Leveraging Clinical Decision Support to Improve Quality in a Safety Net Setting
Fine-tuning clinical decision support (CDS) tools so that they actually work without overburdening clinicians with alert fatigue remains a health IT design challenge. But clinicians with CDS experience also remind us that all decision support tools are not created equal, and a lot of work is required to tie them into other care team processes.
“Out of the box, CDS tools don’t do very much,” said Daren Anderson, M.D., chief quality officer of Community Health Center Inc. (CHC), a safety net provider in Middletown, Conn., that has 13 primary care hubs and 130,000 patients.
Redesigned workflows and improved teamwork are essential for maximizing the utility of CDS and managing alert fatigue, he added. “We have been putting data into the EHR since 2006,” Anderson said. “Only now are we getting things out to drive improvement.”
On March 22, Anderson and other members of the CHC team put on a great presentation sponsored by the federal Health Resources and Services Administration (HRSA). They focused on how CDS is really just the starting point of much more in-depth quality improvement initiative.
Instead of using standard EHR registry tools, CHC hired a team of programmers to create a data warehouse and to use business intelligence tools to feed customized clinical dashboards. For instance, hypertension and diabetes dashboards help clinicians prioritize needs before a visit and provide a post-visit “missed opportunities” report. Retrospectively, providers can look back at how many patients missed receiving screens they need. “It is an immediate feedback mechanism, and a powerful motivator for teams to drive the quality of care,” said Bernadette Thomas, A.P.R.N., chief nursing officer,
CHC looked to business quality improvement efforts such as Toyota Lean and Six Sigma to redesign some of its processes. Thomas described the processes CHC has put in place to ensure its CDS tools are used to their full potential. It involves a quick huddle of providers each morning. But before the huddle, there is a pre-huddle process. A medical assistant reviews the CDS for scheduled visits for the next day and notes things that are due on a paper copy of the schedule. A registered nurse reviews patient schedules for vaccine and other disease management needs. The medical assistant convenes a huddle five minutes before the start of patient schedules for a brief team review of what is due and a discussion of a plan for complex cases.
“It is not just use of the EHR that is going to allow you to improve rates for cancer screening,” Thomas said. “It is how you use the EHR in combination with systems you design with quality improvement processes.” And even improving how you are doing on screenings only takes you so far, she added. It doesn't close the loop to make sure every abnormal result is followed up on.
Veena Channamsetty, M.D., associate chief medical officer, spoke about the importance of deciding what you want to prioritize on and then customizing CDS. “If you don’t use it meaningfully, it won’t have meaning,” she said. The organization has to decide what to focus on, she added. “You have to decide which alerts to use and train staff extensively on them. Otherwise they get ignored. The physician passes through them quickly or doesn’t look at them.” Just having support tools isn’t enough. You have to have a system behind it to translate it into actions, she said.
During the webinar, the audience was asked this question: “Do you have the ability to build/modify clinical decision support tools (such as flow sheets or templates) in your EHR to enhance quality improvement?” And 54.9 percent of respondents said yes.
CHC continues to focus on other gaps in its screening processes and is using “lean” tools to develop new processes for handling abnormal test results. I thought their talk was a great reminder that using an EHR and its clinical decision support only for documentation or point-of-care reminders is missing out on opportunities to connect important pieces of information to improve care. I have another example of an informaticist thinking along these same lines I will write about soon.
