CDS Moves Beyond Alerts
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| Image source: Eastern Maine Medical Center |
Surgeons at Eastern Maine Medical Center, in Bangor, know firsthand how customized clinical decision support built into computerized provider order entry (CPOE) can lead to better blood management. Using CDS, the organization reduced its rate of unnecessary transfusions during surgery by 60 percent—one of the accomplishments that made the center a Healthcare Information and Management Systems Society (HIMSS) 2008 Davies Organizational Award winner for heath IT excellence.
A red light was going off
As late as 2007, 37 percent of patients who came to Eastern Maine for elective hip or knee replacement underwent blood transfusions as a result of their surgery. “This is an elective operation, so obviously a red light was going off,” says C. Eric Hartz, MD, oncologist and CMIO at Eastern Maine Medical Center, a 411-bed non-profit hospital whose 300 physicians provide approximately 75 percent of the Bangor area’s primary care.Hartz and colleagues’ first step was to begin examining patients one month prior to their surgery, to ensure that anemia and other conditions were under control. Next, the team enlisted the medical center’s Cerner CPOE system to standardize the protocol for transfusion orders.
As physicians went through the order process to electronically document the indication for transfusions, they were provided with current, evidence-based and institution-specific standards, which have changed considerably in the time since most faculty physicians trained as residents, Hartz notes. Links to hospital guidelines and clinical trials were likewise embedded in CPOE.
A review of CPOE records showed that many transfusion orders were placed for patients who were not actively bleeding, so Hartz and colleagues programmed the system to require a pathologist consult for any “not bleeding” indications that fell outside of the staff’s predefined guidelines, as well as for any orders of more than one unit of blood.
Since the 2007 implementation of CDS for blood management, EMMC’s transfusion rate has declined 60 percent among general surgery, orthopedic surgery and acute inpatients. The system now transfuses 1,200 fewer patients each year, Hartz claims. “For both cardiac surgery and orthopedic hip and knee replacements, length of stay is down, infection rates are down and mortality is unchanged.”
During the first year of the blood management program, the hospital saved $517,000 in blood product acquisition costs, from a total budget of $2 million, he says.
CPOE goes electronic
In addition to linking ordering physicians to evidence or to other physician specialists within a health system, advanced CDS can guide physicians to increasingly complicated but optimal treatments. This guidance can be static or dynamic.The University of California, San Francisco (UCSF) Medical Center is currently making the transition from static paper-based CDS to a more dynamic algorithmic ordering process within its CPOE system (Epic). The paper system helped UCSF ascend well into the high 90-percent range for compliance with core measures, according to Michael S. Blum, MD, CMIO and a cardiologist at UCSF. However, Blum says he expects this number to approach 100 percent as the electronic system goes into full force, with full CDS deployment and CPOE, in March 2012.
Whether paper or electronic, the CDS process at UCSF begins with the Core Order Set that physicians complete for almost every admitted patient. This drives standardization of care and provides physicians with robust clinical guidelines and best practices, including deep venous thrombosis (DVT) prophylaxis and pain management, says Blum. The Core Order Set also contains specific addenda for conditions such as myocardial infarction, congestive heart failure, stroke and antibiotic therapy.
“We are essentially trying to improve the signal-to-noise ratio in the alerting process and have moved away from reporting on every drug-drug/drug-allergy interaction that’s out there,” Blum explains.
At Eastern Maine Medical Center, oncologists are guided to particular treatment regimens based on the type and severity of cancer with which their patients present. The interactive CPOE algorithm brings up chemotherapy drugs and dosing based on patient information that is checked against evidence-based guidelines. In addition, the CDS presents physicians with potential toxicities and complications and recommends the patient-appropriate interventions, drugs and dosage to treat each.
Dose range CDS provides physicians with patient-specific dose recommendations and links to dosage calculators.
“That is CDS to the max, where you think of everything that could go wrong and you build it into the system so it’s checked every time by one or more providers. You can’t go ahead until all those conditions are met,” Hartz says.
Feedback builds buy-in
Physician feedback is an essential component to an effective CDS system. At Eastern Maine, which mobilizes more than 350 order sets, dose ranges were monitored for a year by pharmacists, with physician input, before they were included in the CDS system. The hospital is currently adding all core measures to its CDS as well, says Hartz.Feedback is also a critical CDS element at Adventist Health System, says Kshitij Saxena, MD, MHSA, medical director of information systems at the 26-hospital, 7,700-bed system based in Bradenton, Fla. “We survive and thrive only because we get physician feedback,” Saxena says.
After implementing CDS at 22 of Adventist’s hospitals, Saxena has instituted CDS committees dedicated to distinct clinical problems and a CDS/CPOE helpdesk, which accepts phone calls, emails or iPhone/smartphone screenshots as claims.
Building familiarity with the system has enabled physicians to use CDS to improve care for Adventist patients. In the first one to two weeks of CDS implementation, the rate of ignored alerts is higher. However, as physicians become accustomed to the CDS system, the ignore rate levels off to slightly more than 40 percent, says Saxena.
He cites data gathered during the six-month period from July to December 2010: A total of 16,169 alerts were fired in the 22 Adventist hospitals with 100 percent CPOE use. Of those alerts, 8,904 (or a bit more than 55 percent) were overridden by the physicians with no change in the orders for which the alerts fired. The rest of the alerts—7,515 (nearly 47 percent)—changed physician ordering behavior, Saxena says.
“Like anything else, the more you practice, the better the understanding of the system is,” he says.
UCSF has redesigned its CDS system with the input of pharmacists, who now handle the majority of drug/drug and drug/allergy alerts and will continue to do so with the switch to electronic CDS. This frees up providers to manage high-priority alerts—which can still include life-threatening drug interactions. “We pick a few issues to focus on that are known quality and safety concerns, rather than the shotgun approach of all drug interactions,” Blum says.
The fine line
Previously seen as a distraction to physicians more than a safeguard for patients, CDS’ breakthrough came with triaging of alerts. As Hartz points out, though, “There is a really fine line between nuisance alerts and useful CDS.” Staying on the useful side requires feedback and collaboration among vendors, hospital IT and physicians.“What we are trying to do is provide the correct information to the correct person in the correct setting at the correct time, so that he or she can make the best [care] decision,” Hartz says.