The CDS/PI Collaborative Getting Better Faster – Together SM

The CDS/PI CollaborativeGetting Better Faster – TogetherSM

Jerome A. Osheroff, MD, FACP, FACMIPrincipal, TMIT Consulting, LLC

Adjunct Associate Professor of Medicine, U. of PA

April 2012

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Executive summary Overview of the CDS/PI Collaborative Overview of the CHCF-funded pilot project

◦ Phase I, Oct 2011-Mar 2012 [complete]◦ Phase II, Apr 2012-Mar 2013

The CDS configuration template Template use, benefits, evaluation Next steps

Contents

TMIT Consulting, LLC

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Many organizations have joined a Collaborative to enhance how they use CDS to address performance improvement imperatives

A CHCF-supported pilot project ran from 10/11 thru 3/12:◦ 9 CDOs participated to test whether such collaboration would be valuable◦ Participants improved their CDS and PI efforts by using a structured form for

documenting and sharing CDS strategies for 2 targets (VTE, diabetes)◦ All sites got benefits, recommended next steps, and plan ongoing participation

Next the Collaborative will, with further CHCF support:◦ Engage more providers in completing and sharing target-focused CDS

configurations◦ Improve tools for completing and sharing templates, cover more targets◦ Develop and share other tools to support target-focused CDS/PI project

management◦ Engage other stakeholders (e.g. vendors, RECs) more deeply in collaborative

activities ◦ Explore mechanisms to make the Collaborative self-sustaining

Executive Summary


The CDS for Performance Improvement (PI)

Imperatives Collaborative


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Providers face strong and increasing drivers (MU, ACA, VBP, etc.) to improve specific care outcomes associated with quality, safety, costs

Effective CDS is critical for these improvements but complex, expensive, and challenging to get right

Absent widely applicable and vetted target-focused CDS strategies, providers seek collaboration to ‘Get better faster – together’

Other stakeholders (e.g., EHR/HIT vendors, federal agencies, payers) also play critical CDS/PI roles and are likewise interested in collaboration to advance the state of the art and practice

Why the Collaborative Formed


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Accelerate local CDS and PI efforts by documenting, sharing, and enhancing target-focused CDS strategies

Foster development and use of tools that support this strategy sharing and local value realization

Include many provider organizations and PI imperatives Provide major benefits for all stakeholders; especially

Care Delivery Organizations, but also EHR/HIT Vendors, Payers, Federal Agencies, and others

Leverage strategies for improving outcomes with CDS from compendia such as the HIMSS CDS Guidebook Series

Collaborative Goals


http://www.himss.org/cdsguide

Collaborative Underpinnings

All-time HIMSS bestseller, book of the year (2005)

Widely used by CMIOs/others

~100 contributors Bestseller, HIT

book of the year (2009)

Co-sponsors include AHRQ, 3 CIS vendors

6 co-publishers7

New (2/12)! >100 contributors Guidance on successful programs

and interventions Addresses hospitals, systems,

practices, vendors Worksheets underpin template;

‘Tasks’ define CDS success path


CDS Definition

“A process for enhancing health-related decisions and actions with pertinent, organized clinical knowledge and patient information to improve health and healthcare delivery.” Improving Outcomes with CDS. HIMSS. 2012

Very broad: way beyond alerts, order sets

Includes many things providers are already doing (though often not optimally)


Framework: CDS Five ‘Rights’To improve targeted healthcare decisions and outcomes, well developed and deployed CDS interventions must provide:

• the right information (evidence-based, actionable…), • to the right people (clinicians and patients…), • in the right intervention formats (alert, order set,

answers, documentation tools, data display…),• through the right channels (CIS, internet, mobile…), • at the right points in workflow (decision/action ...)

Addresses: What, Who, How, Where, WhenTMIT Consulting, LLC

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Care delivery organizations across country EHR suppliers (Allscripts, Cerner, Epic, GE,

QuadraMed, Siemens) Federal agencies (ONC/AHRQ/CDC) Beacon Communities Society partners (HIMSS, Scottsdale

Institute, Society of Hospital Medicine) CDS and analytics suppliers Clinical transformation consulting firms

Collaborative Participants =Staff from:


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Over 140 participants and growing steadily (driven by word-of-mouth)

California Healthcare Foundation (CHCF)-supported pilot enabled a Project Manager to be engaged, and the feasibility and value of CDS/PI collaboration activities to be tested

The pilot size, speed, and value exceeded expectations

CHCF funded a follow on one-year Collaborative phase focused on scaling and sustainability

Collaborative Status


CHCF-funded Collaborative Pilot Project


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Validate that Collaborative goals are feasible - and work toward them is valuable - by demonstrating that:◦ Provider organizations would refine and use a template for documenting

and sharing target-focused CDS intervention approaches◦ Participating organizations could agree on specific targets for joint

attention and on a common template for documenting interventions◦ Using the templates locally, and sharing completed versions across

organizations, would add value to local CDS/PI efforts Engage key stakeholders in following and supporting the

pilot efforts, and generate ongoing participation beyond the pilot

Ultimately, drive widespread, CDS-enabled improvements in patient outcomes, especially for high priority targets

Pilot Project Objectives (Phase I)


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9 provider organizations met weekly 10/11/11 thru 12/11/11 to refine a CDS configuration template and discuss their effort to get value from using it locally

7 organizations chose VTE as inpatient target focus and 2 chose diabetes as outpatient target focus

Group used a private website/discussion group; https://sites.google.com/site/cdsforpiimperatives/home

Used frameworks/tools from the HIMSS CDS guidebook series to underpin work

Used full Collaborative to follow and provide input on pilot efforts and prepare for scale; conducted all-participant meeting on 11/28/11 (see Appendix)

In March 2012, formally evaluated pilot effectiveness

Pilot Overview


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Commitment to PI, systematizing care processes, leveraging HIT investments

Limited CDS/PI resources but high stakes; be more efficient/effective, learn from others

Successful experiences with other PI collaboratives (get and give help)

Enhance innovation and accelerate its spread throughout their health systems

Improve patient engagement and support Establish best practices for CDS interventions

Why the Pilot Sites Joined


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Inpatient (VTE Prophylaxis):1. Ascension/St John Providence Health System (Cerner)2. Hennepin County Med Ctr (Epic)3. Lehigh Valley Health Network (GE) 4. MetroHealth System, Case Western Reserve U. (Epic) 5. New York Hospital, Queens (AllScripts)6. Texas Health Resources (Epic)7. University of Pennsylvania (Allscripts)

Outpatient (Diabetes Management):8. University of Pennsylvania (Epic)9. Veterans’ Administration (Homegrown)

Pilot Sites


Note: organizations listed in darker font participated most intensively in developing and using the template and sharing results

The CDS Configuration Template


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Starting point was worksheets from HIMSS 2012 book, Improving Outcomes with CDS: An Implementer’s Guide

Pilot sites iteratively refined this material, based on successive efforts to use it in local CDS/PI meetings

Template has 3 parts:◦ Diagrammatic overview of workflow and CDS interventions◦ Tabular view of workflow steps, corresponding target-related

activities, current/planned CDS interventions at each step◦ ‘CDS Five Rights’ view documenting the

‘what/who/where/how/when’ for CDS interventions focused on the target

Different sites used different combinations of these 3 components in their local work

Template Overview

TMIT Consulting, LLCTo view complete template, see online Users’ Guide

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Diagrammatic View

B. History

& Assess.

A. Pre-encounte

r

C. Form. care plan

D. Docu-mentatio

nZ. Pop. mgmt.

K. Post visit/home

care

J. Dischg or svc

transfer &

referrals

H. Results/ new

eventsG. Execute Therapies/ Procedures

F. Order handling

E. Orders/

Rx

I. Consult requests

Pre-visit questionn

aires; facesheet

s

Pattern recogni-tion logic

Knowledge delivery/ interactiv

e ref

Structured

documen-tation

Order sets; error

checking

Error checking;

alternatives

Pt. educ guides;

follow-up care

prompts

Alerts, monitors Time-

based monitors;

pt. reminders

RECOGNIZE PATTERNS

FFORMULATE PLAN

COMMUNICATE (also I)EXECUTE PLAN RESPOND TO

EVENTS


When?

How?*

* Template provides sample interventions for each workflow step; i.e. the ‘How’ items in the grey boxes

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Tabular View, Sample: New York Hospital Queens[EXCERPT Part 1] VTE Prophylaxis (draft date 12/31/11)

Example: VTE Prophylaxis-related Workflow and Interventions


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Tabular View, Sample: New York Hospital Queens[EXCERPT Part 2] VTE Prophylaxis (draft date 12/31/11)

Example: VTE Prophylaxis-related Workflow and Interventions


Generic Workflow Step

Target-specific Clinical Actions/Workflows/Decisions

CDS Interventions that Are Currently Implemented

CDS Interventions that Are Potentially Promising, but Not Yet Implemented

Requirement to document patients who are contraindicated for VTE prophylaxis

Part of VTE order sets – requiring therapy or documentation of contraindication

Part of structured H&P with built-in risk assessment tool

Identification of patients at risk based on past medical history

F. Order Handing

Identification of at-risk patients who are not on VTE prophylaxis

Not done

Require corollary orders Coumadin orders must be made daily and must be accompanied by a INR order for the next morning

Recommend dosing based on indication

Suggested dosing based on indication on Coumadin order form

Coumadin compliant diet Coumadin compliant diet Combined diets, e.g. diabetic and Coumadin compliant diet

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CDS Five Rights View (Excerpt)

Objective

Core Action WorkflowContent Delivery Delivery Logistics

CDS Five Rights dimensions When

(Workflow Step)

What

(Information)

How(Intervention

Type)

Who(Person)

Where(Channel)

Population Management

Z Recognize

patternsPre-encounter

ADemographics, conditions, care gaps, self-progress

Per Worksheet 6-1 Patient, Admin,

Case ManagerPHR/

Registry/ EHR

Recognize patterns / Formulate

Plan of Care

History/Assess. B

History/Physical data, medications, prior data review, inferred conditions

Nurse/ PhysicianEHR ,

flowsheets, data

facesheetsVTE risk

assessment

Answers to comprehensive prompts enable some fields within VTE risk calculator to auto populate.

Comprehensive Prompts (Smart Documentation Forms)

Nurse EHR

Appropri ate VTE Prophy

laxis

Calculator displays appropriate therapy modalities based on individual patient risk.

VTE Risk Assessment Clinical Calculator (Relevant Data Summaries)

Physician EHR


* Template provides sample intervention what/how/who/where for each workflow step

Template Use, Benefits, Evaluation


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High-level target-focused CDS strategy review◦ Standard assessment/communication tool for

CDS approach Get stakeholder consensus/input, identify gaps Understand different approaches/results across health system Organize qualitative/quantitative intervention impact

reporting◦ Roadmap for target-focused CDS activities

Guide decisions about PI opportunities and potential CDS interventions

Plan for best practice care and optimal CDS (which evolves)

Pilots’ Template Use


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Detailed CDS configuration planning◦ Consider each dimension of CDS Five Rights (e.g.,

all care team roles and intervention types)◦ Optimize use of current support tools, determine

need for new tools and approaches◦ Link MU reportable measures (VTE) to CDS

configuration

Pilots’ Template Use cont.


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Better local CDS stakeholder engagement/communication◦ With recipients; leadership; CDS, IT, and quality teams; clinicians◦ Stakeholders better visualize and enhance their inter-related efforts◦ Specifies CDS PI opportunities by making explicit current thinking

and deployments focused on applying CDS to specific imperatives Enhanced strategic planning

◦ “The exercise of categorizing and describing our [CDS/PI] strategies has been very useful and demonstrated the importance of stepping back from ‘the weeds’ to get the big picture of where our efforts are going”

◦ Workflow diagram provides a holistic view of CDS activities and opportunities across all care processes vs. in isolation

◦ Better understand need/opportunities to improve patient engagement

Template Benefits for Pilot Sites


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Improved CDS execution◦ Explain why current CDS approaches not working well◦ Broaden approach to CDS toolkit, recipient and workflow

support opportunities, e.g.: Reassess VTE risk after admission Consider diabetes CDS opportunities across care continuum

◦ Leverage CIS & CDS capabilities better and understand/address limitations

Knowledge sharing accelerates progress◦ Learn from other organizations’ approaches/results

Template Benefits for Pilot Sites cont.


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8* out of 9 sites reported that using the template was somewhat to significantly useful for local stakeholder engagement, CDS/PI strategic planning, and/or CDS implementation

In terms of the net effect of the project on each organization’s CDS/PI efforts, all 9 sites said it was somewhat to significantly helpful

8 sites anticipate continued use of the template in their organization**

All 9 sites indicated that they would like to continue to participate in the Collaborative

Pilot Evaluation Survey Results

** 9th site would use the template if there were a large group sharing completed templates


* 9th site didn’t have an active CDS project focused on the target during the pilot

Next Steps


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1. Foster adoption/value from CDS strategy sharing for additional provider organizations and cover more topics

2. Deepen and integrate engagement of CDS stakeholders other than providers

3. Develop a sustainability plan for maintaining/enhancing the Collaborative

Activity Threads


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Get ≥10 more providers using template Refine Users’ Guide to enable this use and

value without weekly meetings and ‘hand holding’ used to engage sites during pilot

Create electronic fill-in-the-blank version of the template that is more user-friendly

Refine and deploy next-generation online ‘shared library’ for completed templates

Thread 1: Scaling Pilot Value


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Cover at least 3 more PI imperatives Establish forums such as regular target-specific

teleconferences and online discussions wherein Collaborative participants can review and accelerate their respective target-focused CDS/PI work

Develop/use template for documenting and sharing target-focused CDS/PI project management tasks (e.g., stakeholder engagement)

Explore feasibility/value from organization-specific sub-communities to discuss challenges and implementation best practices among facilities in large health systems; goal is to accelerate CDS/PI innovation and spread within the system

Scaling Pilot Value cont.


Sample Improvement Imperatives For Collaborative Work

Preventable complications (Safety)◦ VTE◦ Catheter-associated infections (Blood stream, urinary)◦ Adverse drug events

Condition management/Core Measures (Quality)◦ Cardiovascular (CHF, AMI, Blood Pressure, Smoking)◦ Diabetes

Efficiency (Cost)◦ Readmissions (CHF, AMI, pneumonia)◦ Early sepsis detection

Note: Pilot sites addressed targets in blueTMIT Consulting, LLC

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Create vendor-focused sub-communities to ensure vendor tools are used effectively in PI

Consider other related sub-communities Conduct cross-stakeholder explorations into

enhanced inter-related value propositions from Collaborative, including a possible CDS/PI pilot of this value involving payers, Regional Extension Centers, providers, and EHR vendors

Thread 2: Stakeholder Engagement


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HIT/analytics vendor supports Collaborative subgroup consisting of its clients, for CDS configuration documentation and sharing, and best practice development using a template version adapted to its specific CDS related tools; by-product is insights into how vendor can enhance its CDS tools focused on one or many PI imperatives

Payer supports Collaborative subgroup within its network to identify and disseminate successful PI practices focused on targets of particular interest to the population covered

Health-system oriented sub-community as noted earlier

Examples of Collaborative ‘Sub-Communities’


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National clinical condition-focused initiative supports Collaborative subgroup to focus on identifying successful CDS practices focused on that target, and accelerating spread of these practices on a widespread basis

Clinical Transformation consultancy builds subgroup of its clients to identify and spread CDS/PI best practices faster

Federal agencies (e.g. ONC, CDC, AHRQ) interested in enhancing use of HIT to address population health goals create sub-communities for these purposes (e.g., define and spread successful CDS practices leveraging Beacon Communities, REC’s etc.)

Example Sub-Communities cont.


In Thread 2, we will explore creating these potential sub-communities and examine how they inter-relate with each other and the broader Collaborative to achieve shared goals

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Identify mechanisms to make Collaborative self-sustaining (leveraging Threads 1&2) ◦ Make the collaboration activities self-perpetuating

(e.g., via Users’ Guide and related approaches to systematize steps in the Collaborative’s value delivery process)

◦ Create plan for ongoing funding in return for value delivered to stakeholders

Thread 3: Sustainability Plan


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The pilot validated the hypothesis that the Collaborative delivers value to providers

There is strong, multi-stakeholder interest in scaling the pilot activities

We have established Phase II funding from CHCF in order to:◦ Scale provider engagement and value◦ Cultivate cross-stakeholder value propositions◦ Develop a sustainability plan

Conclusion


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Project Director: Jerry Osheroff, MD◦ [email protected]

Project Manager: Lynne Schabert◦ [email protected]

Project Website/Discussion Group (Private to Collaborative)◦ https://sites.google.com/site/cdsforpiimperatives/home

Informational Website on Project (Public)◦ Includes form to request entry into the Collaborative◦ https://sites.google.com/site/cdsforpiimperativespublic/home

Users Guide for Collaborative and Template (Public)◦ Includes: configuration template; slides about it that pilot sites used locally◦ https://sites.google.com/site/cdsforpiimperativespublic/cds-for-pi-imperatives-users-guide

HIMSS CDS Guidebook Series◦ www.himss.org/cdsguide

Contact Information/Websites


mailto:[email protected]

mailto:[email protected]

https://sites.google.com/site/cdsforpiimperatives/home

https://sites.google.com/site/cdsforpiimperativespublic/cds-for-pi-imperatives-users-guide



Documents

The CDS/PI Collaborative Getting Better Faster – Together SM