An Introduction to Clinical Decision Support for Cardiology
In an era of healthcare reform and a push to meet appropriate use guidelines for tests, imaging and therapy amid declining reimbursements, there has been much discussion about implementation of clinical decision support software (CDS). There is apprehension by some physicians who view CDS as technology telling doctors how to practice medicine. There are others in healthcare who are concerned about adding cost with the implementation of this software and how it will be updated based on the most current clinical data and practice guidelines. However, if implemented in a way where it is integrated with workflow and accepted by the physicians and hospital leadership, CDS has helped some hospitals meet appropriate use criteria and reduce unnecessary tests, which in turn helped reduce healthcare costs.
CDS is supposed to help clinicians do more with less by identifying at-risk patients, eliminating inappropriate procedures and to help physicians adhere to practice guidelines. It is unreasonable to expect physicians to remember hundreds of pages of ever-changing appropriate use criteria (AUC), which is where CDS can offer an instant resource. In addition, the software records data can be mined for information, such as benchmarking to target education and quality improvement, or to see patterns of use over time.
Healthcare reform initiatives include payment incentives for hospitals that provide better healthcare. Most of these incentives have been for hospitals leveraging information technology in a meaningful way to better manage patient care. An electronic medical record (EMR) by itself does not mean better care any more than a good road means no accidents. Similar to the adoption of GPS by motorists, CDS can help healthcare providers navigate complex care situations and improve outcomes. CDS does not replace a skilled clinician, but like a GPS, it can help them take the best route to their desired destination.
Stage 2 meaningful use requirements for EMRs, released in August 2012, call for physicians to use some form of clinical decision in their practice. It was left intentionally vague so physicians can find software that best meets their needs. This requirement has brought CDS to the forefront of healthcare IT.
“Healthcare providers are increasingly under pressure to make appropriate clinical decisions, document those decisions and do so efficiently,” said V. Katherine Gray, Ph.D., president, CEO and founder of Sage Health Management Solutions, a provider of CDS software. “With the recent economic pressures, patients, payers and the government are demanding more accountability in managing the costs and value of all healthcare services, especially in the burgeoning diagnostic imaging services.”
CDS for Cardiology and Radiology
In cardiology and radiology, the main use of clinical decision support is to quickly determine what type of imaging exam or diagnostic testing is needed for a patient with specific symptoms. The software is based on AUC set by various medical societies, including the American College of Radiology (ACR), the American College of Cardiology (ACC), Heart Rhythm Society (HRS) and American Heart Association (AHA). Some societies are creating software to help clinicians stay up to date on the criteria and make it easier for them to implement these standards.
The ACC’s Imaging in FOCUS initiative is aimed at reducing inappropriate use of diagnostic imaging through the use of CDS software to track AUC. As a measure of success, participating practices have been able to reduce inappropriate ordering by close to 50 percent in one year (from 12 to 7 percent).
The Society of Cardiovascular Angiography and Intervention (SCAI) recently released an AUC app, the SCAI Quality Improvement Toolkit (SCAI-QIT). It is the first of several AUC and guidelines apps that will help interventional cardiologists more easily determine whether their patients are appropriate candidates for percutaneous coronary interventions (PCI). The app is designed to put the lengthy AUC guideline document at providers’ fingertips.
“The new app is a calculator tool that makes it simple to access the AUC on heart revascularization without having to carry around printed documents,” said Kalon Ho, M.D., FSCAI, architect of the new tool. “While we don’t intend for this tool to replace clinical judgment, we do hope it provides easier access to information that can guide the cath lab team’s decisions.”
Once members of the cardiac cath lab team input facts about a patient’s case, the app will indicate where a typical case with those same characteristics would fall on a spectrum of “appropriate,” “uncertain” or “inappropriate” for revascularization, as defined by the latest recommendations from leading cardiology societies, including SCAI and the ACC Foundation. Interventional cardiologists can then use that information to make recommendations for treatment.
Emerge originally developed CDS software to help guide cardiologists in the diagnosis and management of heart failure patients. Its inspiration came from several articles examining the gap in cardiologists meeting guidelines to appropriately manage these patients. The software now includes risk stratification for sudden cardiac death, guidelines for use of implantable cardioverter defibrillators (ICDs), and management of peripheral artery disease and atrial fibrillation. The company is also developing software on AUC for sleep disorders and heart valves.
Emerge’s specialty is AUC for cardiac nuclear imaging. The software evaluates variables in a patient’s EMR to decide if sending them for a perfusion exam meets the guidelines.
“It just shows you if it’s appropriate or not,” said William Daniel, M.D., director of quality control at Mid-America Heart Institute, Kansas City, and CMO of Emerge. “It’s not for the differential diagnosis, it’s about helping the clinician to meet the appropriate use criteria. It’s not about telling them how to practice medicine.”
As an example, if a patient has an extremely low risk of heart disease and no symptoms, there is little need to send them for expensive imaging tests.
“You get rid of improper referrals and inappropriate imaging tests,” Daniel said. “We take discreet data in the EMR and run it through algorithms to see if it matches ACC, AHA and HRS AUC. There is also an issue with not providing appropriate therapies that we are missing, and CDS can help bridge that gap. But, it leaves the decision in the hands of the clinician.”
He said the software also acts as a filter to remove unconscious biases because the system just looks at data from a list of yes or no questions. “There were a couple of revelations we found that are important. One example was we got rid of gender and racial bias for ICD implants. The software does not care if the patient is fat, skinny, male, female or what race you are — it just tells you if something is appropriate or not,” Daniel said.
Following best practice guidelines set by societies is one thing, but following reimbursement guidelines by payers is another. Daniel said the system also can layer in payment guidelines. An example of how this might aid clinical decisions is Emerge’s heart failure software, which outlined a previously required waiting period of several months when considering implantation of an ICD in heart failure patients.
Tips For What is Needed in CDS Software
Daniel shared several points clinicians should consider when shopping for CDS systems. “For clinical decision support to be used and effective, it must be integrated into the workflow. It has to make sense and not require all sorts of extra pointing and clicking,” he said. “It has to make sense and work seamlessly. Everyone today is just too busy to deviate from their workflow.”
Along with society guidelines, each hospital has its own set of protocols, so CDS software needs to be customizable. “It needs to be very flexible, it has to be useful,” Daniel said.
CDS software can be hosted on a hospital’s server or on a cloud server. The advantage of the cloud is it can be accessed anywhere through an encrypted connection. It also allows for easier updates due to guideline or reimbursement changes.
In addition to offering decision support, a system should offer feedback reports. It should be customizable to analyze each physician to see if they met AUC. If the system identifies a large number of cases where the criteria was not met, Daniel said it may not be a problem with the doctor, but may indicate there is an issue with guidelines.
“I think what you are going to see is once people begin to use the software to meet meaningful use, they will want to take it a step further,” Daniel said
He said the software can help document everything to remove interim steps to care, such as case review boards or pre-certification of a procedure. It also can better guide physicians to more closely align their care to the guidelines, which may improve patient outcomes.
CDS as a Second Set of Eyes
MDDX offers Smart Read for real-time guidance while interpreting medical images. It has an integrated report engine that checks each answer put into the system against a database of common pitfalls, acceptable averages (i.e., radiation dose) and clinical correlations. It also checks for inconsistencies between the physician’s interpretation and the patient’s previous medical history. The Smart Read system aggregates expert wisdom into easy-to-understand points that are displayed during image interpretation. The system’s cardiac computed tomography (CT)angiography report engine incorporates 160 expert rules derived from the world’s top cardiac CT luminaries. Their advice helps flatten the learning curve and ensures physicians are up-to-date with the latest trends.
“In contrast to most CDS systems, which aim at physicians’ education, this is a CDS that integrates radiology benefits managers and insurance companies,” said James Min, M.D., FSCCT, associate professor of medicine, Cedars-Sinai Medical Center, and director of cardiac imaging research. “The goal of this type of CDS is that it reduces the need for prior authorization by taking guideline-based evidence, expert opinion and peer-based ordering and reducing the need for cardiologists or radiologists from having to interact with RBMs. Given Obamacare, and the trend toward accountable care organizations, this type of CDS will be a huge advance to saving cardiologists and radiologists a lot of headaches with prior authorization, while ensuring that doctors can perform physician-preferred, rather than insurance dictated, medicine.”
1. William A. Zoghbi. “President’s Page: Plan, Do, Study, Act: A Proven Path to Progress.” J Am Coll Cardiology, July 2012, Vol. 60, Issue 1.