AMDIS 2014: Two approaches to CDS

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OJAI, CALIF.—There is an affordability crisis in healthcare, and clinical decision support (CDS) can play a role in mitigating the problem, said Scott Weingarten, MD, MPH, senior vice president and chief clinical transformation officer at Cedars-Sinai Health System in Los Angeles, during a session on CDS June 18 at the annual AMDIS Physician-Computer Connection Symposium.

In the case of Cedars-Sinai, said Weingarten, not only could a more aggressive use of CDS result in significant savings, while still delivering a high quality of care, there was also a realization that the organization “wasn’t where we needed to be” to succeed in a new healthcare environment.

In fact, an opportunity analysis performed by an outside company for Cedars-Sinai looked at the question of “how prepared are we to go at risk for Medicare Advantage contracts, for commercial HMO contracts,” Weingarten said. “This new world of healthcare where you see the dual eligible Medicaid and Medicare patients who are migrating to a managed care framework in the Los Angeles area.”

The analysis found substantial opportunities to reduce Cedar-Sinai’s per-member, per-month costs and succeed in this new world of healthcare, and still deliver excellent quality of care, Weingarten said. “[The question was] how do we go about addressing these opportunities—what do we do next? So we thought we needed a new approach to clinical decision support.”

Cedars-Sinai asked itself whether it could implement new forms of population health CDS and do it an expedited rate, considering that the organization had been producing just one or two new alerts a month.

“We asked the question . . . what’s better—An error of omission, going too slow, or an error of commission, going too fast?” Weingarten said. He said that an analogous question can be asked in the game of baseball, asking whether it’s better to swing and miss and strikeout, or not swing and get called out on strikes.

The point is that if a batter swings there’s always a chance he’ll connect, and maybe even hit a home run, he said. “So we decided to be less cautious.”

Cedars-Sinai latched on to Choosing Wisely, an initiative of the American Board of Internal Medicine Foundation in which participating medical specialties and organizations have produced lists—including evidence-based recommendations—on appropriate care. Cedars-Sinai embedded the Choosing Wisely recommendations into its EHR, and significantly increased its pace of adding new alerts by 50-fold.

Though the process of embedding the recommendations went live only last fall, the impact has been profound, Weingarten said.

For example, by using the Choosing Wisely recommendations Cedars-Sinai was able to identify a urologist who wasn’t following the American Urological Association’s recommendation that it is unnecessary to order a renal ultrasound if a patient only has a benign prostatic hypertrophy. In another case it was discovered that a physician was ordering numerous tests for Lyme disease despite the fact that Lyme disease is almost non-existent in Los Angeles County.

According to Weingarten, Cedars-Sinai now sees about 320 Choosing Wisely alerts a day. Despite that number, physician complaints have been minimal and they are paying attention to the alerts, with a number of physicians canceling orders immediately after alerts have been fired.

Just from canceled orders alone, Cedars-Sinai is estimating it will save $1.83 million annually, Weingarten said, adding that there is untold amount of money being saved from the “education effect” of training doctors not to order certain tests in the first place.

And up until now, Weingarten said, Cedars-Sinai hadn’t gone after any new Medicare Advantage contracts, but because of efforts like this “we hope to get one or two new . . . contracts.”

At St. Francis Medical Center in Lynwood, Calif., CMIO Judi Binderman, MD, suggested that her experience with CDS is at the “other end of the spectrum” from that of Cedars-Sinai, which has “great technology” to which you can add on and bolt on. “Contrary to Scott’s example, I didn’t have a lot of options,” she said.

For one thing St. Francis had a QuadraMed EHR, which was something she had to learn since she was used to working with Cerner or Epic. And she was “a little surprised” to find out that like Epic, QuadraMed was multi-platform based, but not as integrated, and that it had minimal dynamic functional alert capabilities. Furthermore, she said, alerts occurred at the back end of processing, which was disruptive to clinical workflow. She had to go back to the basics, she said.

And that was one lesson learned, she said—that CDS comes in a variety of flavors, and getting to the pointing of making CDS work “was real hard.”

“It has taken more multi-disciplinary meetings and process and data mapping that I even thought I would have to do for a system that was already implemented,” she said.

It was also difficult getting physicians and nurses to understand the limits of what she going to be able to accomplish considering that many of her clinicians have practiced at other hospitals and are used to working with Epic and Cerner systems with all their bells and whistles.

Still, as she puts it, St. Francis now has a tool that works and that while the process is not at an end, “and it’s not even the beginning of the end, perhaps it is the end of the beginning.”