Clinical Decision Support for Quality: How to Reap the Benefits

1. Jonathan Teich, MD, PhD Elsevier Health Sciences Harvard University August 20, 2008 Clinical Decision Support for Quality: How to Reap the Benefits

2. CDS is Effective (often) • Increases guideline adherence • Decreases medication errors and adverse events • Increases surveillance and monitoring • Improves preventive care • Improves appropriate resource utilization • Saves money • BWH: $5-10M/yr estimate • $ 44 billion waste recoverable from ambulatory CPOE - CITL • $ 3.5 billion from inpatient ADEs – IOM Sources: Chaudhry et al., 2006; many others

3. Impact – medication errors (dosing)

4. News seems to fluctuate Causes errors! Not accepted! Prevents errors! Saves lives and $$!

5. So, the questions are: • What new trends in CDS and technology will help make it more widely valuable and effective? • What is being done at the national level by government and industry to improve the situation? • What can you do locally to make CDS a force for improved quality/safety/cost/benefit?

6. What’s New in CDS?

7. It’s Not Just about Alerts

8. Workflow Support - Order Sets

9. Workflow support – Heads-Up Displays

10. Interactive reference prevents errors

11. Workflow Support - Procedures

12. Classes Appointments Reference Forums Personal record Home monitoring Medications

13. Tomorrow’s key sources – same, without the search • CDS =“Providing clinicians or patients with clinical knowledge and patient-related information, intelligently filtered or presented at appropriate times, to enhance patient care.” • Traditional book and journal information needs to be reformatted and repurposed for effective CDS interventions

14. Infobuttons

16. Triggered reference Visit Type End of Visit Office visit, acute illness QuickPicks Lab Tests Dx Studies Meds Dx Codes CPT Codes Next Visit Pt Educ Lab Tests CBC w/diff ESR Monospot Theo lvl Urine spec grav Blood cx Hematocrit PTH Throat cx Urine cx Electrolytes LFT panel TFT Urinalysis Urine cx + sens Dx Studies Reason For Dx Study R/O infiltrate Abd CT scan Head CT Sinus CT Abd U/S KUB + upright Sinus series CXR PA+LAT EKG Echocardiogram Dx Codes Rank Order Dx Codes Gastroenteritis, viral, NEC, 008.8 Bronchitis, acute, 491.9 Fever, 780.6 Sinusitis, 473.9 Influenza, 487.1 Pneumonia, bact, 482.9 Asthma, 493.90 Pharyngitis, strep, 034.0 1.401.1 Hypertension, primary 2.482.9Pneumonia, bacterial 3. CPT Codes Visit type Office Procedures Inhalation treatment, 94640 Urinalysis, 81000 I+D, abscess, 10040 Hematocrit, 85013 Office visit, estab, moderate, 99214 End of Visit

17. Connected CDS Meds handling CARDIAC CATH Post-procedure Skills Care Plan Order Set Procedure Guidance Discharge planning Angina Dx and Tx info Ambulatory Care Protocols Triage Protocols DISCHARGE NEW PATIENTADMITTEDWITH ANGINA

18. Better delivery Integrated delivery

19. CDS and Quality: National Efforts

20. “End-to-End” CDS QualityOrganizations Guideline Developers ReportingAgencies Providers/Patients CDSProducers EHRVendors

21. CDS for Quality • Quality goals are numerous, complex • Guidelines not designed for easy clinical or EHR use • No simple data set on which vendors can concentrate • CDS not easily sharable from site to site • CDS implementation confusion • No quick, reliable scenario-based CDS • Provider resistance and misuse • Complex administrative reporting framework • No consistent reimbursement tie to quality

22. Widespread, commercially-available information systems being produced, purchased, and implemented, and helping to improve quality and efficiency in many venues National CDS Roadmap (AMIA/ONC)

23. CDS Roadmap: Strategic Objectives • Develop practical standard formats for representing CDS knowledge and interventions • Establish standard approaches to organizing and distributing CDS • Compile and disseminate best practices for usability and implementation • Develop standards to collect, learn from, and share national CDS experience

24. Key activities and outputs Core data set (NCQA) EHR & CDS Industry Consortia (IHE, EHRVA) Pilot Demonstrations (CMS, AHRQ) National Standards and Structures (AHIC, AQA) Impl. guides, education, Resources (HIMSS, DOQ-IT)

25. A technological and psychological affair Practical Implementation:Getting CDS to Work for You

26. CDS Success Factors • Define what your victory will be • Find the right CDS for the job • Communicate frequently • Get everyone to own it • Utilize clinician champions • Top-level organizational support • Communicate more frequently than that

27. The Right CDS at the Right Time

28. Technology success factors • Clinically-orienteddisplay & entry • Support typical practice patterns • Short learning curve to something useful • Enhance workflow • Next-needed information is always at hand • Complete support for a process Add high-value safety features after the system has been accepted!

29. Clinician roles • Vetting original concepts • Giving input to design process • MD,RN,ancillary,management... • Taking clinical leadership • in exchange, system reflects your ideas • Cheerleaders, champions, communicators

30. Take-Home Lessons • CDS can facilitate improved safety, quality, and performance on quality metrics • Not just alerts – smart forms, task guidance, informational CDS • Currently CDS is not supplied or used to full effectiveness in all settings • Can usually attribute to design and communication issues • Full effectiveness comes from • usability design • best-practice implementation skills • facilitation of common elements • group help for small practices

31. j.teich@elsevier.comjteich@harvard.edu