In the meaningful use Stage 3 final rule released last October, CMS began emphasizing the role of clinical decision support (CDS) in promoting value-based care. Of particular interest are the "Stage 3 CDS and Outcome-Based Clinical Quality Measures (CQMs) ," in which CMS recommends CDS interventions that relate to five CQMs as follows:
• Reduced length of stay
• Reduced re-admissions
• Fewer hospital-acquired conditions and medication-related adverse events
• Fewer hospital admissions due to chronic conditions
• Reduced morbidity and mortality associated with chronic conditions
What CMS doesn't provide is guidance on relating CDS usage to these CQMs. Keep in mind that in all cases, the usefulness of a CDS system in supporting these measures depends on its ability to reference evidence-based practice guidelines and deliver prompts and guidance based on sound statistical analysis – consistent with the CMS definition of what constitutes CDS . It's also essential for the CDS system to provide an accurate view of the patient's entire health picture, rather than be limited to information stored in the local EMR.
With those capabilities in place, the following explains how best to support each of the recommended CQMs with CDS.
CQM #1: Reduced length of stay
This is perhaps the most inherent benefit of CDS, as reducing the average patient length of stay is a matter of increasing physician adherence to practice guidelines – deviations from evidence-based best practices are the primary contributors to length-of-stay increases. Physician buy-in to CDS guidance, with the support of hospital leadership, is key. CDS then assumes a key role in issuing unobtrusive reminders of those guidelines at the point of care.
CQM #2: Reduced re-admissions
The most effective tool hospitals have in reducing readmissions is to ensure that patients continue to receive adequate care after they leave the hospital. For CDS to assist in achieving this CQM, it must extend its alerts to the outpatient arena, especially with patients who have chronic disease and are therefore most vulnerable to readmission. CDS can assist in post-discharge management of these patients, for example, with alerts at post-acute care facilities to promote medication adherence and facilitate follow-up appointments for preventive care. With interoperability between dissimilar EMRs continuing to be elusive, CDS systems that operate independently of the EMR can assist with bolstering coordination of care through this CQM.
CQM #3: Fewer hospital-acquired conditions and medication-related adverse events
This CQM includes two separate yet interrelated concerns, as both are driven by prescribing issues. Hospital-acquired conditions are on the rise due to the misuse of antibiotics, which enables drug-resistant organisms; CDS can assist with antibiotic stewardship, issuing guidance that gets each patient on the correct antibiotic, and then off that antibiotic as soon as is advisable. The most effective means of reducing medication-related adverse events is with improved medication reconciliation, which has long been a fundamental CDS role.
CQM #4: Fewer hospital admissions due to chronic conditions
Of all the CQMs emphasized for CDS in Stage 3, this is the least easily addressable with clinical decision support. While CDS can clearly assist in reducing readmissions for patients with chronic conditions, reducing first admission for these patients is primarily a matter of engagement and education. The most effective assistance CDS can offer with this CQM is to push alerts directly to those patients who make good use of patient portals.
CQM #5: Reduced morbidity and mortality associated with chronic conditions
This CQM brings us back to the need for practice guidelines to be evidence-based, with CDS recommendations based on statistical analysis. The CDS system is then able to match symptoms with pathways and assist in early diagnosis/intervention to reduce morbidity and mortality associated with chronic conditions.
Beyond Stage 3: CDS's role in value-based models
Regardless of whether a provider is pursuing Stage 3 at this time, healthcare enterprises are being generally encouraged by private payers to adopt value-based models. For providers who are in or are moving toward models such as accountable care organizations (ACOs), an advanced CDS platform can help them succeed with ACO quality measures, which are fundamentally aligned with the clinical quality measures outlined by CMS.
This is, after all, part of the general shift in healthcare away from a focus on the individual patient to a focus on population health. CDS is very well matched to meet that need, increasing the odds on the number of patients who will have favorable health outcomes while offering a predictable cost for a given pathway.
1CMS-3310-FC and CMS-3311-FC Meaningful Use Objectives and Measures Clinical Decision Support for EPs, EHs and CAHs, HIMSS, Oct. 15, 2015.
2Clinical Decision Support: More Than Just ‘Alerts’ Tipsheet, CMS eHealth University, last updated Sept. 2014.
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