Choosing a clinical decision support system is just the first step to using the software, providers and consultants said in a recent webinar. To reap the maximum benefits of clinical decision support, providers must customize it for existing workflows, provide extensive in-house support and track employee compliance.
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Two years after go-live, I still found things in our EHR that I didn't even know were there. ... You might need to change some basic care processes, but you will need to maintain communication.
health IT consultant, Stratis Health
In a Health Resources and Services Administration (HRSA) webinar, Using Clinical Decision Support in Safety Net Provider Settings, clinical and quality leaders from Stratis Health and Community Health Center Inc. shared their experiences using clinical decision support (CDS) to enhance quality of care.
Lisa Gall, Stratis health IT consultant and family nurse practitioner, urged providers to begin by pinpointing which facets of CDS are already embedded in their EHRs. Many organizations, she said, are simply unaware of which CDS features come with their EHR system, and clinicians and nurses don't know which options are available to them. "Two years after go-live, I still found things in our EHR that I didn't even know were there," she added about her own experience. "Our providers were receiving duplicate results on paper and in the EHR, creating confusion and frustration. Patients were getting multiple calls for the same results."
In assisting a nine-provider, rural critical-access hospital that operated three satellite clinics, Stratis chose one measure on which to focus their EHR-based CDS efforts: blood pressure monitoring control, which Stratis practitioners did only 44% of the time in 2008. They then evaluated current processes, taking care to understand both office and information workflow in the clinic, as well as the patient experience as a whole.
At first, Stratis implemented pop-up reminders to check blood pressure; those were quickly discarded and replaced with bold, red letters on the EHR screen after nurses complained of alert fatigue. On the patient side, decaf coffee began to be served instead of regular in waiting rooms, after providers realized caffeine could be spiking patients' blood pressure levels before their checkups.
"Considering provider preferences is important, but it's also important to consider quality, best practices and health information exchange that are crucial to getting data in a way that can be readily accessed and used in quality reports," Gall advised, warning providers to decide ahead of time how much standardization they will allow their providers to do in the EHR. "You might need to change some basic care processes, but you will need to maintain communication."
Both providers and patients recognized benefits after Stratis' CDS systems were revamped. In 2012, blood pressure reporting improved to 83%.
Providers at Community Health Center's 13 primary care centers spread throughout Connecticut also took a teamwork-plus-technology approach to realizing the benefits of clinical decision support and developing CDS measures, using a patient hub and "pre-huddle system" to both avoid missed opportunities for screening and to optimize CDS-queued alerts.
"The basic process involves making sure CDS happens every day," said Bernadette Thomas, Community Health Center's chief nursing officer. "The 'pre-huddle' is where medical assistants (MAs) review [work that the CDS suggests] the night before scheduled visits, back it up on paper and give it to nurses, who check for and order vaccines or other disease management needs. Then there's the huddle: the pre-shift meeting the next day where providers address the MAs' findings and offer input on what additional items of care the patient might need."
The results are evident. Community Health Center has seen an increase in the rate of screening for all three cancers it tracks, specifically, in mammograms, Pap smears and colon cancer screenings.
Daren Anderson, M.D., chief quality officer at Community Health Center, said now that they've mastered putting information into the system (go-live was in 2006), they can start getting information out via dashboards. "A lot of organizations are waiting for EHR vendors to deliver functionality that would put powerful clinical data in the hands of the clinical teams, but that hasn't happened yet," he said. "We took a slightly different course to build our own clinical dashboards."
Community Health Center's dashboards are essentially windows into the data warehouse, designed to display data from specific groups, such as clinical opiate users or patients with diabetes. Providers look to the dashboards for data about the patient population -- who's taking what, when their next visits are, how treatment results vary and so forth. They can then stratify the population to prioritize their focus.
Moreover, the dashboards double as a "missed opportunity" report, giving motivating feedback on neglected duties and overall quality of care.
Anderson pointed out that CDS systems and dashboards won't necessarily provide the answer to every patient case. Patients with abnormal results and more complex care will sometimes require additional support outside methods suggested by these systems. "If you emphasize putting good information into the system, you can guarantee getting good information out," he said. "But at the end of the day, it's not the EHR that's going to allow you to improve and reduce missed opportunities for cancer screening; it's the combination of EHR with meaningful use and workflow systems and CDS and, maybe most importantly, teamwork."