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Clinical Decision Support

Posted on: Thursday, 10 February 2005, 03:00 CST

PUTTING PATIENT INFORMATION AT CLINICIANS' FINGERTIPS

EXCLUSIVE MOST WIRED SURVEY DATA

PERCENTAGE OF HOSPITAL'S PHYSICIANS USING CLINICAL DECISION SUPPORT FEATURES ONLINE IN REAL TIME (WEIGHTED AVERAGE)

Clinicians work in fast-paced environments and often have to make quick decisions when it comes to patient care. Keeping track of the latest treatments and guidelines for specific conditions is tough, but failure to do so can lead to mistakes. A patient could be given the wrong medication or one that interacts adversely with another drug if doctors aren't up to speed on the patient's medical history.

To reduce the likelihood of error, and improve efficiencies, hospitals are turning to clinical decision support systems such as computerized physician order entry and clinical information systems. These technologies provide doctors, nurses and pharmacists with the best, most up-to-date patient information.

These case studies show how hospitals adopt clinical decision support systems and use them to improve outcomes in care.

VANDERBILT UNIVERSITY MEDICAL CENTER, NASHVILLE

The desire for improvements in patient safety and resource utilization was the impetus behind Vanderbilt University Medical Center's pioneering venture into CPOE. The Nashville, Tenn.-based hospital began its search for what it calls care provider order entry in the early 1990s.

A request for proposal did not turn up a product that met the organization's needs. So, the hospital's information technology staff sought a vendor that would allow joint development of the product. The result was a system known internally as WizOrders; the university has a licensing agreement with San Francisco-based McKesson Corp. that markets the product as Horizon Expert Orders.

With McKesson on board, the organizations developed a prototype that was pilot tested in three hospital wards. Following numerous complaints from staff that the system was too cumbersome, the product was redesigned. This time, physicians and nurses were brought in after hours-paid moonlight wages and provided with dinner- to enter the orders they had written that day. "The physicians and nurses taught us how to build the system," says Randolph Miller, M.D., Donald A.B. and Mary M. Lindberg university professor of biomedical informatics systems.

"We tried to implement a conventional CPOE system," says William Stead, M.D., associate vice chancellor for health affairs and director of the informatics center. "It didn't take long for us to realize that it would not win support from our physicians." With the help of the doctors and nurses, Vanderbilt got an easy-to-use system that provides medication management, as well as patient information, evidenced-based practices and treatment protocols.

Although use of the CPOE system is not mandatory, physician usage stays in the 70 percent to 80 percent range. Physicians place about 80 percent of electronic orders.

For the order entry component, Vanderbilt took the hospital's existing pharmacy system and made it available to clinicians. When clinicians place an order, they are immediately alerted to any potential drug interactions, allergies and dosing problems. "It results in more work for the pharmacists, but eliminates some of the calls they have to make to check an order," Miller says. "It's another form of decision support."

A study published in the January 2004 edition of Pediatrics by Vanderbilt staff showed how CPOE use has reduced medication errors and adverse drug events in the pediatrie intensive care unit. The study, which reviewed a total of 13,828 orders, found that the rate of adverse drug events dropped to 1.3 per 100 orders from 2.2 per 100 orders following CPOE implementation, a 40.9 percent change. The rate of prescription errors dropped to 0.2 per 100 orders from 30.1 per 100 orders after CPOE, a 99.4 percent change.

The clinical decision support component is designed to eliminate variability in care and improve both cost and quality. "Every time we look at it, 40 percent of what we do in medicine is unnecessary," Stead says. "We're trying to make the best information available at the point of care to improve decision-making."

The system provides clinicians with guidelines, protocols and rules that help them select the best course of care. For example, if a physician is ordering heparin, the latest guidelines on the drug will appear, along with a calculator to help determine the correct dose for a specific patient.

A study in the August 2004 issue of the Annals of Internai Medicine shows how the CPOE system helped improve resource utilization at Vanderbilt. Alerts were developed by the Resource Utilization Committee to cut down on unnecessary lab tests and imaging.

When providers log on to the system, they receive a prompt asking them whether they want to cancel any tests scheduled beyond 72 hours. A change in patient condition may make previously scheduled tests unnecessary and providers may forget to cancel the procedure. The study found that metabolic panel component testing beyond 72 hours was reduced by 24 percent and electrocardiograms by 57 percent.

The committee also unbundled serum metabolic panel tests that check sodium, potassium and glucose levels, among other things. Once providers had to order each test separately, overall usage dropped 51 percent. Most importantly, adjusted monthly readmission, mortality, length of stay and transfers to intensive care units remained the same after the implementation of these changes.

A staff of four to six people maintains the clinical decision- making system at the medical center. And, physician experts dedicate about 5 percent to 10 percent of their time to keep the information in the system current. In addition, the IS staff invites physicians to discuss their ideas and concerns at two lunch meetings a week. "The system has to be physician owned and maintained," Miller says. "You have to realize they are complaining for a good reason. If you don't listen to them, you will get into trouble."

COLUMBUS (OHIO) CHILDREN'S HOSPITAL

The complexities of medication administration for pediatrie patients led Columbus (Ohio) Children's Hospital to implement a CPOE system. The 323-bed hospital wanted a system that not only eliminated legibility problems, but also provided guidance to physicians as they placed their orders.

In April 2002, the hospital began incremental implementation- ward by ward-of the Eclipsys Sunrise Clinical Manager with medication management. The hospital customized the clinical decision support functions built into the system as part of the rollout, limiting alerts, rules and order sets to about 30 medications that were either high risk or high use.

To address the specific needs of its young patients, Columbus Children's started with dose ranges, setting upper and lower ranges based on weight, age and body mass. When a physician places an order for a medication, the system will send an alert if the dose falls outside of the preset range. The physician can acknowledge and override the alert or cancel the order and make appropriate changes.

Following implementation of the CPOE system in the first ward, the information services staff reviewed its effectiveness. It looked at how often and for which drugs alerts were raised and whether or not physicians were following the suggestions. The findings were used to adjust the system as the rollout continued. The entire process took 18 months.

"After reviewing the data, we found that we had too many alerts," says Denise Zabawski, director of applications at Columbus Children's. "One of the benefits of the system is to be able to look at data from the back end and see how the system is used."

David Rich, M.D., an associate professor of pediatrics who works part time as a liaison between clinicians and the information services staff, agrees. "The back-end data is very insightfuL and helps to set up the clinical decision support system," he says. "It's not just setting up rules and alerts. The more alerts you fire off, the more immune the end user becomes."

One of the first things the information systems staff changed were the low dose alerts, dropping many from the system. "We found that physicians were appropriately ordering lower doses," Rich says. "You need to focus alerts on things that clinicians should pay attention to."

The IS staff has gradually added new clinical decision support functions to the system and has expanded the medication management system to include the top 100 error-prone and most prescribed drugs. For example, if a physician is ordering Digoxin, the system will send a notice that the patient's potassium level should be checked. The system will also alert the physician if a prescribed drug is not part of the hospital's formulary and will recommend a different drug.

Despite the organization's incremental approach and the gradual expansion of the clinical decision support system, Zabawski says it may have moved too fast for the physician staff. "You're better served to start with less," she says. Use of CPOE is mandatory for all inpatient orders, so like it or not, physi\cians are required to use the system.

"Physicians do see the changes we are making in response to their concerns," Rich says. "It is getting better."

Both Zabawski and Rich stress that clinical decision support is an ongoing process. A multidisciplinary committee meets at least once a month to review usage data and consider how the system can address patient safety issues that arise. In addition, the committee updates ruLes, alerts and order sets as new information becomes avaiLabLe.

Nine full-time employees maintain the CPOE system at Columbus Children's. Zabawski says half a full-time employee a year is dedicated to maintaining the rules and alerts component.

SCRIPPS HEALTH, SAN DIEGO

An effort to electronically integrate the five-hospital Scripps Health system presented the opportunity to provide clinical decision support. When the organization was looking for a new clinical information system that would allow patient and financial information flow between hospitals, Scripps officials recognized an even greater opportunity. "Technology is more than just helping to integrate the different institutions that were acquired through acquisition," says 3ean Balgrosky, senior vice president and CIO. "The information systems are starting to build a Scripps culture that hasn't existed before now."

Scripps selected LastWord, an enterprisewide core clinical system by Seattle-based IDX. The system is being rolled out incrementally; it is currently operational in three hospitals. The two remaining hospitals should be up by November 2005.

LastWord automates clinical, financial and administrative activities around patient care from admission through discharge, as well as encounters with affiliated physicians. Clinicians can access tests results and place orders for tests and exams. Patient history and prescription information are also recorded. Clinical decision support is also built in. LastWord incorporates First Data-Bank software that alerts physicians of potential contraindications with patient prescriptions. Scripps can also customize the rules and alert system to add or remove information when necessary and provides access to medical journals and national guidelines. A physician advisory group helps keep the system current. The system is built to accommodate computerized physician order entry, which Scripps hopes to begin piloting in the near future.

"The system doesn't make decisions for physicians," Balgrosky says. "It gives providers more information to make better decisions." Scripps executives say physicians benefit by having greater access to information, specifically access to patient information, such as current medications and allergies. "It's good to get the information up front before an order is filled," says Chris Van Gorder, president and CEO of Scripps. "The consequences are more severe down the line if mistakes are made. We need more checks and balances."

Balgrosky recommends that hospitals take time to allow physician involvement in the selection and implementation process. "We wanted to make sure to design something tight in terms of workflow," she says. "Don't rush it. You are creating a whole new way to take care of the patient."

LastWord came with a $30 million price tag for implementation at all five hospitals and Scripps Clinic and included ongoing support and maintenance for five years. Balgrosky and Van Gorder, however, are not concerned about calculating return on investment.

"There's no direct ROI that we can come up with," says Van Gorder, noting that it's hard to calculate streamlined workflow. "If people are waiting for clear-cut ROI, they will be waiting for a long time." Adds Balgrosky, "ROI doesn't apply here. You can't place a dollar figure on an error that doesn't occur. The goal is better safety."

TOOLKIT

RESOURCES

* "Clinical Decision Support Implemented Workbook," www.himss.org/ content/cdsw/front.pdf.

* "Computerized Physician Order Entry and Medication Errors in a Pediatrie Critical Care Unit," Pediatrics, January 2004, http:// pediatrics.aappublications.org.

* "Landmines and Pitfalls of Computerized Prescriber Order Entry," the Institute of Safe Medication Practices, www.ismp.org/ PDF/LandminesandPitfallsofCPOE.pdf.

* "The Impact of Peer Management on Test-Ordering Behavior," Annals of Internal Medicine, April 2004, www. annals.org.

* "Ten Commandments for Effective Clinical Decision Support: Making the Practice of Evidence-based Medicine a Reality," Journal of the American Informatics Association, November/December 2003, http://library. ahima.org.

DOs & DON'Ts

FOR ADORING CLINICAL DECISION SUPPORT SYSTEMS

DO:

1. Assemble a multidisdplinary team early on to help in the selection process.

2. Listen to the end users; complaints usually have some bearing.

3. Show clinicians you are listening to their concerns and making appropriate changes.

4. Start slowly and build more alerts and rules into the system gradually.

5. Target areas with the greatest risk to patients, such as high- alert medications.

DON'T:

1. Over-alert clinicians or they will begin to ignore them.

2. Underestimate the upkeep. Alerts, rules and guidelines need to be current.

3. Implement too fast. Incremental implementation will help identify the kinks.

4. Forget to research and talk with other facilities about their experiences.

5. Overlook the need to evaluate the process to see if it is having an impact.

VITAL STATISTICS

VANDERBILT UNIVERSITY MEDICAL CENTER, NASHVILLE, TENN.

PRESIDENT & CEO: Norman Urmy

DIRECTOR OFINFORMATICS CENTER: William Stead, M.D.

BED SIZE: 900

EMPLOYEES: 11,900

NUMBER OF IT/IS STAFF: 360

TOTAL REVENUES: $1.5 billion

IT OPERATING BUDGET: $33 million

WILLIAM STEAD, M.D.

BIO: Associate vice chancellor of health affairs and director of the Informatics Center, Vanderbilt University Medical Center. Bachelor's and medical degrees from Duke University, Durham, N.C.

REWARDS OFTHE JOB: The opportunity to work with many smart people who are committed to changing the culture of health care and who are willing to take risk, fail, and get back up and try again until we succeed. The pleasure of seeing real change take hold.

BIGGEST CHALLENGE: Insatiable demand and opportunity.

IT PHILOSOPHY: Success requires finding a new way of working, a combination of people, process and technology that is impossible without the technology, i.e., discontinuous change.

E-MAIL: biU.stead@vanderbilt.edu

DENISE ZABAWSKI

BIO: Director, applications, Columbus Children's Hospital. Bachelor's degree in psychology.

REWARDS OFTHEJOB: The constant challenges around EMR implementations.

IT PHILOSOPHY: The customer drives the projects, we do the best job we can implementing and providing expert advice, problem solving and consulting to our customers.

E-MAIL: ZabawskD@chi.osu.edu

VITAL STATISTICS

COLUMBUS (OHIO) CHILDREN'S HOSPITAL

CEO: Thomas Hansen, M.D.

DIRECTOR OF APPLICATIONS: Denise Zabawski

BED SIZE: 330

EMPLOYEES: About 5,000

NUMBER OF IT/IS STAFF: 105

OUTPATIENT VISITS: 549,711

TOTAL REVENUE: $451.9 million

OPERATING EXPENSES: $425.6 million

IT OPERATING BUDGET: $16 million

VITAL STATISTICS

SCRIPPS HEALTH, SAN DIEGO

PRESIDENT a CEO: Chris Van Corder

SENIOR VICE PRESIDENT AND CIO: Jean Balgrosky

EMPLOYEES: 10,500

NUMBER OFAFFILIATED PHYSICIANS: 2,600

NUMBER OF IT/IS STAFF: 154

GROSS REVENUE: $1.4 billion

IT OPERATING BUDGET: $17.7 million

JEAN BALGROSKY

BIO: Senior vice president and CIO, Scripps Health. Bachelor's, master's and Ph.D. from UCLA.

REWARDS OF THE JOB: seeing progress toward improved efficiencies and operational enhancements, as well as progress toward the patient- centric electronic health record. Also, hearing from clinicians about how immediate availability of information makes a difference in their speed to diagnose or make a clinical decision.

BIGGEST CHALLENGE: Change in workflow, process and supporting busy clinicians fully while new technology is being introduced. Also, IT is a foreign language to many and communication can be a challenge.

IT PHILOSOPHY: We do IT not for IT's sake, but to serve the core mission of Scripps.

E-MAIL: balgrosky.jean@scrippshealth.org

Copyright Health Forum Inc. Winter 2005

Source: Hospitals & Health Networks

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