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How Clinical Decision Support Drives Care Access in Rural Areas

At CoxHealth, clinical decision support closes care access gaps that plague patients in rural areas. This technology helps primary care providers deliver some elements of specialty care.

rural health clinical decision support

Source: Thinkstock

By Sara Heath

- With healthcare policies prioritizing better patient wellness and value-based care, healthcare organizations are working to drive patient care access. But with care access leaving something to be desired in rural areas, medical professionals must now turn to unique strategies, including tapping health IT and clinical decision support tools.

At CoxHealth, a Missouri-based health system that serves primarily rural areas, clinical decision support has helped providers overcome care access barriers related to extreme geographic distances and specialty provider services.

The support tool allows CoxHealth providers to treat symptoms that otherwise would require a specialty provider who may practice tens or hundreds of miles away, according to Louis Krenn, a CoxHealth primary care physician and the system’s Chief Medical Information Officer.

Using clinical decision support vendor VisualDX, Krenn is instead able to offer more diagnostic services to his primary care patients, he told PatientEngagementHIT.com in an interview.

“The tool is a clinical decision support tool, primarily used for dermatological issues, but it is also expanding into other non-dermatological issues quickly,” Krenn said. “I use this on patients who may come in with a dermatological issue, either a rash or a skin lesion of some sort that I'm not 100 percent sure what it might be.”

READ MORE: CMS Launches Rural Health Strategy for Patient Access to Care

Primary care providers should have a general knowledge of several health concerns, Krenn explained, but dermatology tends to be one of the specialties that does not receive enough attention during primary care education. The clinical decision support tool offers Krenn hundreds of thousands of images of numerous different skin types to help him recognize, diagnose, and treat a dermatologic issue.

To be clear, this tool is different from just searching Google Images for a rash, Krenn said. Instead, Krenn uses it to narrow down his differential diagnosis, to refresh his memory of different condition symptoms, or update himself on best practices for treating a certain skin condition.

In doing so, Krenn removes any need for the patient to travel extraordinary distances to a dermatology specialist, a significant satisfier for a population who faces extreme geographic barriers to care.

“It's a very powerful tool that allows me and my colleagues to treat and diagnose conditions that might otherwise require referral to a specialty provider,” he explained.

“Unfortunately, in Missouri, specialists aren't as accessible as we would like them to be a lot of times,” Krenn added. “In some instances, they may be accessible, but if they're an hour or two away, the patient may have transportation difficulty, or they may not have the finances to make the trip. In rural Southwest Missouri, we have a high poverty level, and sometimes financial barriers do get in the way.”

READ MORE: Strategies for Rural Patient Healthcare Access Challenges

Krenn also uses the tool for another integral part of the patient experience: creating patient trust. This is a hurdle all providers face, but for primary care clinicians, patient trust is essential.

“It's important for us to be able to be confident in treating conditions, but then also try to treat as many conditions as we can without necessarily needing referrals to specialties,” Krenn noted. “I use this tool by going to the condition the patient has and showing her pictures."

Ultimately, that gives patients confidence in Krenn’s diagnostic abilities and in his treatment plan, which increases the likelihood that the patient will follow through with treatment.

But it also takes some work to garner patient trust in the clinical decision support tool, Krenn conceded. Patients can often be concerned with technology they do not understand, so it is Krenn’s job to explain what the tool is and how it helps him do his job.

“I will actually show the patient what I'm looking at,” Krenn shared. “I will show her the tool that I'm using, and explain to her that this is a tool developed by a board-certified dermatologist who has the largest image collection of dermatological conditions in the world. I review with patients what the tool shows and what it's telling me what to do.”

READ MORE: AHA Develops Strategies to Enhance Rural Healthcare Access

In doing so, Krenn is also able to integrate the patient into the care team. Healthcare is entering into an age of participatory medicine, where patients are more knowledgeable about their health and want to engage in conversations with their providers about their treatments.

For Krenn, part of those patient engagement efforts now includes informing the patient about the clinical decision support tool. This is not a tool that helps him Google the answers to medical questions, Krenn tells his patients. Instead, it’s a tool that gathers all of the peer-reviewed medical evidence for certain conditions and filters it for his clinical use.

“We have a focus in our organization to practice evidence-based medicine, and so we use these clinical decision support tools to make sure that we're staying up on the evidence as best we can,” he explained.

Of course, implementing a sophisticated clinical decision support tool is easier said than done. Cost is always a concern, Krenn acknowledged. As reimbursements are declining, clinicians and hospitals are counting every penny.

In those cases, it’s important for organizations to do the cost benefit analysis of each tool. Will this clinical decision support help improve revenue? Will it improve patient outcomes? Does it integrate with existing systems? Does it offer quality information? And, given all of those other factors, is it worth the price tag?

Each of those questions was a key consideration that led Krenn and his team to their clinical decision support tool. For them, the cost was worth the promise of a quality support tool, he explained. For one, the tool proved to offer critical clinical information that could enhance patient care.

For another, the tool proved easy to integrate into the CoxHealth EHR. Because CoxHealth leverages FHIR standards, Krenn was able to plug-and-play the clinical decision support tool into the EHR. This allowed him to cross reference symptoms with patient demographic data seamlessly.

Those FHIR standards are helping CoxHealth connect to other healthcare technologies that can support patient healthcare in rural areas. For example, many rural hospitals and health systems – CoxHealth included – are turning to telehealth to connect patients to health specialists located in disparate regions.

APIs are making it possible for smaller, rural organizations to feasibly use these technologies because implementation is seamless and less costly, Krenn said.

“The Smart Arm FHIR platform has opened up a lot of possibilities to giving particularly rural-based clinicians a lot more tools available to them at a lower entry of cost than maybe what you have for a traditional software application,” he explained.

“That's what makes these types of tools attractive to organizations who are looking to embed them in their electronic health records,” he continued. “All of the major EHRs support the FHIR standard, and so once you get that set up with your EHR vendor, layering on additional tools goes much faster than any type of a software installation that we do, typically, and it makes the tool just that much more useful.”

That’s exactly what is next on the docket for CoxHealth, Krenn suggested. As the rural health system continues its work to connect patients with essential healthcare services, it will need to leverage more health IT. Going forward, the organization plans to leverage its FHIR platform to plug into new technologies to meet those patient needs.

“In addition to clinical decision support tools, we're also trying to bring some of that specialty support and some of that ancillary support to the rural practices through the use of telemedicine,” Krenn concluded. “That's a large focus for us and for providers around the country, particularly for rural practices where patients may have difficulty receiving those services otherwise.”

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