Industry Insights: 5 questions Ginny Kwong, MD, Vice President and Chief Medical Information Officer at Halifax Health

Ginny Kwong, MD, is the Vice President and Chief Medical Information Officer at Halifax Health, East Central Florida's largest healthcare provider.

Halifax Health comprises a 678-bed hospital and more than 500 physicians representing 54 medical specialties, as well as Florida's largest emergency department (ED), with more than 115,000 emergency visits annually. Halifax recently partnered with Wolters Kluwer to improve sepsis outcomes by integrating advanced clinical decision support (CDS) technology.

Question: How is Halifax Health leveraging CDS technology for point of care alerting?

Ginny Kwong: We have been leveraging innovative CDS technology through our partnership with Wolters Kluwer in the form of POC Advisor, which incorporates real-time EHR enterprise surveillance and alerting. The system uses prescriptive analytics to alert the bedside nursing staff and rapid response team for potential cases of sepsis. The clinical staff receives alerts on their mobile Vocera badges, which empowers our teams to initiate early interventions to decrease sepsis morbidity and mortality.

Q: How does CDS support your initiatives aimed at improving patient outcomes related to sepsis?

GK: Halifax Health's goal is to ensure the highest patient safety and quality outcomes to achieve clinical excellence. As part of our preparation for the deployment of POC Advisor, Halifax Health decreased sepsis mortality by 33% in the past year by improving coordinated sepsis education, protocols and evidenced based order sets. We look forward to further reducing our sepsis mortality by using CDS at the point of care.

The power of real-time CDS derives from early identification and prescriptive analytics, including the delivery of highly accurate alerts to the clinician at the bedside. These components are key to identifying sepsis early and intervening with 3- and 6-hour bundle treatments, which are required to meet the CMS Sepsis Core Measure. Every hour that severe sepsis and septic shock go untreated increases the risk of patient death by approximately 8 percent, so time is of the essence when treating these patients. These bundle treatments, which include obtaining blood cultures, initiating proper antibiotics, drawing lactic acids, and giving weight-based IV fluids, decrease patients' progression to organ failure and significantly improve the chance of survival.

Leveraging CDS technology for early identification and treatment of septic patients, whether presenting in the ED or on in-patient units, could improve length of stay by mitigating the clinical progression of sepsis to organ failure or septic shock and avoiding critical care interventions in the ICU. In addition, leveraging CDS support for sepsis screening will identify early cases.

Q: Workflow disruption is perhaps the greatest concern for hospitals considering new technology. How are you deploying point of care CDS that is integrated into clinician workflow without causing alert fatigue?

GK: Good question! Providers experience a high level of alert fatigue with today's systems, leading them to override the majority of electronic alerts because they are false positives or not helpful. This is especially true of sepsis alerts. A meta-analysis from 2015 showed that none of the CDS alerting systems studied up to that point in time resulted in a reduction in sepsis mortality, because all of the systems caused alert fatigue, meaning providers ignored the alerts. This is a problem with sepsis alerting. The Sepsis-2 definition, which is commonly used as the basis for electronic alerting, is known to have a very poor specificity, so the great majority of alerts are false positives. POC Advisor, though has a high test specificity, so it generates few false positive alerts, minimizing alert fatigue.

Beyond false alerts, there are other considerations, including conducting a comprehensive assessment of the current and future states of clinician workflows. You should also be mindful of the Five Rights of CDS. You want to ensure that CDS is designed to deliver the right information, at the right time, to the right provider, in the right format and on the right device to guarantee an actionable and effective intervention is conducted. Since sepsis is so time-sensitive and complex, the integration of new technology needs to be carefully thought out to gain maximum adoption and prevent clinicians from perceiving it as burdensome or disruptive.

Selecting the right method of alerting is one of the most important parts of the assessment. Nurses and physicians are not working in the EHR 24/7. They are constantly mobile and don't always have access to EHR-deployed CDS. Likewise, requiring clinicians to log in to another application for alerting advice adds another task to the already busy and fast-paced ED or medical environment, so you want to avoid that.

Currently, we are working with Wolters Kluwer to begin deploying alerts to mobile Vocera badges to assist the bedside nurses who have already identified a sepsis case. By leveraging the Vocera badges, we are adhering to the "right device" principle outlined in the Five Rights of CDS. We plan to deliver many different types of information to the Vocera badges, but one specific example will be reminders to draw repeat lactate acid levels based on the results of the first lactate level as part of adherence to the Sepsis Core Measure.

Q: In what ways are these challenges unique to your health system? If so, what obstacles might other provider organizations encounter when rolling out new technology and how can they address them?

GK: Every health system has different levels of resources, staffing, and technology assets, all of which need to be taken into account when first evaluating the capability of deploying an advanced CDS system. Having the right stakeholders (physicians, nursing, informatics, pharmacy, ancillary, and IT leadership) at the table working collaboratively to evaluate current clinical workflows and agreed-upon protocols, evidenced based order sets, and device-alerting capabilities is essential to ensure alignment of processes prior to integrating the technology.

Efficiency, productivity and structure in providing quality care is extremely important to clinicians. Deploying any new technology will introduce a new change in their daily routines. Therefore, starting with pilot units and supporting them with education and training is key to a successful implementation. Once the pilot units realize the value the new technology adds to productivity and patient care, excitement and adoption will follow.

Q: How are you using analytics to assess the performance of your CDS systems?

There are three main ways to use analytics to assess overall performance: process measures, core measures and outcomes measures. Examples of process measures we are using with POC Advisor include identifying when clinicians acknowledged alerts and whether they agreed or disagreed. Process reports are used to identify staff who need more education and potential gaps in current processes, as well as other performance improvement opportunities to identify and treat sepsis early.

Examples of core measure support include analytics for the timing and completeness of the CMS sepsis bundle elements (e.g. lactates, cultures, and antibiotics).

The last set of analytics focuses on outcomes measures. Specifically, we plan to study sepsis mortality, length of stay and 30-day readmission, as well as revenue improvement. This will take more time to accomplish, but is an important part of our efforts to continually improve performance.

Once the capabilities of the CDS system are understood, each organization can develop its own innovative ways to leverage the power of that technology to enhance process deliveries of patient care to achieve quality outcomes.

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