As healthcare technology advances, clinicians are presented with a vast amount of data to analyze. Despite the convenience of electronic health records (EHRs) in terms of accessing patient records, the sheer volume of information poses a challenge for clinicians. Patient care in the ICU provides a perfect example of the volume of data that is generated during clinical care. Monitors capture second-by-second readings of heart rate, blood pressure, respirations, oxygen saturation, temperature, EKG tracings, and more. In addition, non-standardized interfaces and excessive notetaking can exacerbate the issue and increase the strain on clinicians, ultimately leading to burnout and potential complications in patient care. This not only affects the staff's well-being but also negatively impacts the delivery of patient care.
Clinical Decision Support (CDS) can be an invaluable solution in alleviating these burdens. When intelligently deployed, CDS is a tool that equips clinicians with pertinent patient data and evidence-based recommendations that support clinical decision-making processes and increase efficiency while optimizing patient outcomes. Integrating CDS into clinical workflow helps clinicians work more efficiently while making smarter decisions resulting in enhanced patient care and outcomes.
At the HIMSS Global Health Conference in 2023, the concern of overburdened clinicians took center stage. With nearly half of US clinicians reporting burnout before the COVID-19 pandemic and 44% of healthcare workers in the UK experiencing work-related stress, clinician burden is a pressing issue. It affects not only clinicians' well-being but also global healthcare's future. Many healthcare workers leave their jobs due to exhaustion and burnout, risking patient care.
Several significant trends contribute to the problem, such as an aging population requiring increased medical services, more medications requiring prior authorizations (PAs), more procedural interventions, and a lack of specialists in many key fields such as Rheumatology.
The clinician burden concerning the EHR was addressed at the "National Burden Reduction Collaborative Meeting" led by Dr. Howard Landa, Chairman of AMDIS and VP of Clinical Informatics at Sutter Health. The meeting identified priorities that would help address the issue of clinician burden, which we will discuss below.
Priorities for Reducing Clinician Burden
- Disease-Specific Standard Electronic Health Record (EHR) interfaces: Most healthcare organizations (HCOs) use EHR interfaces that are not optimized for managing specific diseases. This leads to the suboptimal utility of clinician time and lower quality patient care.
- Data Overload: Politico reported that more than 7 in 10 clinicians suffer from data overload and don't know what to do with all the data. EHR integration can help support clinical disease management, but only if the data is organized and streamlined to support Clinical Decisions Support.
- Note Bloat: There is no ICD code for the disease of Note Bloat, which describes what happens to a healthcare provider's encounter note when it contains far too much irrelevant information. Clinicians spend 30 to 50 percent of their day reviewing, documenting, and entering orders into an EHR. Historically, in paper-based clinical charts, there was an art in keeping notes brief and to the point. However, as EHR systems have proliferated, clinicians have concerns about leaving documentation to support billing and can be prone to cutting and pasting heaps of data into the clinical note as a substitute for analysis. This has led to bloated notes, which increase the time required for clinicians to review a patient's past medical history.
- Interoperability Challenges: The lack of interoperability among different health IT systems makes it difficult for clinicians to access and assemble patient data, leading to increased workload, burnout, errors, and delays in care. The need for seamless data exchange and interoperability standards is crucial to alleviate the burden on clinicians, improve job satisfaction, and ultimately lead to better patient outcomes.
Dr. Landa's group with HIMSS has created project groups to study these areas. During the presentation at HIMSS, Dr. Landa pointed out the duality of the EHR in both creating additional clinical work and being the potential savior. There is a pressing need for clinicians to quickly transform patient data into outputs they can use for improved decision-making, often via electronic knowledge bases that facilitate better healthcare delivery - this transformation of data into outputs used by clinicians for decision support is known as Clinical Decision Support (CDS).
Clinical Decision Support (CDS) as a Solution
Clinical Decision Support (CDS) does not aim to replace clinician judgment but serves as an evidence-based tool using structured patient data to make timely, informed, and high-quality decisions to optimize patient outcomes. Research suggests that clinicians tend to favor CDS solutions such as recommendations, alerts, notifications, and reminders as potential error mitigation methods and assessments that improve outcomes for their patients. Clinical research indicates that clinicians are highly likely to accept the following types of CDS solutions in practice:
- Alerts, notifications, and reminders
- Potential error mitigation
But these CDS solutions can only truly succeed when they seamlessly fit into the clinical workflow. This requires a detailed assessment of the existing workflow and identification of areas in which CDS solutions would be utilized by clinicians to impact patient care. This analysis has to be performed with the assistance of the clinical team. By doing this, we can increase clinical adoption and acceptance while avoiding the dysfunctional nature of distracting the clinician by providing CDS at the wrong time or within the wrong context which can lead to system disengagement by the clinician.
Clinicians may also express skepticism about the CDS. This may be related to their belief that the solution will have no meaningful effect on patient outcomes. Recognizing clinician concerns or reservations related to CDS deployment is crucial. If CDS efficacy was their chief concern, one approach for dealing with it might include providing research demonstrating evidence of CDS' effectiveness as a solution. If the objection is related to efficiency; user training can help reduce doubts and help clinicians become more comfortable about using CDS in clinical practice.
Attributes of Successful CDS Solutions
One of the critical attributes of a successful CDS solution is its need to positively change patient care. This means CDS outcomes need to be tied to specific clinical tasks, or 'clinical order sets'. Clinical order sets are pre-specified tasks indicating tests, medications, and interventions for a specific condition or scenario. These can include any hospital admission (e.g., cardiology admission), condition (e.g., rheumatoid arthritis flare), symptom (e.g., chest pain), procedure (e.g., total knee arthroplasty), or treatment (e.g., chemotherapy). On EHRs, order sets are called computerized provider order entry (CPOE). Research has shown that patient outcomes can be significantly improved when CDS helps drive CPOEs within an integrated clinical workflow.
Dr. Landa also realizes that many hospital departments need more resources and internal support to build CDS tools within their respective departments. To achieve its vision, HCOs must leverage partnerships with other healthcare stakeholders, including pharmaceutical companies, medtech, and payers interested in improving healthcare delivery.
Partnerships for Building CDS Tools
S3 Connected Health has a history of building CDS tools (and CPOEs) for specific disease conditions. As mentioned, any CDS analysis must start with a detailed understanding of the Clinical Workflow. Research indicates that a lack of attention to the clinical workflow has doomed most CDS tools in clinical practice. After the mapping of the clinical workflow, S3 Connected Health utilizes specific CDS frameworks like the "CDS Fire Rights Model" ("Right Information" to the "Right Person" in the "Right CDS Intervention Format" through the "Right Channel" at the "Right Time") to idealize potential CDS tools within the workflow.
S3 Connected Health also works with international medical Key-Opinion-Leaders (KOLs) to test workflow and other assumptions while gauging clinician interest in possible CDS tool solutions. This approach has allowed CDS solutions fielded by S3CH to achieve high clinician and patient acceptance levels. For example, a rare disease CDS tool for Spinal Muscular Atrophy resulted in over 90% of in-country patients being supported.
Case Study: Enodatis for COVID-19
Enodatis was developed in response to the urgent need for a solution that enabled hospitals to optimize and scale acute respiratory care during the COVID-19 global pandemic. More specifically, Enodatis is a web-based CDS to support the critical decision of the level of respiratory support and ICU support required for a COVID-19 patient. It was jointly created by S3 Connected Health with an experienced team of disease specialists.
"(In early 2020,) everybody suddenly became aware of Covid-19... and the effect it was having on health service and on the individual people. We really needed to have a tool that we could use that allowed us to stream the physiological parameters of the individual. We had a conversation with S3 Connected Health... and over the week, between a developmental team…and our clinical team, we were refined and reiterated. And by the following Saturday, we had a HPRA-approved medical device up and running. And two days later, we deployed it." - Professor Richard Costello, Professor of Medicine, RCSI.
The tool delivered tangible results, with the COVID Critical Care Index (CCCI) being more strongly predictive of adverse outcomes than existing tools such as the National Early Warning Score (NEWS) or ROX index. Enodatis is an award-winning web-based clinical support tool, and has achieved:
- 2021 Medical Design Excellence Finalist
- 2020 PM360 Innovator' Innovative Product Award
The burden on clinicians is a global healthcare concern that needs to be addressed. The priorities identified by Dr. Landa's group can help alleviate the burden on clinicians and improve patient care. We can improve clinician efficiency and patient outcomes by optimizing EHR interfaces, streamlining data, reducing note bloat, and integrating CDS into the clinical workflow. The effective use of CDS solutions can provide clinicians with tools to make timely, informed, and high-quality decisions to improve patient outcomes. Understanding the clinical workflow from the clinician's perspective and developing solutions that can integrate into the workflow seamlessly is essential. HCOs must leverage partnerships with other healthcare stakeholders to achieve their vision of improving healthcare delivery.
See here for more info on S3 Connected Health's Digital Health Solutions supporting chronic disease management.