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One Thing I’m Thankful For: Clinical Decision Support (a True Thanksgiving Story)

November 22, 2012
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Yet another anecdote illustrating the crucial importance of clinical decision support at the point of care


I’m writing this blog in real time, on Thanksgiving Day 2012. A close friend of mine, who said she would be glad for me to write about her experience, has asked that I refer to her as “Kelly Green.” And here’s her story.

So, my friend Kelly Green, on Sunday (four days ago), noticed that there was something wrong with her foot, as it looked bloated and discolored. Fearing a possible blood clot, she went to an immediate-care clinic, where the physician on duty diagnosed a bacterial infection. He prescribed doxycycline for her, and sent her on her way. Two days later, on Tuesday, Kelly e-mailed her primary care physician to check in about this; her PCP told her that she (the PCP) thought everything was fine, and not to worry.

Then this morning (Thursday), Kelly noticed that the spot on her foot was worsening, not improving. This being Thanksgiving Day, of course, she had fewer care-access options than normal, and went to the emergency room of the hospital nearest to her. The physician on duty there took one look at the doxycycline bottle and promptly told Kelly that they never prescribe doxycycline anymore, as it’s no longer MRSA-resistant. Instead, he prescribed Bactrim (trimethoprim/sulfamethoxazole), and sent her on her way, telling her that her infection should heal just fine now.

Kelly is deeply grateful that her problem appears to be solved, as she was quite alarmed at what had been happening to her foot. But she also made the comment that it’s ludicrous that because of an easily avoided case of a wrongly prescribed medication, she ended up accessing the most expensive type of care possible in this situation—emergency room care. And I agree.

And here’s the thing: had the doctor in the immediate-care clinic had access to robust clinical decision support (CDS), he would instantly have learned or realized that doxycycline was not the correct medication to prescribe in this instance. What’s more, it seems clear that Kelly’s PCP could also have benefited from having the doxycycline-related CDS information when she participated in the e-mail exchange with her patient.

As Kelly, who happens to be a healthcare journalist like myself, told me in exasperation just now over the phone, “This is why healthcare costs are so excessive. Why are clinicians making mistakes that are always pushing us patients into the most expensive care options?”

What’s more, Kelly’s experience, it seems to me, only serves to affirm on a micro level the findings of a recent RAND Corporation study, which indicated that, as the Nov. 5 press release announcing the study’s results, put it, that “Physicians with the least experience spend significantly more money treating patients than physicians who have the most experience,” based on researchers’ analysis of the health insurance claims associated with the work of 12,000 Massachusetts physicians. That study found that doctors with less than 10 years’ experience had 13.2 percent higher overall costs than those with 40 or more years’ experience.

The lead researcher on the study, Ateev Mehotra, M.D., an associate professor at the University of Pittsburgh School of Medicine and a RAND researcher, cautioned that this team’s findings “warrant further examination and need to be affirmed by additional studies.” But common sense, in an era in which medical developments are outpacing physicians’ abilities to keep up with them, would tend to support the notion that less experienced physicians might naturally tend to make treatment choices that would end up costing more.

And that brings us back to my friend Kelly’s experience. This seems like a clear case of a sub-optimal treatment decision leading to easily avoidable medical costs. And the reality is that turning to clinical decision support within the EHR could have made all the difference here.

And the fact is that virtually no thoughtful physician in practice today will, when pressed on the point, deny the need for clinical decision support at the point of care. With medical developments evolving seemingly at the speed of light, it is simply impossible to keep up with everything these days, from remembering all the names of the newest prescription drugs to being aware of the latest public health alerts and trends. So let Kelly Green’s experience be another small marker among countless ones going forward, signaling both challenge and great opportunity for healthcare IT leaders, at a time of challenge and opportunity for the entire healthcare system.