Making Better Decisions at the Point of Care

Today, physicians and healthcare providers are asked to do more than ever, in less time. They are treating more patients and have less time to spend with each. At the same time, they must meet requirements for quality reporting, keep up with changing evidence-based treatment protocols, and do their best to prevent malpractice and liability litigation.

For many physicians, the practice of “defensive medicine" — including ordering redundant tests — has become the norm. In 2012, the Institute of Medicine found that unnecessary medical tests accounted for $750 billion, or about 30 percent, of all healthcare spending in 2009.

To better cope with these challenges, a growing number of physicians are using clinical decision support (CDS) tools, designed to help them access evidence-based data to improve diagnosis and treatment at the point of care. The HITECH Act required that clinics and hospitals include CDS features in their electronic health records (EHRs), giving the use of CDS a jumpstart. Recent reviews find that the number of CDS tools, whether standalone or part of an EHR or physician-ordering system, is increasing, and their quality is improving.

The Agency for Healthcare Research and Quality (AHRQ) has been closely studying CDS use and effectiveness. In 2016, the agency set up a CDS learning network to help accelerate development of CDS tools and ensure that knowledge gained from patient- centered outcomes research is incorporated into such development.

Although they have noted problems with undifferentiated alerts, physicians are embracing CDS technology. According to a 2016 survey by the American Medical Association, 28 percent of 1,300 physician respondents were already using CDS systems, while another 17 percent planned to use them within the year, and 9 percent expected to start using them within the next 3 years. Respondents were intrigued by the claim that CDS could improve patient safety and compliance, and also improve physicians' work practices.

However, hospitals and healthcare systems have been less enthusiastic, citing reservations over security and integration issues. According to a 2016 survey of 47 health systems executives, only 51 percent were using healthcare apps at the point of care, and less than 10 percent wanted to create or buy CDS apps. This disconnect may slow the adoption of the technology. In any case, if CDS tools are to become part of the physician's toolkit, they must evolve so that they can integrate well with physicians' workflows and IT.

According to the 2016 Roadmap Report on CDS development—based on five years of research—physicians do not tend to use the simpler, "one-dimensional" programs that send out alerts, say, when it's time for a patient's flu shot. Instead, they prefer the more complex CDS systems that can provide more real-time data on individual patients. Such systems have the greatest potential to improve patient outcomes, the report says, although they are also the most difficult to integrate with existing EHR systems.

It is recognized that CDS can help promote appropriate use and cost-effective care. To that end, the federal Centers for Medicare & Medicaid (CMS), which runs the Medicare program, has mandated that providers consult appropriate use criteria in a CDS tool for outpatient advanced imaging procedures (such as CT scans). Once the mandate is in place in January 2019, providers must use CDS as part of their ordering processes for covered procedures.

The Roadmap Report also suggests that evaluation of the evidence basis for the CDS and its usability are crucial, and notes that the following are the key characteristics of a good CDS tool:

• Quality evidence that has been thoroughly validated ability to reduce unnecessary care
• Ease of integration
• Evidence consistent with users' perceptions and values
• Bundled options and automation (e.g., modules for risk assessment that would connect to a risk management tool, or connect preliminary assessments to tools for selecting diagnostic tests)
• Features that can enable shared decision-making.

EviCore has pioneered the use of advanced CDS in a variety of ways and our offerings are consistent with the Roadmap. For example, we offer CDS to clinicians at the point of order that identifies the optimum imaging procedure based on the diagnosis. This improves the quality of care and also speeds to provision of prior authorization. 

Similarly, a web-based tool offers guidelines from the National Comprehensive Cancer Network® (NCCN®) to oncologists in real-time. Results published from the initial pilot program using the tool showed that 99 percent of cancer patients received approval for chemotherapy drug regimens immediately or within 24 hours. The pilot also reduced cancer drug costs by 20 percent.

CDS combined with advanced technologies such as machine learning will remove the barriers to use and drive increased value in terms of improving outcomes and easing decision-making.