Orlando, Fla.—Questions about political and cultural challenges as well as optimal governance dominated the HIMSS roundtable discussion Practical Pearls for Improving Outcomes with Clinical Decision Support (CDS), held Feb. 22 at the annual meeting of the Healthcare Information and Management Systems Society (HIMSS).
Moderator Jerome A. Osheroff, MD, chief clinical informatics officer of Thomson Reuters, based in New York City, opened the session with an overview of CDS basic and reviewed the “Five Rights” of CDS. That is, to improve care with CDS a program must deliver:
- The right information (evidence-based)
- To the right stakeholder (physician, nurse, pharmacist)
- In the right format (alerts, order sets, reference information)
- Through the right channel (internet, mobile devices)
- At the right point in the workflow (to influence action).
Osheroff continued with a checklist for managing, maintaining and improving a CDS program that achieves on high-priority imperatives and minimizes challenges such as alert fatigue. Specifically, Osheroff recommended that organizations:
- Start CDS with a strategic orientation—not as an end itself;
- Commit to measurement;
- Develop planning and decision-making processes and establish a framework for governance and execution;
- Set core competencies focused on existing workflow, measurement and infrastructure;
- Focus on knowledge management at the outset;
- Address opportunities for improvement, using CDS as part of a comprehensive toolkit;
- Design intervention using five rights and goals;
- Vet CDS with stakeholders, working with them to implement CDS not enacting CDS on them;
- Develop a deployment plan;
- Measure outcomes; and
- Implement a knowledge management plan.
Before opening the floor for audience input, Osheroff recommended that organizations frame CDS in terms of Stage 1 meaningful use requirements (which set the stage for success for Stages 2 and 3) and simultaneously focus on the larger goal of delivering measurably better healthcare in terms of quality and safety.
Audience Q &As
Fielding the first question about how to manage cultural challenges and resistance to CDS among outpatient providers, Osheroff reminded the audience that: “Culture eats strategy for lunch every day.” He emphasized the importance of maintaining focus on goals and alignment. Audience respondents suggested beginning with small wins and striving for a balance between patient-centric tools and physician efficiency.
A second change management question queried about the extent of patient and family involvement in CDS. A respondent from the department of pediatrics at Johns Hopkins Healthcare in Baltimore indicated that the department engages parents with a pre-visit questionnaire to help structure the visit and ensure that physicians address parents’ questions. In addition, the health system is creating a process to tie CDS to physician maintenance of certification requirements.
Other audience members shared struggles with managing access to the clinical data warehouse and CDS. Osheroff stressed that the challenge relates to governance and the establishment of boundaries for both CDS and the data warehouse.
Final questions homed in on ground level challenges such as drug/drug alerts and managing alerts to avoid alert fatigue. Boston-based Partners Healthcare relies on a layered solution that tracks overrides and true-positive alerts. The health system also deployed a tiered alert system to help reduce false positives. The system encompasses various levels of physician response: hard stops on medication orders, acknowledge alerts and a warning flash.
The final audience comment emphasized the comprehensive nature of CDS and the importance of education, recommending that decision makers educate users about the capabilities of the entire toolkit beyond alerts as thorough use of back end components can reduce alerts.