CDS success may lie in implementation


Scope and method of implementation plays a critical role in successful implementation of a CDS systems.

The pressure to implement effective Clinical Decision Support systems, particularly for imaging providers is likely to increase. (Photo courtesy of the National  Institutes of Health)If you look at three studies published last week regarding the effectiveness of Clinical Decision Support you might question the wisdom of the $19.2 billion President Obama’s stimulus package allocated to promote Healthcare Information Technology (HIT) use in the United States.

The largest of the three studies was reported by Max J. Romano and Dr. Randall S. Stafford of Stanford University’s Prevention Research Center, and published online Jan. 24 in the Archives of Internal Medicine.

They found little difference in quality of care delivered by doctors using Electronic Health Records (EHRs) compared to those using paper medical records. Clinical Decision Support (CDS) also was not associated with higher-quality care with only 1 of 20 ambulatory care quality indicators showing improvement. That indicator was avoidance of unnecessary electrocardiography during routine examinations (98 percent vs 93 percent).

They used the most recent data available from the National Ambulatory Medical Care Survey (2005-2007) and the National Hospital Ambulatory Medical Care Survey (2005-2007), both conducted by the National Center for Health Statistics. In 2005, there were 24,627 visit records available from NAMCS, 26,806 from the NHAMCS outpatient department component, and 29,747 from the NHAMCS emergency department component, for a total of 81,180 visit records.

The study found that the use of EHRs and CDS in ambulatory visits varied significantly across patient and provider characteristics. The EHRs were used in 41 percent of patient visits in the West, a rate much higher than that of other regions (25 to 30 percent). Among ambulatory visits at which EHRs were used, CDS was more likely to be present in the West (66 percent of EHR visits) compared with other regions (47 to 56 percent). Surgeons (46 percent) and other specialists (35 percent) had the lowest CDS use compared with other physicians (51 to 67 percent).

In an editorial in the same issue, Drs. Clement McDonald and Swapna Abhyankar, both of National Institutes of Health, wrote that this lack of effect of CDS on provider behavior was surprising given the strong effects previously reported in randomized controlled trials of these systems examined in a JAMA review of CDS systems in 2005 led by Dr. Amit X. Garg, of the University of Western Ontario, London.

They pointed out that Romano’s study failed to define which CDS guidelines were implemented in the systems that they studied, noting that practices and EHRs vary considerably in the number and type of CDS rules that they implement.

“We do not know whether the CDS rules implemented by the practices that participated in the surveys addressed any of the 20 quality indicators evaluated by Romano and Stafford,” they wrote. “Second, the current study and Garg and coauthors' review considered very different categories of guidelines. Most of the guidelines (60 percent) in Romano and Stafford's study concern medication use; none of them deals with immunizations or screening tests, which were the dominant subjects in the studies reviewed by Garg, et al.”

The Garg review examined 100 well-designed studies on outcomes of CDS. That study evaluated a total of 3,826 practitioners or practices and more than 92,895 patients. The 44 of the 60 trials (73 percent) involving CDS systems that gave providers automated CDS guidance had positive and often large effects on provider behavior and care processes.

In a small, single-institution study also published last week and reported on by The Hub, Dr. Craig Blackmore and colleagues at Virginia Mason Medical Center in Seattle, suggested that the key to success of clinical decision support for ordering imaging studies may lie in targeting specific kinds of studies. The results of that study showed substantial and sustained reductions in inappropriate use of advanced imaging tests. Blackmore also said that involving providers in the design of the system and development of the clinical decision rules enhanced acceptance of the system, which also may have improved results.

Finally, a Minnesota trial focusing on cost containment and conducted by the Institute for Clinical Systems Improvement and the Center for Diagnostic Imaging, a regional imaging provider with several dozen outpatient imaging centers across 10 states announced early results. With participation from a consortium of nonprofits, medical groups, state government and vendors the trial was most compelling for its focus on the bottom line. After three years of data covering five medical groups and more than one million CT, MRI, PET and nuclear imaging scans, their results showed that the CDS halted the growth of imaging costs, improved diagnostic utility and saved an estimated $84 million.

As a result, BlueCross BlueShield of Minnesota, HealthPartners Health Plan, Medica, UCare and DHS are all going ahead with plans to adopt the CDS tool in preparation for voluntary statewide adoption.

Clearly, the scope and method of implementation plays a critical role in the success of a CDS system. In the Romano study it is clear that adoption of CDS varies greatly by region, indicating patterns of acceptance by providers. Other factors affecting implementation success may be logistical. McDonald and Swapna Abhyankar, call for a standardization of data reports.

“The upstream data producers should deliver clean data that can be imported into downstream EHRs without additional work or cost,” the authors wrote. “Compared with the work that would be required for each site to clean and standardize the data that they receive, it would take just a fraction of the effort for the data sources to tighten up their electronic reporting so that it strictly conforms to national format, content, and code standards.”

One thing all three studies make clear is that regardless of study outcomes, the drive for nationwide use of CDS will continue, and with $84 million is savings shown in a single region, you can bet payors will be increasing the pressure on providers to implement effective CDS systems.

By: Michael O'Leary, contributing editor Health Imaging Hub