential to improve patient care,” Heaton says. “Putting it in doesn’t mean people will use it. But reinforcing and encouraging definitely increases adoption. And I have reason to believe these tools positively impact patient care and outcomes. Even if they were to avoid one complication across the entire system it would be worth it.”