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Healthcare systems are rethinking how they apply CDS tools to assist\u2014and not hinder\u2014clinicians in daily clinical care.

They are implementing CDS to help providers with decision-making in a variety of areas. When KLAS Research surveyed executives about the \u201ccore focus for your organization going forward\u201d for CDS, 82 percent of survey respondents mentioned order sets, followed by surveillance (46 percent), care plans (43 percent), point-of-care disease reference (33 percent), infection control (26 percent) and diagnostic support (21 percent).

Many systems want to get more of their CDS tools from electronic health-records vendors. Most respondents using Epic (61 percent) and Cerner (58 percent) said they expect those vendors to play \u201cvery significant\u201d or \u201csignificant\u201d roles in their future CDS plans, KLAS found in its 2016 survey research. Far fewer respondents envisioned a \u201cvery significant\u201d or \u201csignificant\u201d role for other EHR vendors, including Allscripts (40 percent), Meditech (36 percent) and McKesson (33 percent).

Some examples of use cases include information about key safety issues, such as drug-drug interactions or risk of life-threatening medical problems; best practices to improve clinical outcomes or contain costs; and compliance with requirements from payers, most notably the Centers for Medicare and Medicaid Services.

With so many potential use cases for CDS, it\u2019s not surprising that Frost & Sullivan expects the U.S. clinical decision support market to grow to $4.97 billion by 2021.

Overall, the challenge facing IT departments is how to design CDS systems that sift through vast amounts of data quickly, providing key insights just as providers are making decisions about patients\u2019 medical care.

Combating Alert Fatigue<\/b>
The first step: rethinking how IT departments use pop-up alerts. \u201cWe affectionately call this the sledgehammer alert. It is going to stop you,\u201d says Thomas Selva, MD, a pediatrician and chief medical information officer at University of Missouri Health Care. \u201cIt interrupts your cognitive thought process,\u201d he says.

Too many of these pop-ups can lead to alert fatigue, which happens when clinicians become desensitized to the warnings and then fail to respond to them appropriately. The problem could lead to patient safety issues if clinicians do not react to critical alerts, such as those warning of harmful drug-drug interactions.

The Agency for Healthcare Research and Quality, which has written about this topic extensively, recommends four steps to combat alert fatigue:

\u00b7 Reduce or eliminate inconsequential alerts.
\u00b7 Integrate alerts into clusters of related physiologic indicators.
\u00b7 Tier alerts according to their importance.
\u00b7 Apply the concepts of human factor engineering, which analyzes how well a device or product is likely to work in complex real-world environments.

Using Fewer Intrusive Alerts<\/b>
The IT staff at Cheyenne Regional Medical Center recently addressed alert fatigue by overhauling its approach to Epic\u2019s best practice advisories.

Lucy Stacy, program director for Epic at the medical center, said physicians and nurses complained that the alerts fired too often or fired for the wrong job roles. \u201cIn addition to that, on our side, we were getting multiple requests from multiple places to put these in place,\u201d she says.

The team decided to act. The first step was a comprehensive audit of the medical center\u2019s existing best practice advisories\u2014they found 104 of them. They also compiled information on how often each alert was used or overrode.

The next step was forming a committee, which included representatives from the medical staff and nursing, to analyze the alerts. Based on the committee\u2019s work, Cheyenne Regional Medical Center retired 25 of the alerts and kept 37 of them as is.

The committee also modified 42 other best practice advisories, ensuring that they only fire for the appropriate roles. In some cases, the committee created silent alerts that perform work in the background. For example, if a nurse documents in the EHR that a hospital patient has not had a flu vaccine, the system orders the shot automatically.

To avoid alert creep in the future, the IT staff developed a formal process in which the committee vets all requests for new best practice advisories. \u201cWe don\u2019t put a BPA in place anymore unless it has been properly reviewed,\u201d Stacy says.

\u201cFrom a clinician\u2019s perspective, they feel like they are being heard\u2014that changes are being made,\u201d Stacy says. The alert-reduction project has been so popular with physicians and nurses that the IT staff plans to go through the same analytical process for medication alerts.

Children\u2019s Hospital Colorado also has cut back on alerts, using them in \u201ca much more targeted way and only in the areas of greatest impact,\u201d explains Angela Swanson, director of clinical effectiveness at Children\u2019s Hospital Colorado.

For example, an alert in the emergency department lets physicians know if a patient is at risk for suicide, based on the results of a screening tool. \u201cNone of us want to send a suicidal patient out the door because we\u2019ve failed to ask,\u201d says Lalit Bajaj, MD, an emergency medicine physician and medical director of clinical effectiveness at Children\u2019s Hospital Colorado.

A key question to ask when assessing the usefulness of an alert is if it will \u201cimmediately change my management of that patient,\u201d Bajaj says. If the answer is yes, the alert probably will help clinicians.

Before new alerts are turned on for providers, the hospital rigorously tests them.

For example, the hospital is building an algorithm using machine learning to predict the risk of emergency department patients developing sepsis. The plan is to embed the tool \u201cin the background, so that we can watch it fire, without notifying the provider, to see what the fatigue and what the firing rates might look like,\u201d Bajaj says.

Other Flavors of CDS<\/b>
Selva says MU Health Care is designing methods to provide information at the point of care in a less intrusive fashion, such as by placing key insights on the right-hand side of the screen next to the patient chart. \u201cThis is where we surface alerts as more of a nudge.\u201d

For example, the academic medical center is using this approach to notify a provider if a child\u2019s blood pressure is high\u2014a calculation involving numerous variables, such as age and gender. \u201cWe do the math for the user. There is a slider that pops out that says, \u2018You might want to pay attention, the blood pressure looks a little high. Click here to see what it is,\u2019 \u201d Selva explains.

The functionality, called SmartZone, is part of Cerner\u2019s Millennium PowerChart. MU Health Care was the first pilot-test site for SmartZone, which is now commercially available, according to Cerner.

MU Health Care also incorporates what it calls \u201crelated results\u201d into the appropriate order screen. For example, as a physician is ordering a statin medicine, the patient\u2019s most recent cholesterol levels will appear within the order screen without interrupting the workflow.

Cedars-Sinai Medical Center often designs ordering screens to cut down on pop-up reminders. One example is an order for a medication for which a patient takes an initial dose and then a follow-up maintenance dose. The order set will be structured so that physicians order both doses at the same time. \u201cIt tees it up for them in a way that makes it easier for them,\u201d explains Yaron Elad, MD, a cardiologist and associate medical director of clinical informatics at Cedars-Sinai.

Despite the strides these institutions have made, reducing the number of intrusive alerts at the point-of-care is difficult because there are so many data points involved in providing medical care for a patient.

A case in point is a new requirement mandated in the Protecting Access to Medicare Act, or PAMA. The law, passed in 2014, includes a program to encourage the appropriate use of expensive imaging modalities, such as computed tomography, positron emission tomography, nuclear medicine and magnetic resonance imaging.

Beginning in January 2021, clinicians will be required to consult a certified CDS tool to ensure they are ordering these tests according to appropriate use guidelines. Medicare will not pay imaging centers for these tests unless they document that physicians used a CDS tool to order the tests.

Testing of the new program\u2014without the negative financial consequences\u2014is scheduled to begin in January.

Cedars-Sinai is in the process of evaluating potential CDS tools, which will be integrated into the EHR workflow, Elad says.

Education and Communication<\/b>
Elad says the medical center doesn\u2019t just rely on CDS solutions to encourage compliance with new programs, such as government mandates. It also creates educational programs and incorporates marketing tactics, such as creating screen savers or sending email blasts to publicize new mandates.

Children\u2019s Hospital Colorado also uses a variety of techniques\u2014including branding, education or pledges\u2014in combination with CDS to launch new initiatives.

One example is a project to encourage pediatricians to follow care guidelines from the American Academy of Pediatrics for treating bronchiolitis. The illness, which is a viral infection causing mucus plugging and lower airway swelling, primarily occurs in infants and toddlers between the ages of one and 24 months.

The hospital wanted to decrease the utilization of X-rays, viral tests and bronchodilators to treat non-severe cases of bronchiolitis. While pediatricians commonly use these tests and treatments, evidence suggests that they are often unnecessary. And chest X-rays can have unintended consequences because bronchiolitis looks similar to pneumonia in these images, leading physicians to prescribe antibiotics.

To launch this improvement project, a multidisciplinary team developed a care pathway and then revised the order set to lead pediatricians in the new direction. They also produced a dashboard, which tracks providers\u2019 treatment patterns, but they did not implement a pop-up alert.

They also used tactics to publicize the program and its goals, including creating a slogan, \u201crest is best\u201d; T-shirts; informational handouts and videos for parents; and a pledge for physicians to sign.

Because of the program, the hospital logged utilization decreases of 40 percent in chest X-rays, 41 percent in bronchodilators and 22 percent in viral testing.

At the end of the day, however, education and marketing won\u2019t drive adoption if end users conclude that the software tool is clunky and slows workflow.

Brian Edwards, an independent validation consultant for artificial intelligence vendors, says software developers typically don\u2019t spend enough time making sure their CDS solutions work for end users. That\u2019s because the standard software-development process doesn\u2019t involve input from end users to the extent that is necessary in healthcare, he says. \u201cThe question of\u2014Is it useful\u2014is mostly unanswered by any clinical decision-support vendor,\u201d he explains.

Selva agrees, saying that software vendors often focus more effort on meeting a specific requirement\u2014such as complying with a federal regulation\u2014than on usability. \u201cYou have a product that meets the requirements of the federal government, but the end user finds it very clunky, and it is not very helpful. Then what happens is people build workarounds,\u201d he says.","saveContent":"You might think of this as clinical decision support 2.0.

Healthcare systems are rethinking how they apply CDS tools to assist\u2014and not hinder\u2014clinicians in daily clinical care.

They are implementing CDS to help providers with decision-making in a variety of areas. When KLAS Research surveyed executives about the \u201ccore focus for your organization going forward\u201d for CDS, 82 percent of survey respondents mentioned order sets, followed by surveillance (46 percent), care plans (43 percent), point-of-care disease reference (33 percent), infection control (26 percent) and diagnostic support (21 percent).

Many systems want to get more of their CDS tools from electronic health-records vendors. Most respondents using Epic (61 percent) and Cerner (58 percent) said they expect those vendors to play \u201cvery significant\u201d or \u201csignificant\u201d roles in their future CDS plans, KLAS found in its 2016 survey research. Far fewer respondents envisioned a \u201cvery significant\u201d or \u201csignificant\u201d role for other EHR vendors, including Allscripts (40 percent), Meditech (36 percent) and McKesson (33 percent).

Some examples of use cases include information about key safety issues, such as drug-drug interactions or risk of life-threatening medical problems; best practices to improve clinical outcomes or contain costs; and compliance with requirements from payers, most notably the Centers for Medicare and Medicaid Services.

With so many potential use cases for CDS, it\u2019s not surprising that Frost & Sullivan expects the U.S. clinical decision support market to grow to $4.97 billion by 2021.

Overall, the challenge facing IT departments is how to design CDS systems that sift through vast amounts of data quickly, providing key insights just as providers are making decisions about patients\u2019 medical care.

Combating Alert Fatigue<\/b>
The first step: rethinking how IT departments use pop-up alerts. \u201cWe affectionately call this the sledgehammer alert. It is going to stop you,\u201d says Thomas Selva, MD, a pediatrician and chief medical information officer at University of Missouri Health Care. \u201cIt interrupts your cognitive thought process,\u201d he says.

Too many of these pop-ups can lead to alert fatigue, which happens when clinicians become desensitized to the warnings and then fail to respond to them appropriately. The problem could lead to patient safety issues if clinicians do not react to critical alerts, such as those warning of harmful drug-drug interactions.

The Agency for Healthcare Research and Quality, which has written about this topic extensively, recommends four steps to combat alert fatigue:

\u00b7 Reduce or eliminate inconsequential alerts.
\u00b7 Integrate alerts into clusters of related physiologic indicators.
\u00b7 Tier alerts according to their importance.
\u00b7 Apply the concepts of human factor engineering, which analyzes how well a device or product is likely to work in complex real-world environments.

Using Fewer Intrusive Alerts<\/b>
The IT staff at Cheyenne Regional Medical Center recently addressed alert fatigue by overhauling its approach to Epic\u2019s best practice advisories.

Lucy Stacy, program director for Epic at the medical center, said physicians and nurses complained that the alerts fired too often or fired for the wrong job roles. \u201cIn addition to that, on our side, we were getting multiple requests from multiple places to put these in place,\u201d she says.

The team decided to act. The first step was a comprehensive audit of the medical center\u2019s existing best practice advisories\u2014they found 104 of them. They also compiled information on how often each alert was used or overrode.

The next step was forming a committee, which included representatives from the medical staff and nursing, to analyze the alerts. Based on the committee\u2019s work, Cheyenne Regional Medical Center retired 25 of the alerts and kept 37 of them as is.

The committee also modified 42 other best practice advisories, ensuring that they only fire for the appropriate roles. In some cases, the committee created silent alerts that perform work in the background. For example, if a nurse documents in the EHR that a hospital patient has not had a flu vaccine, the system orders the shot automatically.

To avoid alert creep in the future, the IT staff developed a formal process in which the committee vets all requests for new best practice advisories. \u201cWe don\u2019t put a BPA in place anymore unless it has been properly reviewed,\u201d Stacy says.

\u201cFrom a clinician\u2019s perspective, they feel like they are being heard\u2014that changes are being made,\u201d Stacy says. The alert-reduction project has been so popular with physicians and nurses that the IT staff plans to go through the same analytical process for medication alerts.

Children\u2019s Hospital Colorado also has cut back on alerts, using them in \u201ca much more targeted way and only in the areas of greatest impact,\u201d explains Angela Swanson, director of clinical effectiveness at Children\u2019s Hospital Colorado.

For example, an alert in the emergency department lets physicians know if a patient is at risk for suicide, based on the results of a screening tool. \u201cNone of us want to send a suicidal patient out the door because we\u2019ve failed to ask,\u201d says Lalit Bajaj, MD, an emergency medicine physician and medical director of clinical effectiveness at Children\u2019s Hospital Colorado.

A key question to ask when assessing the usefulness of an alert is if it will \u201cimmediately change my management of that patient,\u201d Bajaj says. If the answer is yes, the alert probably will help clinicians.

Before new alerts are turned on for providers, the hospital rigorously tests them.

For example, the hospital is building an algorithm using machine learning to predict the risk of emergency department patients developing sepsis. The plan is to embed the tool \u201cin the background, so that we can watch it fire, without notifying the provider, to see what the fatigue and what the firing rates might look like,\u201d Bajaj says.

Other Flavors of CDS<\/b>
Selva says MU Health Care is designing methods to provide information at the point of care in a less intrusive fashion, such as by placing key insights on the right-hand side of the screen next to the patient chart. \u201cThis is where we surface alerts as more of a nudge.\u201d

For example, the academic medical center is using this approach to notify a provider if a child\u2019s blood pressure is high\u2014a calculation involving numerous variables, such as age and gender. \u201cWe do the math for the user. There is a slider that pops out that says, \u2018You might want to pay attention, the blood pressure looks a little high. Click here to see what it is,\u2019 \u201d Selva explains.

The functionality, called SmartZone, is part of Cerner\u2019s Millennium PowerChart. MU Health Care was the first pilot-test site for SmartZone, which is now commercially available, according to Cerner.

MU Health Care also incorporates what it calls \u201crelated results\u201d into the appropriate order screen. For example, as a physician is ordering a statin medicine, the patient\u2019s most recent cholesterol levels will appear within the order screen without interrupting the workflow.

Cedars-Sinai Medical Center often designs ordering screens to cut down on pop-up reminders. One example is an order for a medication for which a patient takes an initial dose and then a follow-up maintenance dose. The order set will be structured so that physicians order both doses at the same time. \u201cIt tees it up for them in a way that makes it easier for them,\u201d explains Yaron Elad, MD, a cardiologist and associate medical director of clinical informatics at Cedars-Sinai.

Despite the strides these institutions have made, reducing the number of intrusive alerts at the point-of-care is difficult because there are so many data points involved in providing medical care for a patient.

A case in point is a new requirement mandated in the Protecting Access to Medicare Act, or PAMA. The law, passed in 2014, includes a program to encourage the appropriate use of expensive imaging modalities, such as computed tomography, positron emission tomography, nuclear medicine and magnetic resonance imaging.

Beginning in January 2021, clinicians will be required to consult a certified CDS tool to ensure they are ordering these tests according to appropriate use guidelines. Medicare will not pay imaging centers for these tests unless they document that physicians used a CDS tool to order the tests.

Testing of the new program\u2014without the negative financial consequences\u2014is scheduled to begin in January.

Cedars-Sinai is in the process of evaluating potential CDS tools, which will be integrated into the EHR workflow, Elad says.

Education and Communication<\/b>
Elad says the medical center doesn\u2019t just rely on CDS solutions to encourage compliance with new programs, such as government mandates. It also creates educational programs and incorporates marketing tactics, such as creating screen savers or sending email blasts to publicize new mandates.

Children\u2019s Hospital Colorado also uses a variety of techniques\u2014including branding, education or pledges\u2014in combination with CDS to launch new initiatives.

One example is a project to encourage pediatricians to follow care guidelines from the American Academy of Pediatrics for treating bronchiolitis. The illness, which is a viral infection causing mucus plugging and lower airway swelling, primarily occurs in infants and toddlers between the ages of one and 24 months.

The hospital wanted to decrease the utilization of X-rays, viral tests and bronchodilators to treat non-severe cases of bronchiolitis. While pediatricians commonly use these tests and treatments, evidence suggests that they are often unnecessary. And chest X-rays can have unintended consequences because bronchiolitis looks similar to pneumonia in these images, leading physicians to prescribe antibiotics.

To launch this improvement project, a multidisciplinary team developed a care pathway and then revised the order set to lead pediatricians in the new direction. They also produced a dashboard, which tracks providers\u2019 treatment patterns, but they did not implement a pop-up alert.

They also used tactics to publicize the program and its goals, including creating a slogan, \u201crest is best\u201d; T-shirts; informational handouts and videos for parents; and a pledge for physicians to sign.

Because of the program, the hospital logged utilization decreases of 40 percent in chest X-rays, 41 percent in bronchodilators and 22 percent in viral testing.

At the end of the day, however, education and marketing won\u2019t drive adoption if end users conclude that the software tool is clunky and slows workflow.

Brian Edwards, an independent validation consultant for artificial intelligence vendors, says software developers typically don\u2019t spend enough time making sure their CDS solutions work for end users. That\u2019s because the standard software-development process doesn\u2019t involve input from end users to the extent that is necessary in healthcare, he says. \u201cThe question of\u2014Is it useful\u2014is mostly unanswered by any clinical decision-support vendor,\u201d he explains.

Selva agrees, saying that software vendors often focus more effort on meeting a specific requirement\u2014such as complying with a federal regulation\u2014than on usability. \u201cYou have a product that meets the requirements of the federal government, but the end user finds it very clunky, and it is not very helpful. Then what happens is people build workarounds,\u201d he says.","order":0,"get_parent":{},"attributes":[],"attributesType":{"content":{"type":"string","source":"raw"},"lock":{"type":"object"}},"dynamicContent":""}]

Providers aim to take decision support to the next level

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