Clinical Decision Support - Dr. Greenes

Clinical Decision Support (CDS) should be viewed as support to help clinicians reach an informed decision. The amount of support which can be provided to a clinician should be carefully considered and this area of informatics is continually evolving. The EMR offers immediate access to patient data in which the system can evaluate and formulate support alerts but the number of alerts to provide and how to prioritize what should and shouldn’t be a CDS alert needs to be evaluated. Just as Internet searching brings massive amounts of data with a few clicks, the EMR could do the same but it could also bring the same noise and actually become detrimental because of frustration. At some point, the interruption of a physician’s thought at the wrong time can lead to additional errors or omission. So the concept of presenting the CDS information at just the right time requires understanding physician and nursing workflows, how they approach ordering and planning care for their patients and the timing associated with the plan of care.

Medicine is a science and making major decisions should use similar decision analysis concepts. If probabilities are not known for some of the arms of the decision tree because of lack of information, the models may not be of much assistance. Also, measuring a patient’s utility and physician biases of practice and incorporating that into the decision analysis model adds complexity.

In creating CDS, then, the EMR can’t take utility or quality of life into account and so the CDS is meant to add information to a clinician and combine this information with their knowledge of the patient to help make informed decisions. Even though the support might recommend a certain action, it may not be the correct action for every patient. Thus CDS is always an open loop action requiring human interaction to decline or implement the recommendation.

Just like in medical studies, the different models used to determine the decision analysis conclusion have to be reviewed and the data used for probabilities is only as good as the studies they come from. As was shown in the balance sheet for decision analysis, the same advantage can also be the disadvantage – such as needing diverse data. Although models are an important step in trying to analyze and make decisions, I think it must be understood this information and the decisions made can be quite variable when you add in all the elements of the tree for an individual patient.

Posted by : Debbie Carter