Achieving Successful CDS-EHR Integration via the HL7 Infobutton

Dr. Stephen Beck discusses how HL7 Infobutton technology helps improve outcomes, accelerate clinician adoption of CDS and EHR technologies at Catholic Health Partners.

Clinical decision support (CDS) resources such as evidence-based reference content, order sets, care plans, medication alerting systems, and surveillance technology have been identified as key elements to successfully achieving the aggressive quality goals laid out in federal initiatives. However, leading industry research groups, including KLAS and The Advisory Board, report that widespread CDS use is hampered by electronic health record (EHR) integration challenges.

Achieving Successful CDS-EHR Integration via the HL7 Infobutton

Stephen Beck, MD, CMIO at Catholic Health Partners.

An increasingly popular solution is use of the Infobutton standard, which is context-sensitive links from EHRs to knowledge resources. To standardize integration between CDS and EHRs, Health Level Seven (HL7) developed the Context-Aware Knowledge Retrieval (Infobutton) standard, which has subsequently been included in the Standards Certification Criteria for the Meaningful Use of EHR Systems. Specifically, it has been required for use for identifying patient education material and is also one of the options for identifying diagnostic and therapeutic reference information for linked referential CDS.

Standards allow for the use of coded terminologies, free text searches or both. Supported parameters include:  coded concepts (ICD-9, ICD-10, LOINC®, SNOMED CT, RXNORM, NDC, GPI); subtopics (diagnosis, treatment, etiology, etc.); information recipients (provider, patient); severity observations (for lab results; high, low); patient age; patient gender; encounter types (inpatient, outpatient); task context (problem list review, medication order entry, etc.); user types (resident, nurse, specialty, etc.); and CME user details (system identifier, user identifier).

Improving Clinical Satisfaction and Patient Outcomes

HL7 Infobutton works within the clinical workflow in two ways:

1) Clinical references by providing provider-specific information for clinical decisions, diagnoses, and treatments

2) Patient education by giving clinicians quick access to targeted topics at the suggested educational level.

Physicians can seamlessly conduct tailored searches of clinical content relevant to a specific patient’s disease, condition, medication, or lab results – in combination with age, gender, and other contextual criteria – without exiting their workflow. This, in turn, increases utilization of both CDS and EHRs, and improves clinician satisfaction with EHRs.

Consider the result of a clinician survey of UpToDate clinician users by Wolters Kluwer Health, in which 91 percent of respondents indicated having clinical content embedded in their EHR is important to patient care and 89 percent reported that it enhances satisfaction with their EHR. 40 percent suggested that having clinical content embedded in their EHR encourages use of their EHR, which underscores the value of this integration to improve overall quality of care and support meaningful use requirements.

Further, studies have shown an association between use of CDS resources and improved clinical outcomes. For example, a study conducted by researchers at Harvard found an association between use of CDS and reduced length of stay, lower risk-adjusted mortality rates and improved quality performance. (J. Hosp. Med., 7: 85–90. doi: 10.1002/jhm.944)

However, HL7 Infobuttons are not without challenges. While the Infobutton standard specifies a set of contextual attributes and standard terminologies, it leaves it up to knowledge resource developers to decide how to use them to retrieve the most relevant content. Making that determination is cited most often by developers as their main implementation challenge, in particular trying to locate the most relevant content based on the attribute values for a given Infobutton request. (J Am Med Inform Assoc 2013;20:218–223)

HL7 Infobutton in Action

At Catholic Health Partners (CHP), one of the largest non-profit health systems in the U.S., we have successfully navigated the challenges of integrating one of our CDS resources, UpToDate, into our EHR system via HL7 Infobutton. By integrating HL7 messaging at critical areas of the patient chart, including Problem List, Medications, Health Maintenance, Clinician Order Entry and Chief Complaint, CHP clinicians can access context-specific information within seconds.

For example, a physician may know a diagnosis but may not recall the most current treatment protocol.  Now, with a right click, a relevant search is performed and information on the latest treatment and testing recommendations contextual to their specific patient is presented to the provider without the need for additional keystrokes, cutting and pasting, or using discrete buttons.  This helps make “smart providers smarter.”

CHP worked closely with Wolters Kluwer Health to implement HL7 capability. Queries submitted to UpToDate via the Infobutton contain a coded term (ICD or RxNorm) combined with narrative text when coming from the problem or medication list, or controlled terms when coming from the lab results.

To accelerate adoption of and satisfaction with HL7 Infobutton, customized training on Infobutton functionality was provided as part of each hospital EHR system go-live. This included educating our IT and EHR trainers, as well as integrating CDS and Infobutton training into the overall curriculum. Clinicians were provided with training and educational tip sheets. For sites already live on the EHR, optimization sessions were held to re-educate clinicians on the use of Infobutton tools. In all, face-to-face training took less than 10 minutes.

Currently, clinicians are averaging 317 HL7 Infobutton queries per month (1,902 in six months).

As demonstrated by CHP’s experience, HL7 Infobuttons overcome integration challenges that continue to hamper widespread use of CDS resources by providing easy to navigate, context-sensitive links from EHRs to knowledge sources. At CHP, we believe Infobutton technology helps improve outcomes, accelerate clinician adoption of CDS and EHR technologies, and support our mission and values.   Other organizations can share in these positive factors when Infobuttons are properly deployed.

About the Author

Stephen Beck, MD, FACP, FHIMSS, currently serves as Chief Medical Information Officer at Catholic Health Partners. He has more than 15 years of experience in planning, implementation, training and follow-up of EHR installations in civilian and military populations and was one of the first physician users of a fully integrated EHR in Southern Ohio. Dr. Beck was among the first physicians to attain CPHIMS certification, has been a content reviewer for the HIMSS National Conference, and chaired the HIMSS National Professional Practice Task Force. He is a Fellow of both HIMSS and the American College of Physicians and serves on the HIMSS Clinical Decision Support Workgroup.

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