CMIO/CHIO Summit: Managing Clinical Decision Support and Improving Workflow | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

CMIO/CHIO Summit: Managing Clinical Decision Support and Improving Workflow

December 27, 2016
by Trudy Millard Krause, UTHealth School of Public Health
| Reprints
The Scottsdale Institute CMIO/CHIO Summit set out to foster collaboration among chief medical information officers and chief health information officers from prominent healthcare systems across the country

Executive Summary: Twenty chief medical information officers (CMIOs) and chief health information officers (CHIOs) of leading health systems gathered in Chicago this past fall to share best practices and lessons learned regarding clinical decision support (CDS) and improving clinical work flow. This report captures their discussion and shared insights.

Summit participants: David Classen, M.D., Pascal Metrics and University of Utah; Greg Forzley, M.D.,  Trinity Health, Anupam Goel, M.D., Advocate Health Care, Greg Hindahl, M.D., BayCare Health System; Kim Jundt, M.D., Avera Health; Michael Kramer, M.D., Spectrum Health; Michele Lauria, M.D., EasternMaine Healthcare Systems; Thomas Moran, M.D.; Northwestern Medicine; Nnaemeka Okafor, M.D., Memorial Hermann Health System; Theresa Osborne, M.D., Spectrum Health; Jerry Osheroff, M.D., TMIT Consulting, LLC, Luis Saldana, M.D., Texas Health Resources; Anwar Sirajuddin, Memorial Hermann Health System; Andy Spooner, M.D., Cincinnati Children’s Hospital Medical Center; Peter Springsteen, M.D., Munson Healthcare; Pete Stetson, M.D., Memorial Sloan Kettering Cancer Cente; Jeffrey Sunshine, M.D., University Hospitals; Randy Thompson, M.D., Billings Clinic; Paul Veregge, M.D., Catholic Health Initiatives; Alan Weiss, M.D., Memorial Hermann Health System

Organizer: Scottsdale Institute; Sponsor: Deloitte; Moderator: Deloitte (Ken Abrams, M.D.)

Introduction: The Scottsdale Institute CMIO/CHIO Summit was held in Chicago on September 30, 2016. The objective of the Summit was to foster collaboration among chief medical information officers (CMIOs) and chief health information officers (CHIOs) from prominent healthcare systems across the country, with the intention of learning from shared experiences, best practices and proven approaches.

The group was tasked with reviewing the maturity of the clinical decision support (CDS) processes within organizations that responded to a pre-summit survey. Based on those findings a productive discussion evolved regarding CDS and lessons learned. Future visions and emerging trends and technologies were explored, along with the impact to CDS and the CMIO/CHIO role. The impact of future payment policies such as MACRA and bundled payments on information systems was also explored.

Webinar

Mastering the EHR: How Optimization Services Foster Quality Documentation & Physician Satisfaction

We know the goal of the electronic health record (EHR) is to create an optimal work environment that allows providers to maintain a healthy work/life balance while efficiently capturing critical...

Throughout the Summit, underlying themes stressed the importance of CDS in patient outcomes, physician performance, organizational quality metrics and, ultimately, reimbursement strategies. This critical component thereby requires organizational commitment and support along with evolving strategies for system improvement and sustainability to meet future demands and opportunities.

Pre-Summit Survey Results

In advance of the summit, the Scottsdale Institute circulated a survey among CMIOs and CHIOs regarding CDS with the intention of collecting information to initiate fact-based discussion during the summit. The survey was written by Dr. Michael Kramer, Dr. Nnaemeka Okafor, Dr. Luis Saldana, Dr. Anwar Sirajuddin and Dr. Alan Weiss. Twenty-two responses were returned. The responses indicated there were varied levels of maturity in CDS implementation and design. A summary of responses follows:

> The most frequently identified knowledge-management system used for CDS was an EHR tool such as Epic or Cerner, but other responses reported using tools such as Word, Excel, Tableau or others.

> CDS project-management initiatives were most frequently organized by steering committees or councils, but the majority of responses varied greatly.

> 59% of respondents reported that the CDS elements were not reviewed on a regular basis.

> 65% reported that very minimal customization of the CDS tool was allowed across hospitals or practices.

> 68% stated that the organizational approach to alerts and CDS was a combination of “buy” and “build.”

> Among the value-added decision support initiatives that showed a return on investment (ROI), Sepsis and VTE ranked as the top two.

> Analytics for Radiology was the top area of CDS that was being considered by the respondents.

> 73% felt that ACR Appropriate Use Criteria were the most appropriate for radiology.

> 89% were not incorporating cognitive computing or artificial intelligence.

> 50% reported limited activity around consumer related data integration such as patient monitoring.

Discussion on the survey results pointed out the great variation in maturity in CDS system integration. Dr. Jerry Osheroff noted the CMS-recommended “CDS 5 Rights Framework” is a very helpful guide to shape CDS to drive performance and quality. The spectrum of maturity levels can be seen in each of the 5 CDS Rights dimensions. The challenge: “Make the RIGHT thing to do the easy thing to do!”

Dr. Michael Kramer noted that very few organizations assess all the 5 Rights during the development. Even less common is some form of evaluation to see if the rule continues to fire. In one example, a health system’s lab-test names changed but the rule was not updated. Important safety and quality outcomes can become unreliable without anyone knowing the system configuration has changed.

There was common support for a goal of finding non-interruptive methods in CDS. Alerts are a feature in the immature stage, whereas non-interruptive functionality would reflect the mature stage. Alerts can be seen as “guard rails,” designed to keep the user on track. However, they can eventually turn into “stop signs” that become interruptive and lead to “alert fatigue.” Dr. Pete Stetson of Memorial Sloan Kettering Cancer Center noted that alerts are a form of data displays, but the real need is cognitive support through visualization and summarization—“finding what you need when you need it.” Dr. Michael Kramer said, “Good design means that best practice is hardwired into the workflow and the alert only fires when someone deviates from that standard. Good alerts are designed in the context of streamlined workflow and rarely trigger.” Dr. David Classen added that CDS alerts should be viewed along a continuum—they initially educate on evidence-based medicine guidelines and over time they become guardrails as clinical knowledge becomes learned behavior.

The discussion evolved into identifying a “mature” model of CDS, and agreed that a standardized maturity model does not yet exist. Key elements in the maturity of CDS were listed as follows:

> Definitions

> Goals

> Internal Alignment/Buy-In

> Control/Management

> Alerts/Order Sets

> Process/Workflow—Future Vision

> Tools

> Accountability

> Performance Management

Dr. Osheroff offered an example of the mature CDS approach that makes the right thing easy as the Society of Hospital Medicine’s recommended/proven approach to improving VTE prophylaxis (a top priority target of SI organizations, per the Pre-Summit Survey). They recommend powerful order sets that incorporate simple VTE risk stratification (directly linked to corresponding risk-appropriate orders), as well as an easy mechanism to document contraindications to chemoprophylaxis via check box within the order set. This makes risk assessment and risk-appropriate ordering, as well as signaling exclusion from quality measures in appropriate circumstances, all a seamless part of the ordering workflow.

Dr. Michael Kramer noted that organizations may have hundreds of rules. Many of these rules predate any informatics standards and what are now recognized as best practices. It is common to have rules become ineffective or incorrect as codes change or processes change. Ownership through event analysis and decision-logic tracking and documentation are critical to keep the CDS timely, accurate and useful. In order to avoid an “interruptive” CDS, the process should be amended to evolve from alerts and redundancies to a system that delivers analytics and improves workflows. Yet, it was agreed, most systems are still in the interruptive phase of CDS. To advance to workflow applications the organization must embrace data as part of the clinical mindset rather than alert response. To do this, the organization requires layered teams of academics, clinicians and practical users creating decision strategies as a group. At Texas Health Resources, Dr. Luis Saldana formed the CDS Team to manage the lifecycle of CDS knowledge, e.g., order sets and alerts, and to measure the resulting demonstrable impact.

Drs. Alan Weiss, Nnaemeka Okafor and Anwar Sirajuddin summarized their learnings at Memorial Hermann by noting the following key points:

> Maturation of CDS requires support from the CEO, making it an organizational priority.

> To advance the application, you must recognize the problems through smart data analytics, identifying trends, spotlighting causes and explanations, finding options for solutions and using reports to change behavior.

> Strong analytics are needed to support improvements in both physician and patient outcomes.

Dr. Michelle Lauria from Eastern Maine concurred, noting that CDS supports consensus-building and alignment across clinical units, connecting specialties together, although establishing care guidelines across the full continuum is still in an early stage of development.

Additional supporting comments centered around the challenges in leading diverse groups to a CDS consensus, especially if alignment across the organization is lacking. Additionally, maturity levels may vary across clinical teams: some systems simply providing documentation templates (immature) to alerts (moderate maturity) and to efficient decision-support messaging systems (mature). An efficient decision-support messaging system should recognize that some care protocols require absolutes and some allow variations.

Dr. Kramer asserted that the CMIO/CHIO’s role should be to create visibility to such chaos and assign accountability to move forward to an improved quality focus both to legacy and new rules. CDS teams ensure there is a rigorous process to evaluate existing rules before adding more alerts to a system. The team should include subject-matter experts from the clinical side and the informatics side for coordination and elimination of chaos. Dr. Kramer offered questions to consider (see p. 5), stating that the safety and reliability of care processes are at-risk if the answer is no to any of the questions. Informatics teams should lead rigorous knowledge management and regular evaluation of clinical decision support and partner with clinical-evidence-based experts and process owners. “Expensive? Perhaps. Such expertise and rigor are the table stakes of managing our new models of hardwired and reliable systems of care,” he said.

The best strategy for an effective CDS system is Informatics + Analytics + Quality. Deployment for this strategic framework includes interdisciplinary management of the infrastructure, reduction of redundancies and alert fatigue and streamlining workflows through visualization to ensure predictive analytics that support clinical decision making.

The group acknowledged shared experiences and lessons learned from CDS implementation and management. Key concepts included issues related to the level of data required, the usability of the system, the need for monitoring, acknowledgement of organizational needs and acceptance of change. Fostering an environment where change is accepted and collaboration across organizations to create best practices are two key areas the group identified.

Future Visions

CDS is an IT-enabled tool that has changed the way care is delivered. Effective mature CDS contributes to improved clinical outcomes for the patient as well as improved performance measures for the physician and the healthcare organization. A mature CDS incorporates elements of actual clinical practice and the human equation. According to Dr. Nnaemeka Okafor, CDS evolution requires process engineering and accountability. Process engineering studies the workflow and collects and analyzes data, then relates the findings to the CDS toolbox. Accountability applies the appropriate resources, assigns training and monitors utilization and practice.

Dr. Jeff Sunshine said we should engage CDS to provide feedback on clinical choices that inform the physician, for example, of the percentage of clinicians who had previously selected each option or to offer predictive outcomes of the choices for that patient. Dr. Andy Spooner added, “Ideally you want the relevant knowledge presented at exactly the point a decision is about to be made—but how do you accurately predict that?”

An ideal future development would be the cross-system application of CDS so that one vendor system could “talk” to another vendor system across platforms. The reality is that patients cross systems and collaboration across platforms would contribute greatly to coordinated patient management. As Dr. Alan Weiss noted, “Cross-platform data integration does facilitate knowledge sharing, but the real challenge is leadership—holding people accountable for behavior change is key—how do we make that easy?”

Emergent Technologies

It was generally agreed that technological advances are only useful if they contribute to the organizational objective by providing valuable new options for getting the CDS 5 Rights correct through enhanced information, channels and formats. The current reliance on reports can lead to data overload without actionable strategies. If the purpose of reports is to change behavior then they need an appropriate display to create a culture of change. Retrospective reporting needs to change to real-time prospective predicting.

Some helpful technological advances could focus on the following:

> Natural language processing (NLP) and voice recognition to convert speech to text and trigger real-time relevant alerts, recognizing that speech creates a better patient story;

> Data mining to continually identify the most commonly used notes to simplify and standardize documentation;

> The Internet of Things, which represents an opportunity for real-time alerts based on data streaming;

> Patient, or consumer-generated data, inclusive of patent-reported outcomes, biometrics and notifications, allows patients to become part of the care team, which could be transformative, with tools such as Open Notes and Patient Portals that garner greater patient satisfaction;

> Patient-aggregated information, which can challenge privacy issues and result in external data in the record that is not vetted or validated, leading to new risks;

> Patient engagement outside of the encounter is a top priority for the organization, yet a real challenge to the provider, who must avoid the potential data tsunami of too much information.

Data overload was recognized as a real risk, with the related new technologies potentially becoming distractions from the real goal of improvements in clinical decision making. Dr. Thomas Moran said, “Technology is not the disrupter, we, the physicians need to be the disrupters!” The CMIO and CHIO must activate the catalyst for change. To do so, the CMIO and CHIO must have credibility, must have a seat at the C-Suite table and must relate actions to ROI.

What CMIOs/CHIOs Can Do to Prepare for MACRA and New Payment Models

MACRA will revise payment models by combining meaningful use and quality for the MIPS scale. The goal of CMS is a drop in resource utilization. In order to be prepared for MACRA the group agreed that certain strategies can be implemented in advance:

> Build MACRA provider planning and tracking capabilities to ensure a clear understanding of the annual MIPS or APM path that each provider will follow.

> Identify quality measures and build displays for those measures at the provider level even if using group reporting.

> Base performance assessment on Hierarchical Condition Coding (HCC) levels with Alternative Payment Model (APM) and Quality and Resource Use Report (QRUR) adjustments.

> Work toward a methodology to identify a true cost of care for specific services that will be bundled, such as total hips and knees for 2018.

> Identify clearly in advance decisions on shared payments per episode and reach those decisions via collaboration.

> Understand that risk adjustment, quality measures and payment may be dependent on documentation quality and accuracy, including the use of HCC codes and comprehensive problem lists. The care-planning process must include both medical and social problems to have the greatest impact. Risk-based APM’s may depend on managing non-medical problems.

Data Quality and Documentation Quality

Data quality and documentation quality are related but present different challenges. When performance measures drive compensation, the baseline data is critical and must be accurate. The care team relies on both clinical documentation and quality assessors in the EHR. Yet everyone agreed clinical documentation often is of poor quality, generally from cut-and-paste behaviors and redundancy. Dr. Stetson suggested the use of the Physician Documentation Quality Instrument (PDQI) as a simple means of assessing quality and providing feedback for improvement. Dr. Michelle Lauria suggested that physicians be required to do note-review on peers to identify issues and foster improvement. Dr. Jerry Osheroff described a new checklist tool to ensure that quality-measure data are accurate and trustworthy (recently published within a guide to improving care processes and outcomes). Dr. Alan Weiss said that part of the problem is the physician hasn’t defined data quality based on purpose—purpose related to influencing medical decision-making and clinical value.

Lessons Learned: How CMIOs/CHIOs can Advance CDS

1. Stress documentation reform to make records medically meaningful for the patient benefit. Change data documentation and collection from a reimbursement focus to a patient outcome focus.

2. Synthesize the experiences and strengths from the organizations within the Scottsdale Institute to identify what the future of CDS could look like.

3. Articulate the value proposition of the CDS Informatics Team to lead to role clarity and improved collaboration.

4.  Develop a maturity model for CDS levels, along with a recommended staging process and a corresponding benchmarking process facilitated by the Scottsdale Institute.

5. CMIO/CHIOs should take a critical role in translating health reform such as MACRA and other value-based contracting efforts into a value platform that leverages people/process/technology best practices.

6. Teach responsible clinical documentation skills and etiquette in medical schools as a requirement for delivering quality care.

7.  Apply pressure to vendors to standardize CDS tools and maintain CDS as a core function of the EHR. Knowledge management and analytics to ensure CDS reliability should be part of the standard EHR CDS package from vendors. Informatics teams should be able to easily report on alert fatigue and gaps in the annual review process with subject-matter experts.

8. Continue to expand CMIO/CHIO and Informatics resources and personnel in health systems, with senior-level decision-making, to realize the ROI on CDS.

9. Build a culture of innovation throughout the health system.

10. Build informatics capability that includes ongoing review and prudent development of CDS alerts. This process should include assessment and monitoring of CDS effectiveness against negative factors like alert fatigue.

 


2018 Raleigh Health IT Summit

Renowned leaders in U.S. and North American healthcare gather throughout the year to present important information and share insights at the Healthcare Informatics Health IT Summits.

September 27 - 28, 2018 | Raleigh


/article/ehr/cmiochio-summit-managing-clinical-decision-support-and-improving-workflow
/news-item/ehr/survey-physicians-sour-value-based-care-metrics-ehrs

Survey: Physicians Sour on Value-Based Care Metrics, EHRs

September 19, 2018
by Rajiv Leventhal, Managing Editor
| Reprints
They new research has several key findings related to value-based care, health IT and burnout

More than 50 percent of U.S. physicians who receive value-based care compensation said they do not believe that the metrics the reimbursement is tied to improve the quality of care or reduce costs, according to a new survey.

The research comes from The Physicians Foundation, an organization seeking to advance the work of practicing physicians and helps them facilitate the delivery of healthcare to patients. The Foundation’s 2018 survey of U.S. physicians, administered by Merritt Hawkins and inclusive of responses from almost 9,000 physicians across the country, reveals the impact of several factors driving physicians to reassess their careers.

Specifically, the new survey underscores the overall impact of excessive regulatory/insurer requirements, loss of clinical autonomy and challenges with electronic health record (EHR) design/interoperability on physician attitudes toward their medical practice environment and overall dissatisfaction—all of which have led to professional burnout.

The research revealed several key findings, including that value-based compensation is directly connected to the overall dissatisfaction problem, which is tied to metrics such as EHR use, cost controls and readmission rates, etc. Forty-seven percent (compared to 43 percent in the 2016 survey) of physicians have their compensation tied to quality/value, but when physicians were asked if they believe that value-based payments are likely to improve quality of care and reduce costs, 57 percent either disagreed or strongly disagreed that this is the case, while only 18 percent either agreed or strongly agreed that it is.

As one responding physician put it: “We are no longer in the business of healthcare delivery, we are in the business of ‘measures’ delivery.” More than 13 percent of physicians are not sure if they are paid on value.

What’s more, the research found that 88 percent of physicians have reported that some, many or all of their patients are affected by social determinants. Conditions such as poverty, unemployment, lack of education, and addictions all pose a serious impediment to their health, well-being and eventual health outcomes. Only one percent of physicians reported that none of their patients had such conditions.

Additional notable findings from the research included:

  • 18.5 percent of physicians now practice some form of telemedicine
  • 80 percent of physicians report being at full capacity or being overextended
  • 40 percent of physicians plan to either retire in the next one to three years or cut back on hours—up from 36 percent in 2016
  • 32 percent of physicians do not see Medicaid patients or limit the number they see, while 22 percent of physicians do not see Medicare patients or limit the number they see
  • 46 percent of physicians indicate relations between physicians and hospitals are somewhat or mostly negative

Coupled altogether, 78 percent of physicians said they have experienced burnout in their medical practices, according to the survey’s findings. And the results show that one of the chief culprits contributing to physician burnout is indeed the frustration physicians feel with the inefficiency of EHRs.

“The perceptions of thousands of physicians in The Physicians Foundation’s latest survey reflect front-line observations of our healthcare system and its impact on all of us, and it’s sobering,” Gary Price, M.D., president of the Foundation, said in a statement. “Their responses provide important insights into many critical issues. The career plans and practice pattern trends revealed in this survey—some of which are a result of burnoutwill likely have a significant effect on our physician workforce, and ultimately, everyone’s access to care.”

More From Healthcare Informatics

/article/ehr/brigham-health-s-3-pronged-approach-reducing-ehr-s-contribution-burnout

Brigham Health’s 3-Pronged Approach to Reducing EHR’s Contribution to Burnout

September 18, 2018
by David Raths, Contributing Editor
| Reprints
Focus is on individualized training, reducing unnecessary clicks, voice recognition tools

Research studies have found that “burnout” is nearly twice as prevalent among physicians as among people in other professions.  Physician surveys have found that 30 to 60 percent report symptoms of burnout, which can threaten patient safety and physician health. With EHR documentation ranked high among aspects of their work physicians are dissatisfied with, Brigham Health in Boston has taken a three-pronged approach to reducing the pain.

Brigham Health, which is the parent organization that includes Brigham and Women’s Hospital, Brigham and Women’s Faulkner Hospital and the Brigham and Women’s Physicians Organization, rolled out its implementation of Epic in 2015. In a Sept. 18 presentation that was part of the Harvard Clinical Informatics Lecture Series, Brigham Chief Information Officer Adam Landman, M.D., said the organization’s initial EHR physician training was eight hours of classroom training on where to find things in the EHR instead of focusing on workflows and how to use the EHR to support it.  “Our experience was not the best,” Landman admitted.  They followed up with tip sheets, a help desk and a swat team to do service calls, but providers only rated those interventions as somewhat helpful, so Brigham informaticists re-doubled their efforts to:

• Improve the EHR;

• Provide one-on-one training in the clinical setting; and

• Offer voice recognition software and training.

Webinar

Mastering the EHR: How Optimization Services Foster Quality Documentation & Physician Satisfaction

We know the goal of the electronic health record (EHR) is to create an optimal work environment that allows providers to maintain a healthy work/life balance while efficiently capturing critical...

Landman said IT teams at Brigham feel a sense of urgency about reducing the burden of EHR documentation. “Burnout is an epidemic, and the EHR is a component of this,” he said, adding that the changes are not just a one-year cycle but must involve continual iterative improvements. “We need to be more aggressive about making changes,” he said.

He described some efforts to reduce notifications and remove clicks from the medication refill process. They also removed a hard stop when discontinuing a medication. Those three changes alone reduced the number of clicks per month by 950,000 across the health system.

They also worked to reduce clinical decision support alerts with very low acceptance rates by turning them off. Three alerts with very low acceptance rates were turned off. “If we thought they were important, we would fine tune them to increase the acceptance rate,” Landman stressed. “That is part of clinical decision support lifecycle management. But we will continue to iterate to reduce the number of unnecessary clicks.”

A year and a half ago, Brigham also created a one-to-one support program, in which an expert trainer would meet the physicians in their practice and help them with their work flow. A pilot project involved four specialties, including general surgery. Each session was 90 minutes to two hours long, and providers were offered one or more follow-up sessions, as well as optional training on speech recognition. After seeing some negative feedback on their initial classroom training, the one-to-one sessions were met with a very positive response. Almost 95 percent said it was valuable, and 95 percent said they thought their efficiency with the EHR would improve following the training. Based on that early success, the training effort is now being rolled out to much larger groups of physicians at Brigham and across the Partners HealthCare network.

In another attempt to improve documentation turnaround time, Brigham has made voice recognition tools and training available to physicians. They made two-hour training sessions mandatory for those interested in adoption, with additional personalization sessions also available. Informaticists partnered with departments to build department-specific order sets. (Brigham also started offering 15-minute e-learning sessions for residents.) More than 90 percent of surveyed physicians said the training met expectations, and 70 percent said they would be willing to have additional training, Landman said. Currently 5,000 physicians across Partners are trained to use voice recognition tools with the EHR.

Landman also cited a study that compared U.S. and international use of Epic that saw a huge disparity in length of documentation notes. The U.S.-based users’ notes were nearly four times longer on average than those of their international counterparts. Epic users overseas tend not to complain about the burden of documentation, he noted. This has to do with how the provider notes are used in billing, he said, adding that CMS is working on proposals to change billing requirements that may alleviate some of the documentation burden for physicians.

In closing, Landman urged informatics colleagues to think about working on EHR optimization research and studying the impact of policy and technology changes. “New technology tools can seem fun and exciting, but for physicians who see up to 100 patients per day, they can be quite overwhelming,” he said. “We don’t want physicians spending half their time doing administrative work.”

 

 

 

 

 


Related Insights For: EHR

/whitepaper/electronic-consent-setting-new-standard-informed-consent

Electronic Consent: Setting a New Standard for Informed Consent

Please register to download


The Direct Impact on Satisfaction, Compliance, Productivity, and Cost

The inefficiencies inherent to paper-based consent form processes can result in missing or improperly scanned forms. This leads to delays and inconsistencies, drains the valuable time of clinicians, exposes hospitals to risk, and ultimately, impacts patient safety.

For many health systems, enhancing the informed consent process is directly tied to key strategic initiatives, such as patient safety, cost savings, and risk management.

See more on EHR