medCPU VTE Case Study

The Academy The Health Management Academy

The Academy Innovation Series:

Clinical Decision Support Improving VTE Prophylaxis Compliance

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Authors James (Jay) Flounlacker, M.B.A. Senior Vice President The Health Management Academy Charles Watts, M.D. Executive-in-Residence The Health Management Academy

The Academy Innovation Series: Clinical Decision Support The Health Management Academy, in partnership with medCPU, created the Center for Advanced Solutions in Healthcare (the Solutions Center). The Solutions Center will accelerate the adoption of innovative clinical decision support solutions designed to increase quality of care and improve clinical, financial, and operational performance at the point-of-care.

The Academy interviewed hospitals and health systems to document use of clinical decision support software tools in multiple clinical settings for various diagnoses. This case study reports on the use medCPU tools at East Jefferson General Hospital (EJGH) in Metairie, LA to improve quality and safety around thromboembolic event risk and Venous Thromboembolism (VTE) prophylaxis.

The project was undertaken by East Jefferson General Hospital in conjunction with medCPU to design a point-ofcare (POC) decision support solution to improve compliance with order sets and protocols for VTE prophylaxis.

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Contents Authors

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The Academy Innovation Series: Clinical Decision Support

2

Key Findings

4

Study Introduction: Using Point-of-Care Solutions to Enhance the Treatment Process

4

An Identified Need: First Steps to Improve Compliance with Appropriate VTE Prophylaxis

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The Next Step: Selection and Implementation of Point-of-Care Support for Appropriate VTE Prophylaxis

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Point-of-Care Decision Support: How the Solution Worked at Golive

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Evolution of the Process: Measuring the Impact

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The Importance of the Audit Feedback Loop & the Role of the Quality Nurse

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Committed Leadership with a Well-defined Objective

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Creating a Learning System and an Audit Feedback Loop

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An Adaptable POC Solution

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Endnotes

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Suggested Readings

10

The Health Management Academy

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medCPU

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Clinical Decision Support

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Key Findings Success

with a point-of-care (POC) VTE prophylaxis solution requires a committed leadership team and a well-identified process for selection and implementation of an effective POC technology.

EJGH

created a continuous learning system, where the process for POC VTE prophylaxis assessment was frequently evaluated and modified based on experience and learnings from users, leading to progressive overall performance improvements.

Success

of the project was in large part due to the creation of an audit feedback loop, where clinicians received both passive and active prompts to initiate VTE prophylaxis for appropriate candidates.

Clinicians

were continually engaged in the development and selection of protocols for the POC decision support solution. This assured prior knowledge and acceptance of the protocols, resulting in a smoother implementation process with greater clinical buy-in.

Study Introduction: Using Point-of-Care Solutions to Enhance the Treatment Process The healthcare environment is adapting to increased pressure to improve performance and reduce costs as both consumers and providers are taking on greater risk for the cost of care. This case study explores how one leading organization, East Jefferson General Hospital (EJGH), has deployed an innovative clinical decision support solution designed to improve compliance with agreed upon protocols for the prevention of Venous Thromboembolism (VTE). VTE risk (i.e., deep vein thrombosis (DVT) and pulmonary embolism (PE)) is high for hospitalized medical and surgical patients and while VTE prophylaxis has been shown to reduce risk of VTE, the percentage of patients receiving VTE prophylaxis remains relatively low.1-18 EJGH’s experience with the use of decision support software tools and subsequent performance improvement in increasing compliance with VTE prophylaxis protocols highlight the importance of strong leadership, use of a well-defined process, and the creation of an audit feedback loop to encourage and support compliance. The confluence of these characteristics led to the creation of a high-functioning “continuous learning system” that improves awareness and appropriate use of VTE prophylaxis.

An Identified Need: First Steps to Improve Compliance with Appropriate VTE Prophylaxis Approximately ten years ago, the EJGH executive leadership team recognized the need for solutions to improve appropriate VTE prophylaxis for inpatients with a risk of VTE. Prior to the installation of the Cerner Electronic Medical Record (EMR), the first phase of which was implemented in 2006, efforts to improve the use of evidence based VTE prophylaxis through Premier’s QUEST Quality Initiative included widespread discussion of the importance of VTE prophylaxis for inpatients, collaborative review and selection of paper based protocols and order sets for specific patient populations, and subsequent elective use of these protocols and order sets, without reminders or audits of individual compliance with feedback. Raymond DeCorte, M.D., the Chief Medical Officer for EJGH commented that, “as a medical staff, we know we do good work, but we need to validate that with data”. This effort yielded marginal improvements, and measures of the level of compliance continued to be low, placing their organization in the 59th percentile among peers. Additionally, the outdated paper-based processes were associated with a low level of awareness for institutional and individual physician use of appropriate VTE QUALITY IMPROVEMENT prophylaxis, prompting leadership to consider alternative solutions.

“As a medical staff, we know we do good work, but we need to validate that with data.”

The subsequent approach and program to improve VTE prophylaxis compliance was part of the implementation of the Cerner EMR computerized provider order entry (CPOE) system. The Order Set Review Committee, worked with physician groups to create hundreds of standardized CPOE order sets for use in the Cerner EMR. This process was collaborative and directly – Raymond DeCorte, M.D., Chief Medical Officer

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involved clinicians and clinical leadership actively reviewing evidence based practice guidelines and working with Cerner to format and integrate the order sets into the CPOE system. The jointly developed protocols and order sets included specific order sets for the appropriate use of VTE prophylaxis, which could be accessed on the EMR during CPOE and added to the patient’s orders, if the physician chose to do so. However, this system did not provide prompts to order or consider VTE prophylaxis, reminders to do so if VTE prophylaxis had not been ordered, or any other intervention during the episode of care. Audit and reporting of frequency of use of VTE prophylaxis and compliance with the protocol was used for quality review, only available retrospectively, and as a result had no impact at the point-of-care. Post-implementation measurement of VTE prophylaxis showed no improvement in protocol compliance without POC reinforcement. The leadership team deemed it necessary to make further changes in POC support that would improve compliance during CPOE.

The Next Step: Selection and Implementation of Point-of-Care Support for Appropriate VTE Prophylaxis East Jefferson General Hospital required a solution that would apply the collaboratively developed best-practice VTE protocols while fitting into the existing clinical workflow to increase clinical recognition of need for VTE prophylaxis at the point-of-care and order entry. The goal of the new solution would be to create a system that identified appropriate candidates for VTE prophylaxis at POC, document whether or not the candidate received VTE prophylaxis, and provide documentation in the chart when candidates for VTE prophylaxis did not receive it. Two options were considered: (1) implement a ‘hard stop’ in the Cerner EMR for ordering VTE prophylaxis, or (2) identify a POC solution to provide clinical decision support to the physician in real-time during order entry.

Given EJGH’s collaborative, learning culture, a solution that provided support, education, and guidance was deemed the preferable option. In addition, when considering the effort involved in administering a ‘hard stop’ solution, Christopher Barrilleaux, M.D., EJGH’s Chief Medical Information Officer at the time, determined that an automated tool that presented information to the physician in real-time would require less ongoing effort to COST-BENEFIT ANALYSIS manage, and this became part of the cost-benefit “Looking at the staffing issues, medCPU’s analysis and justification for implementing a POC automated, POC clinical decision support tool clinical decision support solution. was a good fit to present data in real-time to physicians.”

The EJGH leadership team identified potential – Christopher Barrilleaux, M.D., then Chief Medical POC decision support solutions for evaluation.

Information Officer Solution candidates provided demonstrations in summer and fall of 2011 to the EJGH Information Management Systems Committee, comprised of senior leaders in clinical, quality, finance, and information technology functions. The committee is responsible for the selection of the solution as well as funding for all information technology applications via an annual system-wide prioritized budgeting process. In early 2012, after narrowing down the selection to two potential candidates, the committee elected to implement the medCPU Advisor tool at the point-of-care. Because the solution is ingrained into clinical, quality, IT, and administrative processes, the fully vetted selection process solidified leadership support from all major stakeholders and user groups for the solution, and was critical to the overall success of the tool.

The foundation for the new solution consisted of the existing order sets that had been collaboratively developed for the Cerner EMR and CPOE implementation. While these order sets were for all clinical pathways, many of them included protocols for appropriate ordering of VTE prophylaxis. The medCPU Advisor solution was configured to apply EJGH’s VTE prophylaxis order sets and protocols in real-time at the time of order entry. The medCPU Advisor continuously gathers clinical data and free text notes recorded in the patient’s medical record and compares the data to EJGH’s VTE protocols to determine whether VTE prophylaxis is recommended.

The installation of the medCPU Advisor solution was completed in mid-2012 with relatively minimal disruption to workflows for clinical and IT professionals. Clinical leaders provided demonstrations of the new product prior to go-live, and involvement from clinicians during the development phase led to a smooth transition to the product during implementation.

Clinical Decision Support

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The medCPU Advisor solution was the first application integrated into EJGH’s Cerner EMR. The implementation went well, and required limited effort to integrate with the EMR; over time some communication and process challenges were identified. Ongoing upgrades and system maintenance require a closer working relationship between the in-house Cerner team and medCPU managers than was initially anticipated, as changes in the Cerner EMR can cause gaps in the data collection used to populate the medCPU system. Currently, both Cerner and medCPU provide weekly reports on infrastructure changes so that either party may prepare and test their systems during and after changes.

Point-of-Care Decision Support: How the Solution Worked at Golive The medCPU Advisor tool is seen by clinicians when they are in a patient’s EMR case file, with the first view typically occurring during the patient’s first day at EJGH. While entering the patient’s history, physical, and current and past medical history, the decision support tool determines patient candidacy for VTE prophylaxis by comparing the data in the EMR, inclusive of physician notes, in real-time to EJGH’s VTE protocols. The medCPU Advisor solution continuously monitors updates to the patient’s clinical history, and provides alerts each time a clinician accesses the patient’s record through the EMR. Prior to the completion of CPOE, the physician will receive a passive “Medical Alert” from the medCPU Advisor stating a recommendation for VTE prophylaxis for any candidate deemed in need of treatment where treatment has not been ordered. The physician has the option to update the order to include VTE prophylaxis, or enter additional clinical documentation on why VTE prophylaxis is not recommended. Alternatively, the physician may “Close” the alert for that session, or indicate that they would like to be reminded later before they exit CPOE by selecting “Remind Later”. The physician can also “Discard” the alert, thereby terminating any future alerts regarding VTE prophylaxis for this patient.

At 8:00am on the patient’s second day (after first midnight), if an action had not been taken on a patient deemed a candidate for VTE prophylaxis, an additional passive alert is sent to the physician and floor nurse with a request to order VTE prophylaxis, or to provide documentation why treatment should not be provided. A final alert is issued to clinicians at 3:00pm for any patient still deemed a candidate for VTE Prophylaxis for whom orders have not been recorded. EJGH Leadership believed that the POC alerts, coupled with morning and afternoon ‘reminders’ would provide sufficient support for clinicians to improve compliance with VTE prophylaxis protocols.

Evolution of the Process: Measuring the Impact The 2012 deployment of the medCPU Advisor solution improved compliance with VTE Prophylaxis. Prior to the golive of the medCPU product, EGJH was approximately 50-60% compliant with all cases with a medical candidacy for VTE prophylaxis. During the first phase of medCPU implementation that included the addition of passive alerts to physicians and nurses, the compliance rate rose, and by 2013 over 70% of cases with candidacy for BEHAVIORAL CHANGE VTE prophylaxis had received the recommended “We thought physicians’ behavior change would care through the first year. Senior leadership be easy, but it turned out to be harder than we determined that while this positive change was anticipated.” caused by passive prompts at the point-of-care, – Jody Torres, RN, Director of Nursing Informatics further improvements could be realized.

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The Importance of the Audit Feedback Loop & the Role of the Quality Nurse Led by the quality nurse, the EJGH leadership team measured and analyzed results and conducted root cause analyses in 2013 and early 2014 to determine why VTE prophylaxis had not been ordered when the medCPU Advisor had alerted clinicians that the patient was a VTE prophylaxis candidate. The team identified several issues with the current process, including: Timing

of the alerts should be adjusted to better fit with clinician workflow

Nursing

staff, in particular the quality nurse, should be empowered to directly engage physicians

Medical

leadership should be more visibly engaged

In the second half of 2014, the Quality Council authorized adjustments to integrate the process more effectively with staff workflow and to provide additional active alerts. These changes included moving the initial alert on Day 2 from 8:00am to 6:00am, thereby giving clinicians the opportunity to receive the alert while conducting morning rounds. The second Day 2 alert was also moved from 3:00pm to 1:00pm to avoid conflict with nursing shift changes, allowing nurses more time to contact the physician regarding the indicated VTE prophylaxis. The recipients of both Day 2 alerts were updated to include the chief medical officer, chief nursing officer, and chief medical informatics officer, and the role of the quality nurse was expanded to provide active reinforcement for action to be taken by physicians and nurses for VTE prophylaxis candidates. The quality nurse would contact nursing staff after the 6:00am report and confirm their plan of action to contact and review the recommended VTE prophylaxis with the physician. For any patients that remained on the report at 1:00pm, the quality nurse would reach out directly to the physician to review the recommended VTE prophylaxis. Following these changes in mid-to-late 2014, compliance rates again rose rapidly, moving from approximately 75% compliance to over 90% within 36 hours of inpatient admittance by the end of 2014. As of summer 2015, monthly compliance rates are consistently above 99%. The cause for these improvements was the addition of active feedback via quality nurse communication, expansion of the reporting process to include key senior leaders, as well as the adjustment of the alert process to better sync with the current workflow of the nursing staff.

FIGURE 1. VTE-1 SCORE: VENUS THROMBOEMBOLISM PROPHYLAXIS 100.00%

100%

99.74%

95%

Compliance Rate

90% 89.87%

85%

91.45%

80% 77.76%

75% 70%

77.70%

70.47%

65% 60% 55%

55.00%

50%

Prior to Go-Live

2013

2014 Q1

2014 Q2

2014 Q3

2014 Q4

2015 Q1

2015 Q2

The sustained improvements and success of the decision support tool was in part dictated by the use of an audit feedback loop. This model provided physicians with a passive alert for POC support, as well as an additional safety net via the reports sent to the quality nurse, and subsequent active alerts via communication between nursing staff Clinical Decision Support

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INTERVENTION LEVELS19 A. Present information only B. Pop-up window that the selected intervention does not meet current guidelines C. Intervention that requires an active override to proceed D. Intervention that requires peer consultation before proceeding

and physicians. This multi-layered audit feedback loop provided passive and active alerts and reminders to ensure appropriate action was taken on behalf of the patient (administration of VTE prophylaxis or enhanced documentation).

A critical role in the audit feedback loop at EJGH is the quality nurse. The quality nurse acts as a safety net by providing reminders to physicians and nurses when an alert has not been acted upon.

The quality nurse is also the primary organizer of all open cases where there is a risk of VTE or where VTE prophylaxis is being administered, and provides daily summary reports to health system leaders on the recent activity around VTE prophylaxis, as well as how physicians are utilizing the decision support software product.

A recent article published in the Annals of Internal Medicine identified two solution design factors that correlate with the effectiveness of clinical decision support in improving appropriate use of VTE prophylaxis: characteristics of the intervention, and the use of audit and feedback.19 Interventions were characterized into different levels based upon whether they ranged from passive, informational only alerts that required no action, to a “hard stop” requiring the clinician to gain a second opinion before proceeding or to receive a reminder to ensure an appropriate protocol is being followed. EJGH’s initial VTE prophylaxis POC decision support solution was a “B-level” intervention, with a pop up window and passive reminders, which yielded positive results; however, enhancing the passive process with active follow up from the quality nurse, moved the intervention towards a “C-level” intervention, which delivered even greater VTE prophylaxis compliance improvement.

Conclusions & Key Takeaways With the use of a clinical decision support software tool, East Jefferson General Hospital was able to rapidly and sustainably improve compliance in a historically challenged clinical area. The success of the project was due to multiple factors, including: Committed

leadership;

Continuous

learning system with an audit feedback loop;

A

POC solution that can be adapted to fit the organization.

In the future, EJGH plans to use clinical decision support software tools for projects in additional clinical areas to improve performance at the point of care.

Committed Leadership with a Well-defined Objective The clinical leadership team identified a need and defined what required completion to meet their needs. With sustained leadership involvement throughout the duration of the process including solution development, tool selection, implementation, and refinement, the project was more likely to succeed.

Creating a Learning System and an Audit Feedback Loop The leadership team at East Jefferson General Hospital built a learning system that measured outcomes and focused on improving the process when desired outcomes were not achieved. The identification, building, and implementation of the medCPU decision support software tool engaged all affected parties to improve buy-in. Additionally, the design of the solution revamped a culture of learning and clinical excellence.

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Success, as measured by improved compliance, was largely predicated by the development of a complete audit feedback loop that provided physicians with both passive and active prompts for compliance with previously agreed upon protocols. A crucial role in the audit feedback loop model was the quality nurse, who managed all outstanding medCPU passive alerts for VTE prophylaxis or improved documentation. Additionally, the quality nurse issued active alerts to care-givers, thus creating a complete audit feedback loop. The use of this model ultimately drove compliance up over 99%.

An Adaptable POC Solution The decision support software solution went live with very few glitches. A major factor in the successful go-live was the ongoing engagement with clinical leaders and training provided for clinical staff. The ability of the medCPU solution to adapt and fit with EJGH’s protocols, applications, and workflows resulted in stronger buy-in and acceptance among clinical and administrative staff. The resulting high level of engagement in the process enabled the team to see results early-on, and created a team environment that led to future process improvements and increased compliance.

Endnotes 1

Amland RC, Dean BB, Yu HT, Ryan H, Orsund T, Hackman JL, Roberts SR. Computerized Clinical Decision Support to Prevent Venous Thromboembolism Among Hospitalized Patients: Proximal Outcomes from a Multiyear Quality Improvement Project. J Healthc Qual. 2015; 37(4):221-31.

2

Clagett GP, Reisch JS. Prevention of venous thromboembolism in general surgical patients. Results of metaanalysis.

Ann Surg. 1988; 208(2):227-40.

3

Collins R, Scrimgeour A, Yusuf S, Peto R. Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin. Overview of results of randomized trials in general, orthopedic, and urologic surgery. N Engl J Med 1988; 318(18):1162-73.

4

Leizorovicz A, Haugh MC, Chapuis FR, et al. Low molecular weight heparin in prevention of perioperative thrombosis. BMJ. 1992; 305:913-20.

5

Nurmohamed MT, Rosendaal FR, BĂźller HR, et al. Low-molecular-weight heparin versus standard heparin in general and orthopaedic surgery: a meta-analysis. Lancet. 1992; 340(8812):152-6.

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Kucher N, Tapson VF, Goldhaber SZ, DVT FREE Steering Committee. Risk factors associated with symptomatic pulmonary embolism in a large cohort of deep vein thrombosis patients. Thromb Haemost 2005; 93:494.

7

Cohen AT, Tapson VF, Bergmann JF, et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet 2008; 371:387.

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Kucher N, Leizorovicz A, Vaitkus PT, et al. Efficacy and safety of fixed low-dose dalteparin in preventing venous thromboembolism among obese or elderly hospitalized patients: a subgroup analysis of the PREVENT trial. Arch Intern Med. 2005; 165:341.

9

Rahme E, Dasgupta K, Burman M, et al. Postdischarge thromboprophylaxis and mortality risk after hip-or kneereplacement surgery. CMAJ. 2008; 178:1545.

10

Kahn SR, Panju A, Geerts W, et al. Multicenter evaluation of the use of venous thromboembolism prophylaxis in acutely ill medical patients in Canada. Thromb Res. 2007; 119:145.

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Tapson VF, Hyers TM, Waldo AL, et al. Antithrombotic therapy practices in US hospitals in an era of practice guidelines. Arch Intern Med. 2005; 165:1458.

Clinical Decision Support

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Muntz J. Duration of deep vein thrombosis prophylaxis in the surgical patient and its relation to quality issues.

Am J Surg. 2010; 200:413.

13

Anderson FA Jr, Zayaruzny M, Heit JA, et al. Estimated annual numbers of US acute-care hospital patients at risk for venous thromboembolism. Am J Hematol. 2007; 82:777.

14

Lindblad B, Eriksson A, Bergqvist D. Autopsy-verified pulmonary embolism in a surgical department: analysis of the period from 1951 to 1988. Br J Surg. 1991; 78:849.

15

Stein PD, Henry JW. Prevalence of acute pulmonary embolism among patients in a general hospital and at autopsy. Chest. 1995; 108:978.

16

Sandler DA, Martin JF. Autopsy proven pulmonary embolism in hospital patients: are we detecting enough deep vein thrombosis? J R Soc Med. 1989; 82:203.

17

Heit JA, Melton LJ 3rd, Lohse CM, et al. Incidence of venous thromboembolism in hospitalized patients vs community residents. Mayo Clin Proc. 2001; 76:1102.

18

Spyropoulos AC, Anderson FA Jr, Fitzgerald G, et al. Predictive and associative models to identify hospitalized medical patients at risk for VTE. Chest. 2011; 140:706.

19

Goldzweig CL, Orshansky G, Paige NM, Miake-Lye IM, Beroes JM, Ewing BA, Shekelle PG. Electronic Health Record-Based Interventions for Improving Appropriate Diagnostic Imaging. Ann Intern Med. 2015; 162(8):55765.

Suggested Readings Beeler PE, Bates DW, Hug BL. Clinical decision support systems. Swiss Med Wkly. 2014; 144: w14073.

Haut ER, Lau BD, Kraenzlin FS, Hobson DB, Kraus PS, Carolan HT, Haider AH, Holzmueller CG, Efron DT, Pronovost PJ, Streiff MB. Improved Prophylaxis and Decreased Rates of Preventable Harm With the Use of a Mandatory Computerized Clinical Decision Support Tool for Prophylaxis for Venous Thromboembolism in Trauma.

Arch Surg. 2012; 147(10):901-7.

Kahn SR, Morrison DR, Cohen JM, Emed J, Tagalakis V, Roussin A, Geerts W. Interventions for implementation of thromboprophylaxis in hospitalized medical and surgical patients as risk for venous thromboembolism. Cochrane Database of Systematic Reviews. 2013; 7.

Kucher N, Koo S, Quiroz R, Cooper JM, Paterno MD, Soukonnikov B, Goldhaber SZ. Electronic Alerts to Prevent Venous Thrombeombolism among Hospitalized Patients. N Engl J Med. 2005; 352(10):969-77.

Piazza G, Rosenbaum EJ, Rendergast W, Jacobson JO, Rendleton RC, McLaren GD, Elliot CG, Stevens SM, Patton WF, Dabbagh O, Paterno MD, Catapane E, Li Z, Goldhaber SZ. Physician Alerts to Prevent Symptomatic Venous Thromboembolism in Hospitalized Patients. Circulation. 2009; 119: 2196-2201.

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The Health Management Academy The Health Management Academy (The Academy) provides unique, peer-learning, complemented by highly-targeted research and advisory services, to executives of Leading Health Systems. These services enable health system and industry members to cultivate relationships, perspectives, and knowledge.

In 1998, The Academy created the first knowledge network exclusively focused on Leading Health Systems. This learning model, refined over 16 years of working side-by-side with members, combines peer learning (Executive Forums, Trustee Institute, Collaboratives), research (Health System, Consumer, Health Policy, Advisory), and leadership development (Leadership Programs and Fellowships).

medCPU medCPU delivers accurate real-time enterprise decision support software and services through its proprietary Advisor technology. medCPU captures the complete clinical picture from clinicians’ free-text notes, dictations, discharge summaries and structured documentation entered into any Electronic Medical Record (EMR), and analyzes it against a growing library of best-practice content, generating real-time precise prompts for best care consideration. medCPU’s founding multi-disciplinary team has been pioneering new clinical decision support for nearly 20 years, delivering intelligent error reduction software systems to hospitals across the United States. medCPU’s applications include clinical and compliance support solutions.

Click here to learn more

Clinical Decision Support

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