www.advanceweb.com/executiveinsight I E X E C U T I V E I N S I G H T I 25

F or more than a year, Froedtert and the Med-ical College of Wisconsin (FroedtertMCW) health network has used a clinical decision

support (CDS) platform to improve the safety and utilization of imaging services. With con-sistent monitoring, the system has been highly successful, thanks to more uniform adherence to medical imaging best practices.

The solution succeeds, in part, by closing in-formation gaps in the care continuum and pre-senting clinicians with information of which they might otherwise be unaware. This includes closing care information gaps over time, as the system can advise when a patient has not been fully prepped for a scheduled test or that a test should be ordered. It also includes closing gaps across care teams; when a test is ordered, the CDS solution advises a clinician based on best practices and most recent information, no mat-ter who entered the information.

Improving Safetyand UtilizationLeveraging clinical decision support to close gaps in the care continuum By Jeff Rehm

Jeff Rehm is executive director, Imaging Services, Froedtert & the Medical College of Wiscon-sin health network.

IMAGING/RADIATION

IMPLEMENTATIONIn late 2014, FroedtertMCW implemented med-CPU’s Radiology Advisor, a CDS platform that interprets all data from a hospital-wide electron-ic medical record (EMR), including free text such as progress notes and clinical indications, along with all interfaces throughout the organization for orders, results and admission, discharge and transfer (ADT) system. This gives the platform a complete view of the patient’s clinical condition and history, ensuring all considerations are ac-counted for when ordering imaging.

FroedtertMCW clinicians order imaging un-der the watch of the Advisor, which runs on top of the health system’s EMR. There are no “hard stop” alerts; clinicians perform within their nor-mal workflows, and the Advisor issues an alert when it detects a deviation from best practices.

There is also no interference with established documentation processes. The CDS platform’s ability to interpret unstructured EMR infor-mation eliminates the need to force discrete drop-downs, leaving clinicians free to docu-ment according to their preferences. The system screen-reads free text as it is recorded to support fully informed, real-time alerts.

RESULTS TO DATE: TRENDSFroedtertMCW tracks the total number of cases impacted by CDS prompts each month, along with the total number of prompts issued and the average ratio of prompt compliance to non-com-pliance. After the first few weeks of initial use, tracking revealed steady decreases in both the number of cases impacted per month and num-ber of prompts, while the average rate of compli-ance increased up to 90%—all strong indicators of swift alignment with best practices.

A sudden spike in prompts coincided

The CDS platform is the only new system in memory that did not generate negative feedback; in fact, it generated little feedback period, reflect-ing the system’s intuitiveness and unobtrusiveness.

26 I E X E C U T I V E I N S I G H T I www.advanceweb.com/executiveinsight

ferent background with distinct expertise and training, co-manage-ment of patients in a training setting is ideal for learning to optimize pa-tient care. It also offers opportunities for residents to share knowledge in an open learning environment. The pharmacy residents shared clinical resources and online tools for calculating creatinine clearance. One pharmacy resident demonstrated how to adjust the calculation for obese patients. Another offered med-ications to avoid in elderly patients by highlighting the Beer’s list rec-ommendations. The nurse practitioner resident discussed changes to recent lipid guidelines, and after discussing the case with another pro-vider in clinic, offered recommendations based on practice standards and updated guidelines. The NP resident investigated a question about uric acid levels, and a discussion was initiated by referencing resources and pairing recommendations with patient-specific characteristics.

Collaborative learning through interprofessional co-management of patient care is ideal because questions are live, real and productive. By working together, residents from distinct professional backgrounds are able to better understand each other’s expertise and gain clarity on how to leverage those skills in practice. Finally, after the intentional pairing exercise was complete, residents were familiar and comfort-able with each other, which offered easy opportunity to ask questions ad hoc during a clinic day through email, instant message or paging. This familiarity and trust-building are principal predictors of interpro-fessional collaboration.5

CRITICAL TO HEALTH OUTCOMESIn a healthcare system that is increasingly complex and short on pri-mary care providers, collaboration among professions is critical. A focus on team-based care should begin during professional education so that providers and pharmacists understand each other’s roles and gain appreciation for each other’s expertise.

Complex patients with chronic illnesses require more attention to medication management and education. Often, patient education needs to be provided in more than one way. Co-managed care involv-ing a provider and pharmacist may improve patient understanding and retention. Team-based care enhances communication among all members of the team, including the patient. Relationships among providers of different professions create learning opportunities that are unique and useful. Each brings distinct perspectives and back-ground to the care provided.

References1. Brooks K. The IHI Triple Aim. Available at http://www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx2. Wynia MK, et al. Challenges at the intersection of team-based and patient-centered health care: Insights from an IOM working group. JAMA. 2012;308(13):1327-1328.3. Nurse Practitioners and the Future of Primary Care. Available at http://dhhs.ne.gov/publichealth/licensure/documents/FutureOfPrimaryCare.pdf4. Schnur ES, et al. PCMHs, ACOs, and medication management: Lessons learned from early research partnerships. J Managed Care Pharm. 2014;20(2):201-2015.5. Snyder ME, et al. Exploring successful community pharmacist-physician col-laborative working relationships using mixed methods. Res Social Admin Pharm. 2010;6(4):307-323.

with a cycle of new residents and faculty entering the academic environment. However, quick improvements followed the spike.

AREAS OF IMPACTFroedtertMCW’s high-volume emergency departments (EDs), with as many as 60,000 patient visits per year, are its largest source of data regarding CDS usage. Within EDs, the most pronounced gains from CDS occurred in safety, utilization and efficiency. Safe-ty and utilization improvements resulted from ordering and per-forming the right tests the first time, and efficiency improved as the radiology department spent less time changing orders.

Patient safety has especially improved with the CDS system’s re-direction of orders for contraindicated tests, as the system readily spots patient deficiencies that could result in tests possibly harm-ing the patient. In a memorable example, an MRI was ordered for an elderly patient admitted to the ED less than two weeks after receiving a pacemaker implant. Though the implant was docu-mented in the EMR as a procedural note, it was not entered into a discrete field and was therefore overlooked by the clinician order-ing the MRI. The CDS system accounted for that important detail and issued an alert, and the MRI order was immediately canceled.

Similar increases occurred in efficiency, for example, with the system issuing prompts to ensure patients with low glomerular fil-tration rate (GFR) levels are properly hydrated before certain tests. With the system, clinicians are better able to ensure patient hydra-tion and avoid radiology having to reschedule after discovering the need for hydration when a test is about to begin.

CLINICAL STAFF ACCEPTANCEIn addition to its high effectiveness, the CDS platform has been easy to roll out and was met with immediate acceptance among clinical staff. Initial training required nothing more than clinicians watching a five-minute video. In fact, the system has proven suffi-ciently intuitive, with no need for subsequent training. New users invariably understand the prompts clearly and almost immediately.

When FroedtertMCW leaders heard of the CDS system, there was much skepticism due to a long history of IT solution imple-mentations. The CDS platform is the only new system in memory that did not generate negative feedback; in fact, it generated little feedback period, reflecting the system’s intuitiveness and unob-trusiveness. After fully implementing the CDS system’s radiology module, FroedtertMCW acquired five additional modules and is in the process of growing its library of modules in various clinical specialties.

ON THE WEBThe focus on clinical quality and appropriate use of imag-ing will ultimately come down to utilization and access to information driving the decision to proceed with a particular procedure. Read “Enterprise Wide Success” at www.advance-web.com/executiveinsight

IMAGING/RADIATION STAFFING

Continued from page 20

View article in full publication