Friday, February 12, 2016

The 5 Rights Aren't Wrong,... But...

"In any moment of decision, the best thing you can do is the right thing, the next best thing is the wrong thing, & the worst thing you can do is nothing."

Theodore Rooseveldt 






In November of 2014, The ONC (Office of the National Coordinator, I liked it better when it was ONCHIT) posted guidance regarding clinical decision support (CDS). This guidance proposed “5 rights” that applications & implementations that provided CDS would have to support. The five rights[1] were defined as:
         ·      Right information (evidence-based guidance, response to clinical need)
         ·      Right people (entire care team – including the patient)
         ·      Right channels (e.g. EHR, mobile device, patient portal)
         ·      Right intervention formats (e.g. order sets, flow-sheets, dashboards, patient lists)
         ·      Right points in the workflow (for decision making action)
The ONC also stated that CDS is more than just the delivery of alerts. The 5 rights provide a good context for thinking about CDS & how it can/should be used. In particular the CDS/PI (Clinical Decision Support Collaborative/Performance Improvement) detailed “steps” table[2] seems quite useful, at least as a source of information on CDS.

A number of older, but still relevant (IMHO) academic studies provide more insight into the most effective capabilities & features of CDS systems. Specifically, Kawamoto, et al.[3] did a meta-analysis of the effectiveness of CDS systems in improving outcomes & found that four features made such systems most effective (in descending order):
       1.     Automatic provision of CDS as part of clinical workflow
       2.     Provision of recommendations rather than just assessment
       3.     Provision of CDS at the time & location of decision making, &
       4.     Provision of fully automated CDS rather than partial reliance on the provider to look up information

Other features that were significant but not at the level of these four were:
       ·      No need for additional provider data entry
       ·      Requesting explanation (from provider) of why recommendation(s) were not followed (requires    more analysis of decision by provider & may change decision)
       ·      Provision of CDS results to patient (acknowledgement of usefulness of system & transparency), & finally
       ·      Provider education (often not by vendor) for use & interpretation of CDS

Other studies e.g. Garg, et al.[4] also a meta-analysis, provide highly detailed analysis of effective features for different types of targeted CDS (diagnosis, preventive care, diabetes treatment, etc.).

My semi-recent experience on a federal grant has given me some perspective on this. I was Principal Investigator on a Department of Commerce (NIST) grant to develop a secure network with identity verification at all endpoints for clinical eReferral. This work was done with UC San Diego Medical Center & the San Diego VA. Direct network connections were set up for UCSD & its medical affiliates including a set of CHCs in the Columbia River Gorge area (OR). Part of the project was that eReferrals done through the Direct connections would include the possibility of using the ActiveHealth Management (now owned by Aetna) application for CDS. What we found was that providers, on both sides of the connection were loath to use the CDS as it required: additional &/or redundant information to be entered (usually by the provider) & going out of the Direct connect/EHR context. In addition, providers did not like that the application made recommendations & provided copious amounts of background for the recommendations, but allowed for only minimal provider input & feedback. (FYI – ActiveHealth Management never followed through on its commitments to the grant, so this capability was only tested in prototype.) The result was clear, however. Providers were not interested in CDS/recommendations if they were not fully integrated into their EHR & workflow. Even though ActiveHealth Management was considered “best-of-class” CDS at the time, it was not enough to tempt providers to use it consistently.

Other types of patient-centered recommendation systems may also be interesting & relevant here, specifically the point-of-care recommendation systems under development (& in some cases being used by) by Kaiser, Partners, Geisinger, Mayo Clinic, Cleveland Clinic etc. These systems do operate for the provider at the point-of-care & meet most of the criteria described by Kawamoto, that is:
         ·      Are provided automatically at the time & place of decision making
         ·      Make recommendations, not just summarizations/assessments, &
         ·      Do not require any additional data entry.

Of course, even though these systems make recommendations based on the analysis of many thousands - & in some cases millions – of patient records, they are only as good as the quality of the data that they analyze. Based on our experience with data quality in the Path-2-Analytics[5] project, we can make some assumptions regarding the quality of a data set with millions of records, the compilation of which started 12-15 years ago. Kaiser, for instance, has 9M+ patient records dating from 2003. These types of systems will become extremely important over the next 5-8 years, but today they are more conceptually important than functionally important.

OK – so what’s the bottom line here? The ONC, CMS etc. will continue to mandate that providers begin using clinical decision systems in their clinical practice, but what leverage do these systems actually provide? & how can providers & healthcare organizations select CDS systems that will improve their practice? The ONC defines CDS as: “Clinical decision support (CDS) provides clinicians, staff, patients or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care. CDS encompasses a variety of tools to enhance decision-making in the clinical workflow. These tools include computerized alerts and reminders to care providers and patients; clinical guidelines; condition-specific order sets; focused patient data reports and summaries; documentation templates; diagnostic support, and contextually relevant reference information, among other tools.”[6]  

The Stage 2 Meaningful Use measure for CDS (2016-17) is:[7]
Measure1:Implement five clinical decision support interventions related to four or more clinical quality measures at a relevant point in patient care for the entire EHR reporting period. Absent four clinical quality measures related to an EP’s scope of practice or patient population, the clinical decision support interventions must be related to high priority health conditions.

Measure 2: The EP has enabled and implemented the functionality for drug drug and drug allergy interaction checks for the entire EHR reporting period.”

As ONC points out, this set of capabilities requires the ability to access & analyze patient-specific clinical data, some type of reasoning mechanism (rules, big data analysis, human intervention etc.) to interpret the data & construct recommendations, create care plans, assess current care etc. & the ability to present information & inferences in an understandable & useful way.

It should also be pointed out that the Stage 2 criteria are also linked to interventions related to to the CMS clinical quality measures, that is some action must be taken based on input from a CDS (alert, etc.) that is related to a quality measure as described by CMS[8]. There are currently 64 of these measures ranging from HbA1c measures to colorectal cancer screening to pediatric asthma screening

There are many standalone CDS products, most of which are focused on a specific clinical area. Examples are: interpretation of tumor imaging for specific types of tumors, interpretation of retinal imaging for treatment of macular degeneration, tracking of quality measures for individual patients & alerting provider when measures fall outside of guidelines & many, many others. There are very few general CDS systems, the best-known being ActiveHealth Management, a system that relied on a set of clinicians & human experts that continuously reviewed medical journals & other material to extract the latest information on treatment patterns & outcomes. This information was then translated into a rule set that was used to interact with provider input (or automated input through CDS) regarding specific patients. Treatment recommendations & treatment plans were then suggested to the provider. Very few CDS except for ActiveHealth & the point-of-care recommendation systems using big data analytics work like this. Most are much more targeted. Most CDS function provided by EHRs is in the form of reminders & alerts, although this is starting to change.

So how does a healthcare organization select a CDS that will work to improve outcomes & not just meet meaningful use requirements? Here are some steps:
          1.     Determine what data you have available to serve as the base for decision support. This will include your EHR & PM systems as well as other internal data. It may also include external data as relevant. External data may include clinical data from other sources (HIE, eReferral etc.) or public &/or private clinical datasets.
         2.     Determine what type of decision support you require & who the recipient of this support will be. Are you looking for general point-of-care diagnostic & treatment planning support (order sets, procedure lists etc.)? or are you looking for specific support in particular types of image interpretation or other highly specialized support?
         3.     Develop a set of expectations, goals, requirements, users & use cases for your CDS system.
         4.     Evaluate what CDS capabilities you already have in your EHR or other HIT systems. Identify the gaps in the capabilities you have versus your requirements.
         5.     Research & identify CDS systems that will fill these gaps. Make sure you determine compatibility of any systems you are researching with your existing HIT systems. Also make sure you understand the skills required to use these systems & what training is required (including but not limited to vendor supplied training as your staff may need more general training on decision making & decision support).
        6.     Evaluate & test the system(s) you have identified using the real use cases you described in Step 3. Use data that is as realistic as possible, that is as close to your clinical data as possible (in some cases, it may be possible to actually use your own data).
       7.     Work with the vendor to make sure that the system you will purchase is customizable &/or configurable the way you need & that it is fully compatible with your other software.
       8.     Arrange for a test period & do a series of tests that exercise your use cases. Work with the vendor to remediate any issues you find.
        9.     Arrange for any training that the vendor &/or external organizations can provide.
At this point you are ready to purchase your CDS system.

OK, you say,… that seems like a lot to go through, especially since my EHR vendor assures me that their product provides clinical decision support that is compliant with meaningful use, PCMH, MIPS & any other regulation or guideline you have asked about. My experience, as I’ve already stated, is that the CDS associated with EHR products is mostly limited to alerts that are programmed to fire when specific clinical measures are above guidelines or when a series of values trend above guidelines. More recently, they can also make recommendations for & enable ePrescription of specific drugs or even propose order sets (for CPOE). This is all good, in fact much better than not providing such capabilities at all, but if you have determined a broader set of requirements, then your EHR may not provide everything you need. The bottom line is CDS that actually meets the ONC’s definition is not provided by any current EHR or in fact even by any combination of EHR & dedicated CDS application. It is most closely approached by the point-of-care recommendation systems that are under development & in preliminary use by organizations such as Kaiser Permanente, Geisinger, Partners etc. These systems combine ultra-large data sets with advanced deep learning & pattern recognition capabilities that will be in general use in the next 3-5 years, but today are the exception.

I believe that the best we can do today is a combination of CDS provided by your EHR along with a more specialized system that addresses some of the additional requirements you have identified. EHR decision support will get better only if it is required to, but Stage 2+ meaningful use requirements as well as the proposed Stage 3 (maintaining the two requirements for Stage 2 with additional emphasis on appropriate position of CDS in the clinical workflow[9]) do not push for CDS as described by the ONC except to say that CMS wants to encourage innovative development & use of decision support beyond alerts & notifications. We have a long way to go before CDS is a really effective addition to the care of patients… No number of definitions, usage descriptions of reports by Federal agencies will make it happen. Vendors will develop effective CDS only if it is required, so it is up to providers, policy experts & healthcare organizations to both push for this development & to produce their own definitions, descriptions, use cases & even prototypes as appropriate & possible. Now is the time to start…








[1] https://www.cms.gov/Regulations-and Guidance/Legislation/EHRIncentivePrograms/Downloads/ClinicalDecisionSupport_Tipsheet-.pdf
[2] https://sites.google.com/site/cdsforpiimperativespublic/CDSQI-stepbystep
[3] K. Kawamoto, C. Houlihan, E.A. Balas, D.F. Lobach. Improving clinical practice using clinical decision support systems: A systematic review of trial to identify features critical to success. BMJ, doi:10.1136/bmj.38398.500764.8F (published 14 March 2005)
[4] A.X. Garg, et al., Effects of computerized decision support systems on practitioner performance & patient outcomes. JAMA. 293(10). P. 1223-1238.
[5] Path-2-Analytics Project: Process & Results Review, Association of Clinicians for the Underserved Annual Meeting. Washington, D.C, June 2015.
[6] https://www.healthit.gov/policy-researchers-implementers/clinical-decision-support-cds
[7] https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/EP_ObjectiveMeasuresTable-.pdf
[8] https://www.cms.gov/regulations-and-guidance/legislation/ehrincentiveprograms/ecqm_library.html
[9] https://www.healthit.gov/providers-professionals/how-attain-meaningful-use

      

No comments: