Penetration and Availability of Clinical Decision Support in Commercial Systems

1
Penetration and Availability of Clinical Decision
Support in Commercial Systems

• Clinical Decision Support - The Road Ahead
• Chapter 7

2
Overview

• A summary of the progress of availability of
  commercial Clinical Decision Support systems and
  their usage in health care organizations
• Focus on the usage of complex CDS from 2002 to
  2005
• These are rule-based. No machine learning/ data
  mining methods is involved

3
KLAS

• KLAS Enterprise is a research firm, specialized
  in independent monitoring of Healthcare
  Information Technology (HIT)
• Performs confidential interviews with officials
  in 4500 hospitals and 2500 clinics
• Has targeted the use of CDS since 2001

4
Status of CDS in 2002

• KLAS interviewed 72 healthcare professionals, for
  the definition of CDS.
• The definitions by respondents were grouped into
  three types
• Reminders
• e.g. reminder that patient needs an immunization
• Simple Alerts
• e.g. drug-drug and drug-allergy conflicts
• Complex Rules
• A reminder or an alert based on multiple
  parameters from different clinical systems

5
Status of CDS in 2002 (cont)

• Virtually every hospital had at least one
  software application that provided a minimal
  level of CDS
• Most common CDS
• Pharmacy Information Systems
• Drug-drug interaction alerting
• CDS in laboratory
• Abnormal result checking
• Duplicate order checking

6
Status of CDS in 2002 (cont)

• Of the healthcare professionals interviewed
• One-third reported use of some alerting and
  excitement in doing so
• Most alerts, while designed and developed, were
  not active, and have not yet benefited the
  organization
• The alerts most heavily in use focused on
  administrative and financial (business) side

7
Obstacles to CDS in 2002

• Two reasons cited by most hospitals for not
  having complex CDS implemented
• Extreme difficulties physicians had in electronic
  ordering and interacting with electronic records
• Lack of alerting viability in the software
  products

8
CPOE Inquiries 2002-2005

• Computerized Physician Order Entry (CPOE)
• One of the areas where rules, alerts, and
  knowledge-based actions comes heavily into play
• KLAS has performed an in-depth inquiry of CPOE
  activities in USA, since 2002
• There is a close linkage between usage of CPOE
  and CDS

9
CPOE Inquiries 2002-2005 (cont)

• Changes from 2002-2003
• Some growth in complex CDS
• Still very limited
• Only 25 out of 125 live CPOE sites were doing any
  complex CDS with their software
• Changes from 2003-2004
• Increase in number of CPOE sites doing complex CDS

10
CPOE Inquiries 2002-2005 (cont)

• Changes from 2004-2005
• Increase in percentage of hospitals doing CPOE
  with a commercially available software
• 2003 ? 1 of hospitals
• 2004 ? 2 of hospitals
• 2005 ? 4 of hospitals
• Sizable jump in the number of physicians doing
  CPOE
• 2003 ? 45,000 physicians
• 2004 ? 69,000 physicians
• 2005 ? 113,000 physicians
• Growth of Complex CDS is not as universal
• It is one thing to go live with CPOE. It is
  entirely another to do complex CDS

11
Challenges of Complex CDS

• Ineffective rules (e.g. false alerts)
• Acceptable response to an alert is still
  undefined
• No normative set of decisions acceptable to
  healthcare and legal community
• Effective CDS is difficult when orders and
  discrete results are not mapped accurately
• Issues of one-to-many and many-to-one
  relationships
• Tied to database design and health data dictionary

12
Comments from Users

• We have a rule and alert oversight committee of
  physicians, nurses and pharmacist from across the
  system. They monitor alerts, so we look at them
  periodically to see how many of them are being
  overridden, if they are written the way they
  should be, and if they are giving the type of
  benefit that we hope to get from them.

13
Comments from Users (cont)

• Physicians satisfaction is kind of a mixed bag.
  They understand the importance of it so they are
  happy about the evidence-based order based, and
  the lack of interpretation of handwriting. Fro ma
  safety standpoint, they are happy with the
  system.We are starting to experience a little
  alert fatigue at one site. We are revisiting some
  of the alerts that are in the system

14
Comments from Users (cont)

• We have had to abandon doing any rules or alerts
  beyond the most simplistic ones. It takes a lot
  of concurrence to get anything out and live and
  we do not have the time to work on it right now.
  If we had something off the shelf, it would be a
  different story, like what they use for the
  standard drug interactions in the pharmacy
  system.