Peter Basch, M.D., offers a succinct summary of why the 1,000 physicians he helps with IT are moving to electronic health records: "We are shifting to EHRs not to punish doctors by making them typists, but to use the value of information to improve care."
That's why Basch is making clinical decision support a top priority as he heads an EHR effort in his role as medical director of ambulatory clinical systems at MedStar Health, Columbia, Md.
Basch, like many other EHR proponents, stresses that offering physicians timely decision support is perhaps the most valuable component of a shift to electronic records. That's because receiving timely advice, based on sound medical evidence, when making treatment decisions can dramatically improve care quality while saving money on inappropriate treatment.
Practices are taking widely varying approaches to implementing decision support, ranging from simply using an EHR to alert physicians when a patient is overdue for a test to developing sophisticated protocols that provide a step-by-step guide to treatment of a specific condition.
Recognizing the value of decision support, doctors at Community Care Physicians in Latham, N.Y., recently began using evidence-based clinical treatment protocols. "This has streamlined the order process for the diagnoses that we see most frequently," says Barbara Morris, M.D., chief medical officer at the 160-physician practice. By integrating the protocols so they fit physician workflows, doctors have to make fewer clicks to order appropriate tests and medications and document treatment, she says. And that makes their lives easier, while improving the quality of care.
Group practices that are pioneers in the clinical decision support arena envision a day in the not-too-distant future when they'll carefully analyze the use of protocols and other decision support aids to measure what approaches work best. "That's likely our next step," says Nancy Babbitt, administrator at Roswell Pediatric Center in Alpharetta, Ga. The group practice is using EHR templates for documenting care that include decision support functions.
Many group practices with EHRs, however, are just getting started with phasing in the full clinical decision support capabilities of their systems. And some, such as MedStar, are working with consultants to build robust, tailor-made decision support functions.
Of course, a majority of practices have yet to even acquire an EHR system. A variety of surveys suggests that as few as one-fifth of group practices use the technology. But Medicare and Medicaid EHR incentive payments under the federal economic stimulus program could lead more practices to take the electronic records plunge. And the pending definition of "meaningful use" of EHRs-the cornerstone of incentive eligibility-requires that practices implement at least some decision support functions.
"A lot of what it's going to take to achieve 'meaningful use' is getting clinical decision support right," says Jerry Osheroff, M.D., who chairs the HIMSS Clinical Decision Support Workgroup, which has created a collaborative Web site on decision support. Osheroff is chief clinical informatics officer at Thomson Reuters, a New York-based software vendor.
Osheroff points out that proponents use many different definitions of clinical decision support. The workgroup adopted a broad definition: "intelligently filtered patient data that helps inform decisions that lead to better outcomes." That definition, he says, could encompass advanced clinical systems as well as a sticker on a patient chart.
Many clinics that have EHRs are starting their decision support efforts by simply turning on preventive care guideline alerts that come with the systems, says Rosemarie Nelson, principal at MGMA Healthcare Consulting Group, Englewood, Colo. These alerts offer reminders about overdue tests, such as mammograms.
Beyond that, Nelson advises clinics to look for "easy first steps" that automate workflows a majority of physicians already use, rather than immediately launching into developing dozens of sophisticated treatment protocols.

The Next Step

At MedStar, however, Basch and his team are going far beyond the easy first steps; they are implementing robust treatment protocols. The integrated delivery system has rolled out an EHR from GE Healthcare, Waukesha, Wis., to about two-thirds of its 1,000 employed physicians. Now, it's bolting on sophisticated protocols created in partnership with Clinical Content Consultants, Concord, N.H.
"This allows us to build as many or as few prompts as we wish that are tailored to the patient and the physician opening the prompt," says Basch, a practicing internist. When a doctor is using the EHR, a button glows yellow to indicate if there is a suggested protocol available, such as breast cancer screening, that's relevant to the case. By clicking on the protocol, physicians can view a series of suggestions for tests and procedures to order. MedStar is phasing in protocols gradually to avoid overwhelming physicians with information, Basch says.
"I was concerned about decision support that's forced, with lots of popups in your face," Basch says. Such an approach disrupts the doctor's workflow, he contends. "With our system, I can click on the yellow button when I'm ready, such as once I hear the patient talk about why they are here." The protocol "changes the dynamic of the office visit to a two-way conversation" because the doctor can go over a list of appropriate questions that are displayed in the protocol.
In the months ahead, MedStar will track which protocols are opened most often and what action is commonly taken so physicians can fine-tune the system. For now, using the protocols is voluntary. "My belief is that doctors want to do the right thing," Basch says. "If we enable them to work more efficiently, they'll use the protocols."
MedStar's records system includes "a very simple screen" that shows medication history and allergies. The e-prescribing component offers alerts, such as for adverse drug interactions, as well as guidance regarding what drugs are on the formulary and covered by insurance. "But knowledge-based medication management doesn't really exist; it must be built," Basch argues. "We do not have, nor do most clinics have, a decision support system that looks at the implications for use of a drug and recommends the most appropriate and cost-effective drug for that condition."
The physician is hopeful of eventually implementing a system with business intelligence to achieve that goal. Meanwhile, the protocols implemented so far include recommendations on drugs to order for specific conditions.

Immediate Action

One key to making "best practice alerts" effective is enabling physicians to easily take immediate action, such as by placing an order, contends David Kauff, M.D., associate medical director, health informatics, at Group Health Permanente. The practice is affiliated with Group Health, a Seattle-based cooperative with payer and provider components. "It's fine to be told that a diabetic is due for a test, but we connect that reminder to an order so that the clinician can order it right when he's seeing the best practice displayed," Kauff says.
When it comes to alerts, Kauff argues that the goal should be to "push the work as far upstream as you can." That's why the system displays alerts, such as for overdue tests, when the record is accessed by any clinician so, for example, a nurse can immediately remind the patient. "We've tried to make the alerts as brief as possible. We want our patients to get all the right things done at every touch point in our system."
Going beyond the alerts, Group Health clinicians have created hundreds of "smart sets" for specific types or visits or conditions within their EHR system, from Epic Systems Corp., Verona, Wis. The smart sets include a standard note that pulls in relevant components of the patient's medical history and medications. It also includes links to suggested procedure orders, lists of medications that should be ordered, patient education material and a suggested follow-up plan.
So far, physicians are primarily using a small number of these smart sets, Kauff says. These include sets for annual exams and preventive medicine visits as well as those for treatment of certain common conditions, such as diabetes, asthma and coronary artery disease.

Evidence-Based Medicine

Much like Group Health's use of "smart sets," clinicians at Community Care Physicians use "care guides" that make it easier to apply evidence-based medicine, says Morris, the chief medical officer. So far, the physicians at the New York practice have fine-tuned about 20 of the care guides that were included in its EHR from Allscripts, Chicago. These pertain to the most common diagnoses the doctors make, Morris says.
"Our approach has been to only turn on those care guides that we've reviewed and edited," she says. But in the coming months, as Allscripts updates hundreds of guides with new information, Morris expects to rapidly activate many more.
When a physician clicks on a diagnosis in the record, it automatically displays "Care Guide" in blue if a relevant guide exists. The guide, similar to those at Group Health, then provides suggestions for medications and procedures, enabling doctors to make choices with a minimal amount of clicks.
The New York practice also equips physicians with "health maintenance plan" alerts for overdue tests. Plus, it enables physicians to prepare custom reports. "I can configure the system so that once a month it generates a report of all children ages 5 to 15 who have asthma and are using a particular medication and have not been seen in the last six months," says Morris, a pediatrician. The records system then automatically sends her a monthly e-mail with a list of patients she should see for follow-up care.
Morris expects the practice eventually will conduct outcomes research for populations of patients with certain diseases by leveraging all the information in the records.

Leveraging Templates

As they implement electronic records systems, many clinics are taking advantage of disease-specific point-and-click documentation templates that vendors provide. And these templates can offer timely advice for physicians, says Babbitt, administrator at Roswell Pediatric Center. For example, a template for urinary tract infection cases immediately alerts physicians at Roswell when a child has had multiple infections within a defined period. In these instances, the system reminds the clinician to do a "full workup" to pinpoint the cause, Babbitt says.
Because Roswell was the first pediatric practice to use EHR software from Noteworthy Medical Systems Inc., Cleveland, it helped develop many of the 130 pediatric-specific templates that the vendor built, the administrator says. "And when new asthma guidelines came in from the American Academy of Pediatrics, it was easy to add them to the existing templates," she says.
The electronic prescribing function embedded in many EHRs provides decision support that goes beyond alerting to adverse drug interactions, allergies and formularies. For example, when the parent of a child with attention deficit disorder who was prescribed a controlled substance calls to request a refill, Roswell's EHR reminds staff that the patient must come in for a follow-up visit every six months.
Some practices have found that EHR technology unleashes creativity on the part of the medical staff users. At Grove Medical Associates in Worchester, Mass., three physicians customized templates in their EHR during two days of training, says Gail Cetto, R.N., office manager. The practice uses records software from eClinicalWorks Inc., Westborough, Mass., that's accessed remotely via the Internet. Now, when doctors see a diabetes patient, they're reminded to conduct a foot exam, and when they see a coronary artery disease patient, the system asks them if they've ordered an echocardiogram within the last year, she adds.
"We have good control now," Cetto says. "I'm not afraid that we're missing something." Because everyone from front desk staff to nurses and physicians see alerts about overdue tests, for example, "there are more people teaching patients," she adds.
When the 14 physicians at Avenel Iselin (N.J.) Medical Group use an EHR from Aprima Medical Software Inc., Carrollton, Texas, they can open a "health maintenance slider" that displays whether the patient is up to date with all appropriate tests, says Marc Mayer, D.O., medical director. "It's becoming part of our routine," he says. "If I see you're overdue for a PSA test, I can order it right from the slider."
The records system "learns from what we do," Mayer adds. For example, if a doctor clicks on a diagnosis of a sore throat, the system automatically displays medications the physician has ordered in the past for similar cases.
"I can't imagine being able to do decision support on paper," Mayer adds.

HIMSS Offers Resources

The Healthcare Information and Management Systems Society offers several resources designed to help hospitals and clinics that are adopting clinical decision support.
The Chicago-based association's Clinical Decision Support Workgroup in July unveiled a "CDS Wiki," a collaborative Web site on the subject. Although the Wiki initially is focused on using inpatient clinical decision support to prevent venous thromboembolism, it will expand early next year to cover other topics, says Jerry Osheroff, M.D., who chairs the workgroup. That likely will include discussions of issues that clinics face, he says.
The workgroup also has produced a series of guidebooks, the most recent focusing on improving medication use by applying clinical decision support. Information on the reports is available at

Collaborative Web site on clinical decision support

'Meaningful Use' Definition Will Bloom in Spring

The final definition of the "meaningful use" of electronic health records that will be used to determine eligibility for incentive payments under the economic stimulus program will not be available until the middle or end of spring 2010. That's the prediction of David Blumenthal, M.D., national coordinator for health information technology.
The preliminary definition of meaningful use requirements will be issued by the end of this year, followed by a 60-day comment period, Blumenthal said.
"I'm glad they're going to take a hard look at the meaningful use definition" instead of rushing through an imprecise definition, says Rosemarie Nelson, principal at MGMA Health Care Consulting Group, Englewood, Colo. Across the nation, group practice administrators are awaiting precise details, especially how the final definition spells out clinical decision support, she says.
Under the American Recovery and Reinvestment Act, hospitals and physicians can receive Medicare and Medicaid incentive payments for making meaningful use of certified electronic health records systems.
The law, for example, states that physicians will be required to use an EHR that offers both clinical decision support and some form of computerized physician order entry. But regulators have yet to spell out precisely what kinds of decision support or CPOE implementation will be required to qualify.
A recommendation by the HIT Policy Committee's Workgroup on Meaningful Use, for example, appears to accommodate pilot CPOE projects in progress by 2011.
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