What does agriculture have to do with healthcare reform?
New Yorker writer and surgeon Atul Gawande takes a look
In The New Yorker issue of December 14, 2009, Atuk Gawande, a New Yorker staff writer and Harvard surgeon, looks at the healthcare reform bill in the US Senate and compares it to the successful history of the US Department of Agriculture’s Extension program in the 20th century. Gawande also talked to the agricultural agent for his home town, Athens, Ohio, where Gawande’s parents are retired physicians. It’s a story of town by town–farm by farm–work sharing knowledgable advice locally, learning by example, and using subject matter experts.  And while the Senate bill contains a “hodgepodge” of trial programs, Gawande concludes that mix is a necessary formula for reforming healthcare. 

In reference to digitization of health information, Gawande states “Among the most important, and least noticed, provisions in the reform legislation is one in the House bill to expand our ability to collect national health statistics. The poverty of our health-care information is an embarrassment.” While Electronic Health Records are not the focus of this article,  the Ag Department’s Extension program was the model for ONC’s Regional Extension Center Program, and the article is worth reading for understanding that role.

For more on ONC’s Regional Extension Centers, see e-Healthcare Marketing archives.

Clinical Decision Support (CDS) Workshop Meeting Summary: ONC
As part of a series of special stakeholder workshops held by ONC in 2009, this post, recently added to ONC site, is made up of excerpts from a summary of “proceedings of a Clinical Decision Support (CDS) Workshop held by the Office of the National Coordinator for Health Information Technology on August 25-26, 2009, in Washington, DC. The CDS Workshop was a widely attended gathering of subject matter experts who shared their thoughts on a series of topics related to advancing the utility, usability, and meaningful use CDS. Attendees represented a broad spectrum of expertise, including clinical informatics, quality improvement, patient advocacy, provider, payor, knowledge vendor, and electronic health records (EHR) system vendor perspectives.”

ONC Clinical Decision Support Page
Workshop Summary Document (17-page pdf)

Clinical Decision Support
When broadly defined as “information that is filtered to circumstance and displayed to best effect”, CDS may take many different forms. At least a dozen different types of CDS have been identified, including:
–Relevant data displays
–Smart documentation forms
–Order facilitators (order sets, order consequents, order modifiers)
–Extended-time guideline and protocol followers
–Targeted reference, including contextually relevant medical references or info buttons
–Reactive alerts
–Task assistants for tasks such as drug dosing and acknowledging laboratory results
–Diagnostic suggestions
–Patient summaries for hand-offs between clinicians
–Procedure refreshers, training, and reminders
–Performance dashboards with prompts for areas needing attention
–Tracking and management systems that facilitate task prioritization and whole-service management

The Health IT Policy Committee’s 2009 CDS-related recommendations for meaningful use criteria for the 2011 payment year include:
• Capturing clinical data in a standard, coded manner
• Utilizing computerized provider order entry
• Implementing drug-drug, drug-allergy, and drug-formulary checks
• Implementing one CDS rule for a priority condition
• Setting patient reminders per patient preference
• Performing medication reconciliation at transitions of care

Themes Discussed at the Workshop
–CDS should support team-based care
–A culture of quality improvement is important to effective use of CDS
–Clinician engagement in CDS planning and implementation is critical to success
–User adoption depends upon implementation of highly usable systems
–Greater CDS specificity can reduce alert fatigue
–Other fields offer computer interaction principles that can be leveraged
–Promote collaborations among stakeholders that can support effective use of CDS
–Including CDS in the definition of meaningful use of EHRs is important
–Meaningful Use should allow for variations in CDS techniques, objectives, and localization of goals.
–Specialties and different practice types must not be overlooked
–Provide effective guidance and best practice examples
–Incentives and drivers can promote CDS adoption
–Providing liability protection or advantage may speed CDS adoption
–Patients have a role to play in CDS
–Translating guidelines into CDS is complex, so we should be able to leverage collective efforts
–Opportunities for data standardization
–Translation of knowledge into codified structures and mechanisms for dissemination of codified knowledge are key to sharing and reuse of CDS interventions
–CDS & Quality need to quickly incorporate evolving evidence
–Specific ideas that stakeholder groups may consider for focused development/action

Specific ideas that stakeholder groups may consider for focused development/action
The experts and stakeholders in attendance at the workshop expressed a wide variety of opinions about the most important action areas for CDS. Each of these topics could lend itself to further exploration and possible actions by private or public groups. During the course of the workshop, participants proposed a number of specific ideas and suggestions for the advancement of CDS. A partial list of the expressed suggestions follows:

• Identify a “short list” of the most important drug-drug, and drug-allergy interactions to support with CDS. This will necessitate the development of a model for rule creation/review/editing.
• Develop a reference of best CDS practices and exemplary implementation sites
• Build a library of CDS reference implementations, by practice type, as a starting point that others could emulate.
• Develop a “usability checklist” that identifies standard wait times of no longer than X seconds, etc.
• Collect good practices and exemplars associated with incorporating a computer into the exam room during ambulatory patient visits.
• Build a national health IT simulation lab, similar to the national driving simulator, to help providers assess the functionality and usability of EHR and CDS systems. Products could be configured to address specific patient scenarios, and users could “test drive” them to assist vendors in improving their products while giving providers information on which systems are the most functional and usable.
• Develop a vendor-independent certification for “expert implementers of Health IT systems”-similar to a Good Housekeeping seal or Angie’s List.
• Develop an accreditation for guideline developers to ensure that they follow required principles in translating guidelines into codified knowledge and CDS interventions.
• Develop a robust set of use cases to test the hypothesis that a common data set could service both CDS and quality measurement.
• Develop a list of CDS intervention types with key parameters, as a first step in standardization and sharing of CDS across disparate EHR systems.

Participants offered several suggestions about how new or existing organizations may help meet people where they are and give them a compelling reason to move to where we need them to be in 2011 and 2013. Examples include:

• The 2008 CDS American Health Information Community (AHIC) recommendations included idea of a forming a national CDS alliance as a public-private, multi-stakeholder entity to focus on CDS. Participants in this August, 2009, CDS workshop noted this may be a useful mechanism to consider for promoting knowledge sharing among stakeholders. Several participants expressed concern that any new organization may need to be public/private to assure the needed breadth of expertise and perspectives for its products to be accepted and trusted.

• Workshop participants noted that it could be helpful to leverage the National Institutes that are responsible for specific diseases to build some of these collaborations. For example, the National Heart, Lung and Blood Institute (NHLBI) has established a National Knowledge Network for cardiovascular disease which brings together knowledge generators, specialty societies, performance measurement, and CDS professionals.