Clinical decision support (CDS) can produce impressive results in improving clinician workflow, reducing utilization and allowing easier access to evidence-based care for better patient outcomes. However, as with any endeavor that impacts a widespread enterprise, the effort is rife with challenges. Even years after implementation, facilities face obstacles such as optimizing alerts and managing liability concerns. CMIO hosted a CDS roundtable with physician leaders from facilities well along the CDS spectrum. They discussed implementation, ongoing challenges and their views on the future of CDS.
|Donald L. Levick, MD, MBA, CMIO Lehigh Valley Health Network, Allentown, Pa. Co-author of Improving Outcomes with Clinical Decision Support: An Implementer’s Guide, Second Edition; live on computerized physician order entry (CPOE) and clinical decision support (CDS) since 2001|
|Kenneth Ong, MD, MPH, CMIO, New York Hospital Queens, New York City, 2007 Spirit of HIMSS Award recipient, editor of the 2007 HIMSS Book of the Year, Medical Informatics: An Executive Primer, Edition 2.0; live on CPOE and CDS since 2006|
|Natalie Pageler, MD, Medical Director of CDS,
Lucile Packard Children’s Hospital, Palo Alto, Calif.;
live with CPOE and CDS since 2007
How was your CDS implementation experience?
LEVICK: When we first went live with computerized physician order entry (CPOE), U.S. penetration was pretty low and it was new to most people. One thing we did well was implement CDS in a very slow, deliberate manner. We started with the least intrusive interventions and then over time became more intrusive—a continuum of intrusion. Once the physicians start to acclimate to CPOE, see the alerts and work with order sets, you can get more aggressive with how much you steer them. As a result, we never endured huge push-back on the number of alerts or alert fatigue, which are seen in other hospitals.
ONG: New York Hospital Queens went live with CPOE and CDS long before I came. The systems were put in place with guidance from the Clinical Informatics Committee, which was comprised of chairs of the clinical departments. I am told by physician leadership that they wish they had a CMIO at that time to help shepherd the process because there were dozens, if not hundreds, of requests. Prior to the formation of the CDS Committee, which I chair, there was no real process in place to review and prioritize requests.
PAGELER: We took the slow route. We had the pharmacy IS live before we went live with CPOE, so we could track the alerts from the pharmacy. We made some very big decisions before we went live, including the possibility of turning off drug-drug interactions for the provider. The pharmacy already was getting overloaded, we could see how many alerts there were and that many of the alerts weren’t clinically significant in our pediatric population. Currently, the drug-drug interaction alerts are still live for the pharmacists, but not for the physicians.
Turning off the drug-drug interaction alerts caused us to garner really low scores on our Leapfrog evaluations, but we decided that it was a good decision for our institution based on our strategy of guiding alerts to reducing harm and our understanding that drug-drug interactions are a rare source of harm in pediatrics. Based on further evaluation, we decided to recreate some level of drug-drug interactions through custom work. We are in the process of evaluating which alerts are the most clinically relevant.
What teams do you have in place to manage your facility’s CDS?
PAGELER: We have several teams devoted to CDS issues. We created all of our electronic order sets on paper before we went live with CPOE and an electronic order set committee reviews order set utilization and requests for new order sets or changes to our existing order sets. A CDS committee evaluates all new rules and alerts, ensures the best practices are updated and monitors for alert fatigue. All of our committees include multidisciplinary representatives such as physicians, nurses, respiratory therapists, pharmacists, patient safety and quality representatives, as well as informaticists.
LEVICK: We started first with an order set committee that still meets weekly. That’s where