HIMSS/Physician IT Symposium: CDS only works when done right
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However, clinical decision support (CDS) doesn’t necessarily mean tremendous improvements in quality, he said. “Decision support can work when it’s done right. It can transform an organization but clearly, not everybody is doing it right.”
Sittig cited five “rights” of decision support users must keep in mind. They are: the right information, the right people, the right interventional format, the right channels and the right points in workflow. Aside from these rights, he said that successful CDS requires solid government and management through an oversight committee.
The panel members shared some of their experiences with CDS. Christopher Davis, MD, former physician informaticist at the Center for Medical Informatics, Sisters of Mercy Health System in St. Louis, found a high rate of alert fatigue among providers. In fact, an alert developed for the timely removal of Foley catheters resulted in an average of 13.7 alerts per patient.
Davis studied top DRGs to look for opportunities for improvement such as reduced length of stay and readmissions. Mercy had three order sets for chronic heart failure (CHF), but that wasn’t meeting care needs. Monitoring monthly reports on order set utilization indicated low use rates, so Davis added an electronic alert for providers to check that CHF patients were either given a certain prophylaxis or the decision not to give that prophylaxis was made and documented.
“Often, the right decision support tool is not a single tool,” Davis said.
“Not all interventions need to be pop-ups and alerts,” says Christopher Longhurst, MD, CMIO at Lucile Packard Children’s Hospital in Palo Alto, Calif. Packard installed 60-inch LCD screens that display a variety of patient information such as lab values and nursing documentation. Based on those metrics, each patient gets a red, yellow or green light with the goal of a green light. One-third of patients, he said, have been managed differently because of the metrics on the dashboard.
Because 80 percent of costs are driven by physician orders, Packard has found that attaching lab costs to orders significantly changed those orders.
“The goal should be not just evidence-based medicine,” Longhurst said, “but practice-based evidence.”
Peter Basch, MD, medical director of ambulatory EHR and health IT policy for MedStar Health, a nine-hospital system headquartered in Columbia, Md., measured four clinical protocols including mammography, colonoscopy and smoking status and found lots of variability. “I was shocked by the variability,” he said.
Rather than pop-ups, Basch said MedStar developed a yellow button on almost every screen of its EHR. “I call it passive polite,” he said. The button serves to ask providers whether the system has the answers to certain questions in a structured format.
Use of the yellow buttons was tracked and then Basch and his team interviewed the high and low performers. “We asked them if they were aware of the significance of the clinical protocols. We thought the low performers might be explained by less experienced EHR users but all had been using the system for at least one year.” The low performers gave several excuses for not using the yellow button, the most dismaying that “it’s not my job.”
MedStar decided to achieve Diabetes Recognition Program (DRP) status, as certified by the National Committee for Quality Assurance. To counteract the idea that clinical protocols that don’t immediately pertain to the situation at hand, the organization plans to tie DRP status to competency requirements for reaccreditation. “As of Jan. 31, 2011, 79 percent of primary care providers had reached DRP status and all 14 primary care practices meet or exceed minimal DRP thresholds. Working to achieve DRP status, Basch said, resulted in the sharing of best practices, more aggressive use of insulin and diabetes education and re-envisioning what good performance means. That kind of team effort brings out the best in everyone as opposed to begrudgingly meeting minimum standards."
The lessons learned at MedStar are that the benefits of decision support are not assured. “It won’t work if there is no leadership and it’s got to be tied to something else.” Basch said he would add two more rights to the five covered by Sittig: the right use (consistently) and the right alignment.
“Doctors have to think of CDS as part of their job,” Basch said. “Decision support tools are really important in helping to take care of patients.”
Longhurst added that training is “critical and undervalued and clearly not a one-time thing.”