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Interview with Matthew Warner, M.D. and Justin Kreuter, M.D.
This episode discusses clinical decision support and its role in patient blood management.
A Mayo Clinic podcast for laboratory professionals, physicians, and students, hosted by Justin Kreuter, M.D., assistant professor of laboratory medicine and pathology at Mayo Clinic, featuring educational topics and insightful takeaways to apply in your practice.
This is Lab Medicine Rounds, a curated podcast for physicians, laboratory professionals, and students. I'm your host Justin Kreuter, the Bow Tied Bandit of Blood, a transfusion medicine pathologist at Mayo Clinic. Today, to coincide with Patient Blood Management Awareness Week, we're talking about clinical decision support and its role in patient blood management. Today, we're rounding with Doctor. Matthew Warner, a Mayo Clinic Consultant in Anesthesiology and Perioperative Medicine.
Justin Kreuter:Welcome. Thanks for joining us and welcome today, Doctor. Warner. Yeah, thanks so much, Doctor. Carter.
Justin Kreuter:I appreciate it. It's wonderful to see what color hair you have. Normally, I'm used to seeing you with the OR scrubs and
Dr. Warner:I know, had to leave the PJs behind and I put a suit on today.
Justin Kreuter:So to kick us off, what is Clinical Decision Support? If you could unpack that for us. Then how does that fit in patient blood management?
Dr. Warner:Sure. Happy to talk about it. Clinical Decision Support is an information technology based approach to providing clinicians, with appropriate information, based on general knowledge, medical knowledge, as also patient specific information as garnered from the electronic health care record. And providing that to clinicians integrated into their workflow at the appropriate time and in the appropriate manner so that it can enhance their decision making for a given patient. Now, Clinical Decision Support is applicable to a wide variety of different medical problems.
Dr. Warner:It expands different medical practices. Patient level management is one area where clinical decision support's been utilized. And it's been pretty rudimentary, to be honest, in patient level management. Most of it's been based on giving, clinicians tools for when they order transfusion therapies. For example, it might provide them with guidance about what is appropriate clinical transfusion guidelines that we'd recommend for a given patient or patient population, and then also integrate some of the information from the patient's health record.
Dr. Warner:For example, the patient's most recent hemoglobin is x number within the last twelve hours. That is above what we'd recommend as a as a institutionally endorsed or nationally endorsed transfusion guideline for this therapy. You know? And and it retains the autonomy of the clinician. Where the clinician is still able to make what they think is the appropriate choice for the patient, but they're being informed by these directed, integrated tools to help them make the best decision.
Justin Kreuter:So as you know, my heart goes pitter patter for education. And what you're saying in part, it kind of sounds like in the education world, we talk about just in time education. And I was wondering if you could compare and contrast how is Clinical Decision Support similar to education? How is it a little different than just straightforward education?
Dr. Warner:Sure. So certainly, education is a big component of clinical decision support. So what you're drawing on is you're drawing upon general medical knowledge, evidence based guidelines, you know, the best information available for the given problem. So you're drawing upon that information. You're trying to deliver it to the clinicians at the right moment when they're working in their clinical workflow in front of patients.
Dr. Warner:Now, educational efforts so certainly, there's education involved there because we're trying to educate providers and provide them with the information hopefully hopefully not for the first time, but provide them with the the relevant information at the time of making decisions. Now most educational efforts, there are great educational efforts that happen in clinical workflows at the right time. But a lot of educational efforts extend beyond a clinician's day to day practice, right? So there's educational training, in person sessions, simulation sessions. There's online training modules everyone completes at certain times.
Dr. Warner:And education can extremely helpful, and it can certainly change clinical decision making and behaviors of providers. But it's not always readily accessible in the day to day practice. When you're caring for a variety of critically ill patients in the intensive care unit and you have to make a decision about how to treat this patient's anemia, it can be hard to remember or to take the time to think, this is what I've learned through my educational training is appropriate for this patient. Clinical decision support tries to take some of that burden away from the provider by providing them with that knowledge in real time so that when they're working within their clinical workflow, they're not trying to think back and remember previous training. It's more providing them or prompting them with information they've probably already seen.
Dr. Warner:Sounds like it's a lot of, making it easy for the person to do the right thing. That's the whole goal, to make it easy, to not make it burdensome. So earlier, you
Justin Kreuter:were talking about an important feature of clinical decision support is maintaining that physician autonomy in that moment. And I was wondering if you could kinda share in your experience what makes Clinical Decision Support or, I guess, implementing that, how can you make Clinical Decision Support successful? Because, you know, I I mean, I I suppose that you could just, put up, pop ups that happen and I it's like pop ups that happen on my computer. I click, you know, yeah, ignore, go away. How how do you, make it successful?
Dr. Warner:This is the key point. Everybody who works in the medical environment and interacts with the electronic health record knows that there are a lot of times we're bombarded with information, whether it be best practice alerts or just things we have to acknowledge, it begins becomes very tiresome. Before long, you're not looking at any of the information that's being provided to you. It's simply another thing you have to click just to get through your day to day clinical practice. Clinical decision support, when it's done well, is not that.
Dr. Warner:Mhmm. It's seeking to be something completely different. Now, certainly, there's the potential to make clinical decision support tools that simply just become cumbersome, and they are simply impeding or are perceived as impeding good clinical care when the whole goal is to actually trying to optimize, clinical care. So in order to actually make it successful, you truly need the people who are gonna be using these tools to be engaged in the design, the development, and the implementation. They need to be engaged at all at all aspects of this thing so that they know this is the problem that we see as, something we can improve on.
Dr. Warner:We need new tools to help us improve, and we need them delivered in this fashion so that it's not another click box that we have to get through. It's something that's actually meaningful and is actually informing our practice. So you can't just have this designed by a bunch of, IT technologists that we say, you know, as a patient with management leadership, we recognize that this is a problem. We're transfusing too much plasma, come up with some rules, we'll throw them together. That doesn't work because clinicians aren't going to buy it.
Dr. Warner:You need them engaged. You need them involved in the design and creation of these things.
Justin Kreuter:I'm really fascinated by that. So if we could just take a a second and explore that a little bit more. It it strikes me that sometimes we're bringing together the magic happens at the merger of two different spheres of knowledge. Right now, you're just bringing up the IT knowledge and then the clinician's knowledge. And the IT professional doesn't exactly know what is meaningful and relevant for the physician.
Justin Kreuter:Likewise, I imagine the physician may not even realize what is possible for what can that IT do. And I think a lot of times I see myself and other colleagues either overshooting or undershooting that mark. Was wondering if you could share how that collaboration between you and IT has gone, or how have you navigated so that you can really come out with the best and most meaningful, clinical decision support?
Dr. Warner:Yeah. So it goes absolutely both ways. So we a lot of times assume that things are possible that aren't is usually the case that I've seen, where we say, how hard can it be to build a rule where the patient has this in their medical record that it either triggers this or doesn't allow this? We think that should be easy. But it is incredibly difficult, especially in electronic health record systems that are continually updated.
Dr. Warner:You know, they do an update, all of sudden, what worked before does not work. So there's a ton of moving parts. There's a ton of support and time and money that needs to go into these things if you're trying to sustain it on your own. So it's a lot of work from the information technology side. The for the information technology side, looking at the clinicians, I think, it hasn't been my experience that they have been saying, well, why don't clinicians just do this or follow the rules?
Dr. Warner:I think they truly the folks that I've worked with recognize that we would like some clinical insight because we understand how to create the rules and the processes. But number one, we need to know what's the knowledge that we should integrate into the rules. And number two, how do we actually put it in the clinician's workflow? And I think with that in mind, it's been pretty successful here at Mayo just because our, some of the core leadership of our patient management efforts are clinicians. Doctor Daryl Core, for example, has been heading this for a long time.
Dr. Warner:I've been helping him as well. And we've brought in surgeons, medicine doctors, pediatricians, laboratory medicine, transfusion medicine personnel, everyone who's involved from different areas to really say, this is what would work in the workflow, and this is what would not work from any aspect of our patient management efforts, but certainly from Clinical Decision Support as well.
Justin Kreuter:Fantastic. I hear you saying the engagement is essential for success. I hear you talking about starting with or I guess if I can paraphrase you, starting with what's the purpose rather than, walking in the room as as the physician saying, alright. IT person, this is what I want the the rule to do. But, you know, this is my purpose.
Justin Kreuter:This is my meaning behind, and let the IT person come back with a a solution. Let's just flip this around and talk about the pitfalls of implementing, Clinical Decision Support, either from experience that you've had, personally here or, talking with colleagues at other areas. What are some pitfalls that we should share with our listeners that might be thinking about clinical decision support or might be thinking about improving upon the clinical decision support they already have?
Dr. Warner:Sure. So there are many pitfalls of clinical decision support. So we've touched on some of these already. So number one, making something that's cumbersome to clinical workflows is probably the biggest pitfall, and not having the appropriate people involved when you're creating them. But beyond that, clinical decision support itself, is not always, immune to provider choices.
Dr. Warner:Right? So we wanna keep autonomy for providers. So say someone orders, for example I'll give you an example of ordering a red blood cell transfusion. Very basic clinical decision support. You you go to order a red blood cell transfusion.
Dr. Warner:It provides you with the most recent hemoglobin value, for example, for a patient. It says this is either above or or outside of what we consider a normal transfusion, guideline. Please, you know, select what you what is your indication for transfusion. We give you five choices. We give you an other category so you can clearly fill in, I'm doing this because of this reason, which might be unique, or, no, this patient has an acute coronary syndrome, so this is why I'm transfusing a little bit higher, whatever it might be.
Dr. Warner:What we've found is that even in our best efforts to make this integrated, providers, when they still have this autonomy to make choices, they often will just click a box to click a box. So even though they say we say the hemoglobin is we know the hemoglobin is eight and a half, They'll click the box that says hemoglobin's less than seven. And so we did a very interesting project where we went back and we reviewed the concordance rates between what was selected through the Clinical Decision Support and then the physician, computerized physician order entry and what was actually occurring in the medical record. And in many cases, it's good. Concordance rates are high, eighty, ninety plus percent for certain conditions, pediatric congenital heart disease, those sort of things.
Dr. Warner:But for others, it's very, very, you know, variable. So we had, for certain things, concordance rates less than 30% for what was actually occurring in the medical record and what providers were selecting.
Justin Kreuter:Doctor. Warner, you're breaking my heart here.
Dr. Warner:So certainly, it's something that you need to be aware of. And, again, I I think physicians wanna keep autonomy with clinical decisions, and I think we need to certainly cherish and preserve that. I have a lot of friends who are afraid of artificial intelligence and taking over clinical decision making, and it's hard to glean everything from electronic health record in real time. And I agree. But at the same time, we need to recognize that there's limitations.
Dr. Warner:And when we see people that are selecting the wrong selecting something that's truly not true, we need to ask why are they doing that? Is it because it's truly not true, or is it because our intervention or decision support that we've implemented, maybe we're not implementing it correctly. Maybe there is some fine tuning we can do here to make it more usable for them. Again, the goal is not to make this something we click through as a burden. It's we need to go back to the practice, interview patients, interview our providers that are using these tools, figure out, is this working or not working?
Heidi:Learn how Mayo Clinic implemented a fully integrated patient blood management program, including the use of clinical decision support guidelines, analytics, and patient blood management practices. For additional information, visit nationaldecisionsupport.com.
Justin Kreuter:So Doctor. Warner, now we're kind of getting into an area of evaluating a program. I was wondering if you could share your thoughts on evaluating a clinical decision support program.
Dr. Warner:Sure. It's a great question because we wanna make sure that anything we're doing is having the intended consequences and not becoming what we said unintended consequences or or being burdensome to the practice. So there are a variety of ways to to do this. Probably, the most robust is to implement something, say, in a randomized controlled sort of fashion. You implement it and you, you know, you measure, implement in certain areas and not in others, but that's very time intensive.
Dr. Warner:It takes money. It's impractical to do for many of these interventions. So what's typically been done for a lot of these things is when we design them, clinical decision support systems, for example, we run them in the electronic health record, but they're not available to clinicians. They're running what we call surveillance mode. And so in the background, we're gathering data on when these rules would trigger for for, in clinical care.
Dr. Warner:So we can see, you know, how many times a certain Decision Support rule might show up in a in a clinician's workflow, what the potential consequences might be from the decisions they might make and from on those that are actually made. So we run a lot of this stuff in surveillance mode before it ever goes live, so we make sure that we're triggering at the right times and that there's no bugs before we implement Now when you implement, then what we typically wanna do is you wanna look at changes in behaviors, so provider behaviors, and also in clinical outcomes for patients because we gotta keep this focused on the patient. So we say, in the in the year preceding the implementation of our clinical decision support rule, here are our transfusion behaviors. Here were, you know, how the laboratory values before and after certain things. Here are the hospital lengths of stay, certain patient outcomes, And we really monitor that very closely before we implement.
Dr. Warner:And then we repeat the same thing in a period after implementation. And we truly the whole goal is to say we're improving or we're at least not harming patients by what we're doing. And then something we haven't done as much, but I think it's very important to do, is to do more of this qualitative assessment of the of the folks that are actually using these tools. Right? So we've designed these tools.
Dr. Warner:We've designed them with input from clinicians. Now that we've implemented them, we wanna go back and actually talk to the practice and say, hey. Tell us about this the new clinical decision support that's been implemented. And what are the what are the what are the the potential roadblocks that that impede the workflow for you? Or is it working great?
Dr. Warner:Or what are the things that aren't working? And so by doing that, we gain a lot of insight just by talking and even observing practices and how patients are or how providers are actually using these in their daily workflow.
Justin Kreuter:Wow. That really resonates with me because sometimes it strikes me as it's really hard or difficult to get meaningful numbers. One, two, three, four, five, what's the I think going back to really, if you're going to get meaning out of the information, I think a lot of that qualitative, information because it sounds like you're automatically gonna have a lot of quantitative Yep. Information from the process running itself, but you really need some qualitative information to put some context for that.
Dr. Warner:Absolutely. And that's the thing. In published literature, there's plenty of quantitative sort of information about CDS in patient management space, for example. Even at our own institution, we've published some stuff about changes in transfusion behaviors and some health care outcomes after implementation of certain things, such as moving, you know, default transfusion numbers from two to one unit, those sort of things. But this qualitative aspect is something that we are interested in exploring more, and we've had these conversations, but it's not something that's widely published or widely known.
Dr. Warner:And I think there's a ton of knowledge to gain just by sitting with people and having focused, really, structured interviews or semi structured interviews with these folks.
Justin Kreuter:Let's dive into this a little bit then. So now let's widen the scope a little bit. Patient blood management is the playing field. You've been in this area for several years now. You've published multiple times in this area given many wonderful presentations.
Justin Kreuter:What has surprised you most about patient blood management?
Dr. Warner:It's a great question. I think there's a very common misconception of patient blood management simply being a bunch of folks that just want to take away transfusions. And I think that's not it at all. And I think, we're doing a much better job now of framing it as a way to optimize blood health for patients. So taking away the focus from how do we just prevent really severe acute anemia by transfusing or treating with transfusions, and really moving towards, how do we focus on anemia and not just treating with transfusion, but defining what's causing anemia and thinking of other ways to manage anemia appropriately for patients, not just surgical patients.
Dr. Warner:And also extending this out to hematologic abnormalities, coagulation issues, platelet disorders, or dysfunction. And so what's been surprising is that I think we've brought a lot of people on board with it now that are starting to understand the bigger picture. And I think a lot of people are initially, you know, a little suspect of some of the activities are, I think, now coming along nicely, and we have great representation from all these different areas. So the surprising thing was probably some of the initial reaction to some of the activities, but I think it's really grown. And, it's been very rewarding to see that, we're having difference, making a difference, and a win win for both our institution and saving resources.
Dr. Warner:There's probably some financial implications associated with transfusion reduction and things of that nature. But also, we are certainly not harming patients. In many instances, we're probably doing the right things for patients by trying to optimize their outcomes.
Justin Kreuter:So I was a water polo player back in the day. Team sports are really in my blood. Like you're saying, there's a lot more of a team that 's come and now coalesced around patient blood management. Given that, where do you think the future for Clinical Decision Support is now that we've got all these team players in on the team, so to speak?
Dr. Warner:Yeah. So I think more and more people are interested in building more sophisticated clinical decision support, sort of approaches. So instead of saying, you know, most of them are created for transfusion orders and things of that nature. But instead of that saying, you know, give us some diagnostic support tools for when a patient has anemia during their hospital stay. You know, what what should we be doing to either evaluate this or manage it non transfusion based approaches?
Dr. Warner:Or when you recognize in the electronic health record that a patient has a certain disease condition, to provide them with certain, protocol based, order plans, for example. Let's say, given this patient's condition, consider these therapies rather than these therapies. Or even beyond that, a lot of the data analytics that can come from clinical decision support can help figure out patients at risk for complications of transfusion, for example, transfusion, associated circulatory overload, for example, or things like that, and really trying to tailor, some of the clinical decision support to specific disease conditions that patients have. I think that's kind of where the future lies with clinical decision support. All of that takes a tremendous amount of IT resources and money and structure, and so it's not possible for every place to do this.
Dr. Warner:But there are ways to get around that. And with lots of different medical systems moving to unified electronic health record systems, for example, there's opportunities to have stuff that translates well between different practices.
Justin Kreuter:Seems like, the scalability potential is is just, really the, opportunity we have in front of us. Wow. So normally, I I ask, I have, colleagues, from the laboratory here, and I ask them, you know, what what is it that you wish that the bedside, clinician knew about, the laboratory? And given that we've got a a broad audience, I I thought I'd just flip that question around, to ask you and sort of say, okay. As a bedside, physician, what is it that you wish the laboratory understood, about your practice?
Dr. Warner:That's a very great question and probably a loaded question, too, but it's, one that I think needs to be asked. And I think laboratory medicine folks, transfusion medicine or just laboratory medicine, and clinicians, we all need to get on the same page. So I think we all would benefit from spending time working together and even spend some time visiting physical environments that we each work in. And so I think there's a lot to be gained then. Now, as far as things that I wish that laboratory professionals knew, I guess there are challenges.
Dr. Warner:For example, when you're providing intensive care or acute anesthesia care. There are challenges in, for example, hemostatic management in patients that are diffusely bleeding despite normal appearing laboratory values and things of that nature. So I think sometimes, and I've heard a lot from my colleagues that, oh, it's frustrating when I'm trying to order platelets for my patient who's diffusely bleeding after cardiopulmonary bypass with a platelet count of 100, and I can't get a platelet transfusion, or I can't get two units of platelets when the platelet count's 50. And I understand those frustrations from their side, but I also have spent some time with our transfusion practice, and I understand that this is a very precious resource. There are a lot of implications in releasing multiple units at a time.
Dr. Warner:So I think it's just that crosstalk and just finding ways that that we can actually talk to each other, more intelligently in real time and actually visit each other in our clinical practices to to understand some of the the difficulties that occur in each environment and what the concerns are. And I think once we do that, it's really easy to find some common ground and to say, look, you know, there's some sense here. You know, in this case, it makes sense to give you a platelet transfusion despite the platelet count being high or whatever it might be. And same from our side to say, oh, I understand why the blood's taking longer to get here. I I understand why I need to send in a type and screen on this patient who just had one in an outside hospital.
Dr. Warner:There are some implications from the laboratory side that a clinician might not understand, without actually spending some time with those folks. I don't know if that fully answers the question, but I I think that's, you know, kind of a basic approach I would take.
Justin Kreuter:I love that answer because in my book, anytime a physician orders two platelets at a time, an angel loses its wings somewhere.
Dr. Warner:I'm not advocating for the practice. I'm just I'm telling you what I hear from different folks around the practice, and that's just one example of many.
Justin Kreuter:I think that's a brilliant, point, though, about, sharing and going to and visiting each other's clinical spaces. I wrote an editorial, in the past about the importance of rounding in the clinical environment for the laboratory to appreciate some of these aspects. So if we can take this out a little further, the tagline for this podcast is, connect lab medicine and the clinical practice through insightful conversations. I was wondering if you just share a personal story on how, reaching out to the lab has made a difference, for one of your patients.
Dr. Warner:Sure. So, a recent example is, very rarely, but it does happen. We have patients that require ongoing transfusion support when they're transferring between different environments. For example, usually it's going from the ICU environment down to the Operating Room, but occasionally, it happens the other way. Patients down in the Operating Room, they've had a big surgery, they require continued transfusion support either upon arrival to the ICU or during transport even to the ICU.
Dr. Warner:It'd be a rare circumstance, but it does happen, and I actually had this happen recently. And so I learned that when you have, for example, a massive transfusion protocol in place and working in one environment, it doesn't necessarily translate to the other environment unless you contact the blood bank and your colleagues there to say, oh, we're actually physically moving environments now. Just a heads up that you need to know that so that when we arrive up in our new environment, we're all on the same page that this patient still requires blood product support. And so, that was one area where we had a patient that once that came up, and we were wondering, well, where are the blood products? Oh, the lab hasn't been notified that we've moved the patient out of the Operating Room.
Dr. Warner:And so there was a big gap there. And so we sat down with key stakeholders from the surgical practice, anesthesia practice, ICU practice, and our transfusion nurses and, transfusion medicine blood bank folks. And we came up with what do we do in these sort of, you know, rare extenuating circumstances to ensure that there's no lapses in care, to ensure that everybody knows exactly what's happening on? And it's all about communication so that the the blood bank knows when a patient is no longer needing blood products or when the patient is no longer physically gonna be in, for example, the operating room environment. So without those crucial conversations, there's a potential for patient harm, and none of us want that.
Dr. Warner:The whole goal of all the activities related to patient blood management is improving patient outcomes.
Justin Kreuter:We've been rounding with Doctor. Warner talking about clinical decision support today. Thank you for taking the time to discuss this topic with us. Be sure to check out on Twitter Mayo Clinic Patient Blood Management has their own Twitter account so that's MayoClinicPBM. Thank you for joining us today.
Justin Kreuter:We invite you to share your thoughts and suggestions via email. Please direct any suggestions to mcleducationmayo dot edu and reference this podcast. If you've enjoyed Lab Medicine Rounds podcast, please subscribe. Until our next rounds together, we encourage you to continue to connect lab medicine and the clinical practice through insightful conversations, especially this Patient Blood Management Awareness Week.