Clinical Decision Support: Workflow Integration Is Vital for Optimizing Care

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Healthcare organizations of all sizes are enlisting clinical decision support (CDS) systems to assist providers with decision making. However, to ensure proper utilization and improve the practice of evidence-based medicine, workflow integration at the point of care needs to improve.

In a review of computer-based systems, 66 percent of CDS systems significantly improved clinical practice, while 34 percent did not, according to 1998 study in the Journal of the American Medical Association. Although the technology has improved since that article was published, the message is clear: For clinicians to get the full benefit of CDS, these systems must better engage those who use them.

"Most clinicians are so busy that they can't accommodate any extraneous engagement. Pull technologies that require action on the part of the provider to bring in decision support [are] not conducive to these time constraints," says David F. Lobach, MD, PhD, chief of the clinical informatics division at Duke University Medical Center in Durham, N.C. "Therefore, push technologies that seamlessly integrate into workflow are clearly preferred and more effective."

As a result, "highly directive messages" are necessary for CDS to properly fit into the clinical workflow, says David W. Bates, MD, chief of the division of general medicine and primary care at Brigham and Women's Hospital in Boston.

For example, when a physician prescribes a medication for a patient with kidney complications, the CDS can take into account the patient's kidney function, and recommend the proper dose. "Ideally, the system does not interrupt the provider, but simply steers him or her in the proper direction," Bates says. To avoid interruption, some systems suggest a dose appropriate for that specific patient, and will only present a warning if the provider selects too high a dose.

Even small CDS alterations can make major differences. For example, Bates and colleagues at Brigham determined that ondansetron, which is used to prevent nausea and vomiting caused by cancer therapies, was as effective if given at a lower dose three times daily rather than the previous routine of four times daily. Simply changing the default dose and frequency on the ordering screen had an effect: In the four weeks before changing the default frequency, 89.7 percent of the orders for ondansetron were for four times daily and 5.9 percent were for three times daily. In the four weeks after the change, 13.7 percent of ondansetron orders were for four times daily and 75.3 percent were for three times daily. The change resulted in a cost savings of approximately $250,000 in the first year, according to a study in the November/December 2003 issue of Journal of the American Medical Informatics Association.   

Integration at order entry

CDS should be integrated into the order entry process, as many providers have moved to computerized provider order entry. "Order entry is the point at which decisions are made, and therefore, the point at which a provider should be informed of drug interactions or testing suggestions," Lobach says.

While CDS systems should provide recommendations, the systems need to draw on patient-specific data, says Ben-Tzion Karsh, PhD, associate professor, at the industrial and systems engineering department at the University of Wisconsin in Madison. "Therefore, pertinent patient-specific data need to be documented during the visit, or preferably prior to the visit to provide proper support of clinical decisions," he says.

"Particularly, in busy or ambulatory settings, providers cannot always allot time for proper documentation, and patient-specific information is entered after the visit," Karsh says. "Therefore, the CDS makes recommendations after the patient has departed. For improved utilization, patients should start inputting data via web-based portals, PHRs [personal