Decision Support: Improving Data Quality, Improving Cardiology Decision-making

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mountain-state-tenn.jpg - CVIS - Mountain State Health, Tenn.

Providing excellent healthcare in our data-rich world comes down to having excellent data. The highest quality data today are assisted by decision support software and for structured reporting. Mountain States Health Alliance headquartered in Johnson City, Tenn., is one health system leading the charge and reaping the benefits of a more intelligent, decision support-enabled CVIS with a built-in quality control engine that ensures data entered into the report are consistent. It means the right information gets to the right person at the right time.

Mountain States Health Alliance is a not-for-profit healthcare organization operating a family of 13 hospitals serving a 29-county, four-state region in Northeast Tennessee, Southwest Virginia, Southeastern Kentucky and Western North Carolina. A “Most Wired” award winner, Mountain States includes a large tertiary hospital, a heart hospital, several community hospitals, two critical access hospitals, a children’s hospital, a behavioral health hospital and two long-term care facilities, among other services.

The cardiology department manages six cath labs at Johnson City Medical Center, one at Indian Path Medical Center and one at Johnston Memorial Hospital; together completing 6,000 procedures each year. Mountain States offers echocardiography at all facilities and two outpatient diagnostic locations, which adds up to about 30,000 exams each year. Some 30 cardiologists support the health system.

Digging deeper

One of Mountain States’s core values is to always pursue a higher standard. A decade ago that higher standard meant improving cardiovascular care with the installation of a Siemens syngo Dynamics CVIS. Last summer they raised the bar once again by adding decision support (DS) software to the CVIS. “The decision support tool is excellent for optimizing workflow, automating processes, and evaluating the quality of the data transferred to the report,” says William “Brent” Nottingham, cardiovascular and informatics manager. “It provides great consistency checks. It helps us on several levels: clinical, operational and financial. It has greatly improved efficiency in how quickly we can abstract cases for NCDR purposes because we know the source of the data, and we know the place to go to get those answers.”

Decision support adds a deeper layer of detail to structured reporting, to guarantee accurate, precise and complete data input to the EMR, care teams and/or separate clinical decision support systems. syngo Dynamics DS software helps the cardiovascular care team compile reports knowing the data input is from a trustworthy source.

Here’s how it works: syngo Dynamics CVIS now features an embedded user-configurable rules engine, with which the user can create policies or rule sets for different study types. The IT team at Mountain States can then define rules to automatically inspect study data such as measurements, observations, dates, times, Booleans and text to confirm that a study’s information achieves consistency and clinical relevance. For example, alerts can be generated if questions like these were not answered correctly: Is the qualitative interpretation of the systolic function consistent with the measured value of the ejection fraction? Or, is a 3D echo billing code supported by the physician report that mentions 3D echo was performed?

If there are missing or inconsistent data in the report, users such as sonographers or physicians can be alerted to provide additional information or correct the data. “It’s a great help to the techs doing the echocardiograms,” Nottingham says. “We automate some processes based on study time, some values and a collection of values. This allows us to analyze multiple observations and generate results off of them. For the physician's workflow, decision support is all about results out. It is truly driven by the question: Is the data collected reflected in the interpretation of the physician?"

William “Brent” Nottingham, Cardiovascular and Informatics Manager
 - w-brent

Bits, bytes and benefits

The team at Mountain States spent a great deal of time evaluating their goals for decision support, how they were going to access the data, analyze the data, and who was going to be the responsible party. Parameters were defined based on evidence-based medicine and physician preference, with the team leaning heavily on the American Society of Echocardiography for the echocardiography and other American College of Cardiology guidelines for appropriate use criteria (AUC), ACC semantics, cath lab procedures and measurement ranges. “Once you have that understanding, the vendor provides a good resource for how to create and maintain the rules,” Nottingham says.

At Mountain States, CVIS and decision support live on the main syngo Dynamics server, and connect with an interface engine to provide discrete data export to the EMR, explains IT Analyst Phil Carringer. In the cath lab, the Siemens Sensis system provides hemodynamics data to syngo Dynamics while images flow directly through syngo Dynamics. The decision support tool is executed from syngo Dynamics, which connects back to the single database for data validation and feedback to the user. They also made sure all the data elements had the appropriate security and HIPAA compliant protection.

The techs learned decision support very quickly. For example, for an echo exam, the tech images the patient, uploads the images, and completes the documentation of the case: every chamber, every valve, what he or she saw. For example, does the ejection fraction match the impression? Before the tech can complete the report and give it to the physician, he or she executes decision support via a hard stop in the process. It’s like running spellcheck before finalizing a document. “There's an observation that must be met, which means it must come back clean and error free, before that can be completed and given to the physician,” Carringer notes.

The objectives are clinical, financial and operational, Nottingham chimes in. “If the tech does not document color flow across a valve, we can't get paid for that color flow, or for that echocardiogram,” he notes. “We don't get paid, then we have to re-bill with a different code, therefore, we're being impacted operationally and financially.”

Next the reports go to the physicians. “Once the physicians complete the interpretation of their exams, they can also run the rules [engine],” Carringer says. “Working in the background, the module looks into its database of rules, runs them and compares the finding of the report with the predetermined rules to be sure they are all met. The system will alert the caregiver if there is a problem, which he or she can amend. Once the report is done, with a single click, the results are submitted electronically to our EMR.”

Phil Carringer, IT Analyst
 - p-carringer

Better data, better medicine

The whole cardiovascular care team has learned from decision support. “I've seen some growth in the echo techs and the vascular lab, and the cath team, of truly understanding the reason we are noting what we document,” Nottingham says. “It's improving their quality of work, and now it's ingrained in them—click the button before you’re done. Hopefully, they get the flag that says complete and move forward. If not, they understand they missed a few things and need to go make those corrections.”

The benefits are myriad—patient safety, clinical accuracy, boosts in charge capture for echo exams and gone are the phone calls from physicians’ offices when professional fees are rejected because the physician didn’t document an essential detail. “By ensuring we're getting all the documentation up front, fewer exams need to be performed a second or third time,” Nottingham says. “We're able to identify any shortcomings at the time of the write up, and if our tech needs to go back and get additional images, he or she can go during the time the patient is in-house, before it's been interpreted, and we can resolve those scans prior to interpretation. We're getting all those checks done, that way everything is in place for the physician to provide interpretation.”

Benefits also have come in the form of improved relationships between the techs and the physicians. “As we provide more information to the doctors, their confidence level also grows in the team members,” Nottingham says. “That's probably the biggest thing we did not expect to see that quickly.”

Registry reporting and accreditation are two more areas where Mountain States is seeing decision-support's benefits. The Mountain States team is predicting they’ll see a bump in quality and efficiencies. And over time, as new documentation requirements come down from local payers, Mountain States is equipped to add modifications and alerts as needed, Carringer adds. 

It’s all about building better data, and that comes down to leadership, notes Nottingham thinking back on the project. Decision support needs to be motivated by key stakeholders in business leadership, physician leadership and technical leadership. For the clinical, operational and financial goals to be reached, everyone has to be onboard. “You really have to know what you're trying to do, what you're trying to accomplish, and go do it,” he says. “As better information is collected, our analysis will be better. We'll have better confidence in the collected data.”

Decisions are being supported and data are more robust. “We’re providing better medicine,” Nottingham sums, “eliminating waste and providing a better product for our customers, patients, and primary care physicians. It all comes down to the quality of your data. That is how you compete and get better!”