Clinical Decision Support: The Basics

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1 Clinical Decision Support: The Basics REACH - Achieving - Achieving meaningful meaningful use of your use EHR of your EHR Paul Kleeberg, MD, FAAFP, FHIMSS CMIO Stratis Health Minnesota e-health Advisory Meeting September 9, 2013

2 CDS as it Relates to Meaningful Use Meaningful Use Definition of CDS: HIT functionality that builds upon the foundation of an EHR to provide persons involved in care processes with general and person-specific information, intelligently filtered and organized, at appropriate times, to enhance health and health care. Provider Centric 2

3 What Tools Would Qualify for Meaningful Use If triggered by patient specific information AND relevant to a quality measure, specialty or high clinical priority: Documentation forms or templates Situation-specific flow sheets Relevant data presentation Referential information Interactive sequential advice Order sets Alerts and reminders Protocols and Pathways Automatic dose calculators Not Drug-drug and Drug-allergy interactions 3

4 Provider-Centric CDS Benefits A simple solution Can be very effective Targets the individual most likely to be able to respond Obstacles Leaves all the work to the provider With only one protective layer, the objective risks being missed Does not leverage the health care team Does not leverage the patient The EHR may not be capable or you may not have the expertise or time 4

5 Broadening the Definition of Clinical Decision Support A variety of approaches for delivering clinical knowledge, and intelligently filtered patient information, to clinicians and/or patients for the purpose of improving healthcare processes and outcomes* Making the right thing to do the easiest thing to do * Improving Outcomes with Clinical Decision Support: An Implementer s Guide 5

6 CDS Five Rights To improve targeted healthcare decisions and outcomes, information interventions (CDS) must provide: 1. The right information 2. To the right people 3. Via the right channels 4. In the right formats 5. At the right times The who, what, when, where, how 6

7 Right Information ( What Options) Provides information that is: Evidence-based Current Responsive to clinical needs At appropriate level (depth and breadth) Useful for guiding action 7

8 Right People ( Who Options) The right people to receive or provide information: Providers Nurses Pharmacists Front desk / admission staff Other care team members Patients and their caregivers 8

9 Right Channels ( Where Options) How is the information getting to the right people? EHR modules Registries Portals Mobile devices Smart home devices Paper (e.g., patient handout) , text messages 9

10 Right Formats ( How Options) How is the information presented? As an interruptive event Alerts A gentle reminder Highlighted material in the workflow In a digested format Patient Lists/Provider Scorecards Flow sheets and Graphs Dashboards To provide guidance Documentation Templates Order sets Reference information 10

11 Right Time ( When Options) 11

12 The earlier in the workflow the better Multiple approaches to intervene are more likely to produce the desired outcome Patient due for a preventative service Patient Reminder Front Desk Flow Sheet for MA Flow Sheet for MD Order suggestion Patient leaves without the service Carefully think of the potential interventions at each point of care 12

13 CDS Done Poorly Alerts which force a user to stop disrupting their train of thought Imprecise alerts causing multiple false alarms Force choices with inappropriate options Seemingly important reminders of unnecessary information Can cause the user to miss important things 13

14 Computer Assisted Flying as CDS Adopted from a presentation by Dr. Kevin Larsen, Medical Director of Meaningful Use at the ONC It is winter, sometimes there is snow. Be careful! Press here to document you read this. Scheduled maintenance due in 2 months. Mark here to accept Bathroom water pressure is low! 14

15 Required CDS Capabilities in 2014 certified software (There could be more ) Clinical decision support interventions (push) are to be based on each one and at least one combination of the following data: Problem list; Medication list; Medication allergy list; Demographics; Laboratory tests and values/results; and Vital signs Referential information (pull) are to be based on each one and at least one combination of the above data elements 15

16 The Challenge is the build Example: Appropriate LDL testing Denominator 1: (High Risk) All patients aged 20 through 79 years who Have CHD or CHD Risk Equivalent OR 10-Year Framingham Risk > 20% Denominator 2: (Moderate Risk) All patients aged 20 through 79 years who Have 2 or more Major CHD Risk Factors OR 10-Year Framingham Risk 10-20% Denominator 3: (Low Risk) All patients aged 20 through 79 years who Have 0 or 1 Major CHD Risk Factors OR 10-Year Framingham Risk <10% For Denominator 2 and Denominator 3; Fasting HDL-C > or equal to 60 mg/dl subtracts 1 risk from the above (This is a negative risk factor.) 16

17 CHD or CHD Risk Equivalent Diabetes and its complications Cardiovascular disorders Peripheral vascular disorders Non-hemorrhagic stroke Code System(s) Total Codes ICD10CM 103 ICD9CM 91 SNOMEDCT 194 Total

18 Framingham Risk (Males) Male Age Years Points Diabetes Points No 0 Yes 2 LDL-C (mg/dl) Points < HDL-C (mg/dl) Points < Smoker Points No 0 Yes 2 Blood Pressure Systolic Diastolic (mm Hg) (mm Hg) < <120 0 pts pts pts pts pts Adding up the points Age LDL-C HDL-C Blood Pressure Diabetes Smoker Point total CHD Risk Points 10 Yr Total CHD Risk <-3 1% -2 2% -1 2% 0 3% 1 4% 2 4% 3 6% 4 7% 5 9% 6 11% 7 14% 8 18% 9 22% 10 27% 11 33% 12 40% 13 47% 14 56% 18

19 The Challenge is the build Example: Appropriate LDL testing Denominator 1: (High Risk) All patients aged 20 through 79 years who Have CHD or CHD Risk Equivalent OR 10-Year Framingham Risk > 20% Denominator 2: (Moderate Risk) All patients aged 20 through 79 years who Have 2 or more Major CHD Risk Factors OR 10-Year Framingham Risk 10-20% Denominator 3: (Low Risk) All patients aged 20 through 79 years who Have 0 or 1 Major CHD Risk Factors OR 10-Year Framingham Risk <10% For Denominator 2 and Denominator 3; Fasting HDL-C > or equal to 60 mg/dl subtracts 1 risk from the above (This is a negative risk factor.) 19

20 Major Risk Factors for CHD High blood cholesterol and triglyceride levels High blood pressure Diabetes and pre-diabetes Overweight and obesity Smoking Lack of physical activity Unhealthy diet Stress Source: The NIH s National Heart, Lung and Blood institute: Elevated blood pressure Elevated serum total (and LDL) cholesterol Diabetes mellitus BMI Cigarette smoking Physical Inactivity Gender Heredity Advancing age Source: Texas Heart Institute: mart/riskfact.cfm#major 20

21 Calculating the Numerators Numerators 1 and 2: (High and Moderate Risk) Patients Who had a fasting LDL-C test performed or a calculated LDL-C During the measurement period Numerator 3 : (Low Risk) Patients Who had a fasting LDL-C test performed or a calculated LDL-C During the measurement period or up to 4 years prior to the current measurement period 21

22 What s a Small Facility to do? The Technical Tools: Documentation forms or templates Situation-specific flow sheets Relevant data presentation Referential information Interactive sequential advice Order sets Alerts and reminders Protocols and Pathways Automatic dose calculators Options Electronic: Hard to build, easy to use Paper: Easier to create, but hard to use Consequently, greater reliance on vendor build 22

23 Closing Thoughts Effective Clinical Decision Support is a more than the bells and whistles in an EHR It is a team effort that requires close attention to workflow Until vendors create a friendly interface for CDS creation within an EHR, small facilities will depend on vendors to design EHR-driven interventions Well designed CDS is the secret sauce that allows health information technology assist us in achieving the triple aim of health care: Improving the patient experience of care Reducing the cost of care Improving the health of populations 23

24 Resources HealthIT.gov resources on Clinical Decision Support Improving Outcomes with Clinical Decision Support: An Implementer s Guide Second Edition oductid=3318 CDS/Process Improvement site with draft CDS Template https://sites.google.com/site/cdsforpiimperativespublic/cds-forpi-imperatives-users-guide Stratis Health HIT Toolkits: 24

25 Paul Kleeberg, MD, FAAFP, FHIMSS Key Health Alliance Stratis Health, Rural Health Resource Center, and The College of St. Scholastica. REACH is a project federally funded through the Office of the National Coordinator, Department of Health and Human Services. 25

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