EXECUTIVE SUMMARY
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.
The big lessons in all this? The reality, says Hauck, is that working within an automated system of evidence-based clinical decision support (CDS) and order entry is where healthcare is headed. On their own, physicians can simply no longer keep up with all the new emerging medical evidence. At the same time, the labor intensity of complete self-development of evidence-based order sets ultimately becomes overwhelming over time, both for initial order set development and for content maintenance. Thus, the transition to pre-vetted, CPOE-ready evidence-based order sets is one that he and many others see as inevitable for healthcare organizations nationwide.
A QUICKENING WITH MULTIPLE PROMPTS
Nationwide, more and more clinician and healthcare IT leaders are following the lead of Hauck and his colleagues. The majority is working with a handful of vendors, including not only Zynx, but also with ProVation Order Sets, a Minneapolis-based brand of Wolters Kluwer Health, which also provides evidence-based order sets for physicians. Other organizations are using evidence-based CDS for diagnosis, in the solution from the Ann Arbor, Mich.-based Isabel Healthcare. A small number of other vendors are emerging into this space as well, such as the Boston-based Diagnosis One.
In all of these instances, the clinicians and provider organizations advancing in these areas are being compelled forward by a combination of factors, including:
The quickening pace of clinical advances, which is making day-to-day medical practice more challenging at a time when physicians are more time-pressured and distracted than ever;
The need to bring physicians more quickly into CPOE adoption, with the provision of evidence-based order sets, and/or CDS in the form of evidence-based diagnosis information-an extremely useful “value-add” that can encourage doctors forward, while providing them with truly valuable tools at the same time;
The need for patient care organizations to begin to eliminate unnecessary variations in care patterns and to analyze outcomes farther and farther upstream, in the context of demands for organizational performance improvement coming out of federal healthcare reform and the federal American Reinvestment and Recovery Act/Health Information Technology for Economic and Clinical Health (ARRA-HITECH) Act.
Is Process King?
Getting physician buy-in is key to success in evidence-based care, says one CIO
At SwedishAmerican Health System in Rockford, Ill., Vice President and CIO Phil Wasson is helping to lead his organization forward on a journey around evidence-based care. At press time, Wasson and his colleagues were scheduled to begin preparing the go-live on CPOE, using evidence-based order sets from ProVation, the Minneapolis-based brand of Wolters Kluwer. But the path towards embedding evidence-based order sets in CPOE actually began a few years ago, when SwedishAmerican contracted ProVation to implement its order sets within the CDS element of its EMR, via a ProVation Web-based, evidence-based, peer-reviewed CDS support tool called UpToDate.
What's significant, Wasson says, is how important it is to gain physician buy-in early on, and to engage the doctors in the process of working forward on using evidence in medical care. After analyzing the situation a few years ago, Wasson determined that the existing governance around physician IT was simply unsatisfactory. “We had the traditional physician computing advisory committee,” he recalls. “And we looked at that and said, that's not even efficient or working anymore. So we went to the medical staff and asked them to create a permanent, standing electronic health record committee of the medical staff, just as we have permanent standing committees in pharmacy and therapeutics or credentialing; and we asked them to formally charter that committee. And that was instrumental,” he says.
Out of that discussion came the development of five subcommittees associated with the EHR committee of the medical staff, including ones associated with order entry, metrics (“looking at what needs to be measured and what measures coming from the federal government we need to account for”), workflow evaluation; and a special communications committee, which among other things maintains a special physician EHR Web site that updates both physicians and non-physicians on ongoing EHR and order set development.
What's more, even as his organization prepares to go live with CPOE, “Our physicians are already doing something like 4,000 [Cerner Corp.] UpToDate searches a week,” Wasson reports. “So they're using clinical evidence every day now, and that activity isn't just linked to orders in the order entry system. And once [CPOE go-live] happens, they'll be able to get current information about a particular order they are placing.” What's more, SwedishAmerican gives physicians a 0.5 CME credit for every 15 minutes they use the UpToDate clinical decision support tool, Wasson notes. As a result of all the collaboration and incentives, “We're really changing how medical decisions are made. The days of Marcus Welby are gone; the days when physicians could keep everything in their heads. And it's important that the physicians be able to practice in a way that allows them to acknowledge that they don't know everything, but in which you can put the information they need at their fingertips, at the point of a click. And whether there were some kind of meaningful use legislation or not, we would be doing this,” he concludes.
MOVING FORWARD ALONG DIFFERENT FRONTS
Every patient care organization whose leaders are moving forward in the evidence-based care arena is doing so in a different way, of course, and there are as many case studies as there are patient care organizations.
At the 32-hospital, Newtown Square, Pa.-based Catholic Health East, Donette Herring, R.N., vice president and CIO, reports that her system has been working for more than a year to implement the Zynx order sets, even as she and her colleagues remain in the planning stage of implementing CPOE. Like the Adventist Health System, Herring and her colleagues at Catholic Health East are using the Zynx order sets as a foundation, and customizing those to meet their hospitals’ specific needs and situations.
At the 250-bed Northwest Hospital and Medical Center in Seattle (which one year ago became a part of the University of Washington Medical Center) vice president and CMO Gregory Schroedl, M.D., reports that, as at Catholic Health East, he and his colleagues have been working with Zynx to improve care, in advance of CPOE implementation. In fact, Northwest Hospital has been a Zynx customer since 1998, Schroedl says. He adds that the data analysis element of using evidence-based order sets has been one of the most important reasons for implementing those order sets within the organization.
At the 333-bed SwedishAmerican Hospital in Rockford, Ill., the flagship facility of SwedishAmerican Health System-and at its sister facility, the 60-bed SwedishAmerican Belvidere in nearby Belvidere, Ill., vice president and CIO Phil Wasson has helped to lead the enterprise-wide adoption of evidence-based order sets, using the order sets provided by ProVation/Wolters Kluwer as a basis, and engaging teams of physicians in discussion and development. At press time, the teams at Swedish American had approved or put into final development 114 order sets, up from just 64 six months prior to that. (ProVation offers a total of 456 adult and 162 pediatric order sets, and 203 adult care plans, according to a company spokesperson.) Also at press time, Wasson and his colleagues were about to link the already adopted order sets into the CPOE system that was scheduled to go live early this spring; until recently, the order sets were used as part of the set of clinical decision support tools in the organization's EMR, through a Web-based, evidence-based CDS tool from ProVation called UpToDate.
Using the Cerner Millennium Lighthouse data analysis solution from the Kansas City-based Cerner Corp., clinicians have made considerable strides in a number of areas, reports John Bluford, president and CEO of Truman Medical Centers, also in Kansas City. Among the gains he notes are a dramatic decrease in patient falls, from 4.6 falls per 1,000 patient days to 3.2; and in the presence of pressure ulcers upon discharge, from 5 percent of discharges, to 1 percent, at the 600-bed academic medical center.
At the 1,800-bed Orlando Health, physicians are using the evidence-based CDS solution from Isabel Healthcare, along with the evidence-based ProVation order sets for ordering, reports Steve Margolis, M.D., who was CMIO at Orlando Health until the end of October (he has since joined the Roseville, Calif.-based Adventist Health as CMIO). Among other benefits, Margolis says, is the routinization of the use of the Isabel CDS solution among the 200-plus residents of the hospital organization, which he likens to having an attending at their shoulder at all times.
DESPITE HAVING A GOOD CROSS-SECTION OF PHYSICIANS AND OTHER CLINICIANS INVOLVED IN CONTENT DEVELOPMENT, THERE IS LIKELY TO BE SOME QUESTIONING OR PUSHBACK IN TERMS OF WHAT'S CONTAINED WITHIN AN ORDER SET, BECAUSE IT MAY NOT BE CONSISTENT WITH INDIVIDUAL PHYSICIANS’ CURRENT PRACTICES. SO IT WILL INVOLVE AN ITERATIVE PROCESS.-DONETTE HERRING, R.N.
Of course, even the commercial vendors whose pre-vetted order sets are available to patient care organizations across the country haven't covered every corner of the map, so to speak. And in many cases, clinician leaders are developing their own order sets in a number of subspecialty care areas in which commercially developed order sets are either not available or not yet up to meeting the needs of demanding physicians. In addition, all those interviewed for this story continue to customize pre-vetted order sets to meet their needs, and the requirements of the physicians and other clinicians in their organizations.
IT'S ALL ABOUT IMPROVING PATIENT CARE
What unites all these leaders in all these organizations? Put simply, their recognition of the compelling need to use these emerging tools to improve patient care and clinician effectiveness. “Why wouldn't anyone want to use the clinical evidence for decision support?” asks Orlando Health's Margolis. “I would think you'd want to use it. Now, the 80/20 rule says that 80 percent of the time, you'd be able to make the right diagnoses without such tools. But especially in circumstances like emergency department care or with the potential for rare diseases, these kinds of tools become extremely helpful.”
Margolis agrees completely with those industry observers who note that it is becoming increasingly difficult for physicians to keep everything in their minds as they go through their busy days of patient care delivery. Expert systems, whether for diagnosis or ordering, he emphasizes, don't in any way remove the power of decision-making from doctors; they only enhance their ability to make the right decisions at the right time. Indeed, he says, an analysis of past cases (cases from prior to Isabel implementation) by Orlando Health analysts found that some diagnoses would have been reached earlier in the care process had the Isabel CDS solution been available to doctors at that time.
Given the clear benefits of moving in this direction, why wouldn't any patient care organization's leaders want to move forward on leveraging clinical IT to facilitate evidence-based care? The answer is, fewer and fewer organizations are ignoring the compelling logic in this arena, says Laura Berberian, R.N., M.S.N., senior clinical consultant at the Chelmsford, Mass.-based Concordant. Berberian, who specializes in consulting on clinical issues for EMR implementations, says, “I would say that a majority of hospital organizations are pursuing this path, at least on the inpatient side, in the context of CPOE. “Berberian also agrees with all those, including Hauck and Margolis, who have discovered that custom-building every order set from scratch quickly becomes impossible to sustain.
“The ability to build and maintain this content is very resource-intensive,” Berberian notes. “It's not just the content involved, it's creating a culture around that content, including the ability to advise clinicians and establish consensus around the content. It's just very difficult to develop everything in-house.”
GOVERNANCE IS CRITICAL
All those interviewed agree that there are several critical success factors involved in building evidence-based data into care delivery processes, both with regard to diagnosis and treatment. Among these:
Begin with a core clinician and clinical informaticist leadership group, one with authority and scope, in the form of a clinical advisory committee or governing committee, and with subcommittees, as appropriate, to manage critical elements of the development work;
Make sure to make that leadership group multidisciplinary-i.e., include physicians, nurses, and clinical pharmacists in the group, as well as any other appropriate members, plus clinical informaticists and other IT professionals;
Have a sense of overall goals in mind;
Work out deliberate processes for how evidence-based order sets will be developed;
Design a formal, workable communications plan that will help communicate information to clinicians on the front lines.
MY ADVICE WOULD BE THAT IF YOU CREATE AN EASY-TO-USE AND UNDERSTANDABLE CATALOG AND CREATE ORDER SETS THAT HAVE GOOD CONTENT AND EASY TO NAVIGATE, CIOS WILL FIND THAT THE MEDICAL STAFF AND CLINICIANS WILL THANK THEM FOR THE PROJECT.-GREGORY SCHROEDL, M.D.
“It's important to establish a system of enterprise-wide processes,” says Concordant's Berberian. What's the standardization process, and what's the maintenance process? The maintenance of evidence-based order sets can come back and bite you if you don't have the resources to sustain this.”
Adds Catholic Health East's Herring, “Despite having a good cross-section of physicians and other clinicians involved in content development, there is likely to be some questioning or pushback in terms of what's contained within an order set, because it may not be consistent with individual physicians’ current practices. So it will involve an iterative process. And I think many organizations like CHE have been good at making sure there's a good feedback loop involved.”
Northwest Hospital's Schroedl says that, in his experience, “The key issues are making certain that you're not omitting any important steps in the clinical process that have been shown to improve outcomes, and that using the literature and the evidence as the basis for discussion amongst the clinicians, as far as standardizing practices. Those are the two most important elements.” He adds that facilitating evidence-based care can really help to sell physicians on CPOE, particularly in community hospital settings like his. “We've found that probably the most appreciated component of that conversion from a dictated chart and a paper record, for the physicians, was actually computerized order entry with pre-established order sets. We used Zynx as the basis for reviewing the evidence and helping us build the order sets. And that was a great success for us. The physicians liked and appreciated the speed, the accuracy, the allergy checking, the medication checking, that this provided.”
Asked what he would tell CIOs, Schroedl says, “My advice would be that if you create an easy-to-use and understandable catalog and create order sets that have good content and easy to navigate, CIOs will find that the medical staff and clinicians will thank them for the project.”
Healthcare Informatics 2011 January;28(1):10-17
