Experts say that adhering to evidence-based medicine (EBM) protocols will be part of overarching healthcare reform, and that clinical decision support (CDS) will increasingly be leveraged to improve quality of care.
“It's absolutely a fact that it will be a part of healthcare reform,” says Jerry Osheroff, M.D., who chairs the Chicago-based HIMSS task force on CDS (and is also Chief Clinical Informatics Officer of Healthcare & Science at N.Y.-based Thomson Reuters). “If you look at the meaningful use matrix, there's no question that CDS and evidence-based protocols are something CIOs are going to have to attend to if they want to get the stimulus money - or not get dinged.”
In addition to federal requirements, the need to implement some form of CDS or EBM is driven by the information explosion. And CDS, most agree, is the best way to address the overabundance of information. “The amount of information that is out there for any caregiver far exceeds their ability to understand and to address it all, and to make it into any sense,” says Andy Fowler, CIO of Methodist Le Bonheur, a seven-hospital system in based in Memphis. “There is no way in the world that a physician can keep up with it or make the best decisions without these systems.”
And as CIOs are increasingly tasked with making sure physicians have access to the latest knowledge, they are also responsible for protecting the hospital's bottom line. “A CIO has the responsibility to decrease variability in the hospital and stop redundant or unnecessary testing,” says James Feldbaum, M .D., an independent consultant based in Hailey, Idaho. “If the CDS protocol shows two antibiotics you can use and one is $1-a-dose and one is $10-a-dose, you're going to want to steer them to what's in the hospital's formulary.”
Fowler says the meaningful use matrix - which states hospitals need to implement one CDS rule for a high priority condition by 2011 - has upped the importance of CDS. “It's no longer a carrot and stick environment,” he says. “We don't have to spend time on the stick anymore because the federal government is the stick. Now we have the opportunity to focus on the carrot.”
But what exactly is the carrot? People use the terms clinical decision support and evidence-based medicine interchangeably, but evidence-based medicine is defined as the use of current evidence in making decisions about the care of individual patients, while clinical decision support combines evidence-based rules and the mechanism to communicate them to caregivers. Chicago-based HIMSS defines CDS as a clinical system, application or process that helps health professionals make clinical decisions to enhance patient care.
“Clinical decision support is not a widget,” says Osheroff. “No vendor has all the pieces - the information, how it's delivered and how it's integrated into a different information system.”
Putting the pieces together raises issues, many have found, starting with which systems to use for both evidence-based medicine protocols and clinical decision support. Some vendors sell these solutions as part of their core clinical offerings, but there are also many best-of-breed solutions that need to be interfaced with the EMR. Lastly, many hospitals have gone ahead and written their own home-grown rules. Do any of these work better than others?
“Every vendor of enterprise systems has some degree of CDS built in,” says Osheroff. “It's a complex hodgepodge.” A few years ago, according to Osheroff, the trend was enterprise CIS vendors buying up CDS systems and including them as part of their package - the acquisition of Zynx Health (Los Angeles) by Kansas City, Mo.-based Cerner is a good example.
Today, however, CIS vendors today are no longer buying up CDS systems, preferring to stick to their core business, he says. In fact, Cerner, which purchased Zynx Health in 2002, divested in 2004, though it has maintained a strategic alliance with the company and continues to use its content in Cerner software. “Right now, most of the CIS vendors are taking the approach that developing CDS content is a very different business,” says Osheroff.
Most agree that even if an enterprise vendor does have a CDS offering, the inherent problem is that it doesn't come out of the box ready to go. And most agree that customization is the hardest part.
Terri Steinberg, M.D., CMIO of Christiana Care Health System, a two-hospital system in Wilmington, Del., is using the ubiquitous Zynx system interfaced to her Cerner EMR. “Zynx provides clinical content and order sets, so you can use yours, theirs or a combination of the two. It's a really good starting point.”
Steinberg says the Zynx system is expensive, but that it's worth the money and is helpful in building order sets. “We had hundreds of doctors working together for 18 months writing order sets on the system,” she says. “You can't underestimate the importance of putting your fingerprints on everything that you touch - and when it's all done it gets sucked into Cerner.”