Clinical Decision Support System Improves Lab Test Ordering

Vanderbilt helps physicians practice better medicine

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CEO SUMMARY: Vanderbilt University Medical Center’s “WizOrder” demonstrates that a well-designed clinical decision support system can help physicians make better use of laboratory tests. The early successes of WizOrder demonstrate that the need for improved utilization and application of laboratory tests will be ongoing. It reinforces, once again, that there is an opportunity for lab administrators and pathologists to proactively add value for the clinicians they serve.

IT IS WIDELY-RECOGNIZED THAT CHANGING the way physicians practice medicine is, at best, extremely difficult. This is particularly true when it comes to ordering laboratory tests and using test result data in different ways.

Yet it is also widely-recognized that better utilization of lab testing can generate substantial gains in the quality of healthcare outcomes, accompanied by a lower cost per episode of care. But to date, most efforts by lab executives and pathologists to implement fundamental changes in how physicians order lab tests and use the resulting information have failed, often generating ill-will in the process.

Against this background of widespread frustration, there is a notable exception. At Vanderbilt University Medical Center (VUMC) in Nashville, Tennessee, efforts to move physicians’ clinical behavior closer to desired “best practices” models are not only succeeding, but generating ongoing improvements.

Two Lab Functions Targeted

Among specific clinical practices targeted are two that directly involve laboratories. One goal is to improve laboratory test ordering patterns and the other goal is to insure that clinicians act properly in response to lab test data generated by the specific tests they order. Martha Miers, VUMC’s Executive Director of Clinical Laboratories, tells THE DARK REPORT that “for example, in the first hospital units where the clinical decision support system was implemented, the volume of routine chemistry tests performed has fallen by as much as 30%.”

But this success did not come overnight. VUMC’s journey to its current system for clinical decision support began in the late 1980s. “The main objective of this effort is to reduce variability in how our physicians practice medicine,” stated William Stead, M.D. Associate Vice Chancellor for Health Affairs at Vanderbilt University Medical Center. “Within our system, we could see differences in outcomes and costs which could be attributed to variability in how individual clinicians practice medicine.

“Our first effort was in 1989, funded by a grant from the Robert Wood Johnson Foundation,” said Dr. Stead. “By the mid- 1990s, we had developed collaborative care pathways covering about 80% of our admissions. One of our earliest care pathways dealt with radical prostatectomy. We provided clinicians with raw data on variability. As a result, costs fell by 40% and there were measurable improvements in morbidity.

“The earliest steps toward our current clinical decision support program began about seven years ago,” he continued. “In the mid-1990s, we went live with a physician-ordering system that turned out to be rather unfriendly to doctors. So, for the next five years, we created a different type of system, one that supported the way physicians worked ‘pre-computer.’ That allowed us to begin adding data from the patient record, as well as supporting their decisions with appropriate information.”

“Through in-house efforts, we’ve created two software products that anchor our clinical decision support system,” he explained. “One is a decision support tool we call ‘WizOrder.’ The other is ‘StarChart’, which is our integrated patient record.

“We began down this path when administration noticed that variability in the healthcare system was a real problem,” commented Dr. Stead. “Data showed that there was considerable variability in costs across different regions, yet there was no discernable difference in outcomes. That means extra money spent in one area did not translate into better healthcare.

“Vanderbilt adopted a strategy of reducing variation in clinical practices,” he continued. “We started with this premise: ‘Our fundamental job is to take variability out of the practice of medicine.’

“Our strategy was simple. It was to help clinicians develop ‘best practices’ protocols, then provide them with information they need at various clinical decision points so that their patients were treated in accordance with clinical ‘best practices’.”

This is where Vanderbilt’s WizOrder plays the key role. “One important place to influence variability is when a clinician decides to order procedures he/she considers appropriate for the patient,” noted Dr. Stead. “This is the moment where our clinical decision support system is designed to provide the clinician with the right information in the appropriate context.”

Dr. Stead emphasizes that WizOrder is not simply an order entry system. “This is a sophisticated clinical tool,” he said. “It has practice algorithms developed by our medical staff, full access to patient data, and supporting knowledge needed to provide clinicians with all the information they need to make an informed decision about their patient.”

This is key to understanding why Vanderbilt’s WizOrder has proved to be an effective clinical decision support tool. Unlike a simple order entry system, WizOrder is built upon three basic components, each designed to give physicians information they need to make informed decisions.

WizOrder’s first component involves the “best practices” algorithms. “These are developed by our medical staff,” Dr. Stead observed. “Where laboratory tests are involved, pathologists work with other clinical leaders to provide written guidelines. These clinical practice protocols are the heart of WizOrder.”

The second component is access to patient records. “Our ‘StarChart’ contains an integrated patient record that can be accessed through WizOrder,” he stated. “In real time, it shows the physician which tests and procedures have already been ordered, as well as results from those tests.

“The objective is to provide physicians with information necessary to make sound clinical decisions,” continued Dr. Stead. “As well, it prevents the physicians from ordering unnecessary tests.”

McKesson Licenses WizOrder for Sale

CLINICAL DECISION SUPPORT SYSTEMS may be coming soon to a hospital or health system near you. Vanderbilt University Medical Center (VUMC) has licensed WizOrder to McKesson Corporation.

The current performance of WizOrder has been impressive enough to attract the interest of McKesson. It is already marketing the system to other healthcare systems under the name “Horizon Expert Orders™ .” One of the earliest customers for this product is St. Luke’s Episcopal Hospital of Houston, Texas.

Avoid Unnecessary Tests

“In the laboratory, this has impacted test utilization in an obvious way,” added Miers. “We see fewer test orders because WizOrder cues the physician that either: 1) the test results are already available; or 2) the same test was ordered earlier and results are pending; or 3) trended results of the same test over time indicate that repeat testing may be unnecessary. This is one way WizOrder reduces the amount of redundant testing that is common in most hospitals.”

WizOrder’s third component is the knowledge base which supports best-practices protocols. “At the time a physician is ready to make an order, the knowledge base provides supplemental information necessary for him/her to decide which clinical procedure might be most appropriate for the patient,” said Dr. Stead.

Knowledge Data Base

“Part of the knowledge data base involving laboratory tests was developed by our pathologists,” noted Miers. “Screens with desired information pop up within WizOrder as the clinician searches for supporting information.”

As a functioning clinical decision support system, WizOrder presents the physician with a very complete information resource. “Keep in mind that WizOrder has evolved from all our earlier efforts over the past seven years to provide physicians with healthcare informatics tools,” said Dr. Stead. “We’ve learned how to support physicians’ decisions in a way that maintains their control.

“WizOrder allows the clinician to see the patient history,” he continued, “and supports decisions with appropriate information. ‘Alerts’ are one active feature of WizOrder. As the clinician works through the case, alerts will appear at appropriate moments.

“Alerts are interactive messages which pop up,” he commented. “It could be a potential negative drug-to-drug reaction. Or the patient may have an allergic reaction to the drug being considered.”

Protocols Used As Guides

“If the physician wants to order a procedure that falls outside ‘best practices’ protocols, then WizOrder asks that physician to justify that procedure,” Dr. Stead noted. “WizOrder cues the physician if his/her order might not be most optimal and prompts the accepted practice, helping to guide physicians to the right decision for a particular patient.

“Remember, Vanderbilt’s goal is to eliminate variability,” he emphasized. “We want our doctors to oscillate around ‘best practices’ protocols by helping them make the right decision at the time of the order.”

Alerts are one way to monitor progress toward this goal. Each day, between 500 and 800 alerts are issued. “The number of alerts tells us how physicians are responding to ‘best practices’ protocols,” stated Dr. Stead. “Certainly fewer alerts would indicate that physicians are incorporating the guidelines into their daily clinical practice.”

Although WizOrder was not designed first to be just an order entry system, it has changed the way clinicians order within VUMC. “In the typical hospital, the physician will write an order in shorthand—then a staff member will execute it. That’s not what happens with WizOrder. As the physician works through his/her case, he/she is directly ordering the procedure. This eliminates the need for support staff to perform this task.”

High Acceptance

Dr. Stead indicates that physician acceptance of WizOrder has been high because physicians retain control over the process. “As they realize they have more complete information at the time of decision, it makes it easier for us to make small improvements in ‘best practices’ protocols,” he said.

Widespread physician acceptance of WizOrder is evidence that it meets their needs. The system is used extensively in VUMC’s inpatient settings. “This is because we have fairly complete data sets,” noted Dr. Stead. “In electronic form, StarChart includes all the data we have, including text and images. However, we’ve not yet tried to do online or bedside charting.

“In the outpatient setting, order entry is more difficult to implement,” he added. “Care can be fragmented and it takes longer to access the patient record. However, we are working to overcome these obstacles.”

Vanderbilt’s successes have been significant. Besides the reduction in routine chemistry tests ordered in units where WizOrder has been implemented, there are other measurable benefits.

“WizOrder is also having a big impact on pharmacy. VUMC can track $5 million in savings from improved ordering and use of drugs. A sizable amount of this is attributable to drug substitutions,” said Dr. Stead.

Because detailed cost accounting is not easy to develop, VUMC allows each clinical unit to define its goals and identify how it will measure savings and clinical improvements. Administration wants to track this performance because it uses those savings to justify additional investment in information technology.

Vanderbilt’s IT Spending

“Vanderbilt’s budget for information technology (IT) has been increasing, on average, by more than 10% per year,” observed Dr. Stead. “On the performance side, the goal is to reduce the cost per unit of care by 3% annually.”

Because laboratory testing is integral to many clinical decisions, Vanderbilt’s laboratory department is fully engaged in the “best practices” strategy. “In hospital units where WizOrder has fully deployed, we’ve seen a reduction of up to 30% in the volume of routine chemistry testing from improved lab test ordering patterns,” said Miers. “This volume reduction has allowed our lab to absorb increasing test volumes from other areas without significant budget increases. We plan to measure other areas of testing affected by WizOrder so we can quantify the benefits.”

THE DARK REPORT observes that Vanderbilt’s success with its evolving clinical decision support system validates the potential of such tools to help clinicians improve the quality of care while reducing or eliminating unnecessary costs.

It also identifies one method that allows clinical pathologists and lab administrators to support improvements in how clinicians order lab tests and act upon lab test results—in a way that clinicians see as beneficial and nonthreatening.

“Smart” Clinical Systems

Vanderbilt’s WizOrder is an early example of the type of “smart” clinical systems which will support more effective decision-making by physicians and other providers. It demonstrates how an information bundle that includes: 1) an electronically-accessible and complete patient record; 2) patient care algorithms; and 3) medical knowledge resources, can become a valuable tool for clinicians.

THE DARK REPORT predicts clinical decision support systems can be expected to increase the importance of laboratory executives and pathologists. After all, laboratorians are experts in diagnostic medicine. It is they who know best how to organize and deliver the most appropriate laboratory testing services for the healthcare providers they serve.

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