Healthcare IT leaders nationwide are moving forward steadily to introduce evidence-based care tools into clinician workflows, both with regard to the development of order sets in computerized physician order entry (CPOE) systems, as well as in the context of the medical diagnosis process. As they advance in these areas, they are finding that building everything from scratch is simply too labor-intensive a prospect. And as hospitals and medical groups turn increasingly to the commercially sponsored offerings available, they are finding the insertion of evidence-based decision support to be a plus in winning doctors over to CPOE adoption.
The journey that Loran Hauck, M.D., and his colleagues at the 42-campus Adventist Health System have been on for the past several years exemplifies the broader challenges and opportunities facing healthcare leaders nationwide in a key area of endeavor. Not only have the advances that he and his colleagues at the Orlando-based health system have made in providing information and clinical decision support at the point of care improved physician decision-making; the path they have followed demonstrates the inevitable bundle of choices provider organizations will have to make as they build the foundation for evidence-based care going forward.
Back in 1996, Hauck says, Donald Jernigan, Ph.D., then executive president of the Adventist Health System, and now its president and CEO, approached him with a vision for a physician-driven process for evidence-based clinical best practices. Hauck, at that time the vice president of medical affairs (VPM) of a local Adventist hospital in Calhoun, Ga., responded positively, and was soon working out of the health system's Orlando corporate offices. “We began conducting these very labor-intensive reviews of the medical literature using MEDLINE, from the National Library of Medicine,” he recalls. “We would photocopy articles to everyone on the committee, which included about 12 to 14 people-physicians, nurses, and clinical pharmacists.”
Indeed, at the outset, says Hauck, now senior vice president and chief medical officer for the health system, “We started building order sets by creating electronic templates in Microsoft Word, and printing them out on paper for people.” The problem? “It took three to four months to do the literature review, create the content for an order set, and get that order set thoroughly vetted,” he recalls. Order sets were shared electronically, but at that time, the order entry element was still paper-based. This was in fact years before the health system began implementing computerized physician order entry (CPOE), a process that is continuing in the present, as Adventist Health rolls out its CPOE go-lives one hospital at a time.
Still, the health system moved forward with evidence-based order sets several years ago, beginning in the areas of pneumonia, heart failure, acute myocardial infarction, stroke, total hip replacement, and total knee replacement, and continuing from there. And their work paid off in terms of improved care outcomes, with Hauck and his colleagues documenting an absolute 3-percent reduction in mortality in pneumonia cases over three years, for example, as well as a reduction of 1.1 days in adjusted average length of stay (from 6 days to 4.9 days) over that same period of time for such cases, as documented in a 2004 article in the Annals of Epidemiology.
The trajectory of work in this area was altered when Hauck became acquainted with Scott Weingarten, M.D., who founded the Los Angeles-based Zynx in 1966, creating one of the first healthcare IT vendor companies to provide pre-vetted, evidence-based order sets that were automated and could be directly incorporated into electronic medical records (EMRs) for CPOE. Adventist became one of the earliest hospital-based organizations in the country to work with vendor-provided evidence-based order sets as a basis for their own ordering (albeit modifying the order sets for their own organization's use, of course). Adventist remains a Zynx (Los Angeles) customer organization today.
WORKING WITHIN AN AUTOMATED SYSTEM OF EVIDENCE-BASED CLINICAL DECISION SUPPORT (CDS) AND ORDER ENTRY IS WHERE HEALTHCARE IS HEADED.-LORAN HAUCK, M.D.
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