Clinical content management has become a priority and critical driver of success within quality-based reimbursement models.
Healthcare organizations increasingly recognize that leveraging technological infrastructures to deliver the most up-to-date clinical decision support (CDS) to clinicians at the point of care is not only necessary to meet regulatory requirements but also improve outcomes and costs.
Within any hospital's greater CDS strategy, use of order sets has been identified by leading industry analysts as a key element for driving uptake of evidence-based practices and guiding clinicians to make the best decisions. The challenge is laying a framework for long-term viability of these tools as deployment, implementation and ongoing maintenance can be complex undertakings for the average resource-strapped healthcare organization.
While one notable obstacle to fully leveraging order sets is the ongoing maintenance activity required to keep content aligned with industry best practices, staying abreast of evolving regulatory guidelines for performance is equally challenging. Manual processes and workflows for identifying needed changes within a fluid regulatory landscape and rapidly advancing scientific field often result in compliance challenges and outdated evidence.
Rockford, Ill.-based SwedishAmerican responded to these challenges by deploying a two-pronged strategy based on advanced clinical content management technology and governance. The health system, comprised of a large acute care hospital, medical center and comprehensive network of outpatient providers and clinics, has been able to significantly streamline order set review and editing by applying quality assessment to the front end instead of the back end of processes.
Ongoing Process Improvement: Identifying Opportunities
As part of an ongoing commitment to elevate quality initiatives, SwedishAmerican fosters a culture of ongoing process improvement. The organization's well-honed clinical content management infrastructure and governance model for maintaining order sets are an outgrowth of that culture and designed to lay a foundation for sustainability with CPOE and evidence-based practices.
As part of SwedishAmerican's larger governance strategy, the clinical informatics team conducts regular reviews of the organization's approximately 230 order sets to ensure compliance with industry best practices and national quality measures. Governance is built on three guiding principles: 1) always put the needs of the patient first, 2) clinical users play an integral role in clinical IT decisions; and 3) the IT decision process is standardized, transparent and responsive.
Until recently, a typical quality review process entailed meeting with clinical staff to review new evidence recommended through the comprehensive clinical content management system— ProVation Order Sets, powered by UpToDate® Decision Support. Upon physician approval of edits and changes, content was forwarded to one of SwedishAmerican's seven quality analysts for review to ensure edits were aligned with quality initiatives. Revisions by quality reviewers were then sent back to the designated physician for reexamination.
Not only was the process characterized by repeated back and forth between reviewers and physicians, but reviewers often had to consult with in-house subject matter experts when order set content fell out of their area of specialization. Further, when changes to order sets were minor, the quality review process was often bypassed completely to avoid lengthy, time-consuming processes.
A Better Quality Review Strategy
Recognizing the significant resources required to keep order sets in synch with national quality measures, the SwedishAmerican clinical informatics team identified a strategy for streamlining the effort while also minimizing the potential for compliance gaps. It required that a quality assessment be applied to the front end of order set review rather than the back end by leveraging tools within the existing clinical content management infrastructure.
An automated system comprised of up-to-date national quality measures and customized rules is now used to conduct on-demand gap analyses of order sets and alert the clinical informatics team when content critical to quality measures is omitted or when content deviates from regulatory standards. As revisions are requested, compliance issues can be identified on the front end, eliminating the bottleneck that would previously occur.
When the new workflow and governance strategy was introduced, clinical informatics team leaders held an initial meeting with appropriate quality personnel to identify corresponding rules within abstracting methods for various national quality measures. The initial brainstorming proved beneficial as staff were able to identify opportunities to eliminate duplicated efforts between nursing and quality review. Staff also gained critical insight into the potential impacts of rules on clinical practice.
Today, staff have a greater appreciation of the quality review process and the importance of up-to-date clinical content at the point of care. Processes are also streamlined as clinical informatics professionals are alerted when quality measures fall out of alignment and edits can be made on the fly rather than on the back end of review processes. The resulting efficiencies have freed up time for clinical informatics to focus on higher level clinical initiatives and potentially opened up opportunities to shorten the two-week review deadline.
During the initial review of existing order sets, SwedishAmerican was encouraged to find that very few gaps existed with national quality measures—the most common associated with surgical care improvement project (SCIP) measures for preoperative patients. Overall the implementation of the new workflow has enhanced clinical practice, and staff are confident that measures align with regulatory initiatives and most important: patient care is optimized.
Micki Magoon, MSN, RN, is the clinical informatics nurse with SwedishAmerican.
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