Achieving better care delivery through a phased approach to clinical decision support

I’m encouraged by the progress the industry has achieved in creating robust healthcare information technology (HIT) infrastructure in the United States. Clinical decision support (CDS) is becoming an essential component of that infrastructure, but not without hiccups. In our efforts to provide meaningful recommendations to providers, we have often tried to do everything at once … with varying degrees of success. I maintain that CDS is too complex to implement this way; rather, it must be approached as an evolution, and carefully phased into our healthcare IT infrastructure to provide actionable information to the entire healthcare team—clinicians, staff, and patients.

Healthcare IT bigger than ever

Data Bridge Market Research estimates that the global healthcare IT market will grow to $340.9 billion by 2024, from $131.0 billion in 2016, a compound annual growth rate of 12.5% during the forecast period 2017 to 2024.¹ In the United States, the development of the Medicare and Medicaid EHR Incentive Program (aka Meaningful Use) beginning seven years ago has made a sizeable contribution to this growth. It doesn’t hurt to be rewarded for adopting, implementing, upgrading, and demonstrating the meaningful use of electronic health records technology.

In addition, there has been an organic upward trajectory in the growth and acceptance of healthcare IT in America. Between the proliferation of advanced IT systems and the growing number of technology-savvy physicians and patients, our hospitals, healthcare networks, private practices, specialty medicine, and the long-term care industry are turning to technology solutions to better serve their patients while saving costs.

Clinical decision support not a blockbuster success—so far

To date, the implementation of clinical decision support systems often has been an afterthought of the Meaningful Use program. In an effort to accelerate the adoption of all types of HIT, the dissemination of decision support data has created alert and reminder fatigue. There also is a limit on how much alert content can actually be filtered and made available in a timely manner. Additionally, the time, effort and cost required of hospitals and healthcare systems to produce and deliver this content easily demonstrates why CDS has not been fully embraced.

I am convinced that we can do a better job of ensuring the five “rights” of clinical decision support: Delivering the right information to the right person in the right intervention format through the right channel at the right time in the workflow. Taking a hard look at how we have introduced and used CDS, and adjusting our approach to its implementation, will enable us to guarantee those rights on a regular basis, and move decision support into “must-have” status.

Decision support must evolve in logical steps

Admittedly, clinical decision support is a sophisticated component of HIT. CDS tools can generate data that improve the quality of our healthcare delivery and impact overall safety and efficiency. With a resource this complex, however, it makes sense to move forward in logical steps, getting each one right before we go on to the next. I see these steps as content integration, content harmonization, and the use of evidence in a virtual feedback loop.

In the near term, we must integrate clinical decision support content to help all care team members including physicians, nurses, therapists, care managers, and allied health professionals. We need to go beyond reminders and alerts, providing comprehensive content within the clinical workflow. This content integration will drive each intended clinical action, from inpatient to ambulatory to post-acute care, to even home care. By consolidating CDS for everyone on the care team, we can improve decision-making at all levels while greatly reducing the unintended (and potentially harmful) variability of care.

Mid-term: Add patients to the equation

Patients are more involved with their own healthcare decisions and delivery than ever before. We are all healthcare consumers, shopping around for doctors, comparing the prices of procedures, checking online references, communicating with our providers via emails and portals, and doing what we can to educate ourselves about how to best manage our health. In the next phase of clinical decision support, we must synchronize care team CDS with patient-facing CDS. It is timely and appropriate to deliver the same content both to providers and their patients in a patient-centric manner. This “harmonization” of content will help align patient engagement with their overall care plan. It will also result in more opportunities for patient feedback to both inform the provider pathway and drive the patient pathway. A diabetic patient who shares blood glucose measurements helps guide the physician’s decision-making processes, while personally using the same information to better manage a chronic condition.

Long-term: Use evidence in a virtual feedback loop

Once CDS is finely tuned for all care team members and their patients, we need to evaluate how the evidence generated from clinical decision support systems can be used in a virtual feedback loop. As described by the Institute of Medicine (now the National Academy of Medicine) in The Learning Healthcare System, developing and applying a cycle of evidence generation and content refinement can move healthcare to the next level of innovation².

How do we create this cycle to enhance pathway content? First, using decision-support tools, we generate evidence. We then study the evidence to understand what does and doesn’t work for providers and patients, and respond accordingly. By constantly generating content and refining methodologies, we can help transform the fundamentals of healthcare delivery. In the long term, CDS used in this manner will increase industry alignment around personalized medicine (which is sometimes referred to as precision medicine, although precision medicine also incorporates genomics), ultimately resulting in better patient outcomes.

A commitment to this phased approach to clinical decision support is the optimal way to realize its potential. By evolving from content integration to content harmonization to evidence generation and application in a virtuous feedback loop, CDS will move from an afterthought to an engine that helps drive healthcare in our country to new levels of quality and innovation. Our providers and patients deserve no less.

References

1. Data Bridge Market Research, Global Healthcare IT Market – Trends and Forecast to 2024 (March 2018).
2. Institute of Medicine, The Learning Healthcare System: Workshop Summary (2007).