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Pros and Cons of Clinical Decision Support in the Cloud

April 28, 2014
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Pediatric Emergency Care Applied Research Network develops rules to share across emergency departments

Last November I wrote a feature story about what I called the “Holy Grail” of scalable, interoperable clinical decision support (CDS). I interviewed several clinical informaticists about the limitations of each health system creating and curating its own complex CDS rules. Among other things, that article described a web services solution to CDS developed at Partners HealthCare System in Boston.

The solution extracts a limited data set about a patient, including labs and allergies, in the form of a Continuity of Care Document (CCD), which is sent to Partners. Its system adjudicates rules against that data, and sends back information on which reminders or alerts to fire.

At last week’s 7th Annual Mid-Atlantic Healthcare Informatics Symposium, presented by The Children’s Hospital of Philadelphia's Center for Biomedical Informatics, I saw a great presentation about the benefits and challenges of this approach.

Several clinical informaticists involved in the Pediatric Emergency Care Applied Research Network (PECARN) described how they worked to use the Partners web service and their own Epic systems’ native CDS to provide emergency departments with decision support about children with minor-to-moderate blunt head trauma, with a goal of identifying high-risk and low-risk indicators of traumatic brain injury (TBI). The goal was to derive the evidence on which to base appropriate use of head computerized tomography (CT) in children with acute head injury, which will hopefully reduce the number of unnecessary CT scans for children at very low risk for TBI.

The study involved multiple hospital emergency departments, all using Epic software. The emergency department sites around the country all used the web services approach, with the CDS rules also installed natively on their own systems as a backup.

Basically, the process by which emergency departments would recognize the appropriate cases and send the web query off to Partners was developed at the Children's Hospital of Colorado and then “packaged up and delivered to other sites,” said

Jeffrey Hoffman, M.D., chief medical information officer at Nationwide Children's Hospital in Columbus, Ohio. “Our EHR vendor recommended that we not do this,” he said. “They recommended that we build it at each site, but we didn’t like that idea.” It might introduce errors or invalidate testing done elsewhere, he noted. They went ahead and built it once and distributed it out to many sites. The process worked, although they did have to account for some local variations, Hoffman added. It also required a lot of convincing of health system officials that they were going to take a package built elsewhere, install and use it — and the vendor did not support it. “It took a lot of work to make that happen,” he said. “We found that this distribution model is possible but complicated.".

The project also required considerable customization work, done at the Children’s Hospital of Philadelphia, to package up the information in the EHR, send it to Partners, get the CDS message back and place it in the EHR for physicians to use.

During the course of the research project, the average length of time it took to get the CDS response back from Partners was about 7 seconds.

The pros of having the CDS natively built into an EHR? It is always going to beat the cloud-based system on response time, Hoffman said. And native CDS rules may be shareable among hospitals using the same EHR vendor. You have more local control, and you don’t have to worry about any transfer of personal health information. The cons? A native solution is not shareable across EHR vendors, and many details are site-specific.

What are the pros and cons of a web services approach? Robert Grundmeier, M.D., director of clinical informatics at the Center for Biomedical Informatics at the Children's Hospital of Philadelphia, said it allowed for a single set of complex rules across systems, and it is shareable across all EHR platforms. The cons are that it can be challenging to map it to EHR data, and there is quite a bit of customization involved. In some cases, he said, any latency in the exchange with an external entity would be seen as unacceptable.

So along with Partners’ other partners, PECARN demonstrated that sharing CDS rules across multiple institutions is possible. It’s still not clear whether this approach will become more prevalent, given the amount of technology and policy work required to make it happen.