whitepaper Elsevier Clinical Decision Support: Impacting the Cost and Quality of Healthcare

Transcription

1 whitepaper Elsevier Clinical Decision Support: Impacting the Cost and Quality of Healthcare

2 Healthcare Is Changing as Never Before Fueled by the unprecedented and sweeping reform legislation, healthcare is changing more rapidly than in any other time in recent history. Pressure remains high on a shrinking number of providers to contain ever-rising costs, even as an estimated 30 million newly insured people enter the system. The healthcare legislation also forces providers to pay greater attention to quality and efficiency, with an emphasis on using the latest technologies as support. Providers are faced with a daunting question how will hospitals, health systems, medical groups and payers manage costs and improve access, quality, safety and efficiency as more and more patients are treated by fewer and fewer clinicians? Healthcare organizations have already begun to prepare for the influx of patients and regulations precipitated by healthcare reform. Many organizations are working to keep clinicians current on the latest research and guidelines and better able cope with the escalating volume and velocity of clinical information for example, more than two million articles are published annually by over 20,000 biomedical journals. The bottom line: Clinicians have too much information and too little time to describe, analyze, evaluate, synthesize and act on that information. Healthcare executives and clinicians must zero in on strategies to improve care quality, safety and efficiency as they prepare for the inevitable surge of newly insured patients and the escalating reporting requirements that accompany healthcare reform. Clinical Decision Support is a critical component for organizations seeking to improve the health of the healthcare delivery system. Technology Is Part of the Quality and Efficiency Solution Hospitals, health systems and medical groups already realize that increased patient volume requires more than simply adding staff. It means leveraging technology to improve care quality, access, effectiveness, efficiency and safety, the result of which is better care at lower costs. Many healthcare organizations have implemented CPOE (computerized physician order entry) systems and EHR (electronic health record) systems. Almost twice as many EHR systems were sold to hospitals in 2009 as in 2008, with sales strongly influenced by the American Recovery and Reinvestment Act (ARRA), according to CIO Purchase Decisions: Riding the ARRA Wave, a September 2010 KLAS report. Still, challenges remain in system selection, adoption, implementation and use. 1. Quality problems are significant. Nearly one million patient-safety incidents occurred among Medicare patients from , according to HealthGrades Seventh Annual 2010 Patient Safety in American Hospitals Study 1. More than 40,000 incidents of medical harm occur in the U.S. each day, says the Institute for Healthcare Improvement (IHI) 2, while the Society of Actuaries and Milliman 3 confirm that medical errors cost the U.S. economy $19.5 billion in

3 2. Not everyone is fully on board with technology adoption, implementation and use. Just four percent of physicians report having an extensive, fully functional electronic records system, while 13 percent report having only a basic system, according to a national survey of physicians published in the New England Journal of Medicine 4. This is in spite of the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, which offers financial incentives to hospitals and clinicians that effectively use EHR, CPOE and CDS technologies. 3. EHR adoption alone may not be the solution. Technology that streamlines workflow or digitizes patient information can only go so far without a foundation of evidence-based intelligence. EHRs may not be linked to higher quality care or lower costs, according to a 2010 study of data from some 300 California hospitals published in Health Services Research. Clinical Decision Support Enables Meaningful Care Improvements in care quality, safety, efficiency, cost and access will occur only when clinicians can make timely, accurate, evidence-based decisions at the point of care. Clinical decision support (CDS) embedded within EHRs provides a tool set to ensure the right information is available where, when and how clinicians need it and that clinicians follow the proper clinical processes5. At the highest level, CDS is patient data and health information filtered to fit a specific clinical situation and delivered for optimal impact. CDS includes tools and technologies used within clinical information systems (CIS) to improve patient care quality, safety, efficiency and effectiveness. If developed and deployed effectively, CDS delivers: When integrated properly into a care setting, CDS improves processes of care and allows staff to work more quickly and effectively. CDS makes the right thing to do the easy thing to do by helping clinicians remember information, skills and procedures they likely already know with clinical specifics and backup research. The right information: CDS offers timely, accurate evidence-based information that complements the clinician s action and situation. To the right person: CDS involves every member of the care team physicians, nurses, pharmacists, allied health professionals and patients. In the right CDS format: CDS relies on alerts, order sets and medical references to answer clinicians questions. Through the right channel: CDS is disseminated via a clinical information system (CIS) such as an electronic health record (EHR), personal health record (PHR), the Internet or a mobile device such as a Smartphone. At the right point in the clinical workflow: CDS offers evidence-based content and guidance at the precise moment the clinician must make diagnostic and treatment decisions, which is different from how the EHR simply tracks patient data (e.g., medications dispensed, date of last visit, etc.). Traditional CDS delivers information and insight that assists the clinician in making timely, accurate, evidence-based clinical decisions. 3

4 When a clinician treats a patient and wonders, What should I do next? the answer rests in clinical decision support, which can have an enormous impact on care quality, safety and efficiency, says Jonathan Teich, M.D., Ph.D., Chief Medical Informatics Officer, Elsevier Health Sciences. When integrated properly into a care setting, CDS improves processes of care and allows staff to work more quickly and effectively. CDS makes the right thing to do the easy thing to do by helping clinicians remember information, skills and procedures they likely already know with clinical specifics and back-up research. Clinicians typically use CDS at the point of care. But the information clinicians seek from CDS can vary from confirmation of facts and access, to best practices for managing patients with heart disease, to search and retrieval of the most up-to-date research on hypertension or asthma. The best CDS also incorporates guidelines from entities such as the National Guideline Clearinghouse ( as well as order sets, often customized to the meet the needs of a hospital, health system, medical group or individual clinician. Following are major components of a comprehensive CDS suite: Evidence-Based Clinical Content: Information and knowledge is integrated into the EHR so nurses, physicians, pharmacists and other allied health professionals can make more timely, accurate, and informed clinical decisions at the point of care. Patient-Specific Predictive Analytics, Outcomes Analysis, Regulatory Compliance: Patient-specific, real-time predictive analysis is used to identify a patient s risk for re-admission and hospital-acquired infection while the patient is still in the hospital. Clinicians develop sharper insights at the point of care, while organizations benefit from retrospective outcomes analysis and quality and regulatory compliance reporting. Protocols and Standing Order Sets: Providing clinicians with agreed-upon, standardized set of protocols and orders can help them select appropriate doses, routes, and other parameters when prescribing medications. These order sets and protocols, integrated into an EHR with a CDS system, may reduce the risk of errors that can lead to adverse drug events and can help physician assistants, nurses and pharmacists when they initiate therapies. Interdisciplinary Care Plans, Evidence-Based Clinical Practice Guidelines and Integrated Documentation: EHR-integrated care plans, guidelines and documentation systems drive fulfillment and reporting of quality measures, while also improving the interdisciplinary culture of care, evidence-based practice, performance and patient outcomes. Drug Decision Support and E-Prescribing: By evaluating patients drug regimens and deliver relevant, accurate alerts, CDS modules help clinicians make informed decisions for optimal medication safety and efficacy. 4

5 E-Learning Competency and Staff Management: Integrated, online solutions that meet the training and professional development needs of nurses and other healthcare professionals improve patient care quality, increase revenues and enhance clinical competence especially when powered by a performance and learning management system. Successful CDS adoption, implementation and use demands that hospitals, health systems and medical groups take a systematic approach and incorporate these elements: Analytics: CDS should predict the financial and clinical opportunity of adopting best evidence and best practices and then measure and evaluate the benefits. Best-Available Evidence: CDS should rely on medical references based on the most current research and applied to the patient s unique condition and situation. Best-Practice Workflow: CDS should integrate best evidence into the clinical workflow using alerts, reminders, drug reference and decision support, multidisciplinary care plans and order sets. Trained Clinicians: CDS should ensure that clinical staff receive proper training and demonstrate the highest level of proficiency on best evidence and best practices. Educated and Empowered Patients: CDS should focus on transferring information from clinicians to patients so patients understand how to best recover from or better manage their conditions. Analytics Educated Patients CDS & Meaningful Care Best Evidence Proficient Care Givers Workflow CDS & Meaningful Care Loop 5

6 Proper Workflow Integration Is the Key to CDS Success Hospitals, health systems and medical groups must integrate CDS into their existing environment and workflow (see Figure I). Clinicians are involved in multiple activities, from billing, administration, reporting and compliance with regulatory requirements, to education and research. CDS impacts patient care at every phase of the care process from information gathering and care plan development, diagnosis and drug therapy administration to discharge and consults. When integrated throughout the care process, CDS can significantly improve the quality, safety, efficiency and cost effectiveness of patient care: Reduce medical errors, adverse drug events and clinical risk6 Control lengths of stay Improved care of specific diseases 7 Minimize legal and liability exposure Foster adherence to quality guidelines Improve referrals, test ordering and admissions 8. Increase patient satisfaction 9 Deliver cost effective care Hospitals with properly integrated CDS systems have lower costs, fewer complications and lower mortality rates, according to a study in the January 26, 2009, issue of the Archives of Internal Medicine 10. Physician Activities Regulatory/billing/ admin/reporting Professional education Patient Care/ Treatment Research Patient Care: Inpatient Consults (as neded) Interpret Results Pre-Visit Knowledge gathering Admission: Aquire Info & Nurse Asses. Clinician s H&P and plan Documentation Diagnostics Orders Care Plans Drug/ Therapy Admin & Procedures Discharge Post-Visit /Home care Figure 1: Hospital Workflow 6

7 Overcoming Adoption Challenges Clinicians often question CDS implementation cost, impact on workflow, alert fatigue and other issues unique to their specialty or practice. They can avoid common concerns and problems by confronting issues such as training, usability and alignment before system implementation. Following are some practical suggestions: User training: Make CDS training available to every clinician user via classroom, one-on-one tutoring and self-directed online learning. Usability: Invite clinicians to test the system and offer feedback on variables such as speed, accuracy, timeliness, workflow integration, convenience and ease of use. Alignment: Demonstrate how CDS supports the organization s clinical, business and health IT objectives and strategies. The best CDS systems are fully integrated into the clinical workflow, says Jonathan Teich, M.D., Chief Medical Informatics Officer for Elseiver Health Sciences, of the importance of organization-clinician alignment. They subtly affect the way that work is done and help clinicians work more efficiently. If a CDS system isn t working well, it may not be because of flaws within the system itself, but because the system hasn t been properly integrated into the clinical workflow. CDS Delivers Many Benefits, Including Facilitation of Meaningful Use The American Recovery and Reinvestment Act (Recovery Act) of 2009 authorized the Centers for Medicare & Medicaid Services (CMS) to provide reimbursement incentives to hospitals and healthcare professionals that demonstrate meaningful use of healthcare technology. The three-stage meaningful use initiative is designed to: Improve the quality, safety, and efficiency of care while reducing disparities Engage patients and families in their care Promote public health Improve care coordination; and Promote the privacy and security of EHRs CDS tools support these objectives in these ways: Order sets and care plans embedded within the clinical workflow support quality improvement and care coordination Evidence-based clinical and drug reference and decision support tools facilitate more timely, accurate, and informed clinical decision-making Analytics support retrospective and predictive data mining and reporting. Stage One of meaningful use requires that providers implement one clinical decision 7

8 support rule related to a high priority condition along with the ability to track compliance with that rule, likely setting the stage for more expansive use of CDS in the future. With requirements expected in late 2011, Stage Two calls for use of evidenced-based order sets and CDS at the point of care via reminders and alerts, medication reconciliation at each transition of care from one healthcare setting to another, and receipt of health alerts from public agencies and immunizations histories and recommendations from immunization registries. With requirements expected by late 2013, Stage Three calls for implementation of CDS for national high priority conditions and achievement of minimal levels of performance on quality, safety and efficiency. Accountable Care Organizations (ACOs) are also gaining interest from healthcare providers. Defined in the Medicare Affordable Care Act, an ACO is an organization of health care providers that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it. As physicians, hospitals and other caregivers experiment with workable models of ACOs (and the closely related medical home concept), solutions such as CDS will undoubtedly be critical to help those healthcare providers boost the quality of care while achieving efficiencies. CDS Case Example: EHR Integration For Improved Care To understand how an EHR without CDS provides less-than-optimal clinical support and guidance, consider this scenario: A diabetic patient with abdominal pain makes an immediate appointment with her primary care physician. Because the patient s physician is away at a medical conference, she sees the physician on call who checks her EHR and reviews documentation of her most recent visit, including lab results and medications. The physician enters an order for an abdominal pain medication and provides the patient with a printed prescription. Despite filling the prescription and taking the medication for two weeks, the patient feels compelled to visit the emergency department. She has developed an ulcer caused by an interaction of her pain and diabetes medications. An EHR with an integrated CDS system incorporating an effective alert notification could have prevented the patient s visit to the ED. When the physician on call entered the drug order, CDS could have: - Alerted the physician to potential dangerous drug interactions - Offered guidelines to help the physician evaluate the risks of prescribing a pain medication to a patient already taking a diabetes medication. - Offered evidenced-based clinical guidelines on diabetes. 8

9 Drug Decision Support information Clinicians Carefully Select the Most Effective CDS Solution The majority of hospitals, health systems and medical groups recognize the need to invest in CDS solutions to prepare for a changing healthcare landscape. To choose CDS tools that enhance existing systems and meet meaningful use requirements, healthcare organizations should consider these criteria: Organizational Fit: Does the CDS solution fit the organization s clinical and business needs and complement its clinical, business and IT strategies? Can it be purchased, implemented and used cost effectively, including maintenance and upgrades? Clinician Fit: Is the CDS solution flexible and customizable enough to meet the needs of multiple clinicians within the hospital, health system or medical group? Is the solution relatively easy to learn and use? Patient Fit: Will the CDS solution meet the varied needs of specific patient populations within the service area? Care Setting Fit: Will the CDS solution deliver value and benefit within varied care settings, including inpatient, outpatient or long-term care? Content Quality: Does the CDS solution offer breadth and depth of content? Are recommendations backed by scientific evidence and recognized guidelines? Quality Reporting: Does the CDS solution facilitate quality tracking, measurement and reporting? Workflow Integration: Will the CDS solution integrate with other health IT systems, such as those focused on regulatory reporting? 9

10 Knowledge Sharing: Does the CDS solution facilitate or enable CDS information sharing? Diffusion of Change and Innovation: Is a change management program in place to support introduction and implementation of new CDS technologies, practices and policies? A Partner for CDS Success The discipline of healthcare delivery is evolving and investing in health information technologies such as EHRs and CPOE, and CDS is the first step in keeping pace with this evolution. Hospitals, health systems and medical groups must not only choose solutions from trusted, knowledgeable resources, but also implement systems properly. Elsevier delivers the CDS knowledge, expertise and experience that healthcare organizations demand. Established in 1880, Elsevier is the leading publisher of science and health information in the world. The company draws on this history as well as its depth and breadth of resources to make a difference in the cost and quality of healthcare. Elsevier delivers the CDS knowledge, expertise and experience that healthcare organizations demand As both a medical content expert and a trusted partner to more than 30 million practitioners in hospitals, health systems and medical groups worldwide, Elsevier leverages its legacy of content excellence by intelligently moving content into the clinical workflow and to the point of care. Elsevier makes content actionable so hospitals, health systems, medical groups and patients benefit from CDS solutions. Evidence-Based Clinical Content: Elsevier has several content solutions, including MDConsult, FirstConsult and NursingConsult, as well as Elsevier / Gold Standard drug information product Clinical Pharmacology. Patient-Specific Predictive Analytics, Outcomes Analysis, Regulatory Compliance: Elsevier / MEDai s Pinpoint product suite helps providers and payers develop patient-specific, real-time predictive analysis that identifies a patient s risk for readmission and hospital-acquired infection while the patient is still in the hospital. Interdisciplinary Care Plans, Evidence-Based Clinical Practice Guidelines and Integrated Documentation: Elsevier / CPM Resource Center delivers evidencebased clinical content solutions and services built on a professional practice framework. Drug Decision Support and E-Prescribing: Elsevier / Gold Standard s Alchemy is an integrated drug database and drug decision support engine that helps providers evaluate patients drug regimens and delivers relevant, accurate alerts so clinicians can make informed care decisions. E-Learning Competency and Staff Management: Elsevier / MC Strategies provides healthcare professional performance management, education, clinical information and organizational development tools such as ReadyRN: Disaster 10

11 Nursing and Emergency Preparedness, Mosby s Essential Nursing CE, and Elsevier Performance Manager. Order Sets: Elsevier has partnered with Zynx Health to offer First Consult and MD Consult integrated with ZynxOrder. This partnership offers the most cost-effective, comprehensive and highest-quality evidence-based point of care resource available for physicians. CDS: Next Steps Healthcare organizations must embrace CDS systems and tools to address the ongoing challenges in healthcare quality, safety, efficiency, and performance and the requirements of meaningful use. CDS tools are varied ranging from order sets, drug decision support, e-prescribing, evidenced based clinical content, and e-learning competency, to care plans, guidelines, documentation, predictive analytics, outcomes analysis and regulatory compliance reporting. The most effective CDS tools, such as those developed by Elsevier, fulfill the five rights and focus on analytics, evidence, workflow and trained, informed clinicians and patients. CDS benefits include reductions in errors, liability and length of stay, as well as improvements in satisfaction, care quality, guideline adherence, readmissions, referrals and testing. Executives and clinicians can prevent implementation challenges by leading the charge on usability, alignment, and training. Moreover, they can leverage CDS by extending its use to analytics, handoffs, procedures, certification, discharge instructions, interdisciplinary care, and training. Executives and clinicians will find the best, most appropriate CDS systems if they apply broad selection criteria, including content quality, quality reporting, workflow integration, knowledge sharing, change management, and patient, clinician, care setting, and organizational fit. Elsevier Clinical Decision Support, a division of Elsevier, the global leader in medical and health information, provides world class information and point-of-care technology solutions that optimize decisions and actions to improve the overall quality, safety and cost-effectiveness of care. The business delivers on this promise through actionable clinical content, care planning and documentation, drug reference and decision support, learning and performance management, and data mining and outcomes analytics solutions for provider, pharmacy and payer organizations. 11

12 Addendum How can healthcare organizations prepare for a future dominated by integration of CDS tools into clinical systems? Here are some suggestions. Stay up to date on Elsevier s CDS offerings at Learn as much as possible about actual CDS successes and failures, including underlying challenges, implementation steps, business and clinical results and lessons learned. Monitor CDS initiatives such as those sponsored by American Medical Informatics Association (AMIA) ( CDS Government Collaboratory ( healthit_hhs_gov cds_collaboratory/1230) Participate in the national conversation on CDS by participating in activities such as the HIMSS CDS Wiki ( 12

13 CDS Resources Improving Outcomes with Clinical Decision Support: An Implementer s Guide Decision Support Implementer s Guide Grand Challenges in Clinical Decision Support Clinical Decision Support and E-Prescribing: Recommendations and an Action Plan A Roadmap for National Action on Clinical Decision Support Clinical Decision Support: Defining the Right Strategy, Making the Right Decisions Dr. Jonathan Teich on Clinical Decision Support Challenges and Barriers to Clinical Decision Support Design and Implementation Experienced in the Agency for Research and Quality CDS Demonstrations CDS_challenges_and_barriers.pdf Office of the National Coordinator (ONC) Clinical Decision Support and the CDS Collaboratory ypage&parentid=15&mode=2&in_hi_userid=10731&cached=true 13

14 References 1 HealthGrades Seventh Annual Patient Safety in American Hospitals Study (March 2010) - PatientSafetyInAmericanHospitalsStudy2010.pdf 2 Institute for Healthcare Improvement: 5 Million Lives Campaign - Programs/Campaign/Campaign.htm?TabId=1 3 Society of Actuaries Study Finds Medical Errors Annually Cost at Least $19.5 Billion Nationwide Catherine M. DesRoches, Dr.P.H., Eric G. Campbell, Ph.D., Sowmya R. Rao, Ph.D., Karen Donelan, Sc.D., Timothy G. Ferris, M.D., M.P.H., Ashish Jha, M.D., M.P.H., Rainu Kaushal, M.D., M.P.H., Douglas E. Levy, Ph.D., Sara Rosenbaum, J.D., Alexandra E. Shields, Ph.D., and David Blumenthal, M.D., M.P.P. Electronic Health Records in Ambulatory Care A National Survey of Physicians, N Engl J Med 2008; 359:50-60 July 3, 2008, ( 5 Michael F. Furukawa, T. S. Raghu, Benjamin B. M. Shao. Electronic Medical Records, Nurse Staffing, and Nurse-Sensitive Patient Outcomes: Evidence from California Hospitals, Health Services Research. Volume 45, Issue 4, pages , August ( cdsroadmap.pdf 6 Electronic prescribing with clinical decision support reduces medication errors in community-based practices (AHRQ) EHRs with clinical decision support improve asthma care (AAP News) - aappublications.org/cgi/content/citation/31/7/2-b 8 Support and Assessment for Fall Emergency Referrals (SAFER 1) trial protocol. Computerised on-scene decision support for emergency ambulance staff to assess and plan care for older people who have fallen: evaluation of costs and benefits using a pragmatic cluster randomised trial (NCBI) - PMC / 9 Development of a prototype clinical decision support tool for osteoporosis disease management: a qualitative study of focus groups (NCBI) - pmc/articles/pmc / 10 Amarasingham R, Plantinga L, Diener-West M, Gaskin DJ, Powe NR. Clinical information technologies and inpatient outcomes: a multiple hospital study. Arch Intern Med Jan 26;169(2): PMID:

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