Development and Evaluation of Best Practice Alerts: Methods to Optimize Care Quality and Clinician Communication.

Abstract

Electronic health records (EHR) have created opportunities for health systems and clinicians to leverage technology in support of quality improvement efforts in health care. The Affordable Care Act (ACA) provided a mandate for health care organizations to modernize in support of the Institute of Healthcare Improvement’s triple aim to improve quality, reduce cost, and improve population health.1,2 A fully developed EHR complete with clinical decision support (CDS) is an essential part of a learning health system equipped to navigate an increasingly complex health care landscape. Clinical decision support is an organizing term to describe a variety of tools embedded within the EHR to enhance clinical decision-making through the provision of information to support clinician behavior at the point of care.1 The Best Practice Advisory (BPA) is a CDS tool built into the EHR that can be used by clinicians to promote quality care, reduce inefficiency, and advance communication through web-based delivery of information to providers.1Clinical decision support has a positive impact on outcome and process measures in health care, but adoption of the tool has been limited. For example, use of CDS is associated with cardiovascular risk reduction and improved guideline adherence.1,3 Despite the reported benefits, implementation of CDS varies across the United States. Without a central repository for CDS, individual health care organizations are responsible for development and implementation of effective CDS. Organizational investment in CDS is also challenged by prioritization of competing demands within a complex health care ecosystem. In addition, navigating organizational information technology (IT) infrastructure while balancing clinical commitments are barriers to participation for clinicians interested in leveraging CDS to provide evidence-based, high-quality patient care.Contemporary evidence supports the positive impact of local, relevant, and effective BPAs on evidence-based guideline adherence. A quality improvement initiative to increase referrals for severe aortic stenosis (AS) in a large health care system in the US Midwest demonstrated a significant increase in referral rates after implementation of a BPA (72%-95%, P < .001).4 The BPA featured an inbox message to ordering providers alerting them to an abnormal echocardiogram result, referenced American College of Cardiology/American Heart Association (ACC/AHA) guidelines for referral, and provided an order set to facilitate the referral process.Principles of effective CDS are well described in the literature. Guiding the development of successful CDS are the Five Rights outlined by the Healthcare Information and Management Systems Society and the GUIDES checklist (Table).1,5 Effective CDS design delivers the right information to the right person, through the right CDS intervention format and channel, and at the right point in a workflow.1 An additional resource to support effective CDS design is the checklist published by the GUIDES project following a process of systematic review of evidence, identification of success factors, expert panel consensus on checklist creation, and pilot testing.5 The GUIDES checklist is a practical tool designed to improve success of guideline-based CDS organized around 4 domains: (1) enabling CDS context, (2) appropriate CDS content, (3) effective CDS system and (4) effective CDS implementation.5 Within each domain of the GUIDES checklist, 4 features of effective CDS design principles are outlined (Figure 1). Additional factors for successful CDS design include value-added benefit, inclusion of multiple data types, information delivery to the user, good usability, testability in small settings, and support of quality improvement efforts.1 These principles are evident in the quality improvement initiative reported by Kirby et al4 and provide a roadmap for clinicians interested in developing CDS featuring BPAs to promote guideline-based patient care and enhance provider communication.Enabling the context for successful CDS is the first step in the process of designing effective clinical decision support. Effective CDS context considers the factors contributing to current practice, identifies opportunities for CDS use, describes CDS benefits to stakeholders and users, and addresses CDS feasibility on user workload. Kirby et al4 enabled the CDS context by defining the problem through collection of baseline data for severe AS referral, identifying outcome measures, and assembling a multidisciplinary team.4 The CDS development team included the valve program nurse practitioner, physicians, administrators, and an informatics team member.4 The importance of assembling a multidisciplinary team that includes clinicians, administrators, and informaticists cannot be understated. Interdisciplinary discussion of workflow and opportunities to close quality gaps in severe AS referral led to development of a BPA targeted at existing provider workload processes that was appropriately timed, carefully worded to encourage action, and had the organizational support of administration. In this example, the multidisciplinary workgroup identified a results message delivered to the clinicians’ EHR inbox as the context best suited for BPA delivery.4Delivery of relevant, accurate, and evidence-based CDS content is essential to CDS success. Appropriate CDS content is trustworthy and up to date, addresses the needs of end users, and contains a suitable call to action that is manageable for the provider. In the initiative reported by Kirby et al,4 CDS content was developed using ACC/AHA guidelines for echocardiogram criteria for severe AS. The full echocardiogram report was delivered to the provider, along with the ACC/AHA guidelines.4 Instructions on how to complete the referral process were included and a request was made to update the problem list to include a severe AS diagnosis.4 To support providers in completing the referral, an order set was also developed to reduce workload fatigue and promote efficiency. The BPA developed by Kirby et al4 demonstrates the importance of CDS content that is relevant, accurate, manageable, and actionable.Health care organizations with EHR integration technically support development of BPAs. An integrated EHR system contains the tools to design and sustain BPAs that are easy to use, well-delivered, and targeted to the right user at the right time. Kirby et al4 designed and implemented their BPA in the Epic EHR. Experienced users of Epic are familiar with passive and interruptive BPAs, results messages, inbox messages, and storyboard alerts. Results messages delivered to clinicians’ inboxes through the Epic EHR ensured CDS to the right person at the right time. The BPA for severe AS referral delivered as a results message included the appropriate content to support the desired guideline-based action but also included a reminder to clinicians to review the complete echocardiogram report to ensure additional cardiac problems were not missed.4 As demonstrated in this example, consideration of timing and delivery of information enabled by EHR tools within a CDS system is essential to successful BPA design.Implementation of CDS requires organizational support of continuous quality improvement and administrative recognition of CDS’ potential to improve patient outcomes, increase quality performance, and enhance financial performance. Successful CDS implementation requires communication and documentation of the CDS to end users. Implementation of CDS should be stepwise, with a focus on improvement as clinicians encounter barriers and facilitators to use of CDS. Ultimately, provider CDS use must be assessed and communicated back to users to enhance adherence. A highlight of the quality improvement work reported by Kirby et al4 is the inclusion of physicians, administrators, and informaticists on the BPA development team. Administrative sponsorship of BPA development and implementation ensures a continuous process with clear governance and IT infrastructure support. Alignment between organizational priorities, health system leadership, and a champion to oversee CDS implementation are success factors. Kirby et al4 demonstrated that effective BPA implementation championed by an advanced practice provider in collaboration with a multidisciplinary team can result in significant improvement in guideline-based care.The principles of effective CDS design of BPAs can be applied to any practice where opportunities exist to improve guideline adherence and thus patient care. For an example of how the GUIDES checklist could be used to design a BPA to improve ambulatory cardiac rehabilitation referral for patients hospitalized with acute myocardial infarction in accordance with ACC/AHA guidelines, see Figure 2.Successful CDS using BPAs promotes evidence-based, high-quality care by communicating information to frontline clinicians. The ability to deliver relevant, guideline-based information to clinicians through a standardized process is a feature of BPAs. Multidisciplinary stakeholder involvement in the BPA development process is essential to determine the appropriate delivery of information in compliance with the 5 rights and GUIDES checklist. An added benefit of BPA development that includes stakeholders across an organization is communication between disciplines of a problem and opportunity for improvement. Guidelines are continuously updated and increased clinician workloads can be a barrier to communication of current standards. The work by Kirby et al4 demonstrated a marked improvement in specialist referral for severe AS by delivering a results message to clinicians that included echocardiogram results, ACC/AHA guideline criteria for severe AS referral, instructions on how to complete a referral, and an embedded order set. There are multiple modalities of delivering BPAs within the Epic EHR system. Best practice advisories can be delivered through messages, storyboard alerts, and interruptive or passive alerts in Epic. The goal is enhanced communication of guideline-based care to clinicians; the development team should determine which method is best suited to the organization.Evaluating the effectiveness of CDS through EHR-embedded tools is an opportunity to enhance communication when implementing guideline-based BPAs for a patient population. The Best Practice Alert Cube is a data structure in Epic that allows users to query specific aspects of an alert BPA (eg, alert firings, buttons clicked, free text responses) and obtain an operational report.6 This feature can be used by organizations to provide feedback to clinicians on BPA usage and supports optimization of BPA design when problematic usability patterns emerge. Using data obtained from Best Practice Alert Cube, Douthit et al6 recently evaluated the “right format” of a storyboard alert BPA in Epic through the domains of alert fatigue, behavior influence, and task completion.6 Slicer Dicer is another Epic reporting tool that enables clinicians to generate reports on a patient population, such as patients with heart failure, using simple inclusion/exclusion criteria.7 Using Epic Slicer Dicer, end users can query BPA use for patients admitted with a specific diagnostic code and share performance with registry analysts, quality improvement specialists, clinicians, and organizational leadership. Best Practice Alert Cube and Slicer Dicer are 2 reporting tools in Epic that can be leveraged to enhance provider communication and effective CDS design.Effective CDS using BPAs represents an opportunity for clinicians and health care organizations to leverage technology in pursuit of the triple aim. The quality improvement experience of Kirby et al4 highlights the methods necessary to communicate evidence-based guidelines to frontline clinicians through BPAs. Success factors for effective BPA design are stakeholder involvement of clinicians, administration, and informaticists in the development process. The 5 rights and GUIDES checklist are essential elements of effective BPA design, implementation, and evaluation. Following these methods, clinicians can apply BPAs to any practice area to increase guideline adherence and improve patient care.