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:
> Internal Alignment/Buy-In
> Alerts/Order Sets
> Process/Workflow—Future Vision
> 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.
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