Most Wired

Decision Support for Docs

By Maureen Mckinney

Imbedding medication alerts and other tools into clinical IT can improve patient care and safety. But beware of pitfalls.

The task of implementing real-time clinical decision support rules into existing electronic medical records can bring with it an array of challenges including alert fatigue, technological glitches and disruptions in clinician workflow.

But decision support will likely be a key part of the government's proposed rule on meaningful use, which is expected by year's end.

Bothwell Regional Health Center, a 180-bed hospital in Sedalia, Mo., is taking note and has begun small, measured steps to implement point-of-care alerts and reminders in its electronic medical record, says Tom Fairfax, interim director of information systems. Physicians and nurse practitioners at a Bothwell clinic in late November began using decision support tools from Zynx Health in their daily workflow.

Implementing the changes gradually in one clinic versus the entire hospital provides Bothwell with a "lab setting" to observe problems and work out the bugs, Fairfax says. Using predefined templates from Zynx has also cut down on the amount of time it takes to build alerts.

When a patient enters the clinic with abdominal pain, for instance, checkboxes appear for variables such as the patient's level of discomfort and the time that it began. The system will help the physician determine appropriate tests and interventions. If there are recurring visits, the system will present another set of questions that will refine orders even further.

"Our physicians have been pretty receptive to the new system because they know the stimulus money depends on it and they realize computerization is going to become a bigger and bigger part of their lives," Fairfax says.

Montefiore Medical Center, a four-hospital system with 1,491 beds in the Bronx in New York City, has achieved 100 percent computerized provider order entry and has integrated hundreds of alerts into its EMR, says Jack Wolf, the center's vice president and chief information officer.

Perhaps more interesting, however, are the thousands of alerts and reminders that never made it past Montefiore's regimented testing process for expert decision support rules.

"When you put in rules about medication alerts, drug administration or another intervention, you really have to involve physicians at the early stages and walk through all of the potential situations that the alert could go through," Wolf says. "We were able to eliminate thousands of alerts that we decided would not be effective and may actually be dangerous."

An ineffective alert can pose a real danger, explains Wolf, because clinicians will rely on the rule and potentially forego other mechanisms of checking their orders. For instance, a drug interaction alert that does not adequately prevent an interaction can actually increase the odds of one occurring because the ordering physician would not be likely to recheck the record if the alert said there was no problem.

Montefiore has two physicians in its IT group, and also includes ambulatory and hospital physicians in testing. First, they do a walk-through of any proposed alert to see if it hits the desired mark and how it impacts workflow. Then there's a mock test with a fictitious patient who has lots of comorbidities. If the rule is OK, it is tested with a group of patients. After that, it is tested in a live environment without actually sending orders. It's an arduous process, but one that is necessary to ensure that the right alerts and reminders are in place, Wolf says.

First Steps

Knapp Regional Medical Center, a 233-bed hospital in Weslaco, Texas, is among many hospitals that don't have point-of-care clinical decision support in place and are trying to create an effective strategy to do so.

"We have implemented a new EHR system and are in the process of putting down a good foundation for CPOE, clinical documentation, bedside medication administration, and clinical decision support," says Gary Light, Knapp's vice president and CIO.

For hospitals such as Knapp, the first step after selecting a vendor is to see if all the user groups can provide expert rules that are already operational at their sites, Wolf says. Then, look for best practices from other institutions. "You want to be as prepared as possible," Wolf says. "This is not an area for trial by fire."

Each month, H&HN provides continuing coverage of the annual Most Wired Survey and Benchmarking Study and other IT issues. The 2009 survey is made possible through a partnership among H&HN, the American Hospital Association, the College of Healthcare Information Management Executives and McKesson Corp. CareTech Solutions and Intel provide additional support.

Maureen McKinney is a freelance writer in Chicago.

This article 1st appeared in the December 2009 issue of HHN Magazine.

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