Fall 2024 Issue

Clinical Decision Support: CDS Evolves Under Patient-Centered Care
By Elizabeth S. Goar
For The Record
Vol. 36 No. 4 P. 8

As the body of evidence supporting the benefits of patient-centered care (PCC)—improved outcomes, lower care costs, greater patient engagement, and increased physician satisfaction—continues expanding, hospitals and health systems are adjusting their thinking around clinical decision support (CDS) models.1 In particular, decision support within a PCC environment needs to accommodate a multidisciplinary care team that typically includes a mix of physicians, advanced practice nurses, physician assistants, nurses, pharmacists, nutritionists, social workers, educators, and care coordinators.2

According to Nordic’s e-book Patient-Centered Excellence for a New Era of
Care, under the PCC model of care, operations, strategy, clinical practice, and technology are centered around the individual patient’s needs. The health care experience is transformed into something more personalized, effective, and caring, and health care leaders are empowered to foster an environment where providers, patients, care teams, and caregivers thrive.3

Through the Digital Front Door
While PCC is not a new concept, until recently “it has been kind of haphazardly put together,” according to Craig Joseph, MD, chief medical officer at Nordic. Now, however, a growing number of hospitals and health systems are “developing the digital front door … that is the centerpiece of patient-centered care. They’re developing things to make it easy to interact [and to] meet the patient where they are.”

A digital front door is critical to the success of the PCC model by providing accessibility, engagement, and empowerment for both the patients and their care teams. It comprises a mix of technology tools and software including EHRs, patient portals, telemedicine, and smart devices that provide on-demand access to information and research, virtual visits, and self-care.

The digital front door is also the entryway for more advanced technology tools that leverage the massive volume of data flowing through the average health care facility, including patient information, population health, and social determinants—or drivers—of health. Advanced data aggregation and artificial intelligence-powered analytics help providers sift through mountains of information and assemble holistic patient views constructed from patient information as well as clinical best practices and peer-reviewed research. This, in turn, supports the creation of customized care plans, setting the stage for greater patient engagement and compliance and enhanced health outcomes.

“It’s all connected. It’s not just a matter of [whether] you should use electronic health records. It’s a question of [whether] you’re configuring and leveraging the technology that you have in the most efficient way,” Joseph says.

Atypical CDS
Along with reconfiguring existing technology to center the patient, effective PCC requires a reimagination of tools like CDS to meet the needs of a multidisciplinary care team.

Traditional CDS is meant to be used by one clinician, typically a physician. However, “if you buy into that team-based approach, it makes sense for other team members to get some of these alerts and have access to some of the [decision support],” Joseph says.

“To go even broader, I would argue that the patient is a member of the care team,” he adds. “It’s not a paternalistic [relationship] anymore where we make decisions and tell the patient how it’s going to be. We need the patient to be involved, and part of that is that shared decision-making. It’s about leveraging shared decision-making and having clinical decision support tools that support that.”

Penn Medicine, for example, has developed multidisciplinary care teams including physicians, advanced practice providers, nursing, social work, case management, nutrition, physical therapy and occupational therapy, and more “that assure that all patient and family needs are being considered and addressed,” says chief medical informatics officer C. William Hanson, MD.

Supporting the team’s needs has meant reimagining CDS, in part by expanding its array of technological tools to enrich the quality, depth, and breadth of information available for shared decision-making. These include the following:

• patient reminders via the patient portal for vaccines, health maintenance reminders, and Patient Health Questionnaire-9 sent to the patient prior to a visit;

• personalized genomic data for personalized treatment recommendations;

• patient preferences and social determinants of health (and prompts for case management if needs are identified);

• radiology CDS, such as a three-step conditional order for breast radiology to decrease time from a screening mammogram to a diagnostic mammogram;

• research sources such as Palliative Connect Best Practice Advisory and Banner to encourage providers to connect with patients on ways to improve patient and family quality of life/advance care planning and to address cultural/spiritual needs, psychosocial needs;

• Penn Pathways, which are pathways integrated with the EHR to support clinical indications; and

• individualized care plans, eg, for sickle cell patients in the emergency department using FYI flags.

“The Penn Medicine team strives to make the right thing to do for patients the easiest thing for clinicians to do,” Hanson says. “CDS tools are streamlined to limit interruptions wherever possible. Where there are interruptive CDS tools, we expect each one to offer clinicians a single click to take the desired action. Assembling the right information for the right clinician at the right time in the workflow to make a decision, using the right channel and the right format [per Osheroff et al’s Five Rights] is a bedrock principle of CDS at Penn Medicine.”

Penn Medicine’s PCC Journey
Penn Medicine’s technology-enabled journey to PCC saw it implement several key steps in addition to establishing a multidisciplinary team. It seeks to operate as a high-reliability organization and to be a “leading learning health system, one in which every event within the care process is an opportunity for learning and continuous, relentless improvement,” Hanson says. “Learning health systems, by their nature, are always learning from their experiences to develop better ways of providing patient-centered care.”

Penn Medicine is also committed to evidence-based practice and has invested in a nationally renowned Center for Evidence-Based Practice that seeks to build the evidence base, and that’s recognized and supported at the highest levels.

Underlying it all is a foundation of supportive technologies designed to aid care teams in establishing appropriate care plans for optimal outcomes. One example is the impact of a patient-centered, technology-enabled approach to hepatitis C screening.

“Using nimble, intelligent CDS and by partnering with expert teams across Penn Medicine, such as Infectious Diseases and the Center for Health Care Innovation, the CDS team has made lasting improvements in hepatitis C care in our community,” he says, pointing to the health system’s participation in a study published on JAMA Open Network which found that embedding hepatitis C virus (HCV) screening as a default order in their EHR substantially increased ordering and completion of testing in the hospital compared with a conventional interruptive alert.4

Importantly, Hanson notes, Penn’s approach to CDS under a PCC model reduced clinician burden and improved patient care by reducing the number of steps clinicians need to take—saving valuable time while still achieving desired outcomes.

“And we’ve eliminated barriers to doing the right thing,” he adds. “By creating a hepatitis C linkage team, for example, clinicians no longer need to worry about who will contact patients and how to advise them if they screen positive for hepatitis C. It’s made clinical workflows more efficient. And there is no better satisfier for the clinical staff than offloading tedious and cognitively burdening tasks from them.”

An important aspect of Penn Medicine’s success with PCC is the recognition that more than one team’s expertise is sometimes required to solve a problem. In the case of HCV screening, Penn’s CDS, Infectious Diseases, and the Center for Health Care Innovation teams came together to solve the screening challenge.

The lessons learned from its HCV screening program have been rolled into “an infrastructure to make that the norm every day,” Hanson says. In creating its Center for Applied Health Informatics, Penn brought together expert teams in informatics and related disciplines to concentrate on solving the highest priority health system informatics challenges.

Penn is also sensitive to cultural differences. Hanson notes that aligning practices according to Penn Medicine’s can be challenging, but it’s an important aspect of leadership’s desire to operate as “One Penn Medicine” and maintain focus on what’s best for patients.

“Once we’re all aligned, implementing CDS to support those practices becomes easier,” he says.

Finally, to close technical expertise gaps, Penn Medicine has “adopted a lean and modular approach to CDS … that was recognized by Epic as a model for others and was made part of the Epic foundation system for new customers,” Hanson says.

For example, order sets contain certain core sections that are reused when new order sets are created, thus reducing the build burden on Penn’s technical teams and creating order sets for frontline clinicians with a consistent look and feel.

The Future of PCC CDS
Looking ahead, the future of PCC CDS is likely to involve linking even more technologies and tools to support broader collaboration, “as more and more data are becoming liberated from the EHR—meaning I get access to it and I have the opportunity, as a patient with or without my physician’s approval, to get other kinds of perspectives,” Hanson says, pointing to Epic’s release in July of a feature that makes it easier for patients to securely share their health information to health apps of their choosing.

“I see that happening more in the future as the technology gets more advanced and the information becomes more liquid [and] easily transferred,” he adds.

Meanwhile, Penn Medicine is actively exploring the future of CDS, including collaborations that will enable decision support to be shared across sites, such as with SMART on FHIR and CDS Hooks.

Until then, he looks forward to the day health systems aren’t faced with reimagining CDS on their own to support patient care initiatives—although for now it’s worth the effort to do so.

“At the moment, there is reinventing of the wheel across roughly 6,000 US hospitals,” Hanson says, adding, “We are constantly working to provide patients with information they need to make decisions about their health, and to make engaging with our health system even easier.”

— Elizabeth S. Goar is a freelance health care writer in Wisconsin.

 

References
1. Yu C, Xian Y, Jing T, et al. More patient-centered care, better healthcare: the association between patient-centered care and healthcare outcomes in inpatients. Front Public Health. 2023;11:1148277.

2. Defining the PCMH. Agency for Healthcare Research and Quality website. https://www.ahrq.gov/ncepcr/research/care-coordination/pcmh/define.html. Updated August 2022.

3. Nordic Global. Patient-Centered Excellence for a New Era of Care. https://nordicglobal.turtl.co/story/patient-centered-care/page/1. Published 2023. Accessed August 13, 2024.

4. Mehta SJ, Torgersen J, Small DS, et al. Effect of a default order vs an alert in the electronic health record on hepatitis C virus screening among hospitalized patients: a stepped-wedge randomized clinical trial. JAMA Netw Open. 2022;5(3):e222427.