Clinical Decision Support Provides Better Care
By Robert Murphy
Memorial Hermann is a Houston-based not-for-profit health system that operates 12 hospitals. As the organization’s chief medical informatics officer, I am responsible for leveraging IT and data to improve the quality and safety of clinical care.
However, as the health care industry moves away from fee-for-service payments and begins implementing value-based purchasing models where provider reimbursement is directly tied to quality and safety outcomes, my role is changing. It is evolving from a primary focus on adopting health information technology to that of optimizing care processes to produce financial and quality results.
It’s clear now that our previous vision of reduced variability and high-reliability health care processes is no longer a distant goal, but rather a necessary objective in all aspects of health care operations.
I have been encouraging the use of standardized evidence-based practices across our organization because such practices have been shown to improve the quality of clinical care while reducing costs. But instead of merely populating our electronic health record (EHR) system with this content, I am working to ensure that our organization maximizes the potential of delivering evidence-based clinical decision support (CDS) at the point of care.
To lay the foundation at Memorial Hermann, we implemented evidence-based best practices for six conditions: heart failure, pneumonia, chest pain, chronic obstructive pulmonary disease, gastrointestinal hemorrhage and sepsis. Physicians deliver care that adheres to these best practices by accessing evidence-based CDS, which is embedded in order sets within an EHR system from Cerner Solutions, particularly a Cerner Millennium computerized physician order entry (CPOE) system.
The content for our CDS was developed by using Zynx Health's ZynxOrder, which offers more than 1,100 order set templates covering the major disease-related groups and symptoms for adults and pediatric patients in hospital settings. In addition, the templates are customizable in an online content management system that gives us version control and easy maintenance.
To make the most of this CDS, an editorial board composed of physicians from each specialty reviews the content of the order sets. Each specialty then coordinates the order sets in two phases: emergency department (ED) care and inpatient care. For example, when working on heart failure orders, a group of cardiologists, ED physicians and internists work together to optimize content in the related order set and coordinate care between the two phases. I encourage the organization to think of these initiatives as a continuous quality improvement program.
Based on this experience, I believe it’s important to:
· ensure that evidence-based content is not just housed in the EHR, but is pushed to clinicians at the point of care at the right time, making it more actionable;
· support a group that focuses on continually managing and fine-tuning the content. At Memorial Hermann, the editorial board works closely with physicians, nurses, pharmacists and other clinical support staff, and it seeks consensus in controversial clinical areas; and
· focus on measurement and outcomes. As such, hospital leaders can continually show the value of these programs to internal audiences.
With this continuous performance improvement approach in place, we have experienced admirable results at Memorial Hermann. For example, standardizing one common evidence-based order set for each condition has enabled the system to deliver medical care with less variability, higher reliability and correct clinical care—all of which has also resulted in lower costs.
In 2011, as a result of using evidence-based best practices to treat most of our nearly 12,000 patients, we were able to save $1.4 million, compared with what we would have spent on care if we hadn’t used clinical decision support. Perhaps more importantly, CDS is helping us deliver better care to patients. Based on a nine-month analysis of clinical decision support, we discovered that more than 6,500 potential incidents of incorrect care had been identified and amended before reaching patients.
While we have come a long way with CDS embedded in our EHR, we continue to look for additional improvements. As such, we are relying on ZynxValue+, an advisory service that offers a comprehensive assessment of the CDS content, to give us a greater visibility into any clinical inefficiencies.
With this service, experienced clinicians provide ongoing, evidence-based CDS and update recommendations, ensuring that clinical content complies with new findings, regulations, FDA safety alerts and other changes to clinical evidence. These assessments provide insight into evidence-based interventions that can affect mortality, cost, admissions, re-admissions, hospital-acquired conditions and length of stays.
Such analyses can be especially valuable in high-volume complex care areas such as heart failure and pneumonia. Care for such conditions tends to be highly variable since many specialties may be involved.
So, while we’ve already experienced significant results with our CDS in these areas, we believe we can do even better by expanding this content into transitions of care and in ambulatory settings. As we embrace accountable care and clinical decision support, we are confident that we can deliver on the promises of higher quality with lower costs.
Robert Murphy, M.D., is the chief medical informatics officer at Memorial Hermann Healthcare System in Houston. He is responsible for enterprisewide leadership on the physician aspects of clinical information system projects, especially for clinical decision support and physician order entry.