CMIO Summit: Levick says CDS must be clear for success
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BOSTON – A key tool to ensuring a successful clinical decision support (CDS) program is minding the “continuum of intrusion,” said Donald L. Levick, MD, MBA, medical director of clinical informatics at Lehigh Valley Health Network (LVHN) in Allentown, Pa., at the CMIO Summit Clinical IT Leadership Forum on June 10.

The continuum is a concept Levick developed as a way to describe the relationship between an alert-based CDS system and the willingness of a clinician to adhere to the system. Levick noted that the continuum begins with an order set, continues to simple interventions and ends in the ultimate intrusion in a clinician’s workflow: the hard stop. According to Levick, clinicians must first get used to lower levels of intrusiveness before upgrading to higher levels. “What’s the impact on workflow?” is a question CMIOs should ask when thinking about alert obtrusiveness.

On the whole, CDS should be used as a strategic tool for achieving an organization’s priority care delivery objectives, according to Levick’s presentation “Clinical Decision Support: Where to Start?” These objectives are driven by internal needs such as medical error reductions as well as external forces such as meaningful use regulations.

CDS, as defined by Levick for the purposes of the lecture, is a process for improving health-related decisions and actions with pertinent, organized clinical knowledge and patient information.

According to Levick’s presentation, “information delivered can include a mixture of general clinical knowledge and intelligently processed patient data." There is an academic argument about what clinical decision support can be, said Levick citing that it could mean researching clinical information in a book at a library or pop-ups based on a patient’s chart.

“It’s important to think about [the intiative's] direction and priorities and what direction the organization is going when designing CDS interventions ... If you think [that direction should be in one place] and the organizational priorities [are in another], you’re not going to get support, people, resources or the money to make this happen,” said Levick. “So you have to align your CDS program with interventions [that are] important for the organization you’re in.”

Start with the enterprise alignment of quality and safety priorities and then drill down to smaller goals, added Levick. “Leadership at all levels must understand and support the efforts [and a CDS program should also include a] high level understanding of the ‘Five Rights.’”

For meaningful use, CDS has to include specific patient-related information to offer diagnostic or treatment options to the provider within its logic. Levick noted that in the meaningful use rule, the ability to track compliance is needed to adhere to the rule. For example, with soft stops there are workarounds where a clinician can continue working past an alert and there needs to be a way to track clinician behavior to adhere to the meaningful use rule.

As an organization begins to become more intrusive to a physician’s workflow, there must be champions at all levels for the CDS initiative so when physicians start to complain, there is a network of supporters.

Levick warned that CDS does not make a policy. “Once people get a whiff of what CDS can do, they want it to solve everything,” he said, adding that there are clear limitations to CDS interventions. “It’s important to know the strengths of your program and limitations and draw some boundaries around that. Part of the [CMIO] role is understanding those boundaries.”

In addition to the continuum of intrusion, Levick shared some best practices for ensuring a successful CDS program:

  • The value of the CDS program to the organization must be consistently and continually communicated at all levels;
  • Successful CDS programs implement interventions with the stakeholders, and not to the stakeholders;
  • Think about the impact on workflow and screen response time;
  • Close monitoring of all CDS must occur regularly to ensure validity; and
  • Be prepared to deal with resistors and detractors, including the ability to answer to negative articles in the literature.
As a successful example at LVHN, thanks to CPOE soft alerts and comprehensive communication, brain natriuretic peptide (BNP) test ordering fell from about 1,400 ordered in January 2009 to about 500 in November 2009.

“We couldn't have done this five years ago. There's an evolution of the medical staff users as they acclimate to the system and as the world changes and people are more accepting of evidence-based medicine and clinical standards," concluded Levick. "One of the caveats is, if you're going give clinicians direction, it better be accurate, agreed upon, monitored and updated."

The lecture was sponsored by Wolters Kluwer Health and UpToDate.