Guest Column | January 4, 2018

A Historical Look At The Evolution Of Clinical Decision Support

Clinical Decision Support To ACO Success

When discussing the evolution of Clinical Decision Support (CDS) with regards to diagnostic imaging, it’s always good to step back from all of the acronyms and look at the big picture. This is especially true when it comes to the diagnostic process and quality of care.

Back in 1999, the Institute of Medicine (IOM) published To Err Is Human, which examined a decade of research that showed that 17 percent of deaths in the United States were related to errors in the diagnostic process — exceeding even deaths from medication errors.

Furthermore, from 1985-2005 radiology testing grew at double digit rates. Since 2005 the rate of increase in diagnostic imaging has diminished, although still growing, but not at such a rapid rate. Radiology procedures are used in approximately 10-15 percent of all patient encounters and account for nearly 10 percent of the total health care delivery costs in the U.S. Finally, many studies have shown that inappropriate ordering accounts for about 30-40 percent of all imaging.

Consequently, radiology was an important area where evidence-based standards could ultimately reduce errors and costs, while enhancing outcomes.

Getting to the point where evidence-based standards became fully accepted came with many challenges. First, this type of change would touch virtually all aspect of health care delivery from physicians’ offices to hospitals to free standing imaging centers — no small task for coordination and implementation.

Second, the evidence itself needed to represent not only the imaging expertise of those who perform the procedures, but represent the multidisciplinary perspectives of the ordering providers to be credible and include the rapidly changing technology innovations and research in many areas of medicine.

Third, the medical community would actively resist any approach that did not allow for individual decision-making according to their expertise. Especially as many, if not most physicians, believed that their decision-making was already state-of-the art, and did not know about the variability that the majority of research revealed.

To improve the quality of patient care — further reinforced by the Protecting Access to Medicare Act (PAMA) in 2014 — there needed to be the development of evidence-based decision support systems that demonstrated better outcomes in terms of decision-making compared to traditional processes and showed value to users.

Although there was always considerable rhetoric about quality of care and outcomes, the reality has been that these goals did not drive the healthcare marketplace to show significant results until the adoption of the Affordable Care Act (ACA). The realization of clinical decision support became more feasible with the ACA mandatory requirements that have advanced the use of healthcare IT.

As such, the Internet as well as the evolution of electronic medical records has provided change and disruption, and it has been challenging to develop products, which could work in a variety of systems and settings. Again, the requirements by the Federal government have facilitated more universal “interoperability” even if the goal is not fully realized today.

Today, CDS has become a front-and-center innovation where Center for Medicare and Medicaid Services’ (CMS) is recognizing key solutions as a mechanism that are qualified to provide evidence-based imaging recommendations that supports Appropriate Use Criteria (AUC) for eight current priority clinical areas fulfilling the requirements of CMS.

Thanks to this overall evolution, CDS will continue to help drive down errors, and allow for decisions to be founded on the latest evidence-based knowledge and specific symptoms of each patient. And, this is a great thing for ordering physicians, imaging centers, and ultimately the patient.

About The Author

A pioneer in health care quality and efficiency improvements, in 1997 Dr. Gray founded Sage Health Management Solutions, Inc. and has led an experienced team to develop a patented technology to improve the diagnostic process using Computerized Provider Order Entry (CPOE) combined with evidence-based imaging clinical decision support. She was recognized by the U.S. Department of Commerce for her entrepreneurial efforts when she represented America at the first Franco-American Entrepreneur exchange in Paris in 2005. For more information, click here.