"To me, it's the equivalent of going online to shop on a website or pay your bill and getting these pop-up adds," he says. "If you're shopping on Amazon and you do it frequently, obviously you know where to click. You're familiar with that website you know how to interface with it in a way that is seamless. So if I then institute a pop-up alert – one that interrupts your process when you're not expecting it and you don't want to stop – you're not going to want to shop at Amazon."

Really good health IT isn't necessarily smarter about how it does it's thing, it's better at how it works with its clinical users, Paulson suggests. And he's seen proof of that as Trenton has recently had two clinical sites do EHR rollouts since the citywide CDS project launched.

"They were starting with their EHR adoption having just completed a detailed analysis of their clinical processes," he says.

"They were able to look at the training and say, 'Wait a minute, when I'm caring for diabetes, these are the kinds of things I need to do. How will this tool help me do that, and before we start rolling it out, can we make some slight adjustments to how it interacts with me so I get the right in at the right time in the care process in the right format?'"

Technological advance
A year ago this month, ONC launched the EHR Innovations for Improving Hypertension Challenge as part of Million Hearts, the ongoing nationwide project led by the Centers for Disease Control and Prevention to help practices better use EHRs and CDS to reduce high blood pressure, heart disease and stroke, preventing a million heart attacks and strokes by 2017.

"There are many healthcare providers who employ clinical decision support tools like standardized treatment approaches or protocols to control hypertension among their patients," said National Coordinator Karen DeSalvo, MD, in a statement announcing the EHR initiative. "This challenge helps us find the best examples of those efforts and scale them up."


Left unspoken in that declaration is that some deployments of CDS-enabled quality improvement are still less than ideal.

Hilary Wall is senior health scientist and Million Hearts science lead at CDC. She says she's sympathetic to physicians who chafe at disruptive CDS tools. But she also sees the immense potential for better care when those tools are deployed the right way.

"I'm not a clinician; I'm an epidemiologist by training," says Wall. For her, using computers to marshal data toward better outcomes is a "no-brainer."

That said, she is also keenly aware that she's "never had to integrate (technology) into a clinical workflow, where I've got patients coming in and seeing different staff in a healthcare setting."

Wall understands why alert fatigue and overridden order sets occur across healthcare. But she hopes to see better workflows and more open minds prevail, because she's seen the good that can result from smart CDS.

"I've seen two sides of the coin," she says. "One, I've seen a push for using clinical decision support tools for quality improvement, presented to clinicians and getting pushback: 'It's too much, we can't do it on top of everything else we're having to do.' Clinicians are being tasked with doing a lot of different things at the same time."

At the same time, says Wall, "I've also seen the flip side of that coin, where we've got pockets of clinicians using CDS to its fullest potential in a way that's streamlined for the clinical staff that's using those tools and in a way that really benefits their clinical practice. Once that learning curve is overcome, health systems are really reaping tremendous benefits."

Still, she admits she's "surprised more people haven't been open to embracing clinical decision support, and the different features EHRs have to offer."

At the same time, says Wall, "I know that technology and change are hard. When a healthcare system gets an out-of-the-box EHR and turns it on for their clinical staff, oftentimes the clinicians have not weighed in on what features they're using or what alerts are popping up in their faces. And they either ignore them or turn them off. And I don't blame them."

Simply put: "Getting buy in from the clinical staff is really, really important," says Wall. "CDS tools are most successful when they focus on what we know for sure in the evidence. That's how they make clinicians' lives simpler. They take the evidence-based interventions and they make it automatic. They prompt you. That leaves more time for the staff to use their clinical judgments for the places where the evidence is softer."

Successful practices, she says, "have focused in on those very high-evidence-based strategies so that it doesn't feel like cookbook medicine for their clinical staff."

Meanwhile, like Paulson, Wall points to the acute need for EHR design improvement.

"This is something we need to explore more, but anecdotally what I've heard is that there are too many clinical decision support tools embedded in EHRs," she says. "And not all but many vendors have a canned set. They automatically put them in, they automatically turn them on. They are an annoyance to the clinical staff. There's got to be a way for some of these vendors to work more closely with their clients to tailor which CDS tools are turned on."

Government assistance
In the past few weeks, the federal government has published some very useful resources for health providers looking to amp up their quality improvement initiatives and better treat chronic conditions.

First, CDC published "The Hypertension Control Change Package for Clinicians" as part of Million Hearts. Compiling concepts, ideas and evidence-based tools and resources, the package means to offer resources to clinicians looking for specific changes related to management of hypertensive patients.

Such "change ideas" are able to be "rapidly tested on a small scale to determine whether they result in improvements in the local environment," according to CDC.


Second, ONC published an online guide to electronically facilitated clinical quality improvement, or eCQI.



"Health IT enables more rapid feedback on measurement as well as real-time improvement support tools such as workflow-integrated clinical decision support," according to ONC. "It transforms the basic quality cycle into an upward spiral of performance and outcome improvement for providers, patients, and the health system overall as learning grows through sharing analyzing and using data better."

As part of the resource, ONC offers a substantial series of resources for planning and implementing improved care processes. Among its advice for those at the beginning of their QI journey:

• Cultivate a shared commitment within your team to improving care delivery and results, including fully leveraging Health IT capabilities. Successful QI efforts deliver a 'win-win-win' for patients and their care teams, as well as broader organizational goals.
• Identify and address barriers to collaboration on effective process improvement among all concerned, including providers, care delivery and quality staff, partners (e.g., health IT vendors), and patients.
• Layer the approach and tools below onto your QI methodology.

Track record of quality
One group of providers that's often well ahead of the game with regard to CDS-enabled quality improvement is community health centers. Both the resources and accountability that come from being federally-funded mean most have an innovative ethos of IT-enabled improvement that could offer some useful lessons for other providers.

"Ninety-six percent of health centers are using electronic health records, which is ahead of the curve compared to other types of healthcare organizations; they're definitely leading the charge in that way," says Meg Meador is director of clinical integration and education at National Association of Community Health Centers.

"And they've definitely been using CDS for a while now," she says. "Most of them use things like templates and order sets. They use clinical reminders that prompt providers for needed preventative care. They use embedded guidelines – visual cues like highlighting an elevated blood pressure red. These are things that a lot of them have adopted."

"Community health centers have a track record of quality improvement," says Shane Hickey, senior advisor for health IT strategy  at NACHC.

Initially launched as part of President Lyndon B. Johnson's War of Poverty, over the course of five decades  CHCs "have really learned to think outside the box and be open to innovation and change," says Amy Simmons, NACHC's communications director.

"That kind of approach has been their hallmark. They are built by the community, from the bottom up, that makes them effective in their approach. They understand the population they serve. They have always been results-driven because they have been of the community and by the community.

"They've also always had to be accountable," says Simmons. "This is a program that relies on federal support, so accountability and transparency and results have always been important."

As a quality improvement professional, Meador specializes in rapid-cycle change approaches to workflow and information systems, putting population health data and IT to work improving quality and driving better outcomes. (Part of her work is serving as lead on a Million Hearts project focused on undiagnosed hypertension, "Hiding in Plain Sight.")

Certain health centers "are really coming up with some innovative ways to use clinical decision support proactively: getting in front of the analytics piece so they can use CDS for pre-visit planning, so they know in advance which patients they need to outreach to, they know of those patients who already have appointments what tests they might need," says Meador. "The shift is happening – from more of a passive approach to CDS to a much more proactive approach, which is really needed in this environment."

One unique aspect of community health centers is that most – more than 70 percent –  belong to Health Center Controlled Networks: groups of safety net providers who compare notes on improving quality and access and reducing costs. That "create opportunity for economies of scale – particularly in purchasing of health IT or IT services," says Meador.

Health centers are part of HCCNs thanks to the fact that they use the same EHR products – enabling them to come up with best-practice workflows on that specific technology.

"There's a collaborative spirit that pulls everybody up," says Meador.

Getting results
NACHC shared with Healthcare IT News some specific success stories from its membership – providers who have recognized substantial improvements thanks to smarter use of CDS tools.

Among them, Peninsula Community Health Services, based in Kitsap County, Washington, which was able to boost its blood pressure control rate to 84 percent after integrating clinical pharmacists into its care team. (The Million Hearts target is 70 percent).  

Simmons also cites Finger Lakes Community Health, Hudson River Healthcare, and Whitney M. Young, Jr. Health Center – three health centers affiliated with the Health Center Network of New York – who have notched "some big wins using data and clinical decision support tools to drive improvement."

Together, they were able to achieve a 21 percent increase in hypertension control and a 19 percent decrease in undiagnosed high blood pressure since September 2013, thanks to algorithms that can detect potential cases.

The health centers developed electronic registries that helped inform outreach efforts, finding success by embedding a hypertension treatment protocol into their workflows, putting a laser focus on improved accuracy in blood pressure recording (by querying EHR data for rounded systolic/diastolic numbest) and "honing in on those care teams who need training on precise EHR documentation methods."

Going forward, NACHC is expanding its decision support and QI initiatives. "We're piloting a new CDS approach, more centralized, called CDS-as-a-service," says Hickey, where "the EHR pulls down evidence-based guidelines from the CDC in an automated fashion."

Another project is focused on "social determinants of health," he says, working with four different HCCNs and their member centers to develop a standardized patient risk assessment tool that focuses on the factors "beyond medical acuity," such as income and education level.

"All of our heath centers are building templates in their EHRs to capture this data in a structured way," says Hickey, with "all of the teams operating from the same question and answer sets. Once we have a prototype, we can spread it."

All told, we're at a pivotal moment for clinical decision support and QI initiatives. Thanks to a burgeoning awareness about its potential, an increasing effort toward education and an ever-expanding arsenal of toolkits, guidebooks and worksheets – from CMS, ONC, HIMSS and others – there's an impressive and evolving armamentarium providers can draw upon as they work to tackle the most vexing chronic conditions.

As illustrated above, these approaches have proven to have salutary effects on care processes. See below for some helpful links to resources for CDS-enabled quality improvement for clinicians and other care providers:

• CDS/PI Collaborative: bit.ly/CDSPICollab (More details can be found here: bit.ly/CDSPIProjects.)
• ONC eCQI resource for process improvement: bit.ly/oncecqicds
• CDS Hypertension Control Change Package: bit.ly/mhhccp
• CMS CDS tipsheet: bit.ly/cmscdstips
• HIMSS CDS Guidebook Series: www.himss.org/cdsguide