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Closing the Loop on Gaps in Care: Implementing Intelligent Clinical Decision Support at Adventist Health System

In 2017, Adventist Health System (Altamonte Springs, FL) set out to enhance the way care was delivered across its 46-hospital enterprise. In its aim to become a high reliability organization, this meant removing unwarranted care variation to provide exceptional care for all patients.

Spurred by a system-wide Care Transformation initiative, Adventist Health System (AHS) prioritized areas of opportunity to improve outcomes, safety, and patient satisfaction while safely reducing costs. These goals included having all hospitals obtain a four-or-five-star rating from the Centers for Medicare & Medicaid Services by the end of 2020, all hospitals obtaining an “A” safety grade from the Leapfrog Group by the end of 2020, and all hospitals being in the top quartile nationally for the observed-to-expected mortality rate by the end of 2020.

“There was a consensus among our senior executive team that this was a very significant and important initiative for our organization,” said Loran Hauck, MD, Chief Clinical Officer for Adventist Health System at the time.

As the team began examining how to meet these newly outlined expectations, they wanted help determining how new practices and guidelines could be implemented across all hospitals – a task taken on by the consulting team at Premier®.

“There was a question of, can we launch this work successfully ourselves given that we have inconsistent performance across the system today, or would it be helpful to engage a consulting firm to come in and help guide us to launch this work,” Hauck said. “So, we created an RFP and sent it out to several consulting companies, including Premier, and ultimately selected Premier’s advisory services to help us in this engagement.”

In the summer of 2017, Premier Performance Partners visited six sites covering all of Adventist Health System’s regions and interviewed a cross-section of employees, from frontline clinicians to C-suite executives. This process helped ascertain employees’ understanding of care transformation, the level of readiness to implement care transformation, what resources were available across the health system, and if the appropriate structures and governance were in place to implement care transformation.

No More Dumb Alerts

During Premier’s consultation report, one finding showed that confusion existed among the health system’s frontline staff on how reduction of care variation would be executed, highlighting a need for strong leadership across the health system during the process of care transformation.

“Premier was very helpful in identifying the kinds of resources that we had regionally, and here at the corporate office, that would be essential to drive this initiative,” Hauck said.

Adventist Health System began implementing some of Premier’s recommendations, and is already building momentum as 28 of its hospitals received a Leapfrog Safety Grade “A” rating in the spring of 2018, a 40 percent improvement from the fall of 2017.1

In tandem with this work, AHS also had significant interest in advanced, or “intelligent” clinical decision support that would take identified opportunities to reduce care variation and make them actionable for providers within the workflow at the point of decision making.

“We’re at the confluence of a series of events in healthcare that I think are seriously exciting. EHRs have been implemented but need to be optimized. That’s the plumbing, the utility, the railroad tracks,” Hauck noted. “The ability to do natural language processing, machine learning, and artificial intelligence has matured.

We’ve done a lot with Premier to reduce costs in healthcare – labor, supply chain, drug formulary – and identify where our opportunities are to reduce care variation and costs across our system. What’s the next frontier in improving quality, patient safety and cost effectiveness? I think it’s intervening at the point of decision-making to drive real change in the way care is delivered in the areas where we found opportunity.”

Dr. Hauck and his colleague, Dr. Qammer Bokhari, Vice President and Chief Medical Information Officer at Adventist Health System, were concerned about both medical errors that are acts of omission – where a provider fails to do something that should be done, and acts of commission – where a provider is about to order care that might actually harm the patient. And they believed intelligent clinical decision support could help reduce instances of both.

That’s how AHS became the first Cerner EHR client in the country to go live with Stanson’s clinical decision support (CDS) tool, as well as the first Athena ambulatory her customer to do so. Beginning at Florida Hospital, its system flagship, the team rolled out 10 specific rules in the inpatient EHR. Initially Florida Hospital intended to bring the rules live in production but have them run silently in the background to see how often they were firing. They would then begin physician education.

But a simple accident turned into a big learning: The rules were unintentionally turned on provider-facing without change management or physician training.

“We were amazed to find out that, even without education, training, or change management, physicians began changing their behavior,” Bokhari said. “The Stanson technology observes the decisions providers are making and when it sees something that does not align with the guidelines in span class="Apple-converted-space">

When triggered, a Stanson alert contains three pieces of information for the physician:

  • The advice. Why was the alert fired?
  • A link for more information on the advice. What else do you need to know?
  • An option to accept, ignore or override. What is the action you want to take?

When triggered, a CDS alert provides physicians with a short note on the best practice for the particular decision the physician made in the EHR system. It also has a link in case the physician wants to read the full recommendation. The physician can then choose to accept the change, ignore the alert or reject for their original course of action.

“Because the CDS interfaces with our EHRs, we can run analytics on which physicians ignore, accept or reject a recommendation. If you do intelligent alerts over time, it changes physician behavior enough that some alerts do not fire anymore, reducing the concern over alert fatigue,” Bokhari noted.

By year’s end, AHS will be live system-wide in both its inpatient and ambulatory EHRs.

What’s Next?

As a long-time user of Premier’s QualityAdvisor™ tool to perform retrospective decision support and back-end analytics on where there are gaps in performance, Dr. Hauck believes “Stanson Health’s CDS technologies is a beautiful fit for Premier’s suite of solutions.”

“Now you can combine the analytics on where our length of stay is longer, or cost-per-case is higher compared to our peers – or between physicians within our own organization – and implement specific modules in Stanson that will help reduce those gaps in care. And the cycle continues with Stanson’s data on physician decision-making going on to inform our opportunities in QualityAdvisor, closing the loop on care variation gaps, actions and results.”

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