Enhancing
electronic health records –how can incorporating a Clinical Decision Support
System (CDSS) inthe EHR help?
Mary Raju Mathew, Chinnu P.B, Pharm. D
5th Year. Alshifa college of Pharmacy
Hospitals
have increasingly started to switch from paper charts and medical health files
to electronic medical records. This quick shift is clearly because of the
easier and highly manageable benefits these electronic patient records provide
compared to paper records. They provide instant access to patient details like
a patient's medical and medication history, track lab results, help in
prescribing medications, and even store and retrieve discharge summaries. Well,
the EMR, indeed saves a lot of time, makes it easy to manage a big amount of
data, keeps old records easily retrievable within just a click on the mouse and
can also track information regarding medicines including prescribing and
dispensing.
Now, what
if these electronic medical records can be used to flag potentially
dangerous drug interactions (to help prescribing doctors explore
alternative saferdrug options), verify medications and dosages (to
ensure that pharmacists dispense the right drug), and share information
with other healthcare providers, even with patients and their family
caregivers. Such technological solutions can help healthcare providers embrace
tangible improvements in their ability to make better clinical decisions, these
IT solutions are called electronic health records (EHR). EHR’s have been
developed and used in healthcare around the world since the last decade.
According to a national survey[1] of
US doctors whose hospitals use an EHR:
~
94% of providers report that
their EHR makes records readily available at point of care.
~
88% report that
their EHR produces clinical benefits for the practice.
~
75% of providers report that
their EHR allows them to deliver better patient care.
Over the
years, electronic health records and databases help physicians manage the
rising tide of information, the benefits of using an EHR led to developing and
incorporating a more interactive and intelligent clinical decision supporting
health IT system within the EHR called the Clinical Decision Support Systemor
CDSS. In India, e-clinicians CDSS [2]was
launched with an intend to obtain patient-specific recommendations and
solutions which can further improve decision making and help ensure patient
safety. Such e-computer technology, assist by generating case-specific advice
for clinical decision making and as to know how this is programmed and its
various gains, read on.
As use of
CDSS requires familiarity with EHR’S, lets first see what EHR’S are;
An EMR
contains standard medical and clinical data gathered about a patient- which is
in fact just a digital version of a patient’s case record. Electronic Health
Records (EHRs) go beyond such data collected and include more comprehensive details like patient
history& diagnosis,lab data, drug choices, drug allergy alert, drug dose
range alert, drug interaction alerts, drug duplication alert, quick drug
information reference database links, built-in safeguards against potential
adverse events, more reliable e-prescribing which is electronically sent
to the pharmacy, administration details
like time of administration, details of the administering nurse, availability
in the pharmacy, details of the dispenser, dispensing details like next
scheduled date of drug for the patient, automatic drug stop orders for antibiotics
etc.., drug review by pharmacist,
patient education links etc.
EHRs are
designed to contain and share information from all providers involved in a
patient’s care. EHR data can be created, managed, and consulted by authorized
providers and staff from across more than one health care organization. Each
authorised person will have a personal ID and password to access the EHR just
like using an EMR, sometimes the access to certain data is restricted to
specific health care providers. It also allows a patient’s health record to
move with them—to other health care providers, specialists and hospitals. In an
emergency condition, EHRs can also provide instant access to information about
a patient's medical history, allergies, and medications. This can enable
providers to make decisions sooner, thus quickly provide care in life
threatening conditions.
EHR
isa single record that includes all of a patient's health information: a record
that is up to date, complete, and accurate. This puts providers in a better
position to work with their patients to make good decisions. If EHRs are
connected to a network of healthcare institutions[3],then in rural areas where distances between clinics are great
and specialists are often few, EHRs can instantly provide accurate,
up-to-date, and complete information about patients, so rural health care
organizations can make timely decisions and save lives and also enable rural
health care providers toaccess remote clinicians, pharmacists, and staff
members, improving and extending access for patients
EHRs can
also alert potentially dangerous drug interactions, drug allergies
and verify medications and correct drug dose ranges. EHR can automatically
check for drug-drug and drug-allergy interactions whenever a new medication is
prescribed and alert the clinician.A quick drug information database linked to
an EHR like Lexicomp™ can help provide live, accurate and helpful information
to many healthcare professionals.Paper prescriptions can get lost or misread.
With e-prescribing doctors communicate directly with the pharmacy. An
e-prescribing system can help save lives by reducing medication errors and
checking for drug interactions, lower costs, and improve care. It is more
convenient for doctors and pharmacies, and safer for patients.
It’s a
quick and easy means to share information with patients and their family
caregivers, which would help patients and their families to improve their part
in making decisions about their health care.With EHRs, providers can manage
appointment schedules electronically and exchange e-mail with their patients on
next scheduled dose etc. thus creating an avenue for communication with their
patients. Providers and patients who share access to electronic health
information can collaborate in informed decision making.Also, patient
portals with online interactionwith providers and electronic referrals,
allows easier access to follow-up care with specialist.
Administrative
tasks, such as filling out forms and processing billing requests, represent a
significant percentage of health care costs. EHRs can increase practice
efficiencies by streamlining these tasks, significantly decreasing costs.
EHR can be
the foundation for quality improvements: Medication error reporting, drug
use pattern statistics can be generated, change of brand/generic name of a drug
in the hospital formulary can also be notified by email to all the health care
providers.
Over the
last decade, using EHRs in hospitals and health care facilities proved to be
successful in reaping benefits such as reduction in errors, availability of
records and data, drug reminders and alerts, and e-prescribing/refill
automation and thereby the healthcare costs were cut down significantly. The
financial expenditure for installing an EHR proved to reap profits, because of
the reduction in cost aided by preventing various errors. Well trained care
providers, informatics pharmacist, health IT consultants worked together to
test and improve EHRs during the initial years of use in various hospitals
across the world.
When
health care professionals reported that EHR’S assisted in enhancing their
clinical decisions and practices, enhanced decision support systems called
as Clinical decision support systems (CDSS) were developed. The notableCDSSs
being presently usedare MYCIN™, EPIC™, and QMR™etc. CDSS can support the
delivery of high-quality health care by providing
intelligently-filteredpatient-specific knowledge at the point of careto enhance
better health care. CDSS encompasses a variety of tools to enhance
decision-making in the clinical workflow[4].
Clinical decision support softwares (CDSS) are interactive computer programs,
which are designed to assist physicians and other health professionals with
decision making tasks.
A clinical
decision support system uses two or more items of patient data to generate
case-specific advice. The clinician interacts with a CDSS to help determine
diagnosis, analysis, etc. of a patient. 95% of the clinicians around the world
have agreed that CDSS has helped improve the patient care outcome to various
extents in evidence based clinical practice[2].
Clinicians
nowadays, interact with the CDSS by utilizing both the clinician’s knowledge
and the CDSS software to make a better analysis of the patients’ data than
either human or CDSS could make on their own[5].
Typically
the CDSS would make suggestions of outputs or a set of outputs for the
clinician to look through and the clinician officially picks useful information
and removes erroneous CDSS suggestions. The doctor then takes the output of the
CDSS and figures out which diagnoses are relevant and which are not. EHRs can
support provider decision making; EHRs can help providers make effective,
efficient decisions about patient care.
According
to Agency for Healthcare Research
and Quality's (AHRQ) CDSS encompasses a
variety of tools andinterventions such as computerized alerts and reminders,
clinical guidelines, patient data reports, a, documentation templates,
diagnostic support, and clinical workflow tools. CDSS applications range from “electronically
available clinical data (e.g. information from a clinical laboratory system or
information from a disease registry), electronic full-text journal and textbook
access, evidence-based clinical guidelines, and systems that provide patient
and situation-specific advice (e.g., EKG interpretation).The doctor uses these
systems at point-of-care to help them as they are dealing with a patient, with
the timing of use as either pre-diagnosis, during diagnosis, or post diagnosis.
Pre-diagnoses
CDSS systems are used to help the physician prepare the diagnosis. CDSS used
during diagnosis are to help review and filter the physician’s preliminary
diagnostic choices to improve their final results. Post-diagnosis CDSS systems
are used to mine data to derive connections between patients and their past
medical history and clinical research to predict future events.[2]
Now,
Howdoes a CDSS work?CDSS not only keeps a record of a patient's medication
or allergies, it also automatically checks for problems whenever a new
medication is prescribed and alerts the clinician to potential
conflicts. Automated formulary checks and alerts are generated when a drug or
data is entered. The CDSS rely on well-defined mathematical techniques like the
Boolean logic to do the reasoning. International Classification of Diseases
(ICD 10) codes are incorporated to help in data mining and to monitor standards
across health care delivery sites[4]. Each
data like drug names; etc, are coded in the programming language and fed to the
system.
For
pharmacy health professionals, pharmacoinformatics has become an increasingly
valued disciple of study where informaticspharmacists
are trained to manage pharmacy information management systems like the drug
module in a CDSS. They focus on medication-related data information, CDSS
troubleshooting and statistical data mining, by working in concert with IT
consultants and health informatics specialists.
In India,
City-based Coresys InfoTech launched eClinician, a CDSS and its mobile version
on Android software, which will help medical professionals diagnose disease
easily.eClinician CDSS is the outcome of
an ambitious project conceived over 9 years ago. It was developed over the
years by physicians and software developers who have successfully integrated
information from standard medical text books and literature systematically. The
working medical team consisted of 24 medical specialists, many of whom are
academic faculty members throughout the world. In addition to these experts,
the team had general physicians who ensured that the software is user friendly
for general physicians.This software has been refined over several years now
and is seen as an innovative tool that can improve the quality of care and
decision during a patient’s course of treatment[2].
Percentage of physicians whose electronic health records
provided selected benefits: United States,
2011SOURCE:
CDC/NCHS, Physician Workflow study, 2011
In a
survey conducted in 2011,
to identify the percentage of physicians in US whose electronic
health records provided selected benefit shows thata majority of
adopters reported having accessed a patient's chart remotely (74%) and having
been alerted to critical lab values (52%) by using their EHR system within the
past 30 days. A majority also reported that using their EHR system had resulted
in enhanced overall patient care (74%)[6].
Conclusion
A large
part of any physician’s work, involves acquiring information and then, aided by
evidence and experience, making decisions for the best possible outcome. With
the burgeoning amount of data now available for each patient and the increasing
body of medical evidence, we need tools to help us make rational decisions
based on all this information.The final diagnosis by doctors in a study conducted
by using eClinician CDSS in India showed up the list of differential diagnosis
generated by eClinician CDSS, in all the cases under study. In 35 cases, the
final diagnoses made by the doctors were first among the list of differential
diagnosis. For three cases the final diagnosis matched with the second among
the list and for the remaining two it matched with third among the list of
differential diagnosis generated by eClinician.
Computer
technology can thus assist by generating case-specific advice for clinical
decision making. The systems used are usually referred to as clinical decision
support systems or CDSS.In the coming
years,many healthcare ventures will invest in new health information systems.
Computer decision support systems integrated with EHR can help make this
investment worthwhile by leading to safer, more efficient, and more effective
health care.
CDSS
software is fairly accurate, user friendly and has high potential to not only
improve efficiency in providing clinical care but also to improve the overall
quality of health care.
REFERENCES
1.
Jamoom, E., Patel, V., King,
J., & Furukawa, M. National perceptions of EHR adoption: Barriers, impacts,
and federal policies. National conference on health statistics.2012,
August.
2.
Importance of CDSS in Clinical
Practice : Dr. Vijayabhaskar Reddy Kandula Physician, St Mark’s Hospital Salt
Lake City, Utah. USA & Dr. Sanjay Deodhar Consultant, National Rural Health
Mission, Ministry of Health, Govt. of India. Dec 2009. Available from: www.ehealth.com
3.
Benefits of Electronic Health
Record[Internet]. US government: Health IT in association with NLC. 2014 August
[cited December 2014]. Available from:
http://www.healthit.gov/providers-proffesionals.
4.
Eta S. Berne. Clinical Decision
Support Systems: Theory and Practice. 2nd Edition. New York. Springer Science
& Business Media; 2007. p. 34-36.
5.
Van der Lei J. Clinical
decision support systems. In: van Bemmel J, Musen M (eds). Handbook of Medical
Informatics. Heidelberg: Springer-Verlag, 1997:261-276
6.
Jamoom E, Beatty P, Bercovitz
A, et al. Physician adoption of electronic health record systems: United
States, 2011. NCHS data brief, no 98. Hyattsville, MD: National Center for
Health Statistics.2012.
