Clinical decision support tools: 9 ways they improve care

A clinical staff armed with the best clinical decision support (CDS) tools can be a game changer when it comes to improving care quality and reducing care costs.

That’s because clinical decision support tools, which provide clinicians with knowledge ranging from up-to-date clinical guidelines to patient-specific information, enables providers and health plans to make smarter, quicker, and more-informed decisions.

“Recent information about the potential side effects of acetaminophen, ibuprofen, and PPIs; DNA test information; biologics; stem cell therapies are just a few examples of areas that have challenged health plans’ clinical leadership,” says Managed Healthcare Executive Editorial Advisory Board Member Don Hall, a former health plan CEO and principal, Delta Sigma LLC, in Littleton, Colorado.

Here are nine more ways experts say CDS can improve healthcare delivery:

As healthcare continues to evolve, largely driven by the Affordable Care Act, quality and consistency of care and cost savings are core to how practitioners conduct business on a daily basis, with the ultimate goal of improving patient outcomes, says Sean Downs, CEO of Healthx. “CDS is health information technology’s answer to ensuring clinicians and patients or caregivers alike have access to the right patient information at the right time, and that clinical protocols and guidelines are consistent when making care decisions.”

One example of a CDS tool is a robust provider solution that accesses and aggregates data, such as a provider portal. If the portal enables providers to share care plans with other providers and with patients, even better.

“A member portal solution then effectively becomes a partner with the clinician and patient to help ensure the patient is receiving pertinent information to help them better manage their care, whether it’s condition-specific or patient-specific information,” Downs says. “A member portal can also communicate to the provider and patient when care interventions are needed. For example, a tool to identify gaps in care will identify those patients that have missed or are overdue for treatments that are important for their condition or disease.”

CDS tools can help physicians manage the numerous obligations they face each day as patient volumes increase, says David Zieve, MD, MHA, medical director with Health Integrated. These tools can also help them manage more complex and sophisticated medications, quality initiatives, and compliance with regulations.

An electronic health record, for example, can be a great CDS tool for recommending a specific vaccination or screening test the patient may need based on up-to-date national guidelines, says Zieve.

According to Zieve, some examples of how EHRs might provide CDS include:

• Medication orders entered by physicians in the hospital are automatically checked by an order entry system for potential interactions with other drugs a patient may be taking, as well as signs of liver or kidney disease that may require a change in dosage.

• EHRs interpret the data about a patient within an EHR, such as age and past treatments or tests, and bring forth reminders to a physician during a patient visit. The EHR may recommend a specific vaccination or screening tests the patient may need-all based on up-to-date national guidelines.

• Based on clinical information a physician enters, an EHR may automatically send appropriate patient education material to a patient's email or patient portal.

Katherine Ziegler, director, Navigant Healthcare, provides this example to show how CDS tools can help physicians make quicker, smarter decisions.

Example:

A a doctor is seeing a patient in the hospital. The patient has been identified as at risk for falls, and that is flagged in the patient record. The doctor begins to order a narcotic sleeping pill, and receives an alert that this is contraindicated in the organization’s best practice protocol related to patients at risk for falls.  The doctor changes his or her plan of care and prescribes non-narcotic medications.

Another way the EHR serves as a CDS tool is by identifying specific work flows that might apply to certain patients, says Ziegler.

For example, she says, a patient identification algorithm identifies a patient with possible sepsis. “An alert is triggered to the RN, and a clinical work flow is triggered that automatically triggers standing order and generates reminders for increased frequency of vital signs, labs, physician notifications and other best practice components,” Ziegler says. “Work flow tools within the electronic [health] record continue to guide care and ensure that all services are provided at the visit.”

CDS tools can integrate patient information, identify key issues or gaps in care, and present that information in a meaningful format, says Ziegler. “This frees clinicians up to take care of patients, rather than digging through medical records for information.”

For example, to prepare for the patient visit, the physician can use a summary report that includes all diagnoses, lab results, medications, care-management notes, etc. This information helps highlight gaps in care pertaining to treatment of diabetes and other conditions. With this information instantly available, the physician can focus on the patient rather than the chart.

“By reading free notes and text, intelligent CDS software can extract meaningful information that can be used to further clinical management of the patient,” says Allan Strongwater, MD, senior vice president of medical informatics at medCPU, a CDS solutions company.

For example, a patient had a CT scan of the brain two years prior to a current hospitalization. In the radiology report there was mention of an incidental finding of a small cerebral aneurysm. During the current hospitalization, Heparin was ordered to treat DVT. Unfortunately, Heparin is contraindicated in the presence of cerebral aneurysm. Nowhere in the medical record, other than the radiology report was the cerebral aneurysm reported. The CDS provided an alert preventing a potentially dangerous situation, says Strongwater.

“Well-designed CDS can find all of the information relevant to a particular task or particular decision, show it all in one place without a lot of clutter, and make it as easy as possible for you to do the right thing,” adds Jonathan Teich, MD, chief medical informatics officer, Elsevier Clinical Solutions.

“A consumer with a high-deductible health plan may be faced with large out-of-pocket expenses when receiving care,” explains Sally Problete, a health insurance industry expert and the CEO of Wellthie, a healthcare technology company. “Thus, it is helpful to avoid unnecessary or duplicative diagnostic tests.” 

Another example, according to Poblete, is that the consumer could be enrolled in a narrow network plan that does not cover out-of-network benefits.  “When referrals are made, extra care could be taken to ensure that the consumer is being referred to in-network physicians only, to avoid large unexpected expenses,” she says.  “Consumer decision support tools could help the consumer/provider understand if the doctor is in or out of network.”

Each year many new medications are released for use. Every drug has its unique list of adverse reactions (side effects), allergies and interactions with other medications a person may be using, explains Strongwater.

“An adverse interaction was considered to be a contributory factor to the death of Libby Zion, a young woman who died within 24 hours of hospitalization,” Strongwater says. “The growing number of medications makes it virtually impossible for any physician to be familiar with the side effects and adverse interactions of all the medications. However, computers and CDS systems are excellent at remembering large amounts of information and quickly collating and reporting the information to avoid such bad outcomes.”

Patients may not remember medications they had been prescribed years ago, particularly if they received the medication for a brief time and had an adverse outcome, Strongwater adds. “Documentation of such events in a paper chart is often lost or overlooked. Computers equipped with CDS can instantaneously recall the event and pertinent information, thereby avoiding the use of a medication that results in an adverse effect.”

The Institute of Medicine report, “To Err is Human: Building a Safer Health System,” refers to medication errors due to look alike or sound alike medications. “Computers with CDS software can eliminate medical errors due to this phenomena, especially when linked to bar code readers, RF ID chips and other smart technology,” says Strongwater.

Many hospitals report medication errors due to incorrect dosage, according to Strongwater. “Such errors may occur due to the use of unapproved abbreviations, misplaced decimal points, and inadvertent use of microgram for milligram and the like. EHRs [electronic health records] utilizing CDS can be a safety net to avoid such errors. By comparing the patient’s weight to medication dose many of the errors can be avoided. Also, comparing the patient’s past history of medications may be helpful to predict the anticipated correct dose.”

Many hospital beds now have alarms to monitor a variety of physiological parameters, according to Strongwater.

“Most of the alarms are without intelligence and simply respond to a situation of too high or too low,” he says. “Computers linked to the monitoring equipment, running CDS, can monitor much more information in a more intelligent manner. For example, monitoring patient respirations can trigger an alarm long before a critical event occurs as the software detects unexpected slowing of respirations.”

According to Strongwater, EHRs with CDS technology can provide smart advice to improve patient safety. “For example, it is necessary to frequently turn and reposition debilitated patients to avoid decubitus formation,” he says. “A CDS system can provide alerts and notifications to the appropriate staff to remind and improve compliance with a frequent turn policy. As a patient is admitted to a facility utilizing CDS technology, the patient’s status is recorded into the EHR. The patient’s status can be used by the CDS system to generate patient specific protocols to optimize care and minimize hospitalization time.”

CDS tools can help providers be more proactive, and more reactive says Teich.

“Reactive CDS, such as an alert, is very useful in trapping potential errors and hazards before they occur,” he says. “Proactive CDS, such as dynamic order sets and clinical pathways, helps you set up the right plan of care and make the best overall decisions from the very start of the workup.”