Using decision support and standardized workflows is a key step in realizing improvements. Systematizing care this way can reduce variation and improve the accuracy of decision making.
A major problem in all health systems is that care often falls short of evidence based good practice. For example, studies have estimated that diagnostic error exists in 10–15 percent of cases and a study of prescribing errors found 52 errors per 100 admissions.1, 2 Technologies which aid clinical decision making and workflow offer substantial opportunities to reduce variation in care while improving the accuracy and speed of decision making. In the future this support will not only come from access to clinical guidance and prompts but the automated interpretation of clinical data, including genomics.
There is strong evidence that decision support tools can improve the quality of clinical decision making and some evidence it can lower costs.3, 4
However, clinical decision support systems (CDSS) also bring challenges and may be met with suspicion by clinical staff who fear erosion of their autonomy. CDSS range from very passive electronic aids, such as hyperlinks to guidelines, to extremely pro-active one-click flow mechanisms. It is likely that over the coming years there will be a gradual trend of moving from advice for specific, discrete clinical scenarios to much broader-looking, proactive advice to health workers.
You come in with a stroke, the admitting physician with one click of the computer now creates the entire workflow from everything from the [real logic] to the laboratory to the diet to the physical therapy and medication.
— Robert Pearl Kaiser Permanente, US
CDSS are often combined with computerized physician (or provider) order entry systems (CPOE), through which medications, tests and procedures are ordered. When replacing hand-written, physically conveyed systems, integrated CPOE and CDSS systems can offer significant time savings and safety gains. The literature suggests a number of valuable benefits:
Decision support is not just for doctors, it can provide a powerful resource for other staff, particularly in settings where they may not have easy access to other clinical staff and patients.
CDSS can be further developed to build protocols into customized workflows, effectively standardizing an entire care pathway. Clinicians treating patients on this pathway therefore have unambiguous processes to follow and tasks to complete, ensuring consistently high standards of care. While this sits at the very proactive end of the spectrum, clinicians should still deviate where needed to meet individual patient needs. Indeed, at Intermountain Healthcare, where standardized clinical workflows have been developed, clinicians are encouraged to tailor the pathway to individual patients, improving system learning.
Standardized workflows can be taken a step further through “one-click flows” or “one-click ordering”. Information is pushed to a “workflow engine” to initiate the process which then sets in motion all the tasks and processes required for that specific workflow. While the productivity and care coordination benefits of such a system are obvious, “one-click flows” can be very difficult to implement. The process must be agreed across multiple teams, and even organizations, and followed up with a significant nurse training effort.
1Berner ES, Graber ML (2008). Overconfidence as a cause of diagnostic error in medicine. Am J Med;121(5 Suppl): S2–23.
2Lewis PJ, Dornan T, Taylor D, et al. Prevalence, incidence and nature of prescribing errors in hospital inpatients. Drug Saf. 2009;32(5): 379–389.
3Jaspers, M. W. M., M. Smeulers, et al. (2011). Effects of clinical decision-support systems on practitioner performance and patient outcomes: asynthesis of high-quality systematic review findings. Journal of the American Medical Informatics Association 18(3): 327–334.
4Fillmore C L, (2013) Systematic review of clinical decision support interventions with potential for inpatient cost reduction. BMC Med InformDecis Mak. 2013; 13: 135.
5Niazkhani, Zahra, et al. “The impact of computerized provider order entry systems on inpatient clinical workflow: a literature review.” Journal ofthe American Medical Informatics Association 16.4 (2009): 539–549.
6Radley, D.C. et al. (2013) Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems. J Am MedInform Assoc 1;20(3): 470–6
7Stone, William M., et al. “Impact of a computerized physician order-entry system.” Journal of the American College of Surgeons 208.5 (2009):960–967.
8Roshanov PS, Fernandes N, Wilczynski JM, et al. (2013) Features of effective computerised clinical decision support systems: meta-regressionof 162 randomised trials. BMJ, 346 f657.
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