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Stretch Your EHR Investment More than Just a Data Warehouse BY ALLAN STRONGWATER, M.D.

With all of the current focus on healthcare technology, it likely comes as little surprise that 8 of 10 physicians had implemented—or at least planned to adopt—an electronic health record (EHR) as of 2014.1 Considering that EHRs only began to emerge in the 1990s, this statistic speaks volumes about the rapidly accelerating change of pace in healthcare IT. Consequently, most hospitals and health systems are experiencing a significant transition in their thinking about EHRs. The question has changed from, “Should we implement an EHR?” to “How do we maximize our substantial EHR investment?” One answer is to stretch your EHR’s use by leveraging a clinical decision support (CDS) platform to improve care quality and efficiency.

Stretch your EHR’s use by leveraging a clinical decision support platform to improve care quality and efficiency. At its core, a CDS system augments the EHR by continuously analyzing a patient’s past and present medical information against best-practice guidelines and advising clinicians when their EHR entries indicate a deviation from those best practices. With the addition of CDS, the EHR becomes more than just a recording mechanism and data repository, delivering its data as a real-time clinical advisory system. Some can also 46

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generate performance reports to further guide increases in efficiency and compliance. All of this ultimately enables clinicians to best leverage EHR technology, streamline processes, improve patient safety, save time, and reduce costs. To fully understand where the forefront of EHR and CDS technology is today, however, it’s helpful to first take a brief look back.

The CDS Story Prior to the 1990s, most hospitals and health systems functioned using paper medical records and rudimentary computer systems for accounting and billing. Rarely did the mainframe computers of the day store such clinically important data as radiology images, for instance. There were few electronic interfaces from patient equipment to medical hardware. Although some physician notes found their way into the computer by the early 1990s, widespread use of computerized physician order entry (CPOE) was still years away.2 By the mid-1990s, the role of the computer in health care was no longer limited to accounting. Processors were finding their way into all kinds of medical equipment. For the first time, hospitals and health systems began to tap into the technological safety advantages offered by applied computing. Software developed for hospital pharmacy applications, for example, helped minimize drug-to-drug interactions and track patient allergies. Warnings about potentially adverse effects could then be presented. Proper dosing

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algorithms were implemented to account for patient weight, renal function, and the like. These pharmacy systems were the earliest incarnation of CDS. As technology has become less costly, faster, and more powerful, the healthcare industry has begun to take even greater advantage of the tremendous flow of information—within both EHR and CDS solutions. Technology now captures a great diversity of information, and real-time processing is readily available. Technologically, the stage is set for pairing CDS with EHRs to further drive high-quality, efficient care—with many hospitals and health systems beginning to reap significant benefits.

Point-of-Care Advice As EHRs replace paper charting with electronic charting, they create potential for computerized uses of electronic patient information. But EHRs themselves don’t significantly process the data; they simply record and report the information put into them. The data stored in EHRs can contain a good deal of information that is less clinically relevant than other information. The CDS functions to process that information to great effect. CDS platforms typically perform much of their function by running unseen in the background of an EHR. The most advanced systems read, capture, and interpret all of a patient’s data—both structured and unstructured—without disrupting a clinician’s workflow. They clean up this data so that information is accurate, zero in on clinically important data, and compare that data to best-practice guidelines. The healthcare organization itself writes those guidelines, emanating from state or federal authorities or professional organizations. As the CDS analyzes the information in the patient records against best practices, it alerts the practitioner operating the EHR when the data being recorded indicates a significant deviation. It typically also indicates, in real-time, what constitutes a departure from best practices and suggests an aligned course of action. The practitioner then has the option to re-evaluate what’s being done. The decision, of course, remains with the clinician; the value lies in having point-of-care advice given in accordance with the healthcare organization’s standards.

Minimizing Harm By identifying in real-time critical information in the chart that would otherwise be overlooked, the CDS enhances the value, for example, of pharmacy systems that minimize drug-to-drug interactions. Where the unaided EHR would simply record the prescription, the CDS issues an alert when the prescribed drug will JUNE 2016

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interact improperly with another drug the patient is already taking. It then issues an alert at the point at which the problem first occurs—with the writing of the second prescription. CDS systems are increasingly effective at monitoring a wealth of clinical details to enforce patient safety. In the case of critically ill patients, CDS is a safety net, identifying potential deviations from best practices that could cause significant harm.

To Admit or Not Admit Many best practices for patient safety are promoted by mandated guidelines with which providers must demonstrate compliance. A properly and dynamically updated CDS system can assume authority for making sure that the latest guidelines are being adhered to, without clinicians having to be fully aware of those guidelines as soon as they are issued. It can also make sure that all clinicians throughout the enterprise are in compliance. For example, CMS provides guidelines concerning which procedures must be performed inpatient and which must be performed outpatient. Without a CDS, every physician must memorize those guidelines. A CDS can immediately advise the clinician to admit when a necessary procedure must be inpatient.

CDS Intelligence CDS systems add further value by streamlining care processes, the result of comparing all details of a patient’s care in ways that aren’t practical for individual practitioners to do themselves. Just as these CDS systems can immediately identify potential drug-to-drug interactions at the moment of prescription, they can also identify duplicate procedures and tests, along with those that appear to be unnecessary according to best practices. Without that additional intelligence, the practitioner often wouldn’t have the information to keep care optimally streamlined and efficient.

Omission, Commission Errors While much of CDS value-add comes from helping to avoid errors and reduce waste, these systems can also advise clinical steps that may otherwise be overlooked. If best practice indicates the immediate ordering of appropriate tests when a patient admits with signs of sepsis, for example, the CDS can assist in assuring that the tests are ordered at the earliest appropriate moment.

Real Results Today The Froedtert & Medical College of Wisconsin health network (Froedtert & MCW) has used a CDS platform since late 2014 to improve its imaging safety

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and utilization, among other services. Froedtert & MCW’s emergency departments, which treat as many as 104,629 patients each year, generate the most information on CDS impact. Since implementation, the CDS system has tracked the total monthly number of prompts issued and the average ratio of prompt compliance to noncompliance. Tracking during the initial use period showed a steady increase of up to 90% in average rate of compliance, along with a corresponding decrease in prompts. As alignment with imaging best practices remains high, patient safety has also improved with the CDS system’s redirection of orders for contraindicated tests, resulting in significant improvements in both the efficiency and safety of Froedtert & MCW imaging services and its patients.

Unlocking Digital Value In the future, it’s likely that EHRs and CDS will merge into a single, unified platform. It’s also likely that interoperability will assist in extending CDS value across entire care teams in multiple locations, regardless of variations in EHRs in use at those locations. The coming upgrade or replacement of Health Level 7 International (HL7) interface standards will assist in enabling uniform communication from one EHR to another and in providing immediate CDS feedback in real-time across them. Professional organizations such

as the American College of Radiology and American College of Cardiology will continue to develop treatment protocols and best-practice guidelines, and as their libraries grow, they will add tremendous value to the knowledge bases of CDS systems. Still, CDS is unquestionably delivering real value today by enabling health systems to streamline processes, improve patient safety, save time, and reduce costs. They are already enhancing the IT value made possible by the rise in EHRs, unlocking the value of digitized patient health information.

References

1. D. Heisey-Grove and V. Patel. 2014. Physician Motivations for Adoption of Electronic Health Records. ONC Data Brief, no. 21. December 2014. Office of the National Coordinator for Health Information Technology, U.S. Department of Health and Human Services. Accessed April 20, 2016 at www.healthit.gov/sites/default/files/oncdatabrief-physician-ehr-adoptionmotivators-2014.pdf. 2. F. Cassera, S. J. Davidson, S. Haberman, A. Strongwater, A. C. Sullivan, et al. 2013. Maimonides Medical Center Makes a Quantum Leap with Advanced Computerized Patient Record Technology. Presentation for the Health Information Management Systems Society, February 12, 2003 at the San Diego Convention Center, San Diego, CA. Accessed April 20, 2016 at www.providersedge.com/ehdocs/ehr_articles/Maimonides_ Med_Center_Makes_Quantum_Leap_with_Advanced_CPR_ Technology.pdf.

Allan Strongwater, M.D., is senior vice president, medical informatics, at medCPU.

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Stretch Your EHR Investment