The industry is pushing (and being pushed) toward implementing electronic medical records that clinicians can use to improve care and reduce costs, but software applications alone are limited in their caregiver support capabilities. Much of the value of systems like CPOE and medication management actually comes from the underlying clinical decision support systems, not the software itself. Deriving value from those systems means embedding evidence-based clinical content from a respected source, whether it be drug information, CPOE order sets, or coding-aware procedure documentation systems. Wolters Kluwer Health Clinical Solutions provides industry-leading content under such universally recognized brand names as UpToDate®, Medi-Span, Facts & Comparisons, and ProVation Medical. We spoke to Linda Peitzman, MD, chief medical officer of the company.

Providing clinicians with advanced clinical decision support at the point of care has emerged as a priority for healthcare organizations. What is driving this and how is Wolters Kluwer Health Clinical Solutions meeting the decision support needs of its clients?

Clinical decision support improves quality of care and patient safety. Hospitals and EMR vendors both recognize that providing clinicians with current, accurate clinical information at the point of care reduces errors and adverse events and improves outcomes. That, in turn, translates into a cost savings of millions of dollars per year for hospitals.

Equally important is the fact that many hospitals now have the technology infrastructure in place to support point-of-care delivery of clinical decision support tools, such as computerized alerts and reminders, clinical guidelines, order sets, diagnostic support, and advanced clinical workflow tools.

To address our clients’ needs, Wolters Kluwer Health Clinical Solutions leverages its 200-plus years of medical publishing experience, unmatched breadth and quality of content from more than 4,000 publications, and clinical and technological expertise to deliver end-to-end software solutions and content encompassing the full continuum of care.

For example, UpToDate is our evidence-based, peer-reviewed information resource covering more than 7,700 topics and addressing questions that arise in clinical practice across medical specialties. In addition to comprehensive presentation of the evidence, each topic offers practical, detailed recommendations that clinicians can use at the point of care. A study conducted with Solucient — now a subsidiary of Thomson Healthcare and a well-recognized leader in measuring hospital performance — showed that hospitals with access to UpToDate performed significantly better on risk-adjusted measures of patient safety and complications, and had significantly shorter length of stay than hospitals without access. These benefits correlated with how often UpToDate was used at each hospital.

ProVation Order Sets, powered by UpToDate Decision Support, is our actionable, evidenced-based order set authoring and management solution that allows hospitals to put evidence-based healthcare into practice by establishing and maintaining standards of care. It provides clinicians with actionable direction, and also contains editable orders, narratives and live links to supporting evidence-based guidelines for rapid, contextual reference. In addition, it allows hospitals to define a review process for individual order sets, create reusable order set templates, and archive comments, changes and activities throughout the life of an order set.

Medi-Span is our electronic clinical drug information solution that supports CPOE, e-prescribing, and pharmacy dispensing functions. It provides clinical drug information that is embedded within the workflow to support and automate many essential clinical decision support functions, including interaction screening, allergy checking, dose screening, etc. Content is managed in tandem with our Facts & Comparisons drug information reference.

Another aspect of clinical decision support that we are hearing more about is standardized order sets that link to evidence-based medicine. How do hospitals benefit from order set tools?

Standardized order sets have been around a long time, in part to simply avoid the need for physicians to write them over and over. Doctors write numerous orders when they admit someone. For the last 20 or 30 years, physicians have found it more convenient to write an order set once, copy it, and then just check off the required items.

Today, order sets have become fundamental in shaping patient care. They improve clinical performance and regulatory compliance by establishing standards of care and advancing the practice of evidence-based medicine.

In the last five to 10 years, hospitals have been trying to build order sets and make sure they are consistent across caregivers. That’s where the problem comes in. You may have up to 1,000 physicians at a facility who need to agree on the best order set. They also want to see the literature and evidence supporting particular orders.

This is where ProVation Order Sets, powered by UpToDate Decision Support, comes into play. It overcomes these challenges and delivers process improvements, enhanced regulatory compliance, and improved patient safety more rapidly than paper-based order sets.

How would a hospital implement ProVation Order Sets and what are the benefits?

ProVation Order Sets, powered by UpToDate Decision Support, greatly streamlines the authoring, review, and maintenance process so physicians can reach consensus more efficiently. We give them a starter order set with evidence-based content. With one click, they can jump to the original evidence to see why we have structured the order set in a particular way. They can assign ownership to an order set and develop the process they want to use to build consensus.

Our application automatically sends e-mails to the reviewers. They can quickly review the order set via a web browser, add comments, and let the owners know when they are done. All the comments are tracked and can be audited. Our order sets content is very granular, so when they edit an order within our application, it is automatically mapped to our order catalog.

Once everyone involved in a facility’s order set process is done editing, they can simply release that order set and pull it directly into their CPOE system. It also gives the organization a way to audit and maintain order sets. They can see what was changed, when it was changed, even what the order set looked like two years ago. They have all of these tools they never had before that streamline workflow, take out costs, improve quality of care, and improve their financial situation.

In all the discussion about the benefits of EMRs, is clinical content getting the proper amount of attention?

EMRs have evolved in stages, along with hospitals. Everyone started with the main systems and put a lot of time and effort into getting them right. Now they are evolving, and other things are becoming more important, including clinical documentation and content.

Vendors are trying to understand how they can best provide content to the physicians using their systems. Some try to build it themselves. Some ask customers to build it and then share it with other customers. Many are finding that clinical documentation content is very difficult to maintain.

One of the reasons we’ve focused on creating content for EMRs is so that vendors don’t have to worry about that part. We provide the quality content for physicians to document their cases. It is much more effective for the EMR vendor to leverage medical content and decision support created by the experts than for each to try to create their own.

How can your products add value to common existing systems from Cerner, Eclipsys, Epic, and other vendors?

Most of our products integrate with or provide content for EMRs and they add a great deal of value to vendor offerings.

ProVation Order Sets, powered by UpToDate Decision Support, is particularly beneficial for organizations using CPOE and can be used one of two ways. For vendors working with hospitals that use both EMR and CPOE systems, ProVation Order Sets can automatically import a new order set directly into the CPOE system. There is no need to recreate and rebuild that order set. We also have created mappings between our order catalog and the vendor’s catalog, and have tools to allow efficient mapping of our order catalog to the hospital’s order catalog.

Other Wolters Kluwer Health products, such as Medi-Span, are deeply integrated into EMRs or pharmacy billing systems. Medi-Span provides a complete line of drug information databases and tools that power EMRs. It identifies what medication is selected for the patient, recommends appropriate dosing, and then considers the patient’s allergies, age, and medical conditions in conjunction with the selected drug to return alerts and warnings to the clinician based on all the information. Medi-Span can greatly improve patient safety, the quality of care, and outcomes. Facts & Comparisons is another drug information system with EMR compatibility.

ProVation MD, which replaces physician dictation and transcription for procedures, has interfaces with all of the major EMR vendors. Physicians use ProVation MD to quickly generate the procedure note and associated billing codes, which can then be immediately integrated into the patient’s record within the EMR.

UpToDate provides clinical decision support for clinicians at the point of care and can also be accessed directly from the EMR. An UpToDate search box is integrated into the EMR, which allows clinicians to access current and accurate clinical information quickly and easily. UpToDate has more than 340,000 users globally who rely on this content every day. The results of the study I mentioned earlier, where hospitals using UpToDate performed better on patient safety and complications, and had significantly shorter length of stay, potentially translate into better health outcomes and millions of dollars saved per year for an average hospital. This is a huge value for EMR vendors to provide their hospital clients.

Finally, we have an entire Custom Content solution specifically designed for EMRs. We work directly with EMR vendors to build and supply the evidence-based clinical and physician structured documentation content they need and we constantly review it to keep it current. The content is exported to the vendor and resides in their own native functionality.

What that means is that when I sit down in front of a particular EMR, I’m using that vendor’s user interface and functionality, but the content is from Wolters Kluwer Health. The EMR vendor can just pull our content into their application.

Who is the hospital decision-maker for Wolters Kluwer Health Clinical Solutions products and what are they looking for?

Because our products are designed to advance clinical decision support and clinical documentation at the point of care, as well as to improve coding compliance for increased revenues, there are actually a variety of decision makers. But it always starts with someone who has seen our products and immediately understands the value.

We typically start with a physician champion who is willing to answer the clinical questions and say, “This is something we would use and it would improve our patient care and our workflow.” Beyond that, the CIO is involved because they are responsible for understanding the software and technology platforms.

The CFO is interested because our software increases revenue, streamlines workflow, and provides a really strong return on investment. The CMO or CMIO is interested in how the software helps track and document quality measures; how it improves physician documentation and patient care; and how it can help with Joint Commission reporting.

The coding staff is interested in how our software works and how it will affect their workflow. Then, of course, there is the CEO, who coordinates all these things. We talk to all these people and they are all involved in the final decision making process.

Physician usage at the point-of-care implies strong product usability and design. How do you approach that?

One of the things we pride ourselves on is the development of user interfaces that physicians not only use, but really like to use. ProVation MD has a user interface that can provide complete documentation in two minutes. We use that same interface design within our order sets solution, and apply the same technological excellence across all product lines.

All of the end-users of our products are involved in the initial design and development. Pharmacists have driven the design and use of Facts & Comparisons and Medi-Span. Physicians, nurses, coders, and pharmacists have all been involved in the design of the ProVation and UpToDate products. Clinicians know what clinicians need and what their workflow and technological preferences are. Their investment and involvement in the design process is the key to our high satisfaction and utilization rates.

ProVation MD takes a different approach toward clinical procedure documentation than dictation and transcription. How does it work and what are the benefits?

Clinicians use ProVation MD to document their procedures in a wide variety of specialties. The old way clinicians would do things was to dictate, save their work, and then send a file to be transcribed. If the transcriptionist didn’t understand everything the first time, there would be some back and forth.

The note would eventually get to the chart and then be reviewed by a coder. The coder would translate the doctor’s words into a code for billing.

What we do is build deep, embedded medical content so that a physician simply has to make selections on how they accomplished that procedure. It’s very patient-specific. It’s not using a template. All of that content is tied to the proper CPT and ICD code, so if you accurately say what you did, you can be guaranteed that the correct code will be brought up. You can also be sure that the documentation supports that code.

It usually takes under two minutes for a physician to complete their notes in ProVation software. The note can also be e-signed and automatically sent to the billing system for coders to review immediately. The other benefit is that you are automatically creating other documentation while doing the notes. You create the letter to the referring physician, copy other caregivers, and provide patient education for that procedure.

Are economic conditions encouraging hospitals to take a closer look at procedure coding, documentation, and physician efficiency?

The economic climate is making everyone look at everything. Hospitals are looking at ways to enhance revenue, streamline workflow, and become more efficient. ProVation fits in with that in several ways. We consider our ROI to be more than just improving efficiency and workflow. We actually show specific revenue increases.

ProVation can help increase patient throughput, particularly if used in combination with our MultiCaregiver product, which is for peri-procedure nursing and ancillary staff documentation. You can see more patients with the same staff levels because you are not entering the same information into multiple places. ProVation helps increase patient throughput, streamline workflow, and do the same or more with less staff. And, it directly improves revenue.

Is the company well positioned to support its customers on pay-for-performance and PQRI initiatives with the Q1 data reporting system?

Our content is granular and embedded. It allows physicians to click on menu items and rapidly complete documentation. But it’s deeper than that, in that every one of those menu items is tied to a controlled medical vocabulary and a reportable database. When physicians are documenting, it’s not just free text, but granular data elements that can provide all sorts of reports. They can use the data for studies, and it lends itself well to looking at a variety of quality measures, including P4P.

Your Clinical Solutions team includes a sizeable number of clinicians. What influence do they have on product development, implementation and support?

Within Clinical Solutions, we have about 180 on-staff clinicians including pharmacists, physicians, nurses, nurse practitioners, medical informaticists and PAs. In addition, we have another 100 or more medical content specialists with medical backgrounds and technical expertise. UpToDate also works with a community of 4,000 physician authors who are not employees, but are experts in various clinical areas.

Across all our products, clinicians play a very significant role, including a primary role in product design and clinician workflow. Both our on-staff clinicians and clinician customers provide input on how the physician is going to use a product and how it can improve the life of the clinician.

One of our tag lines is, “Built by Clinicians, for Clinicians.” We believe strongly in having people involved who understand what the needs are, how to get it right, and how to improve both the workflow and the value to customers.

In terms of support, we have award-winning customer support teams. We have a great team of implementation specialists and 24/7 phone coverage of any issues. When there is an issue that relates specifically to the medical content, the evidence behind it or workflow for physicians, the clinical team is very involved to understand the customers’ needs and to continue making our products better.

Anything else you would like to add?

We have more than 500 different interfaces up and running. We do a lot of integration with EMR vendors and we also integrate across our products. Right now, we’re working to integrate UpToDate within the other Clinical Solution product lines. We also have products that are integrated across our Wolters Kluwer Health medical research platform. We have integrated Facts & Comparisons and Medi-Span into many of our products. We integrate the type of knowledge they provide into our order set application.

Because we have these state-of-the-art products that span across the point-of-care spectrum, we are able to bring value from each of them into other parts of our products. We’ve been able to integrate the best of them across the entire care delivery continuum.

Fast Facts

Products
ProVation® Order Sets, powered by UpToDate® Decision Support, Medi-Span, Facts & Comparisons, ProVation MD.

Company
Wolters Kluwer Health
Clinical Solutions
800 Washington Avenue North, Ste. 400
Minneapolis, MN 55401
www.pointofcareapplications.com

Notable Customers
Allscripts, Baylor University Medical Center, California Pacific Medical Center (CPMC), Duke University, Exempla Inc., Fox Chase Cancer Center, Massachusetts General Hospital, Orlando Health, St. Dominic-Jackson Memorial Hospital.

The Bottom Line
*   Content and information products from Wolters Kluwer Health Clinical Solutions turn EMRs into a clinical decision-making tool for healthcare professionals.
*  "Built by Clinicians, for Clinicians" ensures that actionable information is evidence-based and provided by an authoritative, internationally trusted, and respected source.
*   The company’s products drive process improvements, regulatory compliance, and patient safety improvements.

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