Can decision support systems improve patient care?

Dr. Alan Brookstone

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Clinical Decision Support

• HIMSS Definition– Clinical Decision Support is a process for enhancing health-

related decisions and actions with pertinent, organized clinical knowledge and patient information to improve health and healthcare delivery

– Made up of:• Clinical elements e.g. reference information• Operational elements e.g. alerts or reminders

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Why Should You Care About CDS?

• You won’t miss stuff• You won’t forget stuff• You can easily find stuff• The stuff is relevant to your patients

• The Right information to the Right person at the Right time

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Types of Clinical Decision Support

• General clinical knowledge and guidance • Intelligently processed patient data, or• Mixture of both

• Formats include:– Data and order entry facilitators – Filtered data displays– Reference information – Alerts, and – Others e.g. Clinical rules

Source: HIMSS

A simple and classic CDS example:Drug Interaction Warnings

Types of CDS

• Drug-Drug Interactions • Drug-Allergy interactions • Dose Range Checking • Pick lists• Standardized evidence

based order sets e.g. for CDM

• Rules (core measures, antibiotic usage, INR management)

• Links to knowledge references (in the EMR or Web-based)

• Alerts• Templates • Relevant data displays • Point of care reference

information• Diagnostic decision support

tools

Additional Perspective on CDS

• Active (Driven by an action)– Order sets– Plans of care– Rules and alerts

• Passive– Reference information– E.g. Image database for Dermatology (VisualDX)

• Must focus on important information without hindering the daily work of the provider

• Customizability

Oder Sets

• Allow doctors to enter one order for a series of actions associated with common conditions and procedures

• Work best for small number of regularly seen conditions• Benefits:

– Make care more efficient and easy for the majority of patients with frequently occurring conditions

– Improve standardization of care – Reminders for safety measures that should be followed

• Usually no order sets for rare conditions

CPOE (Computerized Provider Order Entry)

• Often hand-in-hand with CDS• Examples: Order investigations (labs, DI) or treatment (meds)• Need to be ‘fine tuned’ or can cause problems

– Alert fatigue – overwhelm clinicians with so many alerts that the user ‘tunes out’ the warnings. If do not need actions, cause user fatigue

– Also need training to learn how to interpret and use Alerts properly• Archives of Internal Medicine (Sept 14, 2009)

– 280,000 electronic alerts communicated to Massachusetts prescribers in 2006– E-Prescribing alerts in 7.3 percent of the 1.8 million e-prescribing attempts

examined– Physicians manually overrode 91.1% of 133,051 alerts– 12,000 alerts that were accepted likely prevented 402 adverse drug events, three

deaths, 14 permanent disabilities and 31 cases of temporary disability. – The warnings may also have averted 39 hospital admissions—at an average cost of

$9,000 per admission—kept 34 people out of ERs and avoided 267 physician office visits, for an overall savings of $402,619

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Evaluation Criteria for CDS

• Relevance• Efficiency• Sensitivity• Currency• Usability

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Relevance

• General vs. specialty focused– Alerts, reminders, templates

• Is the tool primary care/internal medicine focused?– Chronic disease management

• How does it relate to your practice?– EMRs have their strengths and weaknesses

• Does the tool slow you down or improve efficiency?– Speed of use (number of mouse-clicks)

• Does the benefit outweigh the cost in terms of the time it takes to use it?– Financial & time cost vs. clinical benefit

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Efficiency

• Does the tool provide the right amount of information to make the decision?– Too much or too little?– Who controls sensitivity settings?

• Individual user vs. practice level

• Need to ensure the right sensitivity settings – Alert sensitivity too high or low won’t provide the right

information at the right time

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Sensitivity

• How timely is the information? Is it up-to-date?– Drug data– Clinical reference data– Out of date information loses relevance

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Currency

• How does the tool fit into your workflow?– If distracting or poorly designed, can increase risk of error

• What is the general satisfaction of users?– Speak with colleagues– Importance of user groups

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Usability & Human Factors

Where Can CDS Add Value?

• Improved quality– By guiding users to best practices

• Increased safety– By verifying an action was the intended one

• Reduced cost– By identifying duplicate or unnecessary orders

• Improved documentation– Using templates or order sets for specific conditions

• Improved communication– Among clinicians regarding patient status– Between clinicians and patients

Source: HIMSS

What Should Decision Support Systems Do?

• They need to integrate with your flow• They must be easily understandable• They must be familiar• They must be current• They must not create fatigue

Features of Clinical DSS that Succeed

• Provided automatically as part of workflow• Support delivered at time and location of decision

making• Provide ‘actionable’ recommendations• Computer based

BMJ, doi:10.1136/bmj.38398.500764.8F (published 14 March 2005)