Clinical Decision Support: Meaningful Rules of Engagement

Among the many differences between the proposed regulations for “meaningful use” of electronic health records and a draft circulated last summer is that the Centers for Medicare & Medicaid Services (CMS) now wants hospitals and physician practices to implement clinical decision support (CDS) for a minimum of five high-priority conditions in order to qualify for federal subsidies in 2011. The earlier draft called for just a single CDS rule during the first year of the EHR incentive program. So what's a hospital to do to comply?

If the more stringent requirement holds when CMS finalizes the definition of meaningful use this spring, it will, of course, mean more work for CMIOs and their charges. “I think some people aren’t thrilled that it perked up from one to five,” says Gerard A. Burns, MD, CMIO of Columbia, Md.-based MedStar Health, surely echoing the sentiments of many of his peers.

“This really puts a laser focus on needing to work together to embrace positive change,” says Robert Murphy, MD, CMIO at Memorial Hermann Medical Center in Houston.

Not just any CDS rule will do. Relatively simple forms of CDS, namely drug-drug and drug-allergy interaction checking, would not qualify based on the current proposal, Burns notes. What likely will qualify are rules that relate to the quality measures that CMS proposes hospitals be able to report on as part of meaningful use. “There’s a strong suggestion [from CMS] that hospitals should link these five rules to some of the quality measures,” says Benjamin Kanter MD, CMIO of Palomar Pomerado Health, a two-hospital system outside San Diego. Indeed, CMS specifically says rules must be “relevant to specialty or high clinical priority, including for diagnostic test ordering, along with the ability to track compliance with those rules.”

When deciding which five CDS rules to choose, both Kanter and Murphy believe a good place to start is with the quality measures themselves. In the CMS plan, take a look at Table 20, titled “Proposed Clinical Quality Measures for Electronic Submission by Eligible Hospitals for Payment Year 2011-2012,” which spells out about three dozen quality measures that CMS proposes hospitals be able to report on.

For hospitals that choose to participate in the Medicaid incentive program rather than seek Medicare bonus payments, Table 21 is the place to start. To be eligible for Medicaid bonuses, a provider must have at least 30 percent of its patients on Medicaid, the lone exception being pediatrics, where the threshold is 20 percent.

Both the Medicare and Medicaid tables include many measures endorsed by the National Quality Forum (NQF) and that are part of the current Medicare Physician Quality Reporting Initiative. A large number of these elements occur at the time of discharge or relate to a patient’s problem list.

“The problem is, they’re not always easy interventions to put in place,” says Murphy. The Memorial Hermann CMIO is a member of the Healthcare Information and Management Systems Society’s CDS Task Force, which has set up a wiki at for health IT professionals to share information on the subject.

CMIOs do understand that clinical decision support and quality go hand in hand. “There has got to be a tight linkage between the two,” Kanter says. “They can’t work in silos.” He cautions against equating CDS with pop-up alerts, saying that decision support needs to be tied into computerized physician order entry (CPOE) so alerts lead to action. Palomar Pomerado Health—geographically the largest hospital district in California—has an EHR content committee with a CDS subcommittee. The primary nurse responsible for quality compliance and the chief medical quality officer are on the subcommittee, Kanter says, because it’s important to have both nursing and quality leadership for CDS.

If a clinical department has a request for a new rule or alert, the EHR content committee hands off the work to the CDS subcommittee, which has expertise about regulatory requirements, the knowledge to use the EHR to deliver support and the wherewithal to build the technology, according to Kanter.

Kanter calls CDS the “secret sauce” of EHRs and CPOE that actually leads to improved patient care.

The Palomar Pomerado IT department is building out CPOE this year to augment its Cerner Millennium EHR, with a target go-live date of January 2011. Kanter expects clinical decision support to be in place to support order entry, featuring Zynx Health clinical order sets and Lawson and Midas+ technology on the administrative side. “If you’re going to do computerized physician order entry, it’s only going to be to drive quality and safety,” Kanter adds.

At Memorial Hermann—the largest not-for-profit healthcare system in Texas, serving greater Houston through 11 hospitals and affiliated institutes and clinics—about 75 CDS rules are in place now through a Zynx Health database linked to a Cerner Millennium EHR, but Murphy isn’t sure how many would count toward meaningful use. “What will be an acceptable rule?” he wonders. For example, will a hospital get credit for giving aspirin pre-admission to a patient with acute myocardial infarction, when the quality measure calls for prescribing aspirin at the time of discharge?

That is unclear right now, but it seems likely that someone outside the organization seeking Medicare bonus payments will have to make that determination. “It always makes us a little bit nervous,” Kanter says of this prospect. He believes confirmation of meaningful use will be based on attestation, with CMS conducting random audits. “Clinical decision support is such a broad term.”

The section of the legislation dealing with meaningful use is relatively short. The proposed CMS regulation is 556 pages, while an interim final rule on standards and certification of EHRs from the Office of the National Coordinator (ONC) for Health Information Technology checks in at 136 pages.

“I fully suspect there will have to be some interpretive guidelines in the months ahead,” Murphy says. “I suspect we’ll have thousands of pages of interpretive guidelines at some point down the road.”

That’s a lot to read, digest and follow in a fairly short period of time. Because Medicare Part A follows the federal fiscal year, the incentive program actually begins Oct. 1, 2010. Part B providers—physicians—can start earning bonuses Jan. 1, 2011.

Although hospitals and physician practices alike only have to achieve meaningful use for 90 consecutive days during the first year to earn a full year’s worth of incentives, they will have to make some quick assessments regarding clinical decision support. 

“I think we’re better off at moving areas where we’ve been deficient,” Kanter says. “We will take a look at the summary measures that have to be reported,” he adds. “We need to take a look at where our needs are.”
It makes little sense to implement rules where compliance is close to 100 percent, which is almost where Palomar Pomerado Health is in terms of giving aspirin for acute mycardial infarction, Kanter advises. Besides, CMS may deny eligibility for meaningful use in such cases. “You can’t game the system,” Kanter says.

If it ain’t broken…

An organization also is setting itself up for alert fatigue and physician rebellion if CDS targets something doctors already do well, according to Kanter.

“Rules have the most value when you find them to have a particular purpose within your organization,” says Burns. This means identifying processes where the hospital or department has intrinsic problems. “It’s about knowing where there are opportunities for quality improvement.”

Adds Burns, “Rules are expensive and they’re tough. And if they’re not value-added, doctors hate them.” Rules can add value by addressing a specific problem without being intrusive. “The best rules are the ones that kind of go away,” Burns says. They fade into the background after correcting an inherent quality problem and only pop up in exceptional cases so they don’t become a nuisance to physicians. Role-based or specialty-specific rules should be like this, according to Burns.

“We really have to be selective and be even more selective in the types of alerts that are seen by which users,” he says. A good place might be in wards where primary care physicians are caring for heart attack patients. “Hospitalists, they’re pivotal for success [with CDS],” Burns says.

CDS, of course, is just one component of a full electronic medical record. “You still need a core EMR,” says MedStar’s Burns. MedStar, a not-for-profit, regional healthcare system including nine hospitals, still uses Azyxxi, the data aggregator developed at the organization’s flagship Washington Hospital Center before Microsoft bought the product and changed the name to Amalga. The health system is in the process of implementing four Cerner modules while also selecting a vendor for CPOE. CDS will help guide clinicians through electronic order entry.

“We have a lot of work to do,” Burns says.