The decision to implement clinical decision support (CDS) may be a tricky one. Once you've committed to spending the time, money and resources on getting it up and running, you want to be certain it will fly within the scope of what your healthcare system can offer. CDS is all about providing a template or launching pad on which physicians can base their orders, making healthcare safer, more efficient and more effective. It is none of those things if the CDS a hospital implements isn't fine-tuned.
Optimizing CDS for a healthcare network is far more challenging than simply installing some software and pushing some buttons. Implementing a quality CDS framework requires testing, outreach and a constant focus on what options each provider has.
Hemant Gupta, MD, CMIO at Lourdes Hospital in Binghamton, N.Y., which is part of Ascension Health, spoke candidly about his organization's adoption, implementation and optimization of a CDS system. Gupta says they started by adopting a nationwide order set from Zynx and then "reviewed those order sets for best practices against the evidence they provided and made an Ascension health order set." Gupta stresses that with today's massive amount of order set data, to succeed in implementing CDS, the health system must focus specifically on its needs.
1. Customize for commonly used local tests and frequently treated conditions. Spoiler alert: Distillation is the buzzword in making CDS a workable part of a healthcare organization. In Ascension's case, they boiled down Zynx's order set to a more manageable one, then pushed out a localized version to each of its hospitals. If a procedure isn't available at a certain hospital, or if lab results take months to come back for a certain test, it doesn't make sense to include it in the order set. Gupta says that making the CDS system work in Ascension's many hospitals comes down to "pruning to what is really useful and flagging the most critical things to doctors and nurses who are using the system." Gupta likens this to going to a dealership and asking for a car with all of the features – most people will work back from there to end up at something with only the features they really need. "That requires the local regional institution to exercise some judgment on what to show," says Gupta.
2. Refine list of medications locally used to become more user-friendly. "When it's redundant, we don't need it." Gupta says that one of the main problems that a CDS system can cause is by being overly-complicated. When certain medicines aren't available or even effective in one region, striking them from the more commonly-used lists can streamline a process that quickly becomes clogged with scads of non-relevant and time wasting information. "It's coming down to pruning to what is really useful and flagging the most critical things to doctors and nurses who are using the system," says Gupta. In essence, this statement sums up the process of making a CDS system fly: Refine, prune, and tighten until the system delivers only the most relevant and useful results. "The longer the order set, the less people actually find it useful. It just makes it less functional and less efficient," says Gupta.
4. Work feedback into the process. "It [has] helped me strengthen the system," says Gupta, about receiving and implementing feedback from users. "You get them using it and excited about it." When physicians are brought into the program and asked to evaluate the order sets that a CDS provides, and are encouraged to weigh in, Gupta says it makes them more accountable and more eager to participate in the system. Additionally, because doctors and nurses are on the frontline, their experiences are invaluable in improving order sets and making the CDS better overall. "Now you're talking about a true evolution," says Gupta.
Problems still faced
CDS has come a long way, and employing all of the above techniques to fine-tune a CDS system will help bring even more usefulness to it, but that doesn't mean there isn't still room for improvement. "The more you create, the more you have to maintain," says Gupta, who admits that maintaining the disparate elements that feed into a CDS can be a headache at times. "You don't create your order sets once and then not review it," says Gupta, reminding that no system stays fully operable forever, and that in order to keep a CDS at top performance, it requires a healthy amount of regular maintenance, input, and response to changes.
Getting the buy-in from members of an organization can be a rough spot, too. Some people "feel that order sets are their enemy," says Gupta. "They see it as cookbook medicine." He takes issue with that view, and likens it to "more of a launching pad" that gives practitioners the starting point they need to make informed clinical decisions. He says the best response to these perceived issues is to sell them on their power as efficiency enhancers in the examining room. Asks Gupta: "If you could spend more time with the patient, if you could spend less time trying to calculate something," wouldn't you want to? "If I give [physicians] the safest choices," he adds, "they can make the best evidence based choices for the patient."
