Jerome A. Osheroff, MD, FACP, FACMI
Principal, TMIT Consulting, LLC
Adjunct Associate Professor of Medicine, U. of PA
April 2012
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Executive summary
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Overview of the CDS/PI Collaborative
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Overview of the CHCF-funded pilot project
◦ Phase I, Oct 2011-Mar 2012 [complete]
◦ Phase II, Apr 2012-Mar 2013
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The CDS configuration template
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Template use, benefits, evaluation
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Next steps
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Many organizations have joined a Collaborative to enhance how they
use CDS to address performance improvement imperatives
A CHCF-supported pilot project ran from 10/11 thru 3/12:
◦ 9 CDOs participated to test whether such collaboration would be valuable
◦ Participants improved their CDS and PI efforts by using a structured form for
documenting and sharing CDS strategies for 2 targets (VTE, diabetes)
◦ All sites got benefits, recommended next steps, and plan ongoing participation
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Next the Collaborative will, with further CHCF support:
◦ Engage more providers in completing and sharing target-focused CDS configurations
◦ Improve tools for completing and sharing templates, cover more targets
◦ Develop and share other tools to support target-focused CDS/PI project management
◦ Engage other stakeholders (e.g. vendors, RECs) more deeply in collaborative activities
◦ Explore mechanisms to make the Collaborative self-sustaining
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Providers face strong and increasing drivers (MU,
ACA, VBP, etc.) to improve specific care outcomes
associated with quality, safety, costs
Effective CDS is critical for these improvements but
complex, expensive, and challenging to get right
Absent widely applicable and vetted target-focused
CDS strategies, providers seek collaboration to ‘Get
better faster – together’
Other stakeholders (e.g., EHR/HIT vendors, federal
agencies, payers) also play critical CDS/PI roles and
are likewise interested in collaboration to advance the
state of the art and practice
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Accelerate local CDS and PI efforts by documenting,
sharing, and enhancing target-focused CDS strategies
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Foster development and use of tools that support this
strategy sharing and local value realization
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Include many provider organizations and PI imperatives
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Provide major benefits for all stakeholders; especially Care
Delivery Organizations, but also EHR/HIT Vendors, Payers,
Federal Agencies, and others
Leverage strategies for improving outcomes with CDS from
compendia such as the HIMSS CDS Guidebook Series
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All-time HIMSS
bestseller, book of
the year (2005)
Widely used by
CMIOs/others
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~100 contributors
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New (2/12)! >100 contributors
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Bestseller, HIT book
of the year (2009)
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Guidance on successful programs
and interventions
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Addresses hospitals, systems,
practices, vendors
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Worksheets underpin template;
‘Tasks’ define CDS success path
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Co-sponsors
include AHRQ, 3
CIS vendors
6 co-publishers
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“A process for enhancing health-related decisions and
actions with pertinent, organized clinical knowledge
and patient information to improve health and
healthcare delivery.” Improving Outcomes with CDS. HIMSS. 2012
Very
broad: way beyond alerts, order sets
Includes
many things providers are already
doing (though often not optimally)
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To improve targeted healthcare decisions and
outcomes, well developed and deployed CDS
interventions must provide:
•
the right information (evidence-based, actionable…),
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to the right people (clinicians and patients…),
•
in the right intervention formats (alert, order set,
answers, documentation tools, data display…),
•
through the right channels (CIS, internet, mobile…),
•
at the right points in workflow (decision/action ...)
Addresses: What, Who, How, Where, When
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Care delivery organizations across country
EHR suppliers (Allscripts, Cerner, Epic, GE,
QuadraMed, Siemens)
Federal agencies (ONC/AHRQ/CDC)
Beacon Communities
Society partners (HIMSS, Scottsdale Institute,
Society of Hospital Medicine)
CDS and analytics suppliers
Clinical transformation consulting firms
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Over 140 participants and growing steadily
(driven by word-of-mouth)
California Healthcare Foundation (CHCF)supported pilot enabled a Project Manager to be
engaged, and the feasibility and value of CDS/PI
collaboration activities to be tested
The pilot size, speed, and value exceeded
expectations
CHCF funded a follow on one-year Collaborative
phase focused on scaling and sustainability
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Validate that Collaborative goals are feasible - and work
toward them is valuable - by demonstrating that:
◦ Provider organizations would refine and use a template for documenting
and sharing target-focused CDS intervention approaches
◦ Participating organizations could agree on specific targets for joint
attention and on a common template for documenting interventions
◦ Using the templates locally, and sharing completed versions across
organizations, would add value to local CDS/PI efforts
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Engage key stakeholders in following and supporting the pilot
efforts, and generate ongoing participation beyond the pilot
Ultimately, drive widespread, CDS-enabled improvements in
patient outcomes, especially for high priority targets
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9 provider organizations met weekly 10/11/11 thru
12/11/11 to refine a CDS configuration template and
discuss their effort to get value from using it locally
7 organizations chose VTE as inpatient target focus
and 2 chose diabetes as outpatient target focus
Group used a private website/discussion group;
https://sites.google.com/site/cdsforpiimperatives/home
Used frameworks/tools from the HIMSS CDS
guidebook series to underpin work
Used full Collaborative to follow and provide input on
pilot efforts and prepare for scale; conducted allparticipant meeting on 11/28/11 (see Appendix)
In March 2012, formally evaluated pilot effectiveness
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Commitment to PI, systematizing care
processes, leveraging HIT investments
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Limited CDS/PI resources but high stakes; be
more efficient/effective, learn from others
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Successful experiences with other PI
collaboratives (get and give help)
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Enhance innovation and accelerate its spread
throughout their health systems
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Improve patient engagement and support
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Establish best practices for CDS interventions
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Inpatient (VTE Prophylaxis):
1. Ascension/St John Providence Health System (Cerner)
2. Hennepin County Med Ctr (Epic)
3. Lehigh Valley Health Network (GE)
4. MetroHealth System, Case Western Reserve U. (Epic)
5. New York Hospital, Queens (AllScripts)
6. Texas Health Resources (Epic)
7. University of Pennsylvania (Allscripts)
Outpatient (Diabetes Management):
1. University of Pennsylvania (Epic)
2. Veterans’ Administration (Homegrown)
Note: organizations listed in darker font participated most intensively in
developing and using the template and sharing results
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Starting point was worksheets from HIMSS 2012 book,
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Pilot sites iteratively refined this material, based on
successive efforts to use it in local CDS/PI meetings
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Template has 3 parts:
Improving Outcomes with CDS: An Implementer’s Guide
◦ Diagrammatic overview of workflow and CDS interventions
◦ Tabular view of workflow steps, corresponding target-related
activities, current/planned CDS interventions at each step
◦ ‘CDS Five Rights’ view documenting the
‘what/who/where/how/when’ for CDS interventions focused
on the target
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Different sites used different combinations of these 3
components in their local work
To view complete template, see online Users’ Guide
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I.
Consult
requests
When?
Z. Pop.
mgmt.
How?*
B.
History &
Assess.
A. Preencounter
Pre-visit
questionn
aires;
facesheets
Pattern
recognition logic
RECOGNIZE
PATTERNS
C. Form.
care plan
Knowledge
delivery/
interactive
ref
F. Order
handling
D. Documentation
Structured
documentation
FFORMULATE PLAN
H. Results/
new events
E.
Orders/
Rx
Order
sets;
error
checking
EXECUTE PLAN
G. Execute
Therapies/
Procedures
Alerts,
monitors
Error
checking;
alternatives
RESPOND TO
EVENTS
J. Dischg
or svc
transfer &
referrals
K. Post
visit/home
care
Pt. educ
guides;
followup care
prompts
Timebased
monitors;
pt.
reminders
COMMUNICATE
(also I)
* Template provides sample interventions for each
workflow step; i.e. the ‘How’ items in the grey boxes
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Example: VTE Prophylaxis-related Workflow and Interventions
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VTE Prophylaxis-related
Workflow and
Interventions
Generic Example:Target-specific
Clinical
CDS Interventions
that Are Currently
Workflow Step
Actions/Workflows/Decisions
Requirement to document patients who
are contraindicated for VTE prophylaxis
F. Order Handing Identification of at-risk patients who are
not on VTE prophylaxis
Implemented
Part of VTE order sets – requiring
therapy or documentation of
contraindication
Not done
Require corollary orders
Coumadin orders must be made daily
and must be accompanied by a INR
order for the next morning
Recommend dosing based on indication
Suggested dosing based on indication
on Coumadin order form
Coumadin compliant diet
Coumadin compliant diet
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CDS Interventions that Are
Potentially Promising, but
Not Yet Implemented
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Part of structured H&P
with built-in risk
assessment tool
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Identification of
patients at risk based
on past medical history
Combined diets, e.g. diabetic
and Coumadin compliant
diet
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Objective
Core Action
Workflow
Content Delivery
When
(Workflow
Step)
Population
Management
Z
VTE risk
assessment
Recognize
patterns
Recognize
patterns /
Formulate
Plan of Care
Appropriate VTE
Prophylaxis
Pre-encounter
A
History/Assess.
B
CDS Five Rights dimensions
What
How
(Intervention
(Information)
Type)
Demographics,
conditions, care gaps,
self-progress
History/Physical data,
medications, prior data
review, inferred
conditions
Answers to
comprehensive prompts
enable some fields within
VTE risk calculator to auto
populate.
Calculator displays
appropriate therapy
modalities based on
individual patient risk.
Per Worksheet 6-1
Comprehensive
Prompts (Smart
Documentation
Forms)
VTE Risk
Assessment
Clinical Calculator
(Relevant Data
Summaries)
Delivery Logistics
Who
(Person)
Where
(Channel)
Patient, Admin,
Case Manager
PHR/
Registry/
EHR
Nurse/ Physician
EHR ,
flowsheets,
data
facesheets
Nurse
EHR
Physician
EHR
* Template provides sample intervention
what/how/who/where for each workflow step
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High-level target-focused CDS strategy review
◦ Standard assessment/communication tool for
CDS approach
 Get stakeholder consensus/input, identify gaps
 Understand different approaches/results across health system
 Organize qualitative/quantitative intervention impact reporting
◦ Roadmap for target-focused CDS activities
 Guide decisions about PI opportunities and potential CDS
interventions
 Plan for best practice care and optimal CDS (which evolves)
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Detailed CDS configuration planning
◦ Consider each dimension of CDS Five Rights (e.g.,
all care team roles and intervention types)
◦ Optimize use of current support tools, determine
need for new tools and approaches
◦ Link MU reportable measures (VTE) to CDS
configuration
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Better local CDS stakeholder engagement/communication
◦ With recipients; leadership; CDS, IT, and quality teams; clinicians
◦ Stakeholders better visualize and enhance their inter-related efforts
◦ Specifies CDS PI opportunities by making explicit current thinking and
deployments focused on applying CDS to specific imperatives
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Enhanced strategic planning
◦ “The exercise of categorizing and describing our [CDS/PI] strategies
has been very useful and demonstrated the importance of stepping
back from ‘the weeds’ to get the big picture of where our efforts are
going”
◦ Workflow diagram provides a holistic view of CDS activities and
opportunities across all care processes vs. in isolation
◦ Better understand need/opportunities to improve patient engagement
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Improved CDS execution
◦ Explain why current CDS approaches not working well
◦ Broaden approach to CDS toolkit, recipient and workflow
support opportunities, e.g.:
 Reassess VTE risk after admission
 Consider diabetes CDS opportunities across care continuum
◦ Leverage CIS & CDS capabilities better and
understand/address limitations
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Knowledge sharing accelerates progress
◦ Learn from other organizations’ approaches/results
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8* out of 9 sites reported that using the template was
somewhat to significantly useful for local stakeholder
engagement, CDS/PI strategic planning, and/or CDS
implementation
In terms of the net effect of the project on each
organization’s CDS/PI efforts, all 9 sites said it was somewhat
to significantly helpful
8 sites anticipate continued use of the template in their
organization**
All 9 sites indicated that they would like to continue to
participate in the Collaborative
* 9th site didn’t have an active CDS project focused
on the target during the pilot
** 9th site would use the template if there were a large
group sharing completed templates
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2.
3.
Foster adoption/value from CDS strategy
sharing for additional provider
organizations and cover more topics
Deepen and integrate engagement of CDS
stakeholders other than providers
Develop a sustainability plan for
maintaining/enhancing the Collaborative
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Get ≥10 more providers using template
Refine Users’ Guide to enable this use and
value without weekly meetings and ‘hand
holding’ used to engage sites during pilot
Create electronic fill-in-the-blank version of
the template that is more user-friendly
Refine and deploy next-generation online
‘shared library’ for completed templates
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Cover at least 3 more PI imperatives
Establish forums such as regular target-specific
teleconferences and online discussions wherein Collaborative
participants can review and accelerate their respective targetfocused CDS/PI work
Develop/use template for documenting and sharing targetfocused CDS/PI project management tasks (e.g., stakeholder
engagement)
Explore feasibility/value from organization-specific subcommunities to discuss challenges and implementation best
practices among facilities in large health systems; goal is to
accelerate CDS/PI innovation and spread within the system
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Preventable complications (Safety)
◦ VTE
◦ Catheter-associated infections (Blood stream, urinary)
◦ Adverse drug events
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Condition management/Core Measures (Quality)
◦ Cardiovascular (CHF, AMI, Blood Pressure, Smoking)
◦ Diabetes
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Efficiency (Cost)
◦ Readmissions (CHF, AMI, pneumonia)
◦ Early sepsis detection
Note: Pilot sites addressed targets in blue
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Create vendor-focused sub-communities to
ensure vendor tools are used effectively in PI
Consider other related sub-communities
Conduct cross-stakeholder explorations into
enhanced inter-related value propositions
from Collaborative, including a possible
CDS/PI pilot of this value involving payers,
Regional Extension Centers, providers, and
EHR vendors
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HIT/analytics vendor supports Collaborative subgroup
consisting of its clients, for CDS configuration documentation
and sharing, and best practice development using a template
version adapted to its specific CDS related tools; by-product
is insights into how vendor can enhance its CDS tools focused
on one or many PI imperatives
Payer supports Collaborative subgroup within its network to
identify and disseminate successful PI practices focused on
targets of particular interest to the population covered
Health-system oriented sub-community as noted earlier
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National clinical condition-focused initiative supports
Collaborative subgroup to focus on identifying successful
CDS practices focused on that target, and accelerating spread
of these practices on a widespread basis
Clinical Transformation consultancy builds subgroup of its
clients to identify and spread CDS/PI best practices faster
Federal agencies (e.g. ONC, CDC, AHRQ) interested in
enhancing use of HIT to address population health goals
create sub-communities for these purposes (e.g., define and
spread successful CDS practices leveraging Beacon
Communities, REC’s etc.)
In Thread 2, we will explore creating these potential subcommunities and examine how they inter-relate with each
other and the broader Collaborative to achieve shared goals
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Identify mechanisms to make Collaborative
self-sustaining (leveraging Threads 1&2)
◦ Make the collaboration activities self-perpetuating
(e.g., via Users’ Guide and related approaches to
systematize steps in the Collaborative’s value
delivery process)
◦ Create plan for ongoing funding in return for value
delivered to stakeholders
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The pilot validated the hypothesis that the
Collaborative delivers value to providers
There is strong, multi-stakeholder interest in
scaling the pilot activities
We have established Phase II funding from
CHCF in order to:
◦ Scale provider engagement and value
◦ Cultivate cross-stakeholder value propositions
◦ Develop a sustainability plan
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Project Director: Jerry Osheroff, MD
◦ josheroff@tmitconsulting.com
Project Manager: Lynne Schabert
◦ Lynneschabert@cox.net
Project Website/Discussion Group (Private to Collaborative)
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https://sites.google.com/site/cdsforpiimperatives/home
Informational Website on Project (Public)
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Includes form to request entry into the Collaborative
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https://sites.google.com/site/cdsforpiimperativespublic/home
Users Guide for Collaborative and Template (Public)
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Includes: configuration template; slides about it that pilot sites used locally
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https://sites.google.com/site/cdsforpiimperativespublic/cds-for-pi-imperatives-users-guide
HIMSS CDS Guidebook Series
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www.himss.org/cdsguide
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