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Quick Hitting Thoughts on CDS (Clinical Decision Support)

Posted on March 21, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I’m finally starting to go through all my notes from HIMSS. Part of that is because I’ve been busy after HIMSS. Part of it is because I like to recover from what I call the #HIMSSHaze. Part of it is that I like to see what still resonates a few weeks after HIMSS.

With that in mind, I was struck by a number of quick hitting comments that I noted from my interview with Dr. Peter Edelstein, CMO at Elsevier. Dr. Edelstein is a fascinating guy that I’ll have to have on a future Healthcare Scene interview. In the meantime, here are some of the quick hitting thoughts he shared about CDS (Clinical Decision Support).

One key point he made is that it seemed like many organizations didn’t have a strategy for CDS. He also aptly pointed out that the same seemed to apply to big data. I agree with him wholeheartedly. If we were to go to a healthcare organization and ask them their CDS strategy I don’t think most of them would have an answer. I think if we dug in, we’d probably find that most of them have essentially deferred their CDS strategy to their EHR vendor. Does anyone else feel like this is a problem?

When I asked Dr. Edelstein what would be his suggested strategy on adopting CDS, he suggested that he’d want to make sure that the CDS solution worked across all provider types. Next he compared the pull CDS solutions (Reference resources, etc) to wearing seat belts in a car and the push CDS solutions (Order sets, care plans, etc) to an airbag in a car. While we certainly need both sets of solutions, he suggested that we should make more of an effort to get the push CDS solutions implemented in healthcare.

I thought the analogy was a great way to look at the various types of CDS solutions. Plus, I agree that we need more push solutions in healthcare. The pull solutions are necessary for some of the most challenging problems, but we all know that when a doctor is busily going about their day they often choose not to check with the pull solutions when they should. The push solutions can be integrated into their workflow so that providers can more easily address any potential issues from within the flow of their day.

Dr. Eldestein also pointed out that Wikipedia is still the most commonly used reference resource despite many studies which have illustrated the medical errors that exist on it. Why do they use it? It’s because it’s simple to use and easily accessible. This is a great illustration of why we need the right CDS information to be more easily available to the doctor at the point of care at the moment they need it.

Definitely some great insights into CDS. What’s great about CDS is that at this point pretty much everyone is using some form of CDS. We’re also seeing CDS integrated more deeply into EHR software. I expect this trend will continue and will become much more sophisticated.

It does beg the question, what’s your healthcare organization’s CDS strategy?

Gathering Consensus for EMR Templates

Posted on January 6, 2016 I Written By

Erin Head is the Director of Health Information Management (HIM) and Quality for an acute care hospital in Titusville, FL. She is a renowned speaker on a variety of healthcare and social media topics and currently serves as CCHIIM Commissioner for AHIMA. She is heavily involved in many HIM and HIT initiatives such as information governance, health data analytics, and ICD-10 advocacy. She is active on social media on Twitter @ErinHead_HIM and LinkedIn. Subscribe to Erin's latest HIM Scene posts here.

By now, most of us have moved beyond the initial phases of implementing an EMR and into the optimization phase. Templates, ordersets, and documentation tools are constantly evolving with input from different departments and clinicians but we need to ensure a centralized EMR change review process is in place to prevent duplication, errors, note bloat, conflicting information, and unnecessary documentation.

Since there are many different uses and objectives for clinical documentation, we must collaborate with many different areas to reach a consensus on the way we capture clinical documentation to ensure compliance. In my experience, the best way to standardize EMR changes and enhancements is to develop a centralized process flow for all requests for changes to clinical documentation. This establishes the team that will provide diverse perspectives and will review and sign-off on all requests before they are built and implemented.

Sometimes we get approached by physicians or other clinicians asking for changes that would be a simple build in the EMR but we must run this and all requests through the change approval process to prevent any potential downstream affects. Even when requests are based on regulatory changes, it’s important to follow the process flow so that all interested parties are aware of the changes and are meeting compliance in all areas.

From the coding and CDI perspective, we need to capture more detail in the documentation to properly assign ICD-10 codes. Adjusting EMR templates to help physicians with descriptive diagnoses is vital to capture all of the detail at the point of entry and time of treatment instead of asking for clarification later. At my facility, we have found success with having our CDI specialists educating the physicians on the diagnosis guidelines and appropriate EMR template use.

The number one objective should be to ensure the EMR captures the clinical story of each patient to provide the best possible treatment and utilization of resources. Achieving consensus on templates can sometimes feel like herding cats but doing it right the first time is important. We must maintain a governance process of clinical documentation to ensure all objectives are properly met.

If you’d like to receive future HIM posts by Erin in your inbox, you can subscribe to future HIM Scene posts here.

CA Hospital Adds CPOE To VistA Implementation

Posted on July 1, 2013 I Written By

Anne Zieger is veteran healthcare editor and analyst with 25 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

It’s still rare these days to see a private hospital roll out open source EMR VistA, despite VistA’s excellent reputation. But one such hospital has not only implemented VistA, it’s added CPOE to its VistA rollout.

The facility in question is Oroville (CA) Hospital, which spent three years self-implementing the VA platform. Oroville has spent seven years developing a paper-based order set system, and has now converted its order sets from paper to electronic.

For a year the medical staff at Oroville had been using paper order sets and the VistA EMR, but that arrangement was getting old, so the transition was a happy one, according to Dr. Matthew Fine, the hospital’s chief medical officer, who’s quoted in a press statement.

“After a whole year of using paper and electronic charts the staff was chomping at the bit to go live and the anticipation outweighed the fear… so turning on CPOE was almost a welcomed event. The inadvertent strategy of having hybrid charts seems to have been a good way to make full conversion to EHR/CPOE more palatable,” Dr. Fine said.

To make the CPOE transition, the Oroville staff created a mechanism for systematically converting order sets to an electronic format, the press release notes. Each order set, once transformed, was reviewed by a relevant group of physicians along with 20-odd additional staff including department/section heads, nurses, pharmacists, nutritionists, lab staff and anyone else who might be carrying out the orders in the order sets.

Since go-live in October of last year, electronic order volume has mounted, and now 80 percent of orders are electronic. The hospital’s goal is for 100 percent of orders to be electronic, but it has hit a stumbling block in that it has been unable to adapt VistA’s original CP Flowsheet module.

For that reason, Oroville will have to create its own CPOE solution for several areas of the hospital, including outpatient surgery and the PACU.

New Hospital Rockets To Top Of HIMSS EMR Adoption Scale

Posted on December 26, 2012 I Written By

Anne Zieger is veteran healthcare editor and analyst with 25 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

Here’s a story of what can happen when a hospital starts out from scratch with the latest in EMR knowledge, rather than having to integrate its system bit by bit.

Texas Health Alliance, a 50-bed acute-care hospital based in north Fort Worth, has been named as achieving the rarely-seen Stage 7 in HIMSS Analytics EMR Adoption Model. At present, only 103 U.S. hospitals, or 1.9 percent, are currently at Stage 7.

Some of the outstanding features of the rollout include:

* Over 95 percent utilization of CPOE (driven predominately by well-designed order set content, HIMSS says)
* Advanced clinical decision support alerts that support best practice protocols
* Smart use of an enterprise data warehouse used to monitor best practice alerts and core measures
* Closed-loop medication administration environment

This award is interesting given that small hospitals have been well behind the curve in Meaningful Use and meeting the HIMSS standards.  But there’s some obvious reasons why it’s been so successful.

For one thing, THA has been open only since September. I’ll bet many readers would kill for the clean slate that offers the IT people there. No need for expensive integration projects to bring the new EMR on board; no having to switch staffers from one technology to another; no major transition from paper to digital; and the list of benefits goes on.

Another major factor working in its favor is that THA is part of nonprofit hospital system Texas Health Resources.

A tiny hospital backed by a sizeable IDN is in a different position entirely than an independent critical access hospital, so it’s not exactly astonishing that it zoomed ahead. And when the parent chain already has its own (Epic) install well under way — and an engaged community of users — that knowledge goes a long way.

Too bad most hospitals can’t start out fresh the way THA did. Innovation always comes easier if it isn’t competing with the stuff you’ve already got.

CPOE, Clinical Decision Support Help Order Set Usability

Posted on August 27, 2012 I Written By

Anne Zieger is veteran healthcare editor and analyst with 25 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

CPOE is coming into its own as a technology, after lagging far behind in adoption for many years. And new evidence suggests that this may be a good thing. A new study has concluded that when paired with clinical decision support, CPOE improves order set usability, decreases providers’ mental workload and increases clinical guideline adherence, CMIO reports.

The study, which was published in the September issue of Pediatrics, compares how a group of surgeons at Seattle Children’s Hospital fared using order sets developed on an ad-hoc basis versus sets developed systematically using software design methods.

Researchers Jeffrey Avansino, MD and Michael G. Leu, both of Seattle Children’s, had seven surgeons complete two order sets, one developed on an ad-hoc basis and one developed systematically.  The surgeons were working with two clinical scenarios, one in which they were treating a child with perforated appendicitis and the other with a nonperforated appendicitis.

When reviewing the order sets, all of the surgeons preferred the systematically developed order sets, saying that they were more usable and easier to think through. As it turned out, systematically developed sets were also more likely to adhere to clinical guidelines.

All that being said, the authors did express some concern that systems like these might limit resident training, as the sets don’t necessarily explain why a particular decision is being suggested. “We are concerned about the potential of these systems to limit resident training, creating an environment for ‘cookbook medicine’ resulting from prechecked orders,” Avansino and Leu wrote, according to the CMIO piece.

Unfortunately, that’s the kind of tradeoff we’re going to be struggling with often as we further leverage clinical decision support and CPOE. You can’t streamline ordering to a high degree without losing some of the educational aspects of independent decision making — there’s no getting around it. Decision-making is messy and idiosyncratic.  We’ll just have to see if carefully-developed order sets are beneficial enough to risk the “cookbook” problem.

Medicare’s New Requirement for Evidence-based Order Sets

Posted on August 13, 2012 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

The following is a guest post by Sean Benson. Sean Benson is co-founder of ProVation Medical and Vice President of Innovation at Wolters Kluwer Health.

In-house creation and maintenance of order sets by hospital staff just got a bit more challenging.

Without much fanfare, a small but significant change to Medicare’s Conditions of Participation (CoP) for hospitals went into effect in mid-July.  The Centers for Medicare and Medicaid Services (CMS) has decreed that Medicare-participating hospitals that use order sets, pre-printed or electronic standing orders and protocols for patient orders must ensure that they are consistent with nationally recognized and evidence-based guidelines and recommendations.

To be clear, this new CoP rule does not prohibit an individual hospital from developing its own pre-printed and electronic order sets. It does define the criteria for doing so, however.  CMS expects a hospital to look to nationally recognized guidelines, which should always be evidence-based, and to its own experiences and in-house studies and data.  CMS wants hospitals to avoid using anecdotal evidence, theories that have not been proven effective, or the old fallback of ‘that’s the way we’ve always done it’ as a basis for establishing its orders and protocols.

In-house creation of order sets has always presented challenges for hospitals.  Significant staff time must be devoted to drafting individual order sets, which can number in the hundreds at some institutions.  Subsequent review and consensus-building by the appropriate clinicians can also prove burdensome and difficult.  And then there is the need to periodically check and update existing order sets to make sure they reflect best practices.

Now CMS has added the requirement that order sets be based on the latest evidence and guidelines. The sheer volume of new medical evidence scattered across hundreds of sources that must be evaluated when creating an order set – an estimated 2 million scientific articles are published each year – means compliance will be a significant drain on internal resources. It also means that flow of evidence must be continuously monitored to determine when it necessitates a change in practice and, thus, a change in one or more existing order sets.

Compliance with the new CoP requirement can readily be achieved by “going digital”.  Electronic order set authoring tools offer pre-defined templates populated with content drawn from medical reference databases that track the latest clinical advances. This streamlines creation of new order sets and maintenance of existing ones, which remain linked to the reference databases. Alerts are generated whenever new evidence or guidelines necessitate a protocol change and, in some cases, impacted order sets can be updated with a single click.

Order Set authoring tools are already being widely deployed in many hospitals seeking to achieve the Computerized Physician Order Entry (CPOE) requirements of Meaningful Use.  Hospitals that have joined new accountable care organizations are also leveraging these solutions to help promote evidence-based medicine in their care coordination efforts.  Medicare’s new CoP rule requiring evidence-based order sets offers CIOs and CMIOs with yet one more incentive to digitize the order set creation process.