CDS can make best-practices guidelines more accessible

Electronic health records offer the opportunity to better integrate clinical practice guidelines (CPGs) at the point of care, but the technology and physician practice must evolve, according to a paper published at BMC Medical Informatics and Decision Making.

Just sending out more reminders to physicians won't do the trick, researchers say. At this point, most information about best practices is "parked" in lengthy documents or graphics, such as decision trees, that are too cumbersome for physicians to parse during a patient encounter.  

Applying CPGs to clinical practices with EHRs will require the use of clinical decision support and effective translation of evidence to practice, they say. In the end, though, it still will depend on physician judgment about the applicability of the evidence to an individual patient, though some aspects of care might be automated or assigned to a staff member.

"An optimal CDS model should allow knowledge engineers to specify the criteria that govern which interventions are available and the rules that govern the interplay among a trigger, input data, and the intervention," the researchers say, adding that physicians may be less likely to use an alert if it does not specify an action, specifies a generic action, or specifies one that is incongruent with the input data.

In their research at Geisinger Health System, the authors helped develop an an EHR-based CDS model ("eDiabetes") that uses four input variables to identify relevant treatment advice among 93 distinct possible messages. Each input variable increases the specificity of the advice, then presents "offered choices" that physicians can follow.

Yet "it will be important to consider how CPGs can be structured to allow physicians to do tasks that they could not do otherwise, or that help them to do tasks better and more effectively," the authors state.

Beyond evidence from randomized controlled trials, observational and longitudinal data culled from EHRs may be studied for comparative effectiveness research, providing the basis of CDS.

The move to CDS is changing work roles, the authors note, and the skill level for specific tasks needs to be clearly defined. For example, all Type-II diabetics without a recent HbA1c should undergo this lab test at appropriate intervals, but neither the decision nor the test requires the physician, they say.

Clinical decision support tools topped health IT leaders' wish lists for 2013, though the talent pool of clinical informaticists who can find ways to improve care from the data are in short supply. A KLAS survey from 2011, meanwhile, stressed the need for CDS tools to fit into physician workflow. That's remains a problem with their EHR systems, as docs tend to rely on workarounds, paper reminders or override alerts to deal with the perceived inadequacies of their EHR systems, according to research published at the Journal of the American Medical Informatics Association.

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