Clinical decision support is a key component of inpatient electronic health record systems. The technology typically relies on multiple sources for its medical knowledge base and rule set, with sources ranging from third-party vendors of clinical data to a hospital’s own best practices.
Dr. John Joe, chief medical officer at Prognosis Health Information Systems, said the company’s decision support software incorporates national and local policies and rules. It uses data and knowledge from clinical trials, evidence-based medical guidelines, and Food and Drug Administration approvals, he said, adding that such information is available via third-party clinical content providers such as First DataBank and Thomson.
Prognosis’ software can also incorporate a hospital’s operating rules. For example, a hospital policy might require a physician to document the reason for requesting a diagnostic imaging study before he or she can place the radiology order.
Computer Programs and Systems Inc.’s EHR product integrates Thomson’s Micromedex clinical data modules to facilitate “clinical decision support across all of the system’s clinical and patient care applications,” said Boyd Douglas, the company’s president and chief executive officer.
Rather than provide a preconfigured decision support knowledge base, Epic Systems works with its customers’ choices. Its sources include third parties such as First DataBank, which offers rules for alerting providers to drug allergies and potentially harmful drug interactions. Customers can also contribute their own clinical best practices or existing decision support tools, said Stirling Martin, division manager of inpatient clinical systems at Epic Systems.
Eclipsys ships its inpatient EHR system with a basic set of alerts that the customer can choose to turn on or off. The company also offers a Web-based rules library that lets clients download alerts that other customers have created. Users can also send alerts to one another via an e-mail list.
In addition, Eclipsys offers toolkits with alerts and documentation for specific diseases, such as pulmonary embolism or acute myocardial infarction, said Dr. Bobbie Byrne, vice president and general manager of clinical solutions at Eclipsys.
Dr. Bernhard Karten, a product manager at Siemens Medical Solutions, said the company’s system goes beyond presenting alerts. Its clinical decision support function also recommends a course of action.
— John Moore
Inpatient electronic health record systems require a gargantuan investment, one that forces hospitals to rethink the way they do business. The systems span core health care functions in much the same way that enterprise resource planning applications automate a range of government and commercial activities.
In another parallel with ERP applications, EHR systems can prove arduous to deploy, as demonstrated by an implementation failure rate of 30 percent, according to the Office of the National Coordinator for Health Information Technology. But even as adoption lags, pressure to deploy the technology is growing.
Against this backdrop, last November the Certification Commission for Healthcare IT announced the first batch of companies to receive certification for their inpatient EHR products. CCHIT studied the vendors’ order entry, medicine administration and clinical decision support capabilities.
The firms whose systems made the grade were Computer Programs and Systems Inc. (CPSI), Eclipsys, Epic Systems, Healthcare Management Systems, Prognosis Health Information Systems, and Siemens Medical Solutions. In late January, CCHIT announced a second batch of certifications, for Cerner’s PowerChart, Meditech’s Advanced Clinical Systems Magic 5.6 and Siemens’ Invision 27.
Initial focus: Physician orders The first round of CCHIT’s inpatient EHR certification focused on two modules: computerized physician order entry (CPOE) and medication administration, also known as the electronic medication administration record (eMAR). Officials said they chose those areas because they have the lowest adoption rate in hospitals but the highest potential for improving care.
Dr. John Joe, chief medical officer at Prognosis, said CCHIT was wise to concentrate on CPOE because it represents the physician’s actions and interventions in patient care, both diagnostic and therapeutic.
Another EHR feature — clinical documentation — records a patient’s admission history, physical exams, and other objective and subjective information. CPOE is the component that shows how a physician acted on that information.
“The orders portion is really the bottom line of clinical documentation,” Joe said.
He added that the eMAR piece focuses on medication safety as encapsulated in the five rights: right patient, right drug, right dose, right route and right time.
Nevertheless, the perceived benefits of EHR systems haven’t led to a groundswell of adoption. In a study published in October, the Centers for Disease Control and Prevention reported no meaningful increase in the adoption of comprehensive EHR systems, which the agency defines as including computerized ordering systems. The percentage of physicians using comprehensive systems stood at 12.4 percent in 2006, according to CDC.
Dr. Bobbie Byrne, vice president and general manager of clinical solutions at Eclipsys, cited a high adoption rate for her company’s CPOE and eMAR products but expressed frustration with the broader market.
“We know if CPOE is implemented correctly, physicians will use it,” she said. “But physicians have had some bad experiences with early CPOE systems.”
Those early systems proved time-consuming and confusing to use, Byrne said. As a result, some physicians are still reluctant to abandon paper records.
Decision support emerges Clinical decision support functions could help vendors overcome physician resistance. In its advanced form, the technology consists of a medical knowledge base and a set of rules to apply that knowledge. It aims to help physicians make decisions about treatment plans.
“Automation without the rules engine will only go so far,” Byrne said. “Without advanced clinical decision support, you’ve just automated your paper. There’s an advantage to that. But no one buys [EHR systems] to convert paper to a screen.”
CCHIT clearly values clinical decision support because it put the technology on its checklist for reviewing CPOE and eMAR. For example, one CCHIT evaluation criterion called for inpatient EHR systems to “provide the ability to detect a cumulative dose that exceeds the recommended daily dose and inform the clinician during ordering.”
“Clinical decision support has many different facets, and a number of those definitely played into the CCHIT criteria,” said Dr. Bernhard Karten, a product manager at Siemens Medical Solutions. “Patient safety drives all of this.”
Joe said clinical decision support plays its most prominent role in CPOE, where it provides alerts on dosing, drug allergies and potentially harmful drug interactions.
But the technology extends into other areas as well, he said. For example, decision support tools can remind a physician to screen a patient for certain conditions that are not directly related to his or her current symptoms but are nevertheless important to the patient’s overall health.
Stirling Martin, division manager of inpatient clinical systems at Epic Systems, said clinical decision support pervades the company’s EHR product, and alerts are embedded into the workflow.
Interoperability CCHIT spent considerable energy evaluating CPOE, eMAR and related decision support features when it reviewed inpatient EHR systems. Reviewers also considered interoperability, but the emphasis was not as strong as industry executives had expected.
Charlene Underwood, director of government and industry affairs at Siemens Medical Solutions, said she thought CCHIT wanted certified inpatient EHR systems to support interoperability and offer the connectivity necessary to create health information exchanges (HIEs). Therefore, she found the decision to focus on CPOE and eMAR somewhat surprising.
But subsequent certification efforts are likely to shine the spotlight on interoperability. “The next phase of certification is about creating networks,” she said. “In that phase of certification, we expect a lot more extensive interoperability requirements.”
CCHIT’s Network Work Group was chartered last year to develop criteria and tests for HIEs. The group plans to publish certification criteria in 2008.
A CCHIT spokeswoman said network certification is unlikely to include EHR product testing. But she added that “all certification efforts are likely to increase the focus on interoperability since there is still a lot of ground to gain there.”
In the meantime, the effect of certification on HIEs remains to be seen.
“Advantages in the broader HIE market are dependent on the market’s perception of the value of certification and future regulatory mandates regarding interoperability and/or [electronic medical record] usage,” said Boyd Douglas, CPSI’s president and chief executive officer.
CCHIT’s inpatient EHR initiative is set to grow this year, with the initial group of certified companies likely to expand as the commission evaluates additional vendors. The organization also plans to broaden the scope of its certification program to include other facets of inpatient EHRs.
From the battlefield to the home front: Managing medical data
Government Health IT presents Col. Claude Hines Jr., program manager for the Defense Health Information Management System, in this recent InSight eSeminar. Col. Hines discusses the health information technology and tactical challenges faced by the military medical community in Iraq, Afghanistan and other areas of conflict. In doing so, he describes the current information technology solutions for transferring clinical data between battlefield care givers to health care personnel at military treatment facilities worldwide.
