The Centers for Medicare & Medicaid Services (CMS) is increasing its emphasis on the use of clinical decision support (CDS) tools, recognizing its role in reducing care costs and improving care quality. Clinicians who have already adopted CDS systems tend to agree they can help significantly. According to a 2013 KLAS report
, 79 of providers who use these systems say automated CDS has led to positive outcomes and has had a positive impact on how well they can care for their patients.
The core reason for this impact is that advanced CDS systems provide clinicians with important information that might otherwise have been unavailable, and deliver it in the form of alerts issued within electronic medical record (EMR) workflows. This can include facts about the patient’s clinical condition that are buried within the EMR or reside on a system that doesn’t communicate directly with the EMR. CDS can also deliver suggestions based on evidence-based best practices from which the clinician is in the process of deviating, as evidenced by EMR documentation entries.
As long as the alerts are accurate and delivered at the proper time, these systems win acceptance from clinicians that see them as resources, leaving them in control of decisions while helping to avoid issues that can arise when critical information is unknown. In doing so, the advantages of using an advanced CDS system fall into four general “reducing” categories.
#1: Reducing the rate of medical errors
Facts about a patient’s current condition and clinical history that can impact patient safety are often buried in EMR free-text and in the databases of labs and radiology departments. If the CDS system is capable of accurately interpreting free text notes and can retrieve data wherever it resides, it can provide broad assistance that ranges from helping to avoid dangerous medication interactions and contraindications to avoiding catastrophic misdiagnoses.
In terms of diagnoses, CDS can be especially valuable in detecting “silent deterioration”—life-threatening developments that cannot be easily observed through examination—through the continuous monitoring of clinical details. Consider sepsis that develops during a hospitalization. When a patient’s white blood cell count begins to slowly rise as measured in lab tests, and the patient is also trending toward fever and hypotension, the CDS can alert clinicians to assess for sepsis development and a possible intervention far earlier than would have otherwise occurred.
#2: Reducing unnecessary or duplicate testing
Because they are informed by a comprehensive view of the patient’s clinical condition and history, CDS systems can reduce care costs by eliminating duplicate and unnecessary tests. This can have safety implications, which is why CMS is working up plans to require that all Medicaid claims for advanced diagnostic imaging include proof of CDS involvement in order to quality for full reimbursement. (The original Jan. 1, 2017 start date for the requirement has been postponed while CMS defines approved CDS mechanisms.) The purpose of the requirement is to eliminate both the unnecessary cost of duplicate imaging and the potential harm to the patient that results from unnecessary exposure to radiation. By eliminating other commonly duplicated tests such as blood work, CDS can further help clinicians avoid unintentional contributions to higher care costs.
#3: Reducing length of stay and instances of hospital-acquired conditions
In addition to presenting clinicians with patient-specific information, CDS systems can issue alerts when they detect deviations from the evidence-based best practices embodied in a hospital system’s clinical guidelines. Deviations from best practices can result in adverse events or hospital-acquired conditions, such as infections—which are a major cause of patient injury, increased length of stay, mortality, and increased national healthcare costs, estimated at almost $845 million per year, according to a study
published in The Quarterly Journal for Health Care Practice and Risk Management
By promoting more uniform adherence to clinical guidelines across all of a health system’s settings and among all of its clinicians, a CDS system can ensure those best practices and guidelines achieve maximum benefit. Reminders delivered at the right time in the form of alerts are much more effective than volumes of paper to be referred to manually.
Next: Hospital readmissions
#4: Reducing hospital readmissions
Reducing hospital readmissions is largely a matter of ensuring that quality care continues after the patient is discharged. If the CDS is capable of issuing alerts to outpatient settings, especially for patients with chronic disease, it can assist in post-discharge patient management. This can include such simple measures as promoting medication adherence and making sure that follow-up appointments for preventive care happen when they should.
Delivering the right information at the right time
Much has been written about alert fatigue. If a CDS system issues numerous alerts that are irrelevant, clinicians will quickly learn to ignore the system—which could mean that an extremely important alert goes unheeded. It is essential that the CDS system be silent until truly ready to provide meaningful support. Its alerts must be accurate, and they must be delivered when they are the most useful. If the system is both exact and timely, alerts will be infrequent—but when they do arrive, they can contribute significantly to reducing errors, inefficiencies, lengths of stay and readmissions.
Keren Ofri, MD, is senior vice president of medical operations at medCPU