Implementing a Health System-Wide CDS System for Diagnostic Exam Ordering in Los Angeles

March 11, 2016
At the Los Angeles County department of Health Services health system, Maitraya Patel, M.D. is helping to lead the enterprise-wide rollout of a clinical decision support solution for diagnostic imaging exam ordering

Radiology decision support is coming into its own within the Los Angeles County Department of Health Services (LADHS) health system, as Maitraya Patel, M.D., can attest. Dr. Patel, a practicing radiologist and the vice-chair of clinical operations in the Department of Radiology at Olive View-UCLA Medical Center in Los Angeles, is helping to lead the staggered rollout of decision support across the health system’s hospitals. He and his colleagues are working with the Toronto-based MedCurrent Corporation. As the Sept. 24, 2014 press release announcing the collaboration noted,  “MedCurrent Corporation, a leading provider of clinical decision support solutions, today announced that Los Angeles County Department of Health Services (LADHS), the 2nd largest municipal health system in the U.S., has chosen MedCurrent’s OrderRight™ Radiology Decision Support system to ensure appropriate ordering of advanced medical imaging.” The Los Angeles County Department of Health Services, the press release noted, “operates four public hospitals; 16 local health clinics; one multi-service ambulatory care center; and provides services to over 800,000 patients in Los Angeles County. LADHS has recently purchased a Cerner Millennium™ EMR system and will be including OrderRight with their Millennium rollout.” And the press release quoted LADHS CMIO Rob Bart, M.D., as saying that “MedCurrent’s OrderRight encompasses the workflow and clinical depth that best fits our system for today and tomorrow. In particular, its seamless integration into our Cerner Millennium electronic medical record system will ensure that adoption by our providers will be accelerated.”

In fact, Patel and his colleagues are getting ahead of the mandate from the Centers for Medicare & Medicaid Services (CMS), originally scheduled to go into effect on Jan. 1, 2017, but which now has been delayed for an undetermined period of time, perhaps six or more months, that will require Medicare-participating physicians ordering diagnostic imaging exams to use clinical decision support tools and follow appropriateness guidelines.

Recently, HCI Editor-in-Chief Mark Hagland spoke with Dr. Patel about the ongoing rollout of these systems. Below are excerpts from that interview.

Can you share about the timeline and forward progress of this overall initiative?

With regard to the L.A. County health system, we’re on long-term initiative to implement an enterprise-wide EHR [electronic health record] with Cerner. The MLK Outpatient Center went live with the MedCurrent solution in February 2015; then in June, LA County-USC Medical Center; and then Olive View and High Desert went live in November 2015. By March, every site in the health system, including all the outpatient ones, will be live.

What capabilities are being implemented, over time?

We’re using MedCurrent for decision support for ultrasound, CT, MRI, nuclear medicine, and breast imaging diagnostic procedure ordering.

What elements are involved for end-users?

When the ordering provider orders an exam in the EHR, the MedCurrent platform pops up and interfaces with the Cerner EHR, and the clinician has to answer one or two questions, and it provides recommendation levels.

What are the recommendation levels, and how do they work?

There are three levels: 1-3 is a low-strength recommendation, 4-6 is a medium-strength recommendation, and 7-9 is a high strength recommendation. If it’s high-strength, the order is automatically created in the EHR. If it’s a medium-strength recommendation, the solution brings up the entire recommendation panel of choices for that procedure, and the ordering physician can either go ahead and order what they wanted, or select a more highly recommended procedure. If it’s low, 1-3, it will tell you so, and it will list a higher-scoring set of procedures. If all the procedures are 1-3, it will recommend that the ordering physician cancel it.

It could still be overridden, then, correct?

Yes, that is correct.

How has this system worked out for the physicians?

Through a lot of education, our providers have been very compliant using the software. In areas where speed is of concern, as in the ED, there were initial roadblocks to utilization of the software. At our largest site, we incented them in the following way: if they used the software properly, they wouldn’t have to make a phone call to the radiologist for approval, and if the score was medium to high, the exam was considered auto-approved.

Do you have any metrics yet to share in terms of outcomes, either around clinical or cost savings?

We didn’t do any baseline before, because we didn’t have any software tools to get at that data. At one hospital, they went live with the EHR in November 2014 and missed the rollout of MedCurrent clinical decision support, so hopefully, we’ll be able to do an analysis of pre-override post-override.

Do you have any general metrics yet?

Some of this data is being submitted to conferences as we speak. But what I can say is that since implementing the workflow improvements in the EHR, we were able to increase our high-appropriateness-level examinations from about 30 percent to 60-70 percent. The medium and low kind of held steady throughout—about 2-3 percent low, and 5-10 percent medium. And the bypass overrides—there were no hard stops. The total low scores have been very low, so any change from a low to a high score would be like 1 percent out of 2-3 percent. Out of the high and medium scores in the past 90 days, the percentage that were changed from a low score might be a 0.4 percent. So when people are ordering an exam, they’re usually starting out high. That being said, across a large volume, that could still translate to a fairly significant number of examinations.

What level of acceptance have you achieved on the part of the ordering physicians?

That’s a good question. Luckily for most of the sties we rolled out, CPOE [computerized physician order entry] and CDS [clinical decision support] were implemented at the same time, so most people sort of assumed that this was part of the EHR. That being said, physicians may not be in love with using the software; any extra clicks they have to click on, annoy them. EHRs are already cumbersome, and adding another layer on top of that—that’s always going to lead to some frustration by ordering clinicians. But overall, our providers have done a really good job of demonstrating compliance with this. And where we can incenvitize to improve ordering outcomes, as in the ED, that has helped. But the fact is that this is coming, it’s mandated, and when it happens, we’ll be prepared in advance.

You’re speaking of the coming CMS mandate under Medicare for ordering physicians to use clinical decision support, of course. Clearly, organizations that are ahead of the curve, like yours, will do well, when the mandate goes into effect, correct?

Yes, definitely. I think it’s now around July 2017. So that’s not that much time. And luckily, we’re already on board with that process. And many organizations are delaying their implementation until they have to. But we take care of the underinsured and uninsured, and everything that’s paid for by taxpayers—everything that can improve the process, is where the Department of Health Services has to go.

How many hospitals are in the system altogether?

Three: LA County USC Medical Center, Olive View UCLA Medical Center, and Harbor-UCLA Medical Center.

How can CIOs and CMIOs help implement this kind of system so that it doesn’t feel punitive?

With these decision support software products, it’s not as simple as purchasing the product and integrating it into your HER. It requires education of providers, and the collaboration of multiple groups of clinicians. And to have leaders within the different departments on board with the software, and having departments analyzing the data to improve work towards best practices, and anything you can do to speed workflow and reduce click volume and time to ordering, all of that can improve acceptance of the software. We started in February of 2015. The implementation has been a learning experience for us, and we’re now finally getting the groove of how to handle these things, and we’ve had weekly meetings with MedCurrent on how to improve the software and implementation.

Do you think that by now, most practicing physicians understand the need to get on board with using clinical decision support systems in their diagnostic imaging procedure ordering?

I think so. Most physicians in leadership, and most in practice, understand. Trainees—residents--may not understand why as an organization this is important. So that becomes part of their training.