Community Health Centers Lead The Way In "Clinical Decision Support" Roll-Out
Since Hippocrates first brandished a pair of bronze
forceps, care providers have aimed for quality. It's always been the
goal to deliver safe and effective care to best extent possible.
But there's always room to improve. And nowadays, with the shift from
volume to value finally taking hold, moving toward better clinical care
is no longer optional.
This past fall, the U.S Department of Health and Human Services
announced it will invest $840 million over four years to help 150,000
clinicians improve patient outcomes, reduce unneeded tests and avoiding
unnecessary hospitalizations. One of the central pillars of its
Transforming Clinical Practice Initiative is to help providers regularly
use electronic health records to examine data on quality and
efficiency.
A few months later, in January of this year, HHS upped the ante –
making an 'historic' announcement of ambitious new timelines toward
value-based care. Furthering its embrace of alternative reimbursement
models such as accountable care organizations and bundled payments, HHS
set a goal of tying 85 percent of all traditional Medicare payments to
quality or value by 2016.
"We believe these goals can drive transformative change, help us
manage and track progress, and create accountability for measurable
improvement," said HHS Secretary Sylvia Burwell.
HippocratesThe clock is ticking on clinical quality improvement. If
hospitals and practices want to be paid in the years to come, it's
incumbent on them to show they're delivering better care.
"Provider organizations are under this increasing imperative to move
the needle on high-priority targets as we shift from volume to value,"
says Jerry Osheroff, MD, a former chief clinical informatics officer and
the founder of TMIT Consulting, which seeks to help providers, vendors
and other stakeholders improve processes and outcomes.
"What does 'value' mean? It means taking care of chronic disease,
taking care of acute disease, not causing unnecessary harm," he says.
"There's now measures associated with all these things, and performance
on those measures is driving reimbursement. Having care delivery be
efficient and effective is no longer a nice-to-do, which it's been for
many decades. It's now a gotta-do."
Osheroff is also editor-in-chief of HIMSS' award-winning guidebooks
on clinical decision support. And CDS, he says, is a crucial component
in helping providers get to where they need to go with their quality
improvement projects.
But a proper understanding of what CDS is (hint: it's not about EHR
alerts) and how to approach it (people come first!) is essential.
Help wanted
In his just-published HIMSS book on clinical informatics, Ken Ong,
MD, chief medical informatics officer of New York Hospital Queens,
illustrates just how important CDS tools and processes are to modern
practice.
To take just one example: The number of medical journal articles has
quadrupled from 200,000 in 1970 to more than 800,000 in 2010, Ong points
out: "With the current number of articles published annually in medical
literature, a recent medical school graduate who reads two articles
every day would be 1,225 years behind at the end of the first year."
Indeed, "if a physician followed all the recommendations from
national clinical care guidelines for preventive services and chronic
disease management and added the time needed to answer phone calls,
write prescriptions, read laboratory and radiology results and perform
other tasks for a typical patient panel of 2,500, he or she would need
21.7 hours per day," he writes. "Information overload coupled with a
paucity of time suggest the value of CDS and greater team-based care."
Clinical decision support tools are myriad and varied.
Ken Ong, MD"The most frequently cited example of CDS is a
drug-allergy interaction alert to a physician at time of order entry,"
Ong writes. "Drug-drug, drug-allergy and drug-food interaction alerts
are indeed prototypical examples of CDS, but there are other tools in
the CDS toolbox. Each CDS intervention can have a different use case,
target audience and fit in a particular point in the clinical workflow."
The book offers a long list of examples: alerts and reminders;
clinical guidelines; clinician patient assessment forms; data flow
sheets; documentation templates; infobuttons; order facilitators (order
sets, order consequents, order modifiers); patient data reports and
dashboards; protocol/pathway support; task assistants; tracking and
management systems.
But the optimal approach to clinical decision support should not be focused primarily – or even secondarily – on technology.
"This work is about people, processes and technology – in that
order," says Gregory Paulson, deputy director of programs and operations
at Trenton Health Team.
Community spirit
Trenton Health Team is a somewhat unique partnership among the two
hospitals of Trenton, N.J. – St. Francis Medical Center and Capital
Health – and the Henry J. Austin Health Center (the city's only
federally qualified health center) and the Trenton Health Department.
Trenton Health has five main strategic initiatives, says Paulson:
expand access to primary care by supporting the FQHC and other area
clinics; provide community-based care coordination; engage members of
the community in their health and wellness; utilize data to improve the
population and become a successful Medicaid ACO under New Jersey's ACO
demonstration project.
It's "a bit of a unique ACO model, in that it's a geographic
distribution – we're responsible for those who reside in our geography
regardless of where they receive care," he says. "It's a bit of a forced
population health model."
Toward those lofty goals, Trenton Health Team has been working since
summer 2014 – with help from a $415,000 state grant and Osheroff's
consultancy – to develop a clinical decision support system to improve
blood pressure and diabetes control for patients in its community.
The goal is to improve care processes at healthcare institutions
across Trenton, deploying targeted CDS tools to make meaningful
improvements in those chronic and all-too-common conditions.
"This initiative aims to combine the power of data, clinical
intervention and the coordination of community providers to improve
patient health," said N.J. Department of Health Commissioner Mary
O'Dowd, in a statement when the grant was first announced.
Her emphasis on providers is key. Over the past five year or so, CDS
has become synonymous in too many minds with EHR-based alerts, says
Paulson. Post-HITECH act, many providers are irritated or fatigued by
these IT interruptions, often to the detriment of quality care as they
ignore the prompts in droves.
"I think one of the big errors of
meaningful use and the adoption of health IT to date has been the focus
on technology, without looking at the processes that were implemented
and the people working with those processes," he says.
By making CDS a key measure of meaningful use, "CMS and ONC went a
long way toward reinforcing a completely wrong and counterproductive
notion in the Stage 1 rules," said Osheroff in another interview earlier
this year.
It's not an interruptive, computer-based intervention, he said. It's
"a process for enhancing health-related decisions and actions with
clinical knowledge and patient information to improve health and
healthcare delivery."
The feds have since changed their tune on clinical decision support,
he concedes, most notably by emphasizing and spreading the word about
the so-called "CDS Five Rights" – clinical interventions that provide:
the right information (evidence-based guidance, response to clinical need);
to the right people (entire care team – including the patient);
through the right channels (e.g., EHR, mobile device, patient portal);
in the right formats (e.g., order sets, flow-sheets, dashboards, patient lists);
at the right times (for key decision or action).
Gregory PaulsonUnprocessed
Embracing that team-based approach to data has already started to pay dividends in Trenton, says Paulson.
One of the key strategies THT has followed is to make a "simple
worksheet that analyzes the clinical workflow to see a normal patient:
what happens out in the community, what happens before a visit, what
happens in a morning huddle, what happens in rooming the patient, what
happens in a provider encounter, what happens in follow-up," he says.
"When we first were looking at doing this work, we didn't quite
understand what the work would be like," he admits. "It seemed so simple
and rudimentary that we didn't see how anything of value could come
from it. But the things we uncovered are just remarkable."
We hear all the time about "process improvement, Lean Six Sigma and
all these things," says Paulson. "But actually going into a clinic and
asking people, 'OK, what happens now? Then what happens? Then what
happens?' Walking through that process you'll get amazing results."
To take just one example: "We have a clinic in one of our hospitals
whose patients are 60 percent Spanish speaking," he says. "They'd spent
all this money on this great automated phone call system to remind
people about appointments. They realized only through doing this
analysis that it functions only in English. Somebody just missed this
step and nobody realized it."
For those keeping score at home: People & Process 1, Technology 0.
"It's great if you have this registry that shows your out-of-control
diabetics," says Paulson. "But if your method of remind people to come
in for an appointment isn't being use effectively, the technology
doesn't matter."
But while technology may be tertiary to clinical decision support,
it's still a critical piece. And if quality improvement is truly going
to take hold, the EHRs need to improve too.
Too often, "when someone things of a clinical decision support
system, they think of a pop-up alert: something that, in the middle of
what you're doing, gives you a piece of information that the technology
thinks is important and wants you to do something to fix," says Paulson.
That breeds antagonism toward CDS, rather than an earnest embrace.
"To me, it's the equivalent of going online to shop on a website and
pay your bill and getting these pop-up adds, he says. "If you're
shopping on Amazon and you do it frequently, obviously you know where to
click. You're familiar with that website you know how to interface with
it in a way that is seamless. So if I then institute a pop-up alert –
one that interrupts your process when you're not expecting it and you
don't want to stop – you're not going o want to shop at Amazon."
Really good health IT isn't necessarily smarter about how it does
it's thing, it's better at how it works with its clinical users, Paulson
suggests. And he's seen proof of that as Trenton has recently had two
clinical sites do EHR rollouts since the citywide CDS project launched.
"They were starting with their EHR adoption having just completed a detailed analysis of their clinical processes," he says.
"They were able to look at the training and say, 'Wait a minute, when
I'm caring for diabetes, these are the kinds of things I need to do.
How will this tool help me do that, and before we start rolling it out,
can we make some slight adjustments to how it interacts with me so I get
the right in at the right time in the care process in the right
format?'"
Technological advance
A year ago this month, ONC launched the EHR Innovations for Improving
Hypertension Challenge as part of Million Hearts, the ongoing
nationwide project led by the Centers for Disease Control and Prevention
to help practices better use EHRs and CDS to reduce high blood
pressure, heart disease and stroke, preventing a million heart attacks
and strokes by 2017.
"There are many healthcare providers who employ clinical decision
support tools like standardized treatment approaches or protocols to
control hypertension among their patients," said National Coordinator
Karen DeSalvo, MD, in a statement announcing the EHR initiative. "This
challenge helps us find the best examples of those efforts and scale
them up."
Left unspoken in that declaration is that some deployments of CDS-enabled quality improvement are still less than ideal.
Hilary Wall is senior health scientist and Million Hearts science
lead at CDC. She says she's sympathetic to physicians who chafe at
disruptive CDS tools. But she also sees the immense potential for better
care when those tools are deployed the right way.
"I'm not a clinician; I'm an epidemiologist by training," says Wall.
For her, using computers to marshal data toward better outcomes is a
"no-brainer."
That said, she is also keenly aware that she's "never had to
integrate (technology) into a clinical workflow, where I've got patients
coming in and seeing different staff in a healthcare setting."
Wall understands why alert fatigue and overridden order sets occur
across healthcare. But she hopes to see better workflows and more open
minds prevail, because she's seen the good that can result from smart
CDS.
"I've seen two sides of the coin," she says. "One, I've seen a push
for using clinical decision support tools for quality improvement,
presented to clinicians and getting pushback: 'It's too much, we can't
do it on top of everything else we're having to do.' Clinicians are
being tasked with doing a lot of different things at the same time."
At the same time, says Wall, "I've also seen the flip side of that
coin, where we've got pockets of clinicians using CDS to its fullest
potential in a way that's streamlined for the clinical staff that's
using those tools and in a way that really benefits their clinical
practice. Once that learning curve is overcome, health systems are
really reaping tremendous benefits."
Still, she admits she's "surprised more people haven't been open to
embracing clinical decision support, and the different features EHRs
have to offer."
At the same time, says Wall, "I know that technology and change are
hard. When a healthcare system gets an out-of-the-box EHR and turns it
on for their clinical staff, oftentimes the clinicians have not weighed
in on what features they're using or what alerts are popping up in their
faces. And they either ignore them or turn them off. And I don't blame
them."
Simply put: "Getting buy in from the clinical staff is really, really
important," says Wall. "CDS tools are most successful when they focus
on what we know for sure in the evidence. That's how they make
clinicians' lives simpler. They take the evidence-based interventions
and they make it automatic. They prompt you. That leaves more time for
the staff to use their clinical judgments for the places where the
evidence is softer."
Successful practices, she says, "have focused in on those very
high-evidence-based strategies so that it doesn't feel like cookbook
medicine for their clinical staff."
Meanwhile, like Paulson, Wall points to the acute need for EHR design improvement.
"This is something we need to explore more, but anecdotally what I've
heard is that there are too many clinical decision support tools
embedded in EHRs," she says. "And not all but many vendors have a canned
set. They automatically put them in, they automatically turn them on.
They are an annoyance to the clinical staff. There's got to be a way for
some of these vendors to work more closely with their clients to tailor
which CDS tools are turned on."
Golden Valley Health Centers, based in Merced, Calif., is another
provider that's using electronically-produced registries generated from
its electronic health record to identify and reach out to potentially
undiagnosed hypertension patients, as part of NACHC's Hiding in Plain
Sight Million Hearts Project. Pictured: Physician Assistant Christopher
Barrett and Karina Farias, one the Medical Assistants on his care
team.Government assistance
In the past few weeks, the federal government has published some very
useful resources for health providers looking to amp up their quality
improvement initiatives and better treat chronic conditions.
First, CDC published "The Hypertension Control Change Package for
Clinicians" as part of Million Hearts. Compiling concepts, ideas and
evidence-based tools and resources, the package means to offer resources
to clinicians looking for specific changes related to management of
hypertensive patients.
Such "change ideas" are able to be "rapidly tested on a small scale
to determine whether they result in improvements in the local
environment," according to CDC.
Second, ONC published an online guide to electronically facilitated clinical quality improvement, or eCQI.
"Health IT enables more rapid feedback on measurement as well as
real-time improvement support tools such as workflow-integrated clinical
decision support," according to ONC. "It transforms the basic quality
cycle into an upward spiral of performance and outcome improvement for
providers, patients, and the health system overall as learning grows
through sharing analyzing and using data better."
As part of the resource, ONC offers a substantial series of resources
for planning and implementing improved care processes. Among its advice
for those at the beginning of their QI journey:
Cultivate a shared commitment within your team to improving care
delivery and results, including fully leveraging Health IT capabilities.
Successful QI efforts deliver a 'win-win-win' for patients and their
care teams, as well as broader organizational goals.
Identify and
address barriers to collaboration on effective process improvement among
all concerned, including providers, care delivery and quality staff,
partners (e.g., health IT vendors), and patients.
Layer the approach and tools below onto your QI methodology.
Track record of quality
One group of providers that's often well ahead of the game with
regard to CDS-enabled quality improvement is community health centers.
Both the resources and accountability that come from being
federally-funded mean most have an innovative ethos of IT-enabled
improvement that could offer some useful lessons for other providers.
"Ninety-six percent of health centers are using electronic health
records, which is ahead of the curve compared to other types of
healthcare organizations; they're definitely leading the charge in that
way," says Meg Meador is director of clinical integration and education
at National Association of Community Health Centers.
"And they've definitely been using CDS for a while now," she says.
"Most of them use things like templates and order sets. They use
clinical reminders that prompt providers for needed preventative care.
They use embedded guidelines – visual cues like highlighting an elevated
blood pressure red. These are things that a lot of them have adopted."
"Community health centers have a track record of quality
improvement," says Shane Hickey, senior advisor for health IT strategy
at NACHC.
Initially launched as part of President Lyndon B. Johnson's War of
Poverty, over the course of five decades CHCs "have really learned to
think outside the box and be open to innovation and change," says Amy
Simmons, NACHC's communications director.
"That kind of approach has been their hallmark. They are built by the
community, from the bottom up, that makes them effective in their
approach. They understand the population they serve. They have always
been results-driven because they have been of the community and by the
community.
"They've also always had to be accountable," says Simmons. "This is a
program that relies on federal support, so accountability and
transparency and results have always been important."
As a quality improvement professional, Meador specializes in
rapid-cycle change approaches to workflow and information systems,
putting population health data and IT to work improving quality and
driving better outcomes. (Part of her work is serving as lead on a
Million Hearts project focused on undiagnosed hypertension, "Hiding in
Plain Sight.")
Certain health centers "are really coming up with some innovative
ways to use clinical decision support proactively: getting in front of
the analytics piece so they can use CDS for pre-visit planning, so they
know in advance which patients they need to outreach to, they know of
those patients who already have appointments what tests they might
need," says Meador. "The shift is happening – from more of a passive
approach to CDS to a much more proactive approach, which is really
needed in this environment."
One unique aspect of community health centers is that most – more
than 70 percent – belong to Health Center Controlled Networks: groups of
safety net providers who compare notes on improving quality and access
and reducing costs. That "create opportunity for economies of scale –
particularly in purchasing of health IT or IT services," says Meador.
Health centers are part of HCCNs thanks to the fact that they use the
same EHR products – enabling them to come up with best-practice
workflows on that specific technology.
"There's a collaborative spirit that pulls everybody up," says Meador.
Getting results
NACHC shared with Healthcare IT News some specific success stories
from its membership – providers who have recognized substantial
improvements thanks to smarter use of CDS tools.
Among them, Peninsula Community Health Services, based in Kitsap
County, Washington, which was able to boost its blood pressure control
rate to 84 percent after integrating clinical pharmacists into its care
team. (The Million Hearts target is 70 percent).
Simmons also cites Finger Lakes Community Health, Hudson River
Healthcare, and Whitney M. Young, Jr. Health Center – three health
centers affiliated with the Health Center Network of New York – who have
notched "some big wins using data and clinical decision support tools
to drive improvement."
Together, they were able to achieve a 21 percent increase in
hypertension control and a 19 percent decrease in undiagnosed high blood
pressure since September 2013, thanks to algorithms that can detect
potential cases.
The health centers developed electronic registries that helped inform
outreach efforts, finding success by embedding a hypertension treatment
protocol into their workflows, putting a laser focus on improved
accuracy in blood pressure recording (by querying EHR data for rounded
systolic/diastolic numbest) and "honing in on those care teams who need
training on precise EHR documentation methods."
Going forward, NACHC is expanding its decision support and QI
initiatives. "We're piloting a new CDS approach, more centralized,
called CDS-as-a-service," says Hickey, where "the EHR pulls down
evidence-based guidelines from the CDC in an automated fashion."
Another project is focused on "social determinants of health," he
says, working with four different HCCNs and their member centers to
develop a standardized patient risk assessment tool that focuses on the
factors "beyond medical acuity," such as income and education level.
"All of our heath centers are building templates in their EHRs to
capture this data in a structured way," says Hickey, with "all of the
teams operating from the same question and answer sets. Once we have a
prototype, we can spread it."
All told, we're at a pivotal moment for clinical decision support and
QI initiatives. Thanks to a burgeoning awareness about its potential,
an increasing effort toward education and an ever-expanding arsenal of
toolkits, guidebooks and worksheets – from CMS, ONC, HIMSS and others –
there's an impressive and evolving armamentarium providers can draw upon
as they work to tackle the most vexing chronic conditions.
