1. Dissemination and Sustained Use of an Outpatient Clinical Decision System with High Use Rates, High Clinician Satisfaction, and Positive Impact on Quality of Care
JoAnn M. Sperl-Hillen MD1,2,3; A. Lauren Crain PhD2; Jay R. Desai PhD2; Karen L. Margolis MD2,3; Heidi L. Ekstrom MA2,3; Deepika Appana BS2; Christina M. Wood BS2; Rashmi Sharma BS2; Patrick J. O’Connor MD, MA, MPH1,2,3
1HealthPartners Medical Group, Minneapolis, MN; 2HealthPartners Institute, Minneapolis, MN; 3HealthPartners Center for Chronic Care Innovation, Minneapolis, MN

2. 2
Background
EHRs have potential to improve quality of chronic disease outcomes, but those gains have rarely been realized
The challenges of Clinical Decision Support (CDS) Systems
Integrating CDS with care workflow (the right time and place to be useful). Increasing office efficiency rather than burden
Remaining patient centered rather than disease specific. Prioritizing thousands of evidence-based recommendations
Updating and maintaining recommendations consistent with evidence and national guidelines
Formatting the CDS to meet the needs of both patients and professionals (patient engagement and shared decision making)
Interoperability, dissemination and scalability

3. Objectives of this presentation3
Objectives of this presentation
Describe the performance of a point-of-care clinical decision support (CDS) system proven in RCTs to improve important patient outcomes
Outline successful dissemination procedures to several external care system clients (inside and outside of research projects)
Discuss facilitators and barriers to dissemination and scalability

4. What Wizard Clinical Decision Support Does4
What Wizard Clinical Decision Support Does
IDENTIFIES HIGH-RISK PATIENTS AUTOMATICALLY
CV Wizard identifies those with high reversible CV risk and targets their poorly controlled CV risk factors.
PERSONALIZED REAL-TIME CLINICAL DECISICION SUPPORT (CDS)
CV Wizard provides CDS for both the patient and provider through the EHR at patient encounters.
PRIORITIZES CLINICAL ACTIONS BASED ON BENEFIT TO PATIENT
CV Wizard calculates 10-year ASCVD risk and potential absolute reversible risk (RR) for each clinical domain (lipids, BP, glycemic control, weight, tobacco use, and aspirin), and then prioritizes them. Goals are individualized and priorities dampened if already on maximal treatment.
PROMOTES SHARED DECISION MAKING
CV Wizard displays treatment options for the six CV risk factors based on other current therapy, most recent lab and BP values, distance from goal, and co- morbidities. Also displays safety alerts for drugs or clinical conditions.

5. Technology and Data Flow5

6. CDS Development Support6
CDS Development Support

7. Example of CV Wizard©- Provider version7

8. New Design – Patient version of Priorities Wizard©8
New Design – Patient version of
Priorities Wizard©

9. New Design – Provider version of Priorities Wizard©9
New Design – Provider version of
Priorities Wizard©

10. CV Wizard© Significantly Reduced 10-year Cardiovascular Risk Over the 14 Month Observation Period (RCT 2015) 10
P<.001
REF: Sperl-Hillen JM, Crain AL, Margolis KL, Ekstrom HL, Appana DX, Amundson G, Sharma R, Desai JR, O’Connor PJ. Clinical Decision Support Directed to Primary Care Patients and Providers Reduces Cardiovascular Risk: A Randomized Trial. J Am Med Inform Assoc Sep;25(9):

11. CV Wizard© Impact on Clinician Communication with Patients11
Clinician Survey Results 
Intervention
Control
P-value
Use calculated CV risk while seeing patients
73%
28%
0.006
Feel well prepared to discuss CV risk reduction priorities with patients
98%
78%
0.03
Able to provide accurate advice on aspirin for primary prevention
75%
48%
0.02
Often discuss CV risk reduction with patients
60%
30%
0.06

12. Clinician Satisfaction with CV Wizard©12
Clinician Satisfaction with CV Wizard©

13. DM Wizard Impact on Diabetes Quality Results of 2012 RCT13
DM Wizard Impact on Diabetes Quality Results of 2012 RCT
Glucose control (A1C levels) was improved by .3%. Each 1% drop in A1C is associated with a 30% lower risk of eye, kidney, and peripheral neuropathy complications).
BP goals were each achieved by 5% more patients. Better blood pressure control translates to lower risk of heart attacks and strokes and diabetes complications.
LDL cholesterol levels were not changed, but significant improvement was observed in both clinics that received and did not receive Wizard.

14. The Impact of CV Wizard© in Studies14
Wizard use rates are high.
Providers use Wizard in over 75% of targeted visits
Providers have reported high satisfaction with the Wizard.
98% feel prepared to discuss risk reduction with patients and agree the tool improved risk factor control.
95% thought the tool was useful for shared decision making.
Improved Quality of Care
A1Cs
BP control
10-year ASCVD Risk Scores
Wizard spread to other care systems
In 2018, used by more than 130 clinics, evaluates 40,000 patient encounters a day (9 million per year) in 12 states.
Essentia (randomized clinics)
OCHIN – federally health care qualified clinics (safety nets) in 10 states
PN primary care system wide
HP primary care system wide
HP specialty departments – Endocrinology, cardiology, psychiatry, diabetes educators, MTMs
Altru from 2014 – contract ended January 2019

15. Implementation and Maintenance Process15
PHASE
ACTIVITY
AVERAGE DURATION
CLIENT INVOLVEMENT
HP TEAM INVOLVEMENT
IMPLEMENTATION 6 MONTHS MINIMUM
LEADERSHIP ENGAGEMENT & APPROVAL
1 MONTH
*QUALITY OR PROJECT LEAD *PRIMARY CARE LEADERSHIP *IT LEADERSHIP *LEGAL DEPARTMENT
*WIZARD TEAM PM & DIRECTOR *LEGAL
SECURITY VALIDATION
LEGAL APPROVAL BAA, BSS, SERVICE AGREEMENT
2 MONTHS
DATA MAPPING – MEDS, LABS, ALLERGIES, DIAGNOSTIC CODES,
3 MONTHS
EPIC PROGRAMMERS
WIZARD TEAM PROGRAMMERS
WEB, EPIC, AND UI
EPIC PROGRAMMING – CUSTOM BUILD PACKAGE, BPA, PRINTER MAPPING
WEB SERVICE PROGRAMMING – INTERCONNECT, URL WHITE LIST
CLINICAL REVIEW OF CDS
QUALITY OR PROJECT LEAD CLINICIAN LEADS
WIZARD TEAM MANAGER CDS CONTENT EXPERTS
COMMUNICATION AND TRAINING OF CLINIC STAFF
MAINTENANCE
TRACKING USE AND PRINT RATES (AUTOMATED)
ONGONG
RECIPRICOL FEEDBACK AND COMMUNICATION
ONGOING
REVIEW AND APPROVE CDS UPDATES AND CHANGES

16. 16
Example HealthPartners Institute Budget to Implement and Maintain CV Wizard in a Care System
Staff / Resource
Estimated Annual Salary & Benefits
Web 10%
$20,000
Epic Programmer 10%
$15,000
Project Manager / 13%
$17,000
Physician Content 8%
$22,500
Indirect costs 10%
$7,500
Total Cost for CV Wizard
$82,000

17. 17
Example of HP and PN Primary Care System Use Data for One Month (December 2018)
89,569 Wizard Web-service calls age 18-75
68,999 unique encounters with a Web-service call
59,221 unique patients with Web-service call
10,815 encounters (16%) meet criteria for high CV risk (BPA to print)
50% printing rate of CDS tools at eligible encounters

18. Facilitators of Dissemination18
Facilitators of Dissemination
Care system interest in quality care improvement
Payer interest in helping a care system improve quality
Clinician champions
Minimal impact on workflow or provider time
Tools for shared decision making
Favorable effects on patient outcomes
Positive patient perceptions
Ability to standardize care and rapidly translate new evidence/guidelines into practice

19. Barriers to Dissemination19
Cost of implementation and maintenance and lack of a clearly understood ROI from the care system perspective
Limited ability and bandwidth for our research organization to devote to dissemination and difficulty finding a corporate entity to market and manage dissemination and maintenance of the CDS system
Interoperability challenges (a lot of effort required to map data)
Need for recipient care system programmers with skill and/or time to implement
call external web services (e.g. using interconnect)
access SOAP based web service,
program BPA to open and/or print based on web-service response,
allow display of URL within the EHR,
Map printers properly to printing interfaces from web browser
Data privacy and security concerns (network and external server security) – although this has been well vetted and approved by multiple clients. This is not the biggest issue.

20. Implications for Research20
Implications for Research
This CDS system had high use rates, high PCP satisfaction, and significantly improved care in targeted adults and children.
After 10 years of NIH-funded development and expansion, several potentially remediable factors limit widespread dissemination.