The supporting player: second generation CDS goes beyond the basics to become intuitive.On a busy Friday night, a patient presented with shortness of breath Shortness of Breath Definition
Shortness of breath, or dyspnea, is a feeling of difficult or labored breathing that is out of proportion to the patient's level of physical activity. in the emergency department (ED) at Boston's Brigham and Women's Hospital Brigham and Women's Hospital (BWH) is a hospital in the Longwood Area of the Boston, Massachusetts neighborhood of Mission Hill. With Massachusetts General Hospital, it is one of the two founding members of Partners HealthCare. , where I serve as attending physician. After examining her, I immediately considered that she might have had a pulmonary embolus Pulmonary embolus
Blockage of an artery of the lung by foreign matter such as fat, tumor, tissue, or a clot originating from a vein.
Mentioned in: Arthroscopy . I entered an order for a CT scan CT scan: see CAT scan.
See CAT scan. with intravenous contrast dye into the patient's electronic health record (EHR (Electronic Health Records) Computerized medical records that bring patient care into the digital age and save time, money and lives. The push to adopt comprehensive electronic documentation between doctors' offices and hospital settings intensified after the RAND ), but received a notice from the clinical decision support (CDS) system that the patient also suffered from renal failure renal failure
Acute or chronic malfunction of the kidneys resulting from any of a number of causes, including infection, trauma, toxins, hemodynamic abnormalities, and autoimmune disease, and often resulting in systemic symptoms, especially edema, and might experience kidney damage kidney damage Kidney injury Nephrology A structural or functional compromise in renal function due to external–eg, athletic, occupational, or other trauma, resulting in bruising or hemorrhage, which can be profuse and life threatening Etiology Vascular as a result of the intravenous dye.
Fortunately, the CDS system led me to information on how to use the drug Mucomyst to prevent this complication, and to an order set for correctly using Mucomyst. This second generation CDS system facilitated several important processes: It not only alerted me to a possible hazard, but also gave me information about what action I might take next, and helped me to execute that action.
Ask most IT professionals for a definition of CDS and they're likely to talk about alerts or warnings related to drug allergies drug allergy An immune response to a therapeutic. See Allergy. or drug-drug interactions. For example, a physician who prescribes cephalexin cephalexin /ceph·a·lex·in/ (-lek´sin) a semisynthetic first-generation cephalosporin, effective against a wide range of gram-positive and a limited range of gram-negative bacteria; used as the base or the hydrochloride salt. (an antibiotic) discovers that the patient has a documented allergy to cephalosporins Cephalosporins Definition
Cephalosporins are medicines that kill bacteria or prevent their growth.
Cephalosporins are used to treat infections in different parts of the body—the ears, nose, throat, lungs, sinuses, and . The CDS system explains the concern and gives the clinician clinician /cli·ni·cian/ (kli-nish´in) an expert clinical physician and teacher.
n. the option of canceling or continuing the order. These early forms of CDS--basic, single-factor, reactive alerts--are still valuable in a variety of clinical situations, particularly as immediate checks for errors related to prescribing and ordering.
But new and emerging second-generation CDS goes far beyond alerts. It infers possible questions and needs before they are explicitly asked, and it combines reference information seamlessly with tools for taking action. It embraces order sets, guideline helpers, problem-based documentation templates, just-in-time flowsheets and data displays, and intelligent integrated reference information. Such interventions can help to contain costs, control medical errors, boost clinical productivity and improve quality.
Each of these interventions is distinguished by the property of workflow friendliness. A clinician might face a workday of 25 or more appointments stacked up at 10-minute intervals. Understandably, the clinician can use information only if it arrives quickly, doesn't require special effort, and remains available when and where the clinician needs it. Second-generation CDS systems can help make delivering the best care also the most efficient option, by providing tailored, filtered information and action items directly on EHR screens where the clinician is already working. As such, it is much more likely to be used, and to have the desired impact.
Some of the most significant innovations in CDS belong to the category of referential or informational CDS. These features play a critical role in quality improvement and compliance programs. As healthcare IT professionals shop for EHRs and tools, they also need to shop for highly active CDS interventions with the potential to realize quality goals. Following are just some of the innovations IT professionals are likely to experience through second-generation CDS systems:
Varying Depth for Varying Needs: CDS programs offer a variety of tools, with varied functions, uses and timeframes. Some forms of CDS, such as infobuttons and short answers, take only seconds to access and use, while other forms, such as reference books and full-text journals, may occupy a clinician for days. CDS tools also vary in terms of function. Clinicians use infobuttons and short answers at the point of care, but tend to depend on quick references, order sets, procedure and radiology radiology, branch of medicine specializing in the use of X rays, gamma rays, radioactive isotopes, and other forms of radiation in the diagnosis and treatment of disease. guides, summary references and handbooks and monographs as reference sources.
Support of the Workflow: All the answers a clinician wants are probably in a book or a journal, somewhere. But few clinicians have the time to scan through these original sources to find those answers. Newer interactive services not only provide information online, but are also transforming texts into neatly packaged answers to highly specific clinical questions. Studies show that a typical clinician only asks about 40-50 different questions in the course of a lifetime of clinical encounters (multiplied, of course, by the total number of patient conditions, medications and procedures). For my patient, the generic question was "What are the hazards of a particular procedure or treatment?" Advanced CDS content providers find and tag paragraphs and sections in traditional materials that address these questions clearly and succinctly suc·cinct
adj. suc·cinct·er, suc·cinct·est
1. Characterized by clear, precise expression in few words; concise and terse: a succinct reply; a succinct style.
2. , and make them available to interactive reference tools.
Infobuttons (or Knowledge-links): Once segmented answers are available, infobuttons make one or more relevant FAQs available right from the patient's data screens in the EHR. For example, a clinician might scan a patient's problem list within an EHR. Zeroing in on the problem of congestive heart failure congestive heart failure, inability of the heart to expel sufficient blood to keep pace with the metabolic demands of the body. In the healthy individual the heart can tolerate large increases of workload for a considerable length of time. (CHF CHF
In currencies, this is the abbreviation for the Swiss Franc.
The currency market, also known as the Foreign Exchange market, is the largest financial market in the world, with a daily average volume of over US $1 trillion. ), the infobuttons might offer information on several FAQ (Frequently Asked Questions) A group of commonly asked questions about a subject along with the answers. Vendors often display them on their Web sites for use as troubleshooting guidelines. topics, such as epidemiology, diagnostic studies, therapy options, new reviews, and clinical guidelines. By clicking on the latter option, for example, the clinician can review the recently published guidelines on CHF.
Information Now and Later: Newer CDS systems serve up the most critical information first and then surround it with more general, supporting information. As a clinician, with an integrated multilevel mul·ti·lev·el
Having several levels: a multilevel parking garage.
Adj. 1. multilevel - of a building having more than one level reference, I can learn how to use Mucomyst right away, if I need it quickly; I can scan an expert review of different options and controversies in managing contrast-dye toxicity with one more click, and then I can study the original references later on, for my own education. Each of the upper levels can also lead to actionable tools such as order sets. Multilevel systems do a better job of providing the right level of information for a variety of different workflows. In addition, they make it possible, as with my patient, to facilitate an entire scenario of care, rather than just stopping a single-point error. Some of these tools also offer the chance to obtain and track CME CME
See: Chicago Mercantile Exchange
See Chicago Mercantile Exchange (CME). credits.
Triggered Reference: Taking this one step further, CDS systems can assume that certain information needs exist, based on the clinical data that has already been entered, without any user request. Imagine that a clinician in office practice has diagnosed a patient with sinusitis sinusitis
Inflammation of the sinuses. Acute sinusitis, usually due to infections such as the common cold, causes localized pain and tenderness, nasal obstruction and discharge, and malaise. , and orders both a complete blood count and a CT scan of the head. The diagnosis, test and procedure codes used in the EHR can kick off a targeted search of the CDS system's reference library, and can offer to print or mail patient information handouts about sinusitis and CT scans.
Multimodal Two or more modes of operation. The term is used to refer to a myriad of functions and conditions in which two or more different methods, processes or forms of delivery are used. On the Web, it refers to asking for something one way and receiving the answer another; for example requesting Reference: Newer generation CDS tools blend interactive text with animation, illustrations and video, particularly for imaging, anatomy and procedures. Sound, sight images and text combine to help the clinician learn a new procedure or review a procedure previously learned. Armed with the latest information and practical multimedia guidance, the clinician is able to approach a medical procedure with confidence.
Two-factor Questions: Most current electronic references can help with a single question: "What medications are recommended for congestive heart failure," but clinicians usually know the basic answers. Many questions that really make a clinician seek reference help are two-factor questions: "What medications are recommended for congestive heart failure in a diabetic patient?" Or, in my case, "What is the best test for pulmonary embolus in a patient with renal failure?" Such questions come up with surprising frequency in the course of clinical workflow. Up-and-coming CDS tools overcome these limitations by answering both specific and two-factor questions and increasing the precision of information available to the clinician.
Patient Access: CDS is also relevant to patients who will increasingly demand answers to highly specific medical questions. Instead of having to perform a highly generalized medical search, future patients will be prompted to type in a word or phrase representing a medical condition, a medication, a procedure or therapy, or complete questions. As it does for the clinician, preconfigured Set up ahead of time. It implies that the device or software application has been modified to suit the customer or situation. See ghosting server. question forms make it much easier to provide the patient with highly specific answers to specific questions.
The right CDS can make a significant quality, efficiency and financial difference for healthcare organizations. Before investing in an EHR or other healthcare IT application, it pays for your organization to consider its own clinical environment, range of services and quality targets. This will lead to a list of top-priority CDS needs. Then, you can carefully research the nature, quality and performance of the available CDS features in the candidate healthcare IT systems, and how well they address those needs. Armed with a greater awareness of new CDS techniques and their capabilities, you will be better positioned to purchase and deploy a system that will facilitate superior care for years to come.
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By Jonathan Teich, M.D.
Jonathan Teich, M.D., is chief medical informatics medical informatics,
n the field of information science concerned with the analysis and dissemination of medical data through the application of computers to various aspects of health care and medicine. officer for Elsevier and an attending physician and professor in emergency medicine at Harvard's Brigham and Women's Hospital.