Decision support at work

June 25, 2015

Decision support capabilities operate much like an electronic advisory board or planning committee, minus the circuitous debates and discussions, distracting smartphone use, and other thoughtless interruptions that break concentration.

Larry Schor,
Senior Vice President, Medecision

Theoretically, they occupy less physical space even though they may be more accessible in a smaller footprint, courtesy of, say, cloud computing and wireless benefits.

Still, decision support tools can be nebulously defined or even taken for granted, both at a provider’s own peril.

“Properly implemented decision support drives best practices and clinical workflow across the entire continuum of care, a particular concern for poly-chronic patients with multiple physicians, often working in separate independent systems,” says Larry Schor, Senior Vice President, Medecision. “Decision support ensures timely attention to patient needs in the right clinical setting at the lowest total cost. In other words, it is a key to achieving the goals of the Triple Aim – patients care about safety, quality, and cost. Data-driven decision support and clinical workflow are essential components to performance consistency, medication management, avoiding the cost and risks of unneeded tests or treatments.”

Sarah Corley, M.D., FACP, Chief Medical Officer, NextGen Healthcare

These tools can function like a prototypical app or search engine, according to Sarah Corley, M.D., FACP, Chief Medical Officer, NextGen Healthcare.

“Decision support can help the physicians by making sure they do not miss guideline-based care, order appropriate tests and medications,” she says. “It improves efficiency by allowing other care team members to provide protocol-based services. It provides peace of mind to physicians and enhanced safety to patients by checking drug and allergy interactions rather than depending upon physician memory. It can help the patient by assuring they are getting the latest evidence-based care. It helps reduce costs to patients and callbacks to doctors by showing formulary information at the point of prescribing.”

Eyal Ephrat, M.D., CEO, medCPU

But Corley issues a word of caution about relying too much on it. “There has to be a balance, however, to limit decision support to the most important areas, so that too many alerts are avoided that might hinder productivity or annoy patients,” she says.

“Failed decision support and interoperability tools have lessened the industry’s enthusiasm for what effective decision support can actually do, which is save lives and money, while making the clinicians job easier,” says Eyal Ephrat, M.D., CEO, medCPU. “But we can’t give up. As a former aviator, I often imagine what it would be like if the pilot settled for only seeing 30 percent of the data from the cockpit. There’s a huge gap between the technological assistance pilots receive and the decision support assistance clinicians receive at the point of care. But the new generation of decision support technology is closing that gap. Proof that it can work is what will ultimately ensure it is given high priority within healthcare organizations.”

Nilo Meharabian, Assistant Vice President, Product Management, McKesson Health Solutions

Nilo Meharabian, Assistant Vice President, Product Management, McKesson Health Solutions, offers a more holistic perspective on the contributions decision support tools make.

“Automated decision support helps both payers and providers ensure high-quality, appropriate care is delivered, based on the latest medical evidence,” Meharabian says. “It allows clinicians and payers to quickly access the evidence-based medical criteria they need to help determine the appropriate care based on a patient’s presented condition.”

Susan Niemeier, R.N., Chief Nursing Officer, CapsuleTech

Decision support can impact patient satisfaction, she continues. “Providing appropriate evidence-based care and avoiding unnecessary, and possibly risky, care are what any patient seeks,” she says. “By bringing decision support in at the right time in the care continuum, which is at the point of decision, we can influence care quality. This is the crucial stage when the physician is determining what care should be provided. Decision management criteria can then be applied throughout a patient’s treatment to measure progress and determine clinically appropriate next steps based on their individual progress.”

Authorization processes can benefit, too. “A patient can know if the authorization was approved before the care is administered,” Meharabian says. “Decision support can also be used for network steerage to help guide the patient to the appropriate physician or facility to get the care or procedure they need.

“In the end, automated decision support can have a substantial value-based impact in several areas,” she adds. “It gives patients transparency into authorization and provider selection – potentially speeding authorizations and start of treatment in the process – and it provides appropriate care guidelines ensuring quality care and reduces unnecessary costs.”

Clinical workflow ties

Susan Niemeier, R.N., Chief Nursing Officer, CapsuleTech, cites the Centers for Medicare & Medicaid Services’ definition of clinical decision support (CDS) as “a tool to assist care team members in making timely, informed, and higher-quality decisions.”

Thomas Van Gilder, M.D., Chief Medical Officer and Vice President, Informatics and Analytics, Transcend Insights

“CDS is not simply an alert or notification,” she says. “CDS provides evidenced-based guidance to the clinician at the right points in workflow to make optimal decisions. Decision support complements and simplifies clinical workflow with the objective of improving patient care delivery that may lead to better outcomes and improved patient satisfaction.”

Certainly, clinical decision support potentially can enhance the interaction between patients and physicians by providing trusted information, according to Thomas Van Gilder, M.D., Chief Medical Officer and Vice President, Informatics and Analytics, Transcend Insights, a wholly owned subsidiary of Humana. “To do this, it’s important that CDS tools provide the kind of information physicians and care team members need to better care for patients and maintain workflow. Poorly executed CDS interrupts workflow, takes the physician’s thoughts and eyes off of patient care, and decreases physician and patient satisfaction,” he says. Transcend Insights was formed in March by the mergers of Certify Data Systems, Anvita Health, and nliven systems.

Kathleen Aller, Director of Business Development for HealthShare, InterSystems

Meharabian ties decision support to healthcare reform. “By integrating into a provider’s workflow, practitioners achieve a level of efficiency that lends itself to successful value-based care,” she says, “where providing the right care, at the right level, and in the right place is paramount. For example, you don’t want someone being admitted to the hospital or undergoing a procedure when the medical evidence indicates it is not needed. In fact, research has shown that patient care varies from the evidence in over 45 percent of cases, and up to a third of procedures are unnecessary.”

Kathleen Aller, Director of Business Development for HealthShare, InterSystems, warns about separating clinical decision support from clinical workflow.

Chris Hobson, M.D., Chief Medical Officer, Orion Health

“Well-designed workflow should inherently support good clinical decision making,” she says. “This includes the way information is presented, reference materials, alerts, logic, and the like, all reflective of the user’s scope of responsibility and all delivering information for timely intervention at the point of decision. In general, clinical decision support should contribute to positive outcomes, better opportunities for shared decision-making, and hence higher patient satisfaction, but there will rarely be an unambiguous cause-and-effect relationship between the two.”

Chris Hobson, M.D., Chief Medical Officer, Orion Health, concurs.

“Rather than affecting clinical workflow, decision support should fit with the clinician’s workflow,” Hobson says. “Clinical decision support should be designed to provide the right information, to the right person, in the right format, through the right channel, at the right time, such as when the information is needed most.”

Donald Voltz, M.D., Department of Anesthesiology and Medical Director of the Main Operating Room at Aultman Hospital

Orion Health promotes clinical pathways and care management, terms that many commonly refer to as clinical workflow. “In this setting, we put a lot of effort into appropriate decision support for clinicians as they manage their patients across the care continuum according to structured care plans, alerts and notifications, intelligent task management, etc.,” he says.

“Patient satisfaction is improved to the extent that patients have safer and improved care at a lower cost, as well as avoidance of adverse drug events and other related issues,” he adds. “It is also possible to provide appropriate clinical decision support to patients directly, exposed through the patient portal or mobile device. As a company, we are investing in this area. We have a clear strategy and have already made concrete progress in delivering this type of capability to our customers.”

Decision support tools can improve the meaningful use of electronic health record systems, too, according to Donald Voltz, M.D., Department of Anesthesiology and Medical Director of the Main Operating Room at Aultman Hospital in Canton, OH.

“One of the problems with all of the current EHRs is a lack of decision support to do even low-level tasks, such as alerting to the completion of a lab result or the addition of a consultant’s opinion in the care of a patient,” Voltz says. “Using decision support to monitor the data coming into a patient’s digital health record and alerting the care team members of this status change would go far to enhance EHR functionality.

“If this is then coupled with an ability to view the newly added data and capture a physician’s interpretation of the data along with an intervention, we would begin to realize gains in efficiency. Without even this low-level decision support, physicians and other members of the care team are forced to search for new information.”

Voltz agrees that decision support can be useful as a patient engagement tool, “provided we give them the opportunity,” he says. Voltz is board certified in Informatics and is an Assistant Professor of Anesthesiology at Case Western Reserve University and Northeast Ohio Medical University.

“More efficient clinical workflow equates to fewer failures, which means better quality of care and improved patient satisfaction,” Ephrat says. “It’s worth noting that clinician satisfaction with decision support is also critical. They should be getting meaningful, accurate alerts in real time, at the point of care, without disrupting their workflow and, as we move into the next generation of decision support technology, clinicians will become more satisfied as well, as long as the technologies they are using meet these criteria.”

ICD-10, data security distracting from decision support, interoperability?

As healthcare organizations concentrate on ICD-10 conversions and data and system security issues, what’s happening with decision support and interoperability concerns? Are they taking a back seat? How do healthcare organizations keep these on the front burners, too? Health Management Technology asks a panel of  IT experts for their insights on how to ensure decision support and interoperability maintain a high-priority level.

“It’s easy to get lost in ‘initiatives de jour,’ or projects of the day, month, or year. However, we must place the lives of patients as the reason why decision support and interoperability take precedent. The first step is to set explicit goals and engage with healthcare organizations, partners, and experts to build an infrastructure of evidence-based steps – perhaps even focusing on preventing harms and avoidable deaths. Don Berwick, M.D., said it nicely when he challenged U.S. hospitals to reaching the bold goal in the Institute for Healthcare Improvement’s 100 Million Healthier Lives campaign: ‘Some is not a number; soon is not a time.’ Dr. Berwick’s message relates today as we consider ways to raise the priority of decision support and interoperability efforts.”
– Susan Niemeier, R.N., BSN, MHA, Chief Nursing Officer, CapsuleTech

“Hospital IT departments face great challenges in the next few years, and we are at risk of stagnating on the interoperability issue. I think the greatest push for connecting data and developing decision support systems will come from the economic, quality, and efficiency gains required in the coming years. There is no question value-based reimbursement and the care delivery models such as medical homes will be dependent on data stored in various health databases.
“We are reaching limits for innovating on staffing and supplies costs. The only realistic area to push innovation is on the technology front. Most healthcare systems and practices will be unable to change EHR vendors due to the expense and disruption that result from such a decision. Even for those who are currently considering or have undergone a merger, most will realize the problems remain. Looking for an innovative way to address these needs and working to design systems that are able to expand to the unforeseen needs of the future will provide the competitive advantage and, most importantly, address the needs of our patients in a cost-effective and acceptable manner.”
– Donald Voltz, M.D., Department of Anesthesiology and Medical Director of the Main Operating Room at Aultman Hospital in Canton, OH

“It’s critical to focus on care and patient experience in order to bring decision support interoperability issues to a higher level. Without interoperability or decision support that enhances the patient experience, the promises of health IT will not be realized. Interoperability and decision support are so important that to worry about downstream issues is putting the cart before the horse. Showing the impact that these tools have on patient outcomes would be the best way to raise these issues to a higher level. Until clinicians and patients are involved in the design process, the care transformation process will not be complete.”
– Thomas Van Gilder, M.D., Chief Medical Officer and Vice President, Informatics and Analytics, Transcend Insights

“All these things contribute to the clinical mission of care providers, but they also fit neatly into two major buckets: remaining financially viable and avoiding legal exposure. We need to make sure people understand them all that way. Navigating through the ICD-10 conversion is about making sure you can send a claim/bill and keep cash flowing. Likewise, interoperability-enabled information sharing and collaboration between partners is a critical success factor for shared-risk payment arrangements and for delivering better, safer – and less litigious – care. Similarly, data breaches are costly and lead to lawsuits. Decision support contributes to more timely interventions and to better outcomes for patients covered by shared-risk payment arrangements; both are important for financial health and avoiding legal exposure from patient safety issues.”
– Kathleen Aller, Director of Business Development for HealthShare, InterSystems

“ICD-10 is a great example of the criticality of strong decision support. Deferring on decision support will be a mistake, as the impact of the event is unpredictable, and will demand fast reactions to unfolding events regarding clinician, administration, and payer performance. We’re planning to broadly share real-time industry data during ICD-10 conversion to help drive decision support and increased transparency.”
– Jason Williams, Vice President, Business Analytics, Financial Solutions, McKesson RelayHealth Financial

“Regulatory mandates, such as ICD-10 or Meaningful Use, and risk management issues, such as data security, are priorities because failure to perform will result in significant financial repercussions. Decision support and interoperability become relevant priorities when investments in these functions can be clearly linked to the enterprise’s financial performance. As alternative payment models become a larger share of total revenue over the next few years, systems will prioritize consistency, quality performance, outcomes measure, and a commitment to the lowest total cost of care — requirements that HIE and decision support enable. System leadership that can ‘see over the wall’ and recognize the strategic imperative of investing early, before fee-for-service margins get even lower, in technologies that will prepare the enterprise for value-based compensation will thrive.”
– Larry Schor, Senior Vice President, Medecision

“Vendor products have been ready for ICD-10 for several years now, and most providers have had ample opportunity to retrain their staff or move to a revenue cycle management service. So the main concern about the ICD-10 transition will be whether there are any delays in payment on the part of insurance companies not being ready to handle the codes. As we move into new payment models where physicians and hospitals are being paid for outcomes, we will see that the business case for decision support and interoperability is going to drive interest and resources to focus on more use of decision support and broader sharing of data. The market will support the business needs of clients, and payment reform will change the business case from counting coding points to supporting accountable care-based reimbursement.”
– Sarah Corley, M.D., FACP, Chief Medical Officer, NextGen Healthcare

“The best method is to leverage an existing infrastructure to achieve interoperability and open it with applications in support of decision support, independently from the infrastructure. Without this approach, healthcare would go back to do over and over the infrastructure via popular practices like ‘rip and replace.’ Rip and replace [approach] resets the health IT organization to ground zero, making it fall behind more in terms of providing clinical decision support to providers and not concentrating on other issues, such as ICD-10 and security.”
– Thanh Tran, CEO, Zoeticx

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