Closing the Loop on Gaps in Care: Implementing Intelligent Clinical Decision Support at AdventHealth

In 2017, AdventHealth of Altamonte Springs, Florida, 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.

After assessing its level of readiness to implement care transformation, AdventHealth put a new organizational chart in place, and the key positions Premier recommended were filled with strong leaders. AdventHealth was ready to keep the momentum up by better managing patients across settings and ensuring patients were receiving the right care at the right time and in the right setting. As such, AdventHealth leaders had a significant interest in advanced, or “intelligent” clinical decision support (CDS) that would take identified opportunities to reduce care variation and make them actionable for providers within the workflow at the point of decision making.

No More Dumb Alerts

“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,” Dr. 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 AdventHealth, 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 CDS could help reduce instances of both.

That’s how AdventHealth became the first Cerner EHR client in the country to go live with a newly-acquired Premier company’s - Stanson’s – CDS tool, as well as the first Athena ambulatory EHR 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 realization: The rules were unintentionally turned on for providers - 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 the system, it can alert the provider within their workflow, allowing the provider to change the action they were going to take.”

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?

CDS alerts also provide 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, AdventHealth will be live system-wide in both its inpatient and ambulatory EHRs.

What’s Next?

As a long-time user of quality improvement analytics in PremierConnect^® 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 PremierConnect, closing the loop on care variation gaps, actions and results.