By Carolyn M. Clancy, M.D., Director, Agency for Healthcare Research and Quality
This commentary first appeared in the July 7, 2011, issue of Government Health IT.
Health information technology (health IT) professionals often are mystified when doctors, nurses, and other clinicians don't embrace their technology. Even taking concerns about start-up costs and interruptions into account, many health IT experts see the cost and quality improvement benefit far exceeding the downside.
The development of clinical decision support (CDS) systems is an example. CDS systems provide patient-specific information that can help clinicians make better decisions by increasing adherence to evidence-based knowledge and reducing variations in clinical practice. CDS applications are frequently included in electronic medical record (EMR) systems, embedded with computerized order entry and electronic prescribing applications.
Yet, despite their clear advantages, uptake and motivation to acquire CDS systems remain low. More than one-third (38 percent) of physicians report using an EMR, but only 4 percent said it came with CDS system capabilities, according to the 2008 National Ambulatory Medical Care Survey.
This might frustrate the health IT vendor community, but the survey may offer a lesson in why CDS systems haven't gained more traction by now. One stands out: Integration into providers' workflow. Systems that aren't intuitive or useful, or don't reflect how providers care for patients, will remain on the shelf, even as EMR adoption climbs.
This is not to say that CDS systems and their interventions can't deliver. Health IT vendors that create clinical software that mirrors or enhances workflow and provide relevant, evidence-based information at the point of care will win acceptance by providers and support better care for patients.
Understanding What Matters
This isn't wishful thinking. A CDS system funded by the Agency for Healthcare Research and Quality (AHRQ) that provides tools to monitor and identify patients at high risk for developing pressure ulcers in nursing homes and integrates tools into daily work structures has reduced their incidence by approximately 40 percent 12 months after implementation.
To date, over 75 facilities have implemented the program, and 10 vendors* have incorporated requirements for the five standard reports that are part of this system into their software.
The project's lead investigator, Susan Horn, Ph.D., a senior scientist at International Severity Information Systems, Salt Lake City, Utah, and her colleagues at Health Management Strategies, Austin, TX, paid close attention to the information that certified nurse assistants (CNAs) needed to collect to track nursing home residents' care. From that, they designed five CDS reports based on a core set of daily clinical data, including patients' weight, nutrition, and continence, and also one that identified and prioritized patients at high risk of developing a pressure ulcer.
Pressure ulcers are a significant problem for nursing home residents. Of the 1.5 million residents in 2004, about 159,000 or 11 percent, were estimated to have pressure ulcers.
An overriding priority in creating the clinical reports was reflecting the information CNAs needed to capture and document as part of their care processes and then standardizing that data in a structured format, including checkboxes. Clinical reports organize, summarize, and trend data collected by CNAs to be used by the multidisciplinary team, including dieticians, social workers, and nurses. Weekly reports include:
- Nutrition report: Shows resident-specific data on average meal intake and weight loss for current week and previous 3 weeks; stratifies residents according to risk.
- Behavior report: Lists frequency of abnormal behavior observed by CNA; can inform assessments by nurses and social workers.
- High-risk trigger report: Identifies residents who show pressure ulcer risk factors such as weight loss, decreased food intake, incontinence, or poor ambulation.
- Skin report: Lists residents with skin tears or reddened areas.
- Priority report: Summarizes information on other reports to identify residents at high risk of pressure ulcers. Residents on this list receive increased attention and needed interventions.
Involving the Clinical Care Team
One takeaway from the On-Time project is the importance of leveraging information from clinical reports with the clinical care team to improve overall care processes. A second is the importance of fostering improved communication among the multidisciplinary team members, including CNAs, when making adjustments to the care plans for residents identified as high-risk.
Staff at nursing homes that use On-Time collaborates with a project facilitator to integrate the decision support tools into routine practice and make timely improvements in their overall care processes. Techniques include: discussing reports at designated care planning meetings and using information to change care plans; holding 5-minute standup meetings with dietary staff, CNAs and nurses to review residents at high nutrition risk and changing dietary orders or referring to speech therapy for swallowing evaluation; and holding weekly rounds with physical therapy, CNAs, and nursing to identify therapy interventions for high-risk residents.
In addition to preventing pressure ulcers, On-Time has been expanded to include a pressure ulcer healing program. It is aimed at monitoring the healing process and identifying risk factors that may affect healing. As part of this program, new weekly reports support nurses' decisionmaking and quality improvement changes are imbedded into the daily work routine to link efficiency and effectiveness. New modules for preventing falls and readmissions to the hospital are being developed by Dr. Horn and her colleagues.
The research behind On-Time and its successful implementation confirm AHRQ's belief that well-designed health IT interventions, reflecting workflow and evidence-based care processes, will gain providers' acceptance, regardless of care setting.
Most important, these health IT-enabled tools can improve outcomes and quality of life for patients, including our most vulnerable. Successful projects such as On-Time give the health IT vendor community important clues about how to design and implement products that meet clinicians where they are rather and where the evidence tells them they should be.
Carolyn M. Clancy, M.D., is Director of the Agency for Healthcare Research and Quality, Rockville, MD.
* Vendors that have embedded the requirements for the On-Time reports into their software are as follows: CareTracker® (by Resource Systems), Optimus EMR (by Optimus EMR, Inc.), Lintech, Mylex, Reliable, SigmaCare® e-Health, American Data, Healthcare Systems Connection, Point-Click-Care®, and HealthMedX™.
Current as of February 2012
Turning the Tide: Providers and Patients Win When Health IT Reflects Workflow. Commentary by Carolyn M. Clancy, M.D. February 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/commentaries/comtide.htm