The Real Value Of Clinical Decision Support (CDS)

Edited by Susan Kreimer, contributing editor, Health IT Outcomes

CDS is helping standardize care at Riverside Health System, making performance measurement more efficient and reliable.

Physicians have historically taken pride in their diagnostic know-how and deductive reasoning. So, suggesting that they should use CDS tools is often downright offensive to many practitioners. Nobody likes the idea of technology second-guessing years of expertise. However, as this Q&A with Dr. Charles Frazier, CMIO, and Kathy Menefee, administrative director of patient care operations at Riverside Health System in Petersburg, VA, proves, CDS isn’t out to babysit doctors. It is a critical tool for facilitating performance measurement and improving overall patient care.

Q: What motivated your facility to begin leveraging CDS tools?

Dr. Frazier: We started using the Zynx Health CDS around 2006 or 2007. Riverside Health System had tried before to standardize what we were doing because we had variability in costs, outcomes, and practices among the physicians. We initially tried to call groups of people together to create evidence order-based sets. We concentrated on medical conditions that were either prevalent or that we didn’t have the outcomes we were looking for. We also chose medical conditions where there were high-cost issues, or a combination of all of these factors.

For example, we had a team looking at order-based decision sets centered on cesarean sections. Another team was looking at order sets for heart failure. They were different groups. Just as we had variability in our prophecies, we had variability in the success of those scripts as well. The reality of it is, some groups met once or twice, while other groups spent a year just surveying the literature, and then they came up with their order sets. It was a very inefficient process, and we had as much variability in that as in anything else. It just didn’t work.

When we tried to actually input order sets, we had a very disjointed process. From communication to approval, it literally took us months to reach actual usage. And from the standpoint of CDS, the order sets guide you to the condition of the practice group. And then, embedded in those orders, you have links to the evidence. That’s how we’ve used Zynx on the inpatient side. We also have used it to create and edit rules that we build into the hospital information system.

Q: Why did you select your CDS solution? How does the technology work?

Dr. Frazier: In 2006, there weren’t a lot of competitors. We felt Zynx was farthest along in development at that point. We also had experience using the Zynx evidence and forecasting tools, which we had access to as a contractor with Premier. We also started using the interdisciplinary plans of care that Zynx offered, and we were interested in the ambulatory component as well.

Working with Zynx and Siemens, we have integrated the order sets with Siemens’ Soarian. Now, when you create an order set in Zynx and it’s approved, you can import it into Siemens’ Soarian. You have to tweak it a little bit, but the input piece works.

Q: Were your clinicians initially comfortable with the idea of CDS? How did you help them see the value of the technology?

Dr. Frazier: The biggest issue they had was going from paper orders to computerized orders. They went from a workflow where a physician wrote the orders and a care secretary interpreted and entered them into the system to a process where the physician has to enter all the orders. Physicians saw that as putting work on them that they didn’t do before. The Zynx solution allowed us to develop these order sets more quickly than we could do on our own. The other thing Zynx allowed us to do is to act as a stepping stone between the paper orders and CPOE (computerized provider order entry). Zynx allows you to have interactive orders and order sets that can be formatted as an Adobe PDF document. Providers, as a first step, had to go on the computer and pull up the Zynx order sets and print them. Then, they filled out the forms online. I think that helped us get ready for CPOE.

Q: How is CDS currently supporting your care decisions and delivery?

Menefee: In early 2011, we needed to convert our paper plans of care to electronic versions. We used Zynx Authorspace, an online collaboration and review tool. Just as it allowed our physicians to review the evidence in their order sets, it also allowed the interdisciplinary team (e.g. physicians, nurses, care managers, therapists, pharmacists, dietitians) to review the evidence for plans of care. We spent about a year developing that, and we went live with it in June 2012. Plans of care are used on the inpatient side today in our hospitals, and we’re looking to expand that to our medical group and our lifelong health division in the future —- about 1,800 beds outside of acute care, everything from long-term care facilities to assisted living.

Q: What results has Riverside realized through its use of CDS?

Menefee: From the interdisciplinary care plan standpoint, the efficiency, primarily during development, was that we did not need to look for evidence. It was presented to us through Zynx, and it allowed our care team to understand there were certain interventions that were proven to be effective through research (e.g. reduced mortality and reduced length of stay). So, we knew which pieces of evidence needed to be maintained in our plans of care; we didn’t need to go out and search for that. And it brought everybody together on a common platform.

Q: Do your physicians have a different opinion of CDS after using it?

Dr. Frazier: They realize the care is more standardized than it used to be. They certainly know we’re tracking compliance with various core measures, and we certainly have improved the performance of those. On the ambulatory side, we’re embedding the evidence into the EMR. Part of the standards for our patient-centered medical home is applying evidence to the care you’re providing to patients. We use Zynx as one way of compiling that evidence, and we do a lot of work embedding it into the EMR form, so that providers have judgment in individual patient care. The evidence guides them toward the right thing to do. That is a standard of the medical home, and we were very easily able to demonstrate this to the National Committee for Quality Assurance (NCQA), which does the medical home recognition.

Q: What best practices would you recommend to other facilities looking to leverage CDS?

Menefee: When we implemented the evidence-based plans of care, we paid a lot of attention to measurement. We collected data based on measures that focused on before-and-after implementation. With CDS, we’ve seen a significant increase in patient satisfaction and a significant decrease in 30-day all-cause readmissions (i.e. a patient’s being readmitted for any diagnosis or reason within a 30-day period). One best practice would be to pay attention to measurements and make sure that what you’re doing using Zynx or any CDS product is making a difference. We also learned a lot from our physician colleagues. In the beginning, the process was very cumbersome until we really started to use the Zynx tool.

Dr. Frazier: The more you embed the evidence into the processes and the informatics platforms, the more success you have. Make it interdisciplinary. It’s more than just the doctors. It’s more than just the providers. In the hospital, it’s the doctors, nurses, therapists, and nurses’ aides. On the inventory side, it’s the medical assistants, too. Everyone needs to be following the same plan of care. Wherever possible, you set up protocols in the order, so everyone is guided in doing the right thing as supported by the evidence.