Protecting the Integrity of EHR Clinical Decision Support Tools

If physicians are going to trust clinical decision support tools embedded in electronic health records (EHRs), the tools must be free of commercial influence and based on evidence and best clinical practices. That’s the takeaway from a commentary in May’s JAMA Internal Medicine, which discussed the EHR vendor Practice Fusion and the $145 million it is paying to resolve civil and criminal investigations into its clinical decision support tools.

According to a U.S. Department of Justice (DOJ) announcement earlier this year, San Francisco-based Practice Fusion admitted to soliciting and receiving kickbacks from a major pharmaceutical company in exchange for using its EHR software to influence physicians prescribing opioid pain medications. The company received $1 million to develop a tool that prompted doctors to increase their prescriptions of extended-release opioids, said the announcement. DOJ did not name the pharmaceutical company, although media outlets have identified it as Purdue Pharma. Chicago-based Allscripts acquired Practice Fusion in 2018 after this conduct occurred.

Electronic health records have been blamed for physician burnout and assorted other ills, wrote the co-authors of the commentary, Julie Taitsman, Andrew VanLandingham and Christi Grimm, staff members of HHS’ inspector general’s office. “Although these criticisms may be overstated, an insidious aspect of EHR has largely escaped scrutiny: corruption of clinical decision-making.”

Physicians who actively engage in EHR deployment and management can help maintain the integrity of clinical decision support tools, experts say. But healthcare executives also have a role in exercising due diligence about vendors’ finances.

Healthcare systems need to be able to trust that their EHR vendor will base any formulary changes on clinical evidence, not on a relationship with a pharmaceutical manufacturer, says Aaron Miri, chief information officer (CIO) of the University of Texas’ Dell Medical School in Austin. Miri says he doubts that a major vendor, such as Epic or Cerner, would jeopardize its relationships with providers by meddling with EHR in an inapproriate way. These relationships are “predicated on trust,” Miri says. “Practice Fusion’s overall business model was really sketchy to begin with,” he says. “I find it ridiculous that this business model was allowed to thrive in the health IT environment.”

Physicians have to be actively engaged because of their clinical training. The role of a CIO in an EHR deployment or management is to serve as “head Sherpa,” Miri says. “That means you’re not the sole person. … Your job is to create a coalition of the willing, which includes doctors and nurses and pharmacists who make steering decisions on quality teams” that govern EHR use.

KLAS Research, a healthcare IT research company in Orem, Utah, is a valuable source of information about EHR companies, says James Ellzy, M.D., FAAFP, a family physician in Washington, D.C., and a member of the American Academy of Family Physicians’ board of directors. Ellzy encourages provider organizations to pay for KLAS membership, which gives them access to its reports and direct communication with company officials.

Practice Fusion’s EHR was free to physicians who were willing to view pharmaceutical ads. That should have been a red flag, experts say. Technology is expensive to maintain, and storage isn’t free, Ellzy observes.

Miri says executives should comb through publicly traded EHR companies’ earnings statements to see if they sell deidentified data. If they do, the health system can write in their contract that the manufacturer can’t sell its deidentified data without written permission.

Aine Cryts is a healthcare writer based in Boston.