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Second-Generation Clinical Decision Support

February 28, 2012
by Mark Hagland
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Healthcare IT leaders are rethinking how to plan and implement clinical decision support to make it more effective—and more appealing to physicians

Jerry Osheroff, M.D., principal at TMIT Consulting in Cherry Hill, N.J., the lead author of Improving Medication Use and Outcomes with Clinical Decision Support: A Step-by-Step Guide and the chair of the HIMSS Clinical Decision Support Workgroup and Task Force (sponsored by the Chicago-based Health Information and Management Systems Society), has spent years collaborating with physicians and others to move forward important clinical decision support (CDS) concepts and embed them into clinical information systems in order to improve patient care.

But Osheroff is clear on one thing: he absolutely hates the term “advanced clinical decision support.” In fact, he says, “I’m very nervous about using the term ‘advanced’ for clinical decision support, because that conceptualization implies that there are a whole bunch of other things you have to do first before you get to the ‘advanced’ stuff; and it implies that there’s a whole bunch of technologically sophisticated stuff; and that’s not really what it’s about.” Instead, he says, “I think we should just call it better clinical decision support.”

Osheroff, who lately has been helping to lead the CDS For Performance Improvement Imperatives Collaborative, a nationwide volunteer initiative encompassing more than 130 individuals representing dozens of hospital organizations and numerous electronic health record (EHR) vendors, all of whom are sharing their knowledge and learnings about clinical decision support, has a point. Nonetheless, what has become clear in the past few years is that the first generation of CDS tools, as embedded in commercial healthcare IT vendors’ core EHR systems, has not lived up to expectations; and indeed, has required continuous customization work on the part of healthcare IT leaders seeking to avert alert fatigue and truly optimize the workflow of physicians and other clinicians. So, what’s next?

“The fundamental learning” coming out of that collaborative, Osheroff says, “is that there are a lot of care delivery organizations and others who are drawn very strongly to this notion of measurably improving high-priority outcomes” through the use of second-generation clinical decision support. “Major learning number two,” he says, “is that there is a relatively small handful of relatively high targets [for broad performance improvement] of interest to care organizations. That’s why folks have locked onto issues such as optimizing VTE [venous thromboembolism] prophylaxis and hemoglobin A1C management; and the next big target will be readmissions.” In other words, he argues, success in CDS implementation going forward will require creating consensus around concrete performance improvement targets the physicians can embrace.

Making Hard Choices About Priorities
And that issue goes to the heart of the problem, as so many hospitals, medical groups, and integrated health systems, first under pressure to implement their EHRs in a timely way, and now under pressure to meet meaningful use requirements, continue to try to very quickly embed basic CDS systems into their EHRs, before achieving full clinician buy-in, with the result being open physician revolt in many cases. Given the intense timetable for fulfilling meaningful use requirements, what’s the solution?

Indeed, says Ferdinand Velasco, M.D., vice president and CMIO of the 13-hospital Texas Health Resources, based in the Dallas suburb of Arlington, Texas, “The challenge will be, which tools do you apply, and in what order? Because now everybody wants advanced clinical decision support for every initiative. And the reality is that we lack the bandwidth or capacity to completely automate and hardwire every single aspect of clinical practice through advanced CDS.” Bottom line? “We’ve had to decide what our top five or 10 performance improvement opportunities are, whether patient safety-related, or around reducing variations in care, for example,” and have had to focus on those areas.

Ferdinand Velasco, M.D.

Beyond the fact of limited resources and bandwidth, there is also, industry-wide, an even deeper problem, notes Peter Kilbridge, M.D., who spent years as a CMIO at large health systems, before becoming a full-time consultant. The New York-based Kilbridge, who is now senior director, research and insights, for The Advisory Board Company, Washington, D.C., says that over the past decade, “We’ve learned a lot about what’s necessary” in clinical decision support. “Unfortunately, there’s a lot of disillusionment now. I think there was an inadequate understanding at first of the sophistication needed to do this right, on the provider side. And on the vendor side, there was a focus on making money.”

As a result, Kilbridge says, a very large number of patient care organizations, particularly hospital organizations, implemented their first-generation CDS systems both too rapidly and rather haphazardly. “So there’s been this kind of this take-the-money-and-run feeling, and the whole thing has been slammed in, and you end up spending six months just trying to fix things that are broken, let alone moving forward on optimization. So as a result of this approach, there’s been this rush to results, and unfortunately, real optimization rarely happens.”

In other words, leaders at many patient care organizations will first have to make peace with their physicians over poorly implemented first-generation clinical decision support systems before they can get them to buy into the second-generation efforts. Only then will healthcare IT leaders be able to get their physicians and other clinicians to embrace the second-generation CDS tools that healthcare leaders nationwide agree will ultimately transform care delivery.

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