To the editor.

Kudos for the series of articles on Electronic Health Records in the July-August issue of The Physician Executive (July/August 2005, Vol. 31(4)). I was particularly interested in the comments by Mitchell Diamond regarding the areas of greatest promise in the near future, CPOE and Clinical Decision Support. He commented that, "use of evidence-based protocols recommended at the time of a specific visit--and the quality of care measured on what the physician does at the time of the visit--are rapidly improving."

[ILLUSTRATION OMITTED]

It is a common expectation that computerized clinical decision support systems will improve the safety, quality, efficiency and cost-effectiveness of care. (1) However, the published evidence that might confirm this optimism is mixed. There are many challenges here. While attractive in theory, guidelines may not deliver on their promise due to their authors' frequent undisclosed conflicts of interest, (2) to the guidelines' probable irrelevance to patient populations with diverse comorbidities, (3) to the guidelines' inadequate adjustments for illness severity and patient preferences, (4) and their unreliable adoption by clinicians. (5)

Without successfully integrating objective clinical decision support into EHRs, we risk automating mediocrity. "Why are we so thrilled that drug orders are going at the speed of light to the pharmacy and coming back, if they shouldn't have been ordered in the first place?" asks Lawrence Weed. "What are we computerizing this for?" (6)

Caution and healthy skepticism are in order here. At their best, advanced clinical decision support systems produced by vendors that have no conflicts of interest can enable clinicians to improve the quality and/or help lower the costs of care. Two articles published in peer-reviewed journals have documented this cost lowering in ambulatory primary care, using context specific, objective, evidence-based (EB) decision support delivered in the workflow.

The first report (7) looked at the first six months of use, using a study group of 19 primary care physicians in a large multi-specialty clinic, with a similar control group in the same clinic. The study group showed a $4.99 reduction in new and refilled prescription cost when compared to the control group, which represented a 13 percent savings.

The second study (8) examined 12-month data, analyzing prescribing behaviors within eight high-cost therapeutic categories as well as prescription cost. Physicians using the EB support continued to demonstrate lower cost prescribing, and the proportion of prescriptions for targeted high-cost drugs was 17.5 percent lower compared to the control group.

When looking at obstacles to introduction of EHRs into clinical practice, the one encountered most frequently is cost, and this is often prohibitive to physician groups. Given the demonstrated savings, at-risk groups using an EB decision support system could realize enough savings to easily cover the costs of EHRs, or could motivate payers (who realize the savings) to help fund same or provide contract incentives.

Roger A. Rathert, MD

Medical Advisor

Purkinje, St. Louis, Mo.

[e-mail]

References

1. Teich JM, Osheroff JA, Pifer EA, and others. "Clinical decision support in electronic prescribing: recommendations and an action plan." J Am Med Inform Assoc 2005;12:365-376.

2. Choudry NK, Stelfox HT, Detsky AS. "Relationships between authors of clinical practice guidelines and the pharmaceutical industry." JAMA 2002;287:612-617.

3. Tinetti ME, Bogardus ST, and JV Agostini. "Potential pitfalls of disease-specific guidelines for patients with multiple conditions" NEJM 2004;351:2870-2874

4. Walter LC, Davidowitz NP, Heineken PA, et al. "Pitfalls of converting practice guidelines into quality measures." JAMA 2004;291:2466-2470.

5. Tierney WM, Overhage JM, Murray MD, and others. "Effects of computerized guidelines for managing heart disease in primary care: A randomized controlled trial." J Gen Intern Med 2003; 18:967-976.

6. Weed, Lawrence. Interviewed by Chris Gaither. "What your doctor doesn't know could kill you." Boston Globe, July 14, 2002.

7. McMullin ST, Lonergan TP, Rynearson CS, and others. "Impact of an evidence-based computerized decision support system on primary care prescription costs," Ann Fam Med. 2004;2:494-498.

8. McMullin ST, Lonergan TP, Rynearson CS. "Twelve-month drug cost savings related to use of an electronic prescribing system with integrated decision support in primary care." J Manage Care Pharm. 2005;11(4):322-32.