We all know that the healthcare delivery system in the United States is decentralized. Patient information is in multiple sources and often times not even accurate or complete. This fragmented system leads to large gaps in care, contributing to poor quality, patient safety issues and increased costs. A nationwide audit assessing 439 quality indicators found that US adults receive only about half of the recommended care, and the US Institute of Medicine has estimated that up to 98,000 US residents die each year as the result of preventable medical errors,1 all of which could have been avoided if the right information was available at the right time.
The federal government has recognized this problem and has incentivized healthcare providers to implement and meaningfully use electronic health records (EHRs) as a way to improve overall healthcare delivery. There is no doubt that systems, such as EHRs, have the ability to transform healthcare. However, it is unlikely any national or organizational goal of improving healthcare can be accomplished without the thoughtful and widespread adoption and proper use of a clinical decision support system2 (CDS).
What is Clinical Decision Support (CDS)
A CDS is an interactive system that provides clinicians, staff and other individuals a process for enhancing health-related decisions and actions with pertinent, organized clinical knowledge and patient specific information to improve health and healthcare delivery3. According to John Glaser, it encompasses a variety of tools and interventions, such as computerized alerts and reminders, clinical guidelines, order sets, patient data reports and dashboards, documentation templates, diagnostic support, and clinical workflow tool to assist clinicians at the point of care2.
Benefits of a CDS
A CDS can positively influence medical decisions at point of care, which in turn can have substantial benefits. Here are just a few simple examples:
Improved Quality: Prevention is vital to improving healthcare. Through various decision support tools and timely alerts, a CDS can help with prevention by scanning patient records for risk factors and by recommending appropriate preventive services, such as routine screenings4, informing the physician that immunizations are not up to date and addressing any additional gaps in care. This is especially useful for patients with certain chronic conditions that require frequent tests and check-ups. A RAND study indicated that roughly 15,000-27,000 deaths could be avoided simply by being vaccinated for pneumonia. Routine screenings and preventative medicine can easily decrease the amount of deaths, such as these, in this country. CDS can also improve quality of care by providing educational information that can be passed along to the patient to encourage proper disease management and assist with compliance to plans of care.
Patient Safety: Every year, millions are hurt or killed by medication errors that could have been prevented. The infamous Institute of Medicine (IOM) report indicated that medication errors account for approximately 1 out of 131 outpatient and 1 out of 854 inpatient deaths. Medication errors can drastically be reduced through CDS. According to Gina Moore, “decision support in the form of evidence-based clinical knowledge delivered in the right format to the right person at the right time can help providers enhance their medication reconciliation strategies by taking steps to ensure patients receive the correct medication, the accurate dosage, avoid drug to drug interactions, check for potential medication allergies, as well as, alert a clinician to reassess the need for medications such as antibiotics that appear to be used for longer than indicated”5.
Cost Savings: Duplicative and/or unnecessary tests can be very costly. For example, physicians who refer patients to a hospital for imaging tests, such as MRI or CT scans, sometimes order tests that are duplicative or not the most appropriate. CDS would prevent inappropriate orders by providing the referring physician with evidence at the point of order6. The evidence could be displayed from the use of the American College of Radiology guidelines, as well as criteria created by the organization within the CDS toolset, to guide physicians to the most cost-efficient and effective imaging test for each patient, saving the hospital and patient hundreds of dollars6.
Barriers to adoption
Despite the promise of CDS systems, numerous barriers to their development and implementation exist. Of these barriers the two most common are physician resistance and cost.
Physician resistance: Physicians resist the use of CDS tools for a variety of reasons, but the main reason is the belief that the use of CDS tools will decrease clinical productivity and impact financial reimbursement7. Usability issues, such as ease of use, speed, as well as its lack of integration into the clinical workflow, concerns about autonomy, and the legal and ethical ramifications of adhering to or overriding recommendations made by the CDS system8 also make physician leery. Other reasons range from not wanting a computer system to infringe on their decision making to something known as “alert fatigue”8.
Cost7: The initial cost of purchasing an EHR with CDS system is compounded by the implementation costs. Once the system is implemented, hospitals incur ongoing costs related to maintaining the system as well as keeping current the evidence-based clinical knowledge that is accessed by the CDS tools. In addition, all of the people using the system require extensive training, further affecting the productivity of the provider and in turn impacting reimbursements.
A CDS holds great potential to overcome the quality, patient safety and cost challenges facing healthcare today. Though there are barriers to its adoption, improvements in these key areas will occur only when physicians can make timely, accurate, evidence-based decisions at the point of care, and from the looks of it a CDS embedded within an EHR may just be what the doctor ordered!
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