Standardization of evidence-based practices is a central goal of initiatives to improve population health, enhance patient experiences and lower costs.

While the ability to reduce variation in clinical response is an important component to reaching these goals, it is even more critical in the case of a public health crisis when time for disease containment is of the essence.

The recent Ebola outbreak and its entry into the U.S. is a prime example pointing to the need for best practice guidance for hospitals and providers to make fully informed decisions. As healthcare organizations scrambled to prepare, one of the greatest concerns voiced by clinical leaders was that the industry lacked standardized protocols for identifying and treating the disease and for protecting healthcare workers.

When Ebola was introduced into the Dallas, Texas area in 2014, Methodist Health System had to quickly develop and initiate an effective response plan. The health system turned to its foundation of clinical decision support to standardize best practices, prepare for additional cases and adhere to the ever-changing national guidelines governing response to the outbreak. In the end, a well-designed governance process backed by a solid clinical content management infrastructure—one that could easily be replicated in any health system— enabled Methodist to standardize clinical response at the point of care within 24 to 48 hours.

A Foundation for High Reliability

Methodist is a seven-hospital system located in Dallas with 30 additional sites of care throughout the greater North Texas region. In 2012, clinical and IT leaders set out to design a technology and governance strategy that would lay a foundation to support high reliability for standardization and use of evidence-based practices.

As part of this effort, Methodist determined that technology and governance processes would need to support clinician satisfaction for high adoption and be flexible enough to avoid bottlenecks in getting evidence-based content to the point of care. In essence, the goal was to make technology drive performance rather than hold it back.

Evidence-based order sets were identified as a key tool within Methodist’s greater clinical decision support strategy for guiding clinicians to make decisions based on the latest clinical evidence. When Ebola arrived in Dallas, Methodist was already using ProVation order sets and UpToDate decision support software.

A well-honed content lifecycle was also in place for developing and deploying order sets. The process began with best practice reconciliation to identify the elements needed in an order set. Leveraging the ProVation clinical content infrastructure, the implementation phase then addressed the building, importing, customization, mapping and exporting of an order set in Methodist’s EHR system, making it available to clinicians at the point of care.

The content lifecycle then extended to governance to address the approval process, version control and downtime formatting. Critical to this phase was having the clinicians who own the workflows involved in developing, vetting and validating content to ensure buy-in and adoption. With Ebola, clinical and IT leaders recognized the importance of quickly engaging emergency department stakeholders at the onset, as they would be on the front lines of the screening process.

The final stage of the content lifecycle addressed downtime—ownership of the approval, releases and printing of up-to-date order sets when systems are down.

While a well-established governance process for approvals ensured involvement and buy-in from all key stakeholders, Methodist also recognized the need for instituting an emergency change process that would address the need for urgent revision. In the case of a public health crisis like Ebola, the need for getting the best clinical decision support to the point of care rapidly was critical to containment.

By leveraging technology tools and available expertise, clinical and IT leaders were able to get an Ebola order set live in less than two days by aligning IT, informatics and regulatory skill sets. The Ebola order set was later sent through the proper governance channels for refining, garnering input and sign-off from workflow owners, specialty collaborators, an informatics steering committee and the medical staff.

Leveraging Clinical Content Management for Effective Response

One of the greatest challenges to deploying an evidence-based approach to Ebola was lack of expertise in the field. As healthcare organizations waited for updated guidance from the Centers for Disease Control (CDC) and World Health Organization (WHO), it became clear that information would not be forthcoming quickly enough to address the urgency of the situation in Dallas. Thus, Methodist turned to its content and clinical partners within that first 24 hours to devise a strategic response.

The first conference call was held the same night following the announcement of the Ebola diagnosis—September 30, 2014. Part of the Mayo Clinic Care Network, Methodist collaborated with clinical experts from Mayo Clinic as well as teams from ProVation and UpToDate. Evidence-based content was gathered to devise a screening workflow and triage assessment, which was incorporated into a final Ebola order set on October 1. On the morning of October 2, the content built in the clinical content management system was uploaded in the EHR and was available to clinicians by 5 p.m. on the same day.

Daily conference calls were initiated across the system to drive a standardized response and get input on potential issues with personal protective equipment and screening processes. Clinical leaders quickly identified a number of gaps that required some redesign of the workflow process, and those were addressed as needed.

The foundation of the Ebola response was built on informatics to drive standardization, but clinical and IT leaders recognized that technology is only as good as the people using it. Education of front-line staff was critical, as was the ability to identify process issues on an ongoing basis.  A communication strategy that centered on person-to-person communications helped the clinical team escalate high-risk cases through a special code used to marshal in resources without creating a panic.

Because the public’s fear response to any facility receiving or treating an Ebola patient was a major concern for hospitals and health systems in the region, a collaborative effort was set into motion to create a regional biocontainment facility. Methodist worked with the CDC and other partners in the region to turn an empty ICU on the Methodist campus into a biocontainment unit. Protocols were established based on evidence-based practices that would take an Ebola patient from screening through the full spectrum of care. Within just a couple of weeks, the biocontainment unit was ready for go-live and could be activated in 12 hours if needed.

When faced with a public health crisis, hospitals and health systems must be able to respond efficiently and effectively in today’s healthcare climate. Methodist’s effective response can be traced directly back to a solid clinical content management infrastructure, a well-honed governance process for getting best practice guidance to the point of care and a willingness to work collaboratively with other partners in the region.

Sam Bagchi, M.D., is the senior vice president, CMO and CMIO with Methodist Health System.

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