ACP: Clinical decision support – is it time?

A guest column by the American College of Physicians, exclusive to

by John Tooker, MD, MBA, MACP

ACP: Clinical decision support   is it time?The recently enacted American Recovery and Reinvestment Act (ARRA, 2009) and Patient Protection and Affordable Care Act (PPACA, 2010) contain provisions that, if implemented, will fundamentally change the way that medicine will be practiced in the future.

As I indicated in a prior post, the new Center for Medicare and Medicaid Innovation (CMMI) will be testing new delivery models such as the patient-centered medical home (PCMH) and accountable care organizations (ACOs). To achieve the desired goals of improved outcomes and value of care in these models, patient-centered decision making will require enhanced clinical decision support (CDS) that couples patient specific data with the best evidence-based clinical knowledge.

Historically, physicians and health care teams have been trained to intuitively assemble patient data, provide the context to apply clinical knowledge to aid in clinical decisions, and access and apply expert knowledge sources – from the curbside consult to paper and online evidence-based references. As the volume and complexity of biomedical data, information, and clinical knowledge have expanded, the human intuitional capacity to make decisions for and with patients has become increasingly limited.

With these current limitations in mind, what CDS innovations are on the horizon in the Meaningful Use provisions of the HITECH Act to improve clinical decision making — and on a national scale?

Clinical decision support has evolved to CDS “systems” employing machine oriented logic designed to match patient information to a clinical knowledge base, providing the opportunity for patient-centered and patient-specific evaluation and recommendations. As a 2010 AHRQ report cites: “When well designed and implemented, CDS systems have the potential to improve health care quality, and to increase efficiency and reduce health care costs.” For those readers interested in learning more about CDS, The Agency for Healthcare Research and Quality (AHRQ) has an extensive online CDS knowledge library. One useful CDS framework is the Five Rights Model:

The CDS Five Rights Model states that CDS-supported improvements in desired healthcare outcomes can be achieved if we communicate:

1. The right information: evidence-based, suitable to guide action, pertinent to the circumstance

2. To the right person: considering all members of the care team, including clinicians, patients, and their caretakers

3. In the right CDS intervention format: such as an alert, order set, or reference information to answer a clinical question

4. Through the right channel: for example, a clinical information system (CIS) such as an electronic medical record (EMR), personal health record (PHR), or a more general channel such as the Internet or a mobile device

5. At the right time in workflow: for example, at time of decision/action/need

CDS was included in the Stage 1 Meaningful Use Final Rule released in July 2010. That rule required only one CDS rule relevant to a high clinical priority, along with the ability to track compliance with that rule. Last month, the Health IT Policy Committee met to make recommendations to the HHS Secretary on the Medicare and Medicaid EHR incentive programs. The Meaningful Use (MU) Workgroup of the Policy Committee presented their recommendations on requirements, including CDS, that eligible professionals will need to meet to qualify for incentives for certified EHR adoption in Stages 2-3 of MU implementation, beginning in 2012. HHS is expected to publish a request for comment on the draft recommendations in January 2011.

If the Secretary follows the recommendations of the Meaningful Use (MU) Workgroup, it is expected that the CDS recommendations will continue to focus on improving performance on high priority health conditions. As clinicians are in the best position to know the likely benefits and pitfalls of changes in CDS requirements resulting from the implementation of stages 2 and 3 of MU, it will be very important for individual physicians, practice groups and professional medical societies – when the request for comment is released – to comment on the proposed CDS requirements that will lead to the Stage 2 and 3 CDS MU Final Rules.

John Tooker is Associate Executive Vice President of the American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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  • LynnB

    I am actually a big fan of decision support in theory. If those “checklists” are imbedded in patient encounters we should have reminders that smokers benefit from a pneumovax, that we should ask elderly patients if they have fallen, that women under 25 should have Chlamydia screening , that this patient is 10 years out form their stent and might be able to stop clopidigrel .

    I practice, when I got a list of 68 patients who had not had an A1c in > 6 months , then winnowed out those who were dead, moved, were over 90 years old , on hospice, had gestational DM 3 years ago and were just getting a yearly screen and so on there were 7 that were overdue. That’s not a great percentage , , but I contacted all 7. Five were overdue because they had lost insurance (not that that makes it OK, but they were contacted and declined) . Mostly, this was a waste of my time. Not “someone’s time”. Not the “nurse’s time-”-those mythical paragons who are available to the patients and to the doc and take absolutely no time to finish their work . It might get better next time, I hope so. In practice, I get a red stop sign from the EMR on every patient who I have on warfarin for A fib saying “coumadin absolutely contraindicated in the face of hypertension” . Clearly my request to put the CHADS2 scale in there hasn’t helped much. In practice United Health Care routinely sends me reminders to do paps on women who have had hysterectomies, and reminding me that I haven’t gotten a lipid panel (the results are in the chart, but United is not the primary payer, so they don;t have those).I spend 2 -hours on the 12 commercial UHC patients , going over the charts and 3-6 months later I get the same darn letter. Because I am a PCP I have an hourly MA, no RN, and we have mandatory staff reductions, so its all me, They say “contact us ” and every time I fill that out so I can fix the problem, there is never a reply . MY partners are quicker learners and just throw the darn thing away. In practice , when I am in hospital I have more than once given prophylactic low dose LMWH to general medical patients who are fully anticoagulated and done repeated HIV tests (universal screening is recommended) on COPD or chronic CAD patients who have no risk factors who get admitted every few months . All of these are from different software vendors using non-communication different systems, none of which work anything like the demo.

    I also have many friends who practice at health systems that have made major investments and find most (but never all) of the decision support software to be helpful. My initial background was computer science– albeit > 20 years ago , so I am sure it can be done better it just takes the investments in software development and investment in adequate hardware.

    I love the idea, but mandating adherence to something that is ineffective for many practitioners will teach doctors to ignore decision support software. Remember, if you are of a certain advanced age, the control room at Three Mile Island where alarms went off constantly. In the same way that I am quite disinclined to listen to UHC , we will all reach the point where we ignore the multiple warnings and arrows that pop up. Most system just want to meet meaningful use criteria. I am cynical and think once they get the incentive we will be saddled with an EMR product from the 80′s that meets the criteria but doesn’t help much with patient care.

  • pj

    What say you my colleagues?- this issue has profound implications for medical practice….

  • Tim Richardson

    It’s too bad that “homegrown” CDS systems show higher relative risk reductions that do commercial, off-the-shelf systems because most of private practices are too small to develop fully featured homegrown systems.

    End user input is critical to the design interface. Clinicians will quickly tire of “pop-up fatigue” and irrelevant reminders, like pap smears for women with hysterectomies.

    I built a physical therapy specific CDSs with 20 clinical decision rules (DVT, spinal fracture, falls risk, etc.) that qualifies for Meaningful Use in 2011 because no commercial vendor had one yet.

    Turns out, no private practice physical therapists are demanding CDSs because physical therapists are not on the list of Eligible Providers mainly because we don’t routinely compile, track or prescribe medications.

    Electronic Medical Records vendors in physical therapy are, unfortunately, mostly targeting their features and marketing towards “code capture” and revenue enhancement rather than improved decision support.


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