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Minimizing Deviations

Clinical decision support as an essential compliance tool

From the January 2017 Issue

Compliance with industry best practices and clinical guidelines has become increasingly essential to the financial wellbeing of hospitals and healthcare systems. To support goals ranging from eliminating waste to aligning care delivery with payment incentives, provider organizations publish clinical guidelines for good reason. Non-compliance can negatively impact the patient experience, patient safety and an organization's bottom line.

With the growing availability of intelligent clinical decision support (CDS) systems, provider organizations have necessary tools available to them for increasing adherence with clinical guidelines. While that's not CDS's sole purpose, advanced CDS systems can reference virtually any clinical guidelines and automatically prompt for, track and report compliance with them. This enables hospitals and health systems to minimize deviations from best practices in efforts to achieve more uniform compliance. For large health delivery organizations, initiatives can be rolled out across the enterprise, encompassing multiple stakeholders who benefit from one development effort.

Promoting Compliance
Clinical decision support systems run on top of electronic medical record (EMR) systems, comparing clinician actions as they are recorded to information that can reside in various repositories -- many of which are not accessible to the clinician at the point of care. This relevant clinical data can include unstructured information in EMR free text, patient monitoring systems, data recorded in the systems of labs and radiology departments and providers' notes.

When CDS analysis indicates a recorded clinical action should be reconsidered, the system presents an alert within an EMR pop-up window. In the best of these systems, alerts are relatively rare, limited to instances of highly probable concern to avoid false alarms. Clinicians remain in charge of all decisions and can chose to comply with or ignore alerts. For "hard stop" alerts, clinicians must record the reason for non-compliance. Intelligent CDS systems track post-prompt actions for each clinician, and provide reports that show compliance rates by clinician as well as trends over time.

SEE ALSO: How to Successfully Communicate Your Clinical Validation Concerns

By issuing alerts at the point of care and within clinical workflow, CDS can address non-compliance issues at the point of origination. A reminder that appears when action is being initiated is far more effective than expecting clinicians to study, remember and keep current on published guidelines in material reviewed separately. With pressing hard-stop issues, requiring clinicians to record the reason for non-compliance can have a dramatic effect on reliable adherence.

Improving Radiology Compliance and Utilization
In 2012 -- well in advance of the coming CMS mandate to involve CDS in advanced imaging orders -- a large health system undertook a CDS project to improve efficiency in CT head scans for non-traumatic headache. The purpose was to reduce unnecessary CT scans without compromising care quality.

This health system's existing CDS platform was configured to reference clinical guidelines for CT scans, with prompts that functioned as compliance reminders when EMR documentation indicated a deviation from clinical guidelines. As clinicians were already familiar with the guidelines and with the CDS system itself, no training was required to support the project. Clinicians were free to ignore each alert, change the order or enter documentation supporting the order, with the CDS system recording each action. Clinical leadership reviewed periodic compliance reports with clinicians who deviated most frequently from guidelines.

The project succeeded in greatly improving CT scan utilization for non-traumatic headache. Within 10 months, the rate of compliance increased from 67% to nearly 90%. As more clinicians began to comply without having to be prompted, monthly alerts fell from 339 to 198, and bypassed alerts dropped from 113 per month to 22. Duplicate scans were nearly eliminated, and unnecessary scans fell from a high of 23% to fewer than 5%. As a result, there were far fewer claims denials for imaging orders.

As this project illustrates, CDS is highly effective at quickly establishing uniformity of care in target processes. Momentary lapses required only a simple point-of-care reminder to return to compliant care. The health system that launched the CT scan project has since expanded its CDS initiative to include all CT imaging for headache, chest and abdominal pain. Early metrics indicate the achievement of results similar to those in the original project.

Increasing Compliance
Deviations from clinical guidelines are most often a simple matter of habit. Expecting clinicians to remember guidelines on their own is an ineffective means to changing habits for multiple clinicians across an enterprise. CDS-driven compliance supported by discussion, education and reporting delivers far better results, with far greater uniformity, through automation. Development of guidelines is expensive and time consuming; focusing efforts on review and workflow decision support is much more productive for organizations.

CDS can improve adherence to virtually any clinical mandates or guidelines, even as they evolve, without the need for clinicians to be fully aware of each new requirement as it is introduced. Properly directed, this unique capability can improve not only clinical outcomes for patients, but financial outcomes for provider organizations in an era when reimbursement is increasingly tied to compliance.

Juliana Hart is vice president, Market Development, medCPU.

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