HIMSS: Unintended consequences of CDS
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Unintended consequences are neither anticipated nor intended specific goals of the CDS intervention. To manage unintended consequences effectively, it’s important to separate the technology from the process and communication issues, Levick said.
Leadership also is extremely important to successful CDS. Your CDS leadership support has to be a group of physicians with physician champions who are seen as credible by the rest of the medical staff, Levick said. LVHN used an IT committee for this effort but changed reporting structures years ago to a medical executive committee. Levick said that lends a lot of credibility to the committee as well as the decisions it makes and endorses. The committee’s meeting minutes go to the organization’s board of directors so they are seen by all levels.
Medical staff leadership is both official and unofficial, he said. Some CDS-resistant physicians are influential opinion leaders, so Levick said health IT leaders should get into the medical staff lounge and operating room (OR) lounge to cut off the unintended consequence of negativity.
Levick said C-suite executives also have to be on board with CDS efforts because they have to approve the required resources. “Make sure they understand what CDS brings to the organization which is not just patient safety but efficiency and cost reduction. They also need to know that unintended consequences will occur.” They are part of the learning process so you need a plan in place to address and mitigate unintended consequences.
Levick said that LVHN’s CDS system began with very mild alerts and moved on to more and more intrusive alerts—a “continuum of intrusion.” That involves moving physicians along to alerts embedded in order sets to alerts embedded into admission order sets and then the most intrusive in which physicians can’t admit patients without going through certain screens, answering relevant questions. “Had we jumped to that step right away, I think we would have had more resistance. This process combined with leadership efforts has been very successful.”
Implementing CDS requires that physicians have access to the system. “Make sure there are enough devices and you have a robust Wi-Fi network so there is no excuse not to interact with CDS.” The most resistant physicians are always going to find a way to work around CDS, he said. “It’s amazing how creative physicians will get.”
Maintaining up-to-date CDS is an underestimated effort, Pucklavage said. While senior leadership might believe that once the system is installed the project is done, there is a lot of maintenance involved regarding new information on medications, new care techniques, medications no longer on the market and more. LVHN found that they needed a different mindset of incorporating IT into meetings. “It took our hospital time to adapt to that.”
Pucklavage also warned of the “curses of success." The faster you do things, the faster people want things done and the more complex problems you manage, the more complex problems they’ll give you to solve.
“No matter how good your team or system, unintended consequences will occur,” Pucklavage said. You need a multidisciplinary team to address unintended consequences, including your facility’s quality and legal committees. LVHN uses an online feedback from that allows users, within two clicks, to type in their issue.
He also cautioned that CDS cannot solve all problems. “CDS is much more than alerts and order sets. You need to understand the full capabilities and you must have a full understanding of clinician workflow and the care process. Organizations must understand what can be solved by technology and what should be solved by process because process change is sometimes the best solution.”