Experts say that adhering to evidence-based medicine (EBM) protocols will be part of overarching healthcare reform, and that clinical decision support (CDS) will increasingly be leveraged to improve quality of care.
“It's absolutely a fact that it will be a part of healthcare reform,” says Jerry Osheroff, M.D., who chairs the Chicago-based HIMSS task force on CDS (and is also Chief Clinical Informatics Officer of Healthcare & Science at N.Y.-based Thomson Reuters). “If you look at the meaningful use matrix, there's no question that CDS and evidence-based protocols are something CIOs are going to have to attend to if they want to get the stimulus money - or not get dinged.”In addition to federal requirements, the need to implement some form of CDS or EBM is driven by the information explosion. And CDS, most agree, is the best way to address the overabundance of information. “The amount of information that is out there for any caregiver far exceeds their ability to understand and to address it all, and to make it into any sense,” says Andy Fowler, CIO of Methodist Le Bonheur, a seven-hospital system in based in Memphis. “There is no way in the world that a physician can keep up with it or make the best decisions without these systems.”
And as CIOs are increasingly tasked with making sure physicians have access to the latest knowledge, they are also responsible for protecting the hospital's bottom line. “A CIO has the responsibility to decrease variability in the hospital and stop redundant or unnecessary testing,” says James Feldbaum, M .D., an independent consultant based in Hailey, Idaho. “If the CDS protocol shows two antibiotics you can use and one is $1-a-dose and one is $10-a-dose, you're going to want to steer them to what's in the hospital's formulary.”
Fowler says the meaningful use matrix - which states hospitals need to implement one CDS rule for a high priority condition by 2011 - has upped the importance of CDS. “It's no longer a carrot and stick environment,” he says. “We don't have to spend time on the stick anymore because the federal government is the stick. Now we have the opportunity to focus on the carrot.”
But what exactly is the carrot? People use the terms clinical decision support and evidence-based medicine interchangeably, but evidence-based medicine is defined as the use of current evidence in making decisions about the care of individual patients, while clinical decision support combines evidence-based rules and the mechanism to communicate them to caregivers. Chicago-based HIMSS defines CDS as a clinical system, application or process that helps health professionals make clinical decisions to enhance patient care.
“Clinical decision support is not a widget,” says Osheroff. “No vendor has all the pieces - the information, how it's delivered and how it's integrated into a different information system.”
Putting the pieces together raises issues, many have found, starting with which systems to use for both evidence-based medicine protocols and clinical decision support. Some vendors sell these solutions as part of their core clinical offerings, but there are also many best-of-breed solutions that need to be interfaced with the EMR. Lastly, many hospitals have gone ahead and written their own home-grown rules. Do any of these work better than others?
“Every vendor of enterprise systems has some degree of CDS built in,” says Osheroff. “It's a complex hodgepodge.” A few years ago, according to Osheroff, the trend was enterprise CIS vendors buying up CDS systems and including them as part of their package - the acquisition of Zynx Health (Los Angeles) by Kansas City, Mo.-based Cerner is a good example.
Today, however, CIS vendors today are no longer buying up CDS systems, preferring to stick to their core business, he says. In fact, Cerner, which purchased Zynx Health in 2002, divested in 2004, though it has maintained a strategic alliance with the company and continues to use its content in Cerner software. “Right now, most of the CIS vendors are taking the approach that developing CDS content is a very different business,” says Osheroff.
Most agree that even if an enterprise vendor does have a CDS offering, the inherent problem is that it doesn't come out of the box ready to go. And most agree that customization is the hardest part.
Terri Steinberg, M.D., CMIO of Christiana Care Health System, a two-hospital system in Wilmington, Del., is using the ubiquitous Zynx system interfaced to her Cerner EMR. “Zynx provides clinical content and order sets, so you can use yours, theirs or a combination of the two. It's a really good starting point.”
Steinberg says the Zynx system is expensive, but that it's worth the money and is helpful in building order sets. “We had hundreds of doctors working together for 18 months writing order sets on the system,” she says. “You can't underestimate the importance of putting your fingerprints on everything that you touch - and when it's all done it gets sucked into Cerner.”
Feldbaum says another benefit of CDS systems is that they allow CIOs to move more quickly with their CPOE rollout. “If CIOs buy Micromedex, they have data that's basically unarguable,” he says, “It may cost me money, but it will be in place in time for my rollout, I don't have to burn up my physician intellectual capital, and I avoid turf wars other than the decision, ‘Do we implement it or not?’”
Though turf wars can be avoided, there still remain many physician concerns to be dealt with - chief among them over-alerts and doctors' fears of interference. “If CIOs set up CDS that they're doing to the clinicians rather than with the clinicians, then you bump into problems,” says Osheroff. “You have to do it with them, not to them.”
Steinberg, a physician herself, agrees that EBM and CPOE have to be presented delicately to sensitive doctors. “‘Hit enter to confirm that the computer is smarter than I am,’ is the way clinicians see CDS - they have a real love-hate relationship with it,” she says. “They like knowing they have a safety net, but they don't like when the computer tells them something they knew already.” Steinberg says she avoided many of those issues by ensuring heavy physician involvement in building order sets.
There are different ways to deal with over-alerting as well. Steinberg says her hospital, like many, wrote custom rules to avoid it. “Our rule is, ‘If you see this, it's important and you better do something about it.’” She also plans to utilize a CDS committee that will decide what high profile alerts are worth escalating to doctors.
Steinberg, who hasn't gone live with CDS at Christiana Care yet, is planning on implementing it as part of CPOE, which brings CIOs to another critical decision hospitals face - timing.
Feldbaum says implementing a CPOE system is an ideal time to tackle CDS. “When you design it, you're looking at your capabilities, what functionality to turn on, and how much clinical decision support to initiate,” he says. “You want to time CDS so as not to be disruptive, and this way physicians automatically associate CPOE with clinical decision support.”
But according to Osheroff, it doesn't have to coincide with CPOE or even with an EMR. “We argue heavily that you can do it before that, without question,” says Osheroff. “We advocate strongly to not wait for CPOE. If all you have is a lab and a data warehouse, you look at those systems and ask how you can optimize.”
Most hospitals have some form of CDS on paper. Before CPOE, Steinberg says she was using paper-based protocols for things such as weight-based heparin guidelines. “We had a lot of paper-based guidelines and order sets,” she says. “You look at the stuff that's hard to do and difficult to remember, and you can start with paper.”
Fowler says he was doing the same at Methodist Le Bonheur. “We were certainly doing some of that before having an EMR,” he says. “But I would challenge that to be effective and to do it well; it's going to be very hard if not impossible to do CDS without a fully integrated EMR.”
Whether paper-based or electronic, Osheroff says, CDS is a means to an end, and he advises beginning any CDS project with completion in mind. “The end is becoming very clearly defined, in line with the items on the meaningful use matrix,” he says. “So what CIOs really must do in order to be successful is start from those drivers for the hospital and focus their efforts on making sure those imperatives get addressed. The second point is to do it with the stakeholders, not to them.”
Fowler says he agrees that engaging the stakeholders will be key to success. “Physicians are looked at as being difficult, but they want to do the best they can,” he says. “They need to know that the opportunities we're providing actually do help, and as soon as they see the evidence, they're all over it.”
“We Saved His Life”
“If sepsis is not identified in the first six hours, it is probably too late. You can write a rule around that, which we did. If we see two or more of these indicators going south, we fire an alert, take a lab and look for major organ dysfunction. If we see that's positive, that goes from possible sepsis to probable sepsis. Then we send an alert to our response team with emails, pagers, and mobile phones to get them on top of that case. That happens in minutes. We had a 23-year old male that presented in the ED, was sent home and appeared to be fine. But the alerts fired for probable sepsis, and by the time he reached his home, he was called back in. He was septic and we saved his life. Think of the value of that: We're adding birthdays to people's lives. In the electronic world, if nurses don't understand the power of this, they'll document at end of shift. When you can show a nurse you're saving lives, now you make it meaningful. This is real transformation.”