HIT In The Exam Room: The Value Of Clinical Decision Support
By James A. Colbert, M.D., VP medical engagement at medCPU
As we entered the era of electronic medical records (EMRs), physicians started spending a portion of their patient exam time interacting with software. The benefits of electronic data capture, including the ability to better track patient progress and share medical records more easily among care team members, came at the expense of patient interaction. Rudimentary EMR clinical decision support (CDS) functions often compounded the distraction by issuing alerts that did not always add value.
Fortunately, intelligent CDS systems have become adept at supplying information that more clearly adds value to exam processes. The best of these systems remain mostly silent during examinations, running in the background and analyzing documentation as it is entered, comparing it with information buried in the EMR as well as other data sources. Alerts only appear when analysis of a clinician’s entries indicates important information has gone unnoticed.
This capability has enabled advanced CDS systems to deliver value in two ways: flagging clinical factors that aren’t easily uncovered during an exam, and aligning care with hospital or health system clinical guidelines. As long as the CDS operates within established workflows — delivering the right information at the right time — CDS represents effective healthcare IT.
Providing Information Not Easily Detected During Exams
One of the most basic functions of CDS is alerting prescribing physicians to contraindications and preventing patients from being harmed. When a physician orders a new prescription, CDS searches the patient’s medical record for existing prescriptions that may cause an adverse reaction. CDS can also discover whether the medication or similar medications have previously been tried, and can alert the provider regarding the prior effects.
This basic function has been extended in intelligent CDS systems to a myriad of patient safety concerns, such as ensuring all indications are met in support of an order for advanced imaging, or noting the presence of a foreign metal object in a patient that could make imaging unsafe. In addition to preventing potential patient harm, CDS can note care steps that have not been taken for a patient but should be taken. For example, making sure every patient with congestive heart failure is scheduled for appropriate follow-up care and is provided with the educational resources needed to best manage his or her condition.
A non-intrusive alert can add significant care value by providing relevant information to a physician that would otherwise have gone unnoticed. Such technology allows a provider to achieve a complete clinical view of the patient, thus facilitating more informed medical decision-making and resulting in better care outcomes.
Supporting Adherence To Clinical Guidelines
In addition to assisting physicians with information specific to the individual patient, CDS can also support system-wide efforts to improve standardization of clinical processes. Variation in clinical practice is widespread and can lead to increased costs and lower quality. Through intelligent CDS, a health delivery organization can reduce undesirable variations in care by nudging providers to follow established best-practice care pathways. This may be as simple as specifying the frequency with which immobile patients are turned to prevent pressure ulcers. Or it could involve reminders to follow set guidelines around use of urinary catheters to reduce the chance of hospital-acquired infections.
It’s impractical to expect every clinician to master and remember every clinical guideline, or to expect a clinician to recall each of the steps in a complex care pathway without external assistance. By programming best-practice guidelines into the CDS system so it issues alerts at appropriate intervention points — such as when documentation entry indicates a deviation from best practices — a hospital or health system can realize significant process improvements that increase uniformity in standardized care quality.
Support Without Unwelcome Intrusion Is Key
Clinicians who voice complaints about healthcare IT intrusion in the exam room often have a valid point. Comparing the presence of technology with the absence of technology can typically provide instances in which a physician must divert attention from the patient. The essential question is: what is gained in the process?
When a CDS system proves capable of increasing patient safety by providing crucial information that would otherwise be unavailable at the point of care, and of presenting a timely prompt to follow a clinical guideline that would have been overlooked at the moment, it is adding true value.
No CDS system will ever be a substitute for a physician’s education, experience or clinical expertise. Yet, on the other hand, physicians don’t have time to read every word in a patient’s EMR; nor can they memorize every clinical practice guideline. Nevertheless, providers are held accountable for outcomes almost as if that were the case.
That’s why CDS represents the best of healthcare IT and has an essential place in the exam room. When skilled clinicians come together with intelligent CDS, the result can be the realization of multiple goals: better patient outcomes, increased care efficiency, and more satisfied clinicians.