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Thursday, May 22, 2014

Health & Tech: Using Technology to Improve Health Care—Part 3: Clinical Decision Support

Caitlin Morris

Director of Affordability Initiatives

The problem: A persistent gap exists between the care patients receive and the best available evidence about medical treatment

Effective medical treatment requires that physicians apply the best available evidence, rely on their clinical expertise, and consider individual patient preferences and values to make decisions about patient care. Yet across most areas of medicine, practice consistently lags behind evidence. Even when physicians have access to evidence in usable formats, like clinical practice guidelines, it can take more than five years for them to adopt these guidelines into routine clinical practice.

Tackling the gap between evidence and practice would improve both patient outcomes and overall efficiency. Our health care system is plagued by chronic underuse, overuse, and misuse of health care services. All of these issues can be attributed—at least in part—to this gap. And when care is not evidence-based, patient safety is compromised and resources are wasted.

The technology solution: Making clinical and patient information available via computers (clinical decision support) puts critical information in the doctors’ hands at the time of treatment

Clinical decision support aims to close the gap between research and practice by providing physicians with computer-generated clinical knowledge and patient information at critical points in the diagnosis and treatment process. By incorporating scientific evidence into decision making, clinical decision support can improve patient safety and treatment. When clinical decision support is linked to electronic health records (EHRs), clinicians can also take advantage of individual patient information.

Clinical decision support can help physicians in numerous aspects of care delivery:

  • Alerting physicians to potential adverse interactions between drugs as they write prescriptions
  • Aiding in the diagnosis of a patient based on his or her individual medical information and the system’s database of diseases
  • Formulating treatment suggestions based on existing clinical practice guidelines

Providing physicians with this information grounds diagnosis and treatment in the best available evidence, allowing physicians to do their jobs better and more effectively.

Case study—Clinical decision support in practice: How a Seattle clinic used clinical decision support to reduce inappropriate orders of diagnostic imaging services

Imaging services like cat scans (CTs) and MRIs are among the largest contributors to growing medical costs. These scans also pose risks to patient safety when used inappropriately and unnecessarily.

Imaging also happens to be an area of health care where high-quality, evidence-based clinical practice guidelines exist to direct physicians toward the appropriate use of these services. Research suggests that when physicians use clinical decision support, they significantly reduce the volume of unnecessary tests that they order. Why? Clinical decision support provides the physician with real-time feedback on the appropriateness of an imaging order, frequently leading him or her to reconsider the scan.

Virginia Mason Medical Center is an integrated, multidisciplinary health care network based in Seattle, Washington. With physicians there performing 260,000 radiology examinations annually, Virginia Mason implemented clinical decision support.

Physicians gained access to evidence-based practice guidelines for two types of imaging services that have been shown to be ordered inappropriately: MRIs of the lower back and head and CTs of the sinus.

After implementation, Virginia Mason saw significant reductions in the rate of inappropriate imaging orders:

  • An approximately 23 percent lower rate of MRIs ordered for patients with low back pain
  • A 23 percent lower rate of MRIs ordered for patients with headaches
  • A 27 percent lower rate of CTs ordered for patients with sinusitis

In this case, clinical decision support was shown to increase patient safety and quality and decrease health care costs by eliminating unnecessary imaging.

Considerations for consumers: Clinical decision support is challenging to implement and maintain

Clinical decision support shows great promise for improving patient health outcomes by increasing clinician access to high-quality information and evidence at the time of care. However, the systems that facilitate clinical decision support are not widespread. And implementation and maintenance of these systems remain a challenge. As with electronic health records, fully realizing the potential of this technology depends on the ability of providers to access and use them on a routine basis.

The absence of a high-quality evidence base in all areas of medicine also hinders full implementation. Some diagnoses are supported by robust clinical practice guidelines, but in many other areas of medicine, evidence isn’t available, or the evidence that exists is poor. In these cases, the potential of clinical decision support to guide physicians is more limited.

Despite these challenges, the promise of clinical decision support to improve medical care is great. And systems that are built to be flexible and responsive should have the ability to adjust as new and/or better evidence becomes available.