Achieving Positive Clinical Outcomes, Cost Savings, and Regulatory Compliance using Clinical Decision Support Alerts in the Electronic Health Record

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2 Achieving Positive Clinical Outcomes, Cost Savings, and Regulatory Compliance using Clinical Decision Support Alerts in the Electronic Health Record Jason Lam, PharmD Assistant Clinical Professor / Lean Six Sigma Green Belt UCSD Skaggs School of Pharmacy and Pharmaceutical Sciences JasonLam@ucsd.edu

3 Disclosure I have no conflicts of interest to disclose.

4 Learning Objectives 1. Identify and describe key process steps on how to design, implement, and monitor clinical decision support (CDS) alerts in the electronic health record (EHR) 2. Develop and complete an alert report template used to evaluate alert effectiveness 3. Provide examples of how CDS alerts can be used to improve patient outcomes, show cost savings, and accomplish regulatory documentation needs

5 My Roles: Past and Present Sharp Healthcare (SHC), San Diego CA ( ) Senior Specialist, Evidence Based Medicine (EBM) EBM Multidisciplinary Team with physicians, nurses and pharmacists Develop and maintain 400+ order sets Implement and monitor CDS alert effectiveness and patient outcomes Electronic Health Record (EHR): Cerner UCSD SSPPS, La Jolla CA (2016-present) Assistant Clinical Professor Electronic Health Record (EHR): Epic University of San Diego, San Diego CA (2012-present) Adjunct Lecturer in CDS and EHR Masters in Healthcare Informatics Advisory Board Member

6 CDS Alerts Key Process Steps Problem and Alert Idea Identify Stake Holders Feasibility and Test Audit and Activate Monitor

7 Rule and Alert Types When does it Pop-up? Clinical Decision Support (CDS) Alert A pop up guiding providers in a clinical decision. An alert includes : Pertinent clinical information (e.g. lab results) Clinical guidance (e.g. evidence based guidelines) Suggested actions to take Suggestion to NOT take action O p e r a t i o n a l R u l e Does not pop up an alert Does not interrupt clinician workflow Facilitate a department or service process (e.g. central supply device order; Foot Pump).

8 CDS Alerts Key Process Steps Problem and Alert Idea Situation (SBAR) Background Assessment Recommendation Identify Stake holders (PARMI) Process Owner Approver Resources Members Interested Parties

9 Situation: Blood Clot Risk Factor Awareness

10 Background: VTE Risk Factors and Triggers Majority of Venous Thromboembolism (VTE) events have specific, identifiable triggering events: Major surgery Trauma Prolonged immobility (e.g. long flights) Hospitalization Factors that disproportionately increase VTE risk beyond age, gender, and race: Major surgery Obesity Recent trauma Steroid hormone exposure Acute infection Smoking Cancer Hospitalization for acute medical illness considered the single most important risk factor for developing a VTE -The Surgeon General s Call To Action to Prevent DVT and PE, 2008

11 Assessment: VTE Improvement Opportunity 1-5 Mortality 1 in 10 hospital deaths attributed to pulmonary embolism (PE) Morbidity Increased lifetime risk for recurrence Increased lifetime risk for chronic complications Cumulative incidence of recurrent thrombosis is 30% over 10 years Reduction of VTE incidence with prophylaxis well documented VTE prophylaxis underutilized or not adequately applied

12 National Hospital Inpatient Quality Measures 6 MEASURE Patient Population Benchmark VTE 1 Inpatient (Non-ICU) 99.9% VTE 2 Inpatient (ICU) 99.9% SCIP-VTE-2 Surgical 100.0% STK-1 Stroke 99.9% Hospitals are compliant when: 6 VTE prophylaxis administered within 24 hours of admission/surgery Exclusion reason documented within 24 hours of admission/surgery Benchmark based on top decile of national rates

13 % of Sampled Population Assessment: VTE Measure Compliance ( ) 100% 95% BETTER 90% 85% n=14,450 % COMPLIANT 80% * *Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 *Q1 Q Pre-Alert Post-Alert Pre-alert compliance at 4 SHC hospitals was below 95% for 3 quarters

14 VTE Prophylaxis Alert - SBAR SBAR Situation Background Assessment Recommendation Details Develop an alert to facilitate VTE Prophylaxis orders to reduce risk of blood clots in the hospital Meaningful Use Stage 2 required implementation of 5 clinical decision support alerts (4 related to core measures) PARMI formed to: Review recent fall outs (when would the Alert help) Determine Alert feasibility Build, test, and monitor VTE prophylaxis alert

15 VTE Prophylaxis Alert - PARMI PARMI Process Owner(s) Approver Resources and Members Interested Parties Stakeholders VP of Quality, VP of Clinical Informatics Quality Directors, Chief Medical Officers Quality, EBM Pharmacy and Nursing Senior Specialist, IT team members Entity quality departments, frontline staff

16 CDS Alerts Key Process Steps Feasibility and Test Evoke Logic Action Audit and Activate Data Review Utilize PARMI Communication

17 Rules and Alerts Elements EVOKE LOGIC ACTION Feasible Evokes add order sign order open chart close chart Keep it SIMPLE! Review clinical data Remove/keep order Add order(s) Evidence link Clinical advisor

18 VTE Prophylaxis Alert Design Evoke: Sign Admission Orders Logic: Inpatient Type (in ED or floor) 18+ years old No anticoagulant treatment order No mechanical/pharmacologic VTE prophylaxis order No VTE exclusion reason order Action: Alert with option to Add orders Pneumatic compression devices Exclusion reason Suggestion for pharmacologic prophylaxis

19 VTE Prophylaxis Alert- Bulletin EMR Training Department Weekly Bulletins Blurbs Targeted by user and hospital

20 CDS Alerts Key Process Steps Monitor Number of Alerts Alert Fatigue Alert Effectiveness

21 VTE Prophylaxis Alert Case H&P: An 87-year-old female with hypertension and unknown valve disorder. She presents to the Emergency Room with right hip pain after mechanical fall. Admitted on 11/5/ :48 PST - Admitting MD signed admission order set 19:48 PST - Alert fired to Admitting MD to notify that VTE prophylaxis was not addressed 19:49 PST - Admitting MD ordered Pneumatic Compression Device (PCD)

22 VTE Prophylaxis Alert Report Elements Patient Demographic Data Elements Patient Name Visit Number Medical Record Number Patient Type Admit date Discharge date Length of Stay Hospital/Facility Relevant Alert Data Elements Alert fired Alert fired date / time Alert Recipient Post alert Mechanical VTE prophylaxis order details Post alert Pharmacologic VTE prophylaxis/treatment order details Post alert Reason No VTE prophylaxis order details Defining Alert Effectiveness NO = No mechanical/pharmacologic VTE prophylaxis or exclusion reason order YES = If there is at least one of the following: mechanical/pharmacologic prophylaxis or exclusion reason order

23 VTE Prophylaxis Alert Output Example Patient Hospital Mechanical Pharmacologic Exclusion Alert Effective? Patient A Hospital 1 Compression device knee High Bleed Risk Patient B Hospital 3 No Patient C Hospital 3 High Bleed Risk Yes Patient D Hospital 3 No Patient E Hospital 4 warfarin Yes Patient F Hospital 5 Compression device knee enoxaparin Algorithm Determined by PARMI built into Alert Effective Column Yes Yes

24 VTE Prophylaxis Alert Data Analysis Jan 2015: alert logic updated to include Emergency Department

25 VTE Prophylaxis Alert Data Analysis Increase in Alert Effectiveness between 2014 and 2015 (p<0.001)

26 VTE Alert Data Analysis (Nov 2013 May 2015) VTE Alert Fired N= % Reported patients to CMS for VTE Compliance N=8756 OVERLAP: N=356 No VTE prophylaxis order on admission Included in VTE prophylaxis quality measure compliance sample for CMS

27 VTE Alert Improved Regulatory Compliance Before Alert (Jan Oct 2013) After Alert (Nov 2013 May 2015) Compliant 5359 (n=5694) 8512 (n=8756) Compliance % 94% 97% Odds of being compliant Odds Ratio Odds After Alert/Odds Before Alert = 2.18 P-value p < (statistically significant) 2X as likely to be compliant after implementation

28 VTE Alert Improved Regulatory Compliance Clinician responded (n=301) Clinician ignored (n=55) Compliant 288/301 37/55 Compliance % 96% 67% P-Value p < (statistically significant) Measure compliance depends on prophylaxis order AND documentation

29 % of Sampled Population VTE Compliance Before and After Alert 100% BETTER 95% 90% n=14,450 % COMPLIANT COMPLIANCE 85% 80% * *Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 *Q1 Q Pre-Alert Post-Alert ED patients added * Partial quarter

30 VTE Prophylaxis Alert Order Outcomes N = 5999 PHARM PHARM + MECH MECH REASON ONLY NO ACTION TAKEN 82% of clinicians responded to the alert by the next day 18% of clinicians ignored the alert by the next day

31 Situation: Blood Transfusion Risk Versus Benefit Blood. Who Gets it? Considering blood utilization; which includes clinical value and patient education Communicating patient requests

32 Background: Blood Clot Risk Factor Awareness 7 There is a one-in-a-million chance that any one of us will be involved in an airplane catastrophe....a one-in-a-thousand chance of us suffering from transfusion-related acute lung injury (TRALI) a one-in-a-hundred chance of getting transfusion-associated circulatory overload (TACO) upon receiving blood. 7 J. Northover

33 Blood Utilization Alerts - SBAR SBAR Situation Background Assessment Recommendation Details Develop two alerts to facilitate: 1. Appropriate blood transfusion guideline compliance 2. Document that the risks and benefits of blood transfusions have been discussed with the patient System-wide hospital blood utilization committee identified need to manage red blood cell transfusion PARMI formed to: Review blood utilization at all hospitals recent fall outs (when would the Alert help) Determine Alert feasibility Build, test, and monitor: 1. Blood transfusion alternative alert 2. Blood transfusion attestation alert

34 Blood Utilization Alerts - PARMI PARMI Process Owner(s) Approver Resources Members Interested Parties Stakeholders VP of Clinical Informatics, Clinical Informaticists Laboratory Clinical Informaticist, System Blood Bank Specialist, Entity Blood Bank Specialist, Pathologist, Bloodless Medicine Manager, OB/GYN MD, Surgeon, Quality Director, CNS Clinical Application Analyst, EBM Pharmacy and Nursing Senior Specialists, Six Sigma Black Belt, Clinical Informaticist Specialist, Clinical Application Analyst, Regulatory Affairs, EMR Training System Blood Bank Specialist, Laboratory Clinical Informaticist, Clinical Application Analyst, EBM Specialist EBM Council, CNO Council

35 Blood Transfusion Alternative Alert - Design Evoke: Sign Transfuse Red Blood Cells Order Logic: Hgb greater than 6.9 g/dl Hct greater than 20.9% 1+ years of age No H&H result within 24 hrs No Surgery within 48 hrs Not a trauma, hemorrhage, GI bleed patient Action: REMOVE Transfusion Order KEEP Transfusion Red Blood Cells

36 Blood Transfusion Alternative Alert - Case H&P: This is a 55 year old male history of colon cancer now with metastasis to lung. Patient scheduled for thoracic surgery. Day 1 Admitted for thoracic surgery. Estimated blood loss of 1 liter in OR. Day PST - H&H 10.1/ PST - Transfusion PRBC ordered; NO ALERT (<48 hrs postop) Day PST - H&H 6.6/ PST - Transfusion PRBC ordered; NO ALERT (met guidelines) Day PST - H&H 9.9/ PST - Transfusion order attempted: ALERT FIRED (no order processed)

37 Blood Transfusion Alert Report Elements Patient Demographic Data Elements Patient Name Visit Number Medical Record Number Patient Type Admit date Discharge date Length of Stay Hospital/Facility Relevant Alert Data Elements Alert fired Alert fired date / time Alert Recipient Post alert Mechanical VTE prophylaxis order details Post alert Pharmacologic VTE prophylaxis/treatment order details Post alert Reason No VTE prophylaxis order details Defining Alert Effectiveness NO = Transfusion ordered and given YES = Transfusion NOT given

38 Blood Transfusion Alternative Alert - Analysis 6,437 transfusions avoided in 27 months (estimated 4.5 million savings) 8

39 Situation: Blood Transfusion Risk Versus Benefit The Paul Gann Blood Safety Act became law in California on January 1, 1990, mandating that patients be informed of the risks and alternatives of blood transfusions. stimulated the surgical team to control blood loss during [cardiac] surgery and to avoid the anticipatory use of component transfusions 9

40 Blood Transfusion Attestation Alert - Design Evoke: Sign transfusion order Red Blood Cells, Plateletpheresis, Cryoprecipitate, Thawed Plasma, Granulocytes Concentrate Logic: 1+ yr in age No Regulatory Requirement Acknowledgement order Action: Alert: with options to add Attestation or Emergent order

41 Blood Transfusion Alert Report Elements Patient Demographic Data Elements Patient Name Visit Number Medical Record Number Patient Type Admit date Discharge date Length of Stay Hospital/Facility Relevant Alert Data Elements Alert fired Alert fired date / time Alert Recipient Post alert Mechanical VTE prophylaxis order details Post alert Pharmacologic VTE prophylaxis/treatment order details Post alert Reason No VTE prophylaxis order details Defining Alert Effectiveness NO = Attestation not completed YES = Attestation signed by Provider

42 Blood Transfusion Attestation Alert - Analysis 89% standardized documentation in 21 months

43 Summary 1. It is important to develop a standard process to design, implement, and monitor CDS alerts in the EHR 2. Custom alert reports are critical in monitoring alert effectiveness 3. CDS alerts can be targeted to Improve quality measure compliance (e.g. VTE Prophylaxis measures) Urinary catheter removal order and documentation alert Postoperative beta blocker alert Reduce cost of care (e.g. blood transfusion) Tetanus 10 year look back alert CT abdomen/pelvis 6 month look back alert Improve regulatory compliance (e.g. blood attestation) 2 midnight documentation alert Rehab Plan of Care documentation alert

44 Into the Future 1. Alert Dashboard Alert Dashboard Percent Alert Effectiveness Quarter and Year Q Q Q Q Alert 1 56% 52% 52% 55% Alert 2 94% 87% 83% 86% Alert 3 93% 91% 91% 89% Alert 4 34% 25% 35% 32% 2. Alert Fatigue Analysis Alerts by hospital Alerts by user

45 Test Questions #1 What are the missing key process steps in the development of CDS alerts workflow below? A. Get funding; Close the ticket B. Engage end users; Report C. Identify Stake holders; Monitor D. Reject request due to alert fatigue concerns; Not applicable Problem and Alert Idea (SBAR) Feasibility and Test Audit and Activate

46 Test Questions #2 The CDS alert example on the right was developed to promote postoperative beta blocker ordering. What relevant alert data elements would you include in the report? A. Beta blocker home medication B. Post alert inpatient beta blocker order C. Exclusion reason D. Vital signs E. All of the above What other data elements can you think of that adds value?

47 Test Questions #3 An engaged pharmacy team member approaches you and says: I saw Dr. Careless order an anticoagulant on an epidural patient again, we need a pop up in our EHR right NOW!! Your response is: A. Let me call the IT director and demand a solution now B. Technology can t help us with that, let s ask the Chief Medical Officer to revoke the physician s privileges C. Let it go, things happen D. Here is our process to evaluate a CDS alert, let s start with the SBAR and PARMI

48 References 1. Bahl V, Hu HM, Henke PK, Wakefield TW, Campbell DA, Caprini JA. A validation study of a retrospective venous thromboembolism risk scoring method. Annals of Surgery. 2010;251(2): Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest. 2008;133: Tapson VT, Hyers TM, Waldo AL, et al. Antithrombotic therapy practices in an era of practice guidelines. Arch Intern Med. 2005;154: Caprini JA, Hyers TM. Compliance with antithrombotic guidelines: current practice, barriers, and strategies for improvement. Manag Care. 2006;15: Holley AB, Moores LK, Jackson JL. Provider preferences for DVT prophylaxis. Thromb Res. 2006:117: Joint Commission. Accessed May 2015 ( 7. Northover, J, Medical Laboratory Observer, October ( 8. Hofmann A, Ozawa S, Farrugia A, et al. Economic considerations on transfusion medicine and patient blood management. Best Pract Res Clin Anaesthesiol 2013;27: Carey JS, et al., Transfusion therapy in cardiac surgery: impact of the Paul Gann Blood Safety Act in California., American Surgeon, Dec. 1991

49 Session Code: 1. Write down the course code. Space has been provided in the daily program-at-aglance sections of your program book. 2. To claim credit: Go to before December 1, 2016.