Since the advent of the current era of healthcare reform, U.S. hospitals have been under mounting pressure to improve the quality of care while reducing costs. Included in the reform legislation with which hospitals must comply are the Health Information Technology for Economic and Clinical Health (HITECH) Act's Meaningful Use of Electronic Health Records (EHR) regulations, the Affordable Care Act's Value-Based Purchasing (VBP) program, and hospital readmissions reduction programs. In addition, there are numerous other recommended reform programs in which hospitals may participate that are designed to improve quality and decrease cost.
The message is clear: In order to comply with the myriad of reform requirements, hospitals must find a way to avoid the variations in care that drive up costs and result in negative outcomes.
Evidence-based care plans in a reformed healthcare environment
A study by Hillestad et al* estimates that $41.8 billion could be saved annually through the widespread adoption of an EHR system, and that 76% ($31.9 billion) of the potential cost savings is related to items that could be directly influenced by clinical decision support (CDS). Evidence-based CDS has the potential to lower costs and improve outcomes by driving evidence-based care at the bedside and improving interdisciplinary coordination, resulting in the standardization of care across an organization. Care standardization also offers many opportunities to improve care efficiency by promoting truly coordinated, non-redundant care by the clinical team.
In the current healthcare environment, this kind of interdisciplinary care standardization will be a critical factor in determining whether a hospital not only survives healthcare reform, but thrives for years to come.
Collaboration is critical
Three factors are key in determining the success of all CDS tools at the bedside: content, technology and adoption. The impact of all three factors is significantly enhanced by the collaboration of an interdisciplinary team consisting of nursing staff, physicians and other bedside clinicians, as well as quality improvement specialists and the informatics team of the organization. When the right people are involved in the design and implementation phases of CDS, plans of care will be provided to the bedside clinicians with critical content embedded in the clinical workflow. The lack of initial engagement by all the key stakeholders may result in poor design and a system that is not usable or meaningful to bedside clinicians.
While effective clinical decision support requires the collaboration of clinicians, informaticists and IT, the hospital or health system chief nursing officer (CNO) must take on the role of clinical sponsor by setting the expectation that care will be delivered based on the most current research and the various regulations required by healthcare reform. The clinical sponsor is also vital in providing the tangible resources for clinicians, informaticists and IT to collaborate in vetting the care plan content, getting it into the electronic health record system, doing the usability testing and actually using the plan of care in practice.
Four steps an interdisciplinary team must take
After the interdisciplinary team is formed, it must follow four critical steps for CDS success:
1. Develop care plan content
First and foremost, care plan content must be based on current research and guidelines. There also must be a mechanism whereby content is routinely updated. In addition, the content must represent the unique contributions of every discipline involved in patient care. And as the content is reviewed and made ready for EHR deployment, redundancies or discrepancies in care provided by the team must be identified to ensure not only high quality, but also coordinated care.
2. Integrate care plan content into an EHR
Effective integration of care plans requires the collaboration of the interdisciplinary team with teams from informatics and IT. This streamlines the process for deploying customized evidence-based clinical content through the EHR and to the point of care in a usable way that truly supports clinical decision making, rather than requiring tasks in the EHR that do not assist the clinician.
3. Test care plan usability
Often a missed opportunity for hospitals and health systems, each member of the interdisciplinary team should have the opportunity to test the content for its usability in their own unique care processes, as well as in the coordinated work of the whole interdisciplinary team on behalf of the patient and family. This testing should take place prior to the system go-live.
4. Promote adoption
Interdisciplinary team participation during the CDS design and development phase plays a significant role in ensuring clinical adoption. Under the leadership of the CNO, a thorough understanding of the research basis for the plan-of-care content provides care team members with the “why” for practice change.
Benefits of CDS in practice
Through the use of evidence-based CDS, clinicians and healthcare systems will gain a critical opportunity to improve quality and cost outcomes. At the same time, no CDS tool will be successful if developed outside of a collaborative team. Care is not delivered in a vacuum and therefore cannot be standardized in disjointed, solitary efforts. A hospital's ability to thrive in the era of reform is dependent on the close and effective collaboration of nurse leaders, interdisciplinary clinicians, and informatics and IT experts.
* Hillestad R, Bigelow J, Bower A, et al. Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. Health Aff (Millwood). 2005 Sep-Oct;24(5):1103-1117.
About the author
Pat Button, EdD, RN, is chief nursing officer, Zynx Health.
