Improving Safety and Utilization

IMAGING/RADIATION

Improving Safety and Utilization

IMPLEMENTATION

Leveraging clinical decision support to close gaps in the care continuum By Jeff Rehm

F

Jeff Rehm is executive director, Imaging Services, Froedtert & the Medical College of Wisconsin health network.

or more than a year, Froedtert and the Medical College of Wisconsin (FroedtertMCW) health network has used a clinical decision support (CDS) platform to improve the safety and utilization of imaging services. With consistent monitoring, the system has been highly successful, thanks to more uniform adherence to medical imaging best practices.

The solution succeeds, in part, by closing information gaps in the care continuum and presenting clinicians with information of which they might otherwise be unaware. This includes closing care information gaps over time, as the system can advise when a patient has not been fully prepped for a scheduled test or that a test should be ordered. It also includes closing gaps across care teams; when a test is ordered, the CDS solution advises a clinician based on best practices and most recent information, no matter who entered the information.

In late 2014, FroedtertMCW implemented medCPU’s Radiology Advisor, a CDS platform that interprets all data from a hospital-wide electronic medical record (EMR), including free text such as progress notes and clinical indications, along with all interfaces throughout the organization for orders, results and admission, discharge and transfer (ADT) system. This gives the platform a complete view of the patient’s clinical condition and history, ensuring all considerations are accounted for when ordering imaging.

FroedtertMCW clinicians order imaging under the watch of the Advisor, which runs on top of the health system’s EMR. There are no “hard stop” alerts; clinicians perform within their normal workflows, and the Advisor issues an alert when it detects a deviation from best practices.

There is also no interference with established documentation processes. The CDS platform’s ability to interpret unstructured EMR information eliminates the need to force discrete drop-downs, leaving clinicians free to document according to their preferences. The system screen-reads free text as it is recorded to support fully informed, real-time alerts.

RESULTS TO DATE: TRENDS

FroedtertMCW tracks the total number of cases impacted by CDS prompts each month, along with the total number of prompts issued and the average ratio of prompt compliance to non-compliance. After the first few weeks of initial use, tracking revealed steady decreases in both the number of cases impacted per month and number of prompts, while the average rate of compliance increased up to 90%—all strong indicators of swift alignment with best practices.

A sudden spike in prompts coincided

The CDS platform is the only new system in memory that did not generate negative feedback; in fact, it generated little feedback period, reflecting the system’s intuitiveness and unobtrusiveness. www.advanceweb.com/executiveinsight I E X E C U T I V E I N S I G H T I 25

IMAGING/RADIATION with a cycle of new residents and faculty entering the academic environment. However, quick improvements followed the spike.

AREAS OF IMPACT

FroedtertMCW’s high-volume emergency departments (EDs), with as many as 60,000 patient visits per year, are its largest source of data regarding CDS usage. Within EDs, the most pronounced gains from CDS occurred in safety, utilization and efficiency. Safety and utilization improvements resulted from ordering and performing the right tests the first time, and efficiency improved as the radiology department spent less time changing orders.

Patient safety has especially improved with the CDS system’s redirection of orders for contraindicated tests, as the system readily spots patient deficiencies that could result in tests possibly harming the patient. In a memorable example, an MRI was ordered for an elderly patient admitted to the ED less than two weeks after receiving a pacemaker implant. Though the implant was documented in the EMR as a procedural note, it was not entered into a discrete field and was therefore overlooked by the clinician ordering the MRI. The CDS system accounted for that important detail and issued an alert, and the MRI order was immediately canceled.

Similar increases occurred in efficiency, for example, with the system issuing prompts to ensure patients with low glomerular filtration rate (GFR) levels are properly hydrated before certain tests.

With the system, clinicians are better able to ensure patient hydration and avoid radiology having to reschedule after discovering the need for hydration when a test is about to begin.

CLINICAL STAFF ACCEPTANCE

In addition to its high effectiveness, the CDS platform has been easy to roll out and was met with immediate acceptance among clinical staff. Initial training required nothing more than clinicians watching a five-minute video. In fact, the system has proven sufficiently intuitive, with no need for subsequent training. New users invariably understand the prompts clearly and almost immediately.

When FroedtertMCW leaders heard of the CDS system, there was much skepticism due to a long history of IT solution implementations. The CDS platform is the only new system in memory that did not generate negative feedback; in fact, it generated little feedback period, reflecting the system’s intuitiveness and unobtrusiveness. After fully implementing the CDS system’s radiology module, FroedtertMCW acquired five additional modules and is in the process of growing its library of modules in various clinical specialties.

ON THE WEB The focus on clinical quality and appropriate use of imaging will ultimately come down to utilization and access to information driving the decision to proceed with a particular procedure. Read “Enterprise Wide Success” at www.advanceweb.com/executiveinsight

STAFFING Continued from page 20 ferent background with distinct expertise and training, co-management of patients in a training setting is ideal for learning to optimize patient care. It also offers opportunities for residents to share knowledge in an open learning environment.

The pharmacy residents shared clinical resources and online tools for calculating creatinine clearance. One pharmacy resident demonstrated how to adjust the calculation for obese patients. Another offered medications to avoid in elderly patients by highlighting the Beer’s list recommendations. The nurse practitioner resident discussed changes to recent lipid guidelines, and after discussing the case with another provider in clinic, offered recommendations based on practice standards and updated guidelines. The NP resident investigated a question about uric acid levels, and a discussion was initiated by referencing resources and pairing recommendations with patient-specific characteristics.

Collaborative learning through interprofessional co-management of patient care is ideal because questions are live, real and productive.

By working together, residents from distinct professional backgrounds are able to better understand each other’s expertise and gain clarity on how to leverage those skills in practice. Finally, after the intentional pairing exercise was complete, residents were familiar and comfortable with each other, which offered easy opportunity to ask questions ad hoc during a clinic day through email, instant message or paging.

This familiarity and trust-building are principal predictors of interprofessional collaboration.5 CRITICAL TO HEALTH OUTCOMES

In a healthcare system that is increasingly complex and short on primary care providers, collaboration among professions is critical. A focus on team-based care should begin during professional education so that providers and pharmacists understand each other’s roles and gain appreciation for each other’s expertise.

Complex patients with chronic illnesses require more attention to medication management and education. Often, patient education needs to be provided in more than one way. Co-managed care involving a provider and pharmacist may improve patient understanding and retention. Team-based care enhances communication among all members of the team, including the patient. Relationships among providers of different professions create learning opportunities that are unique and useful. Each brings distinct perspectives and background to the care provided.

References

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1. Brooks K. The IHI Triple Aim. Available at http://www.ihi.org/engage/initiatives/ TripleAim/Pages/default.aspx 2. Wynia MK, et al. Challenges at the intersection of team-based and patient-centered health care: Insights from an IOM working group. JAMA. 2012;308(13):1327-1328.

3. Nurse Practitioners and the Future of Primary Care. Available at http://dhhs. ne.gov/publichealth/licensure/documents/FutureOfPrimaryCare.pdf 4. Schnur ES, et al. PCMHs, ACOs, and medication management: Lessons learned from early research partnerships. J Managed Care Pharm. 2014;20(2):201-2015.

5. Snyder ME, et al. Exploring successful community pharmacist-physician collaborative working relationships using mixed methods. Res Social Admin Pharm.

2010;6(4):307-323.

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