How clinical decision support fills gaps in clinical data for higher quality care

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Liora Guy-David, Ph.D., Vice President of Data, medCPU

As long as the healthcare industry lacks true interoperability among dissimilar systems, clinicians will have incomplete patient information at the point of care. This includes gaps over time, as when a clinician is unaware of imaging tests already completed, and gaps across care team members who record documentation in separate systems. Both types of gaps can compromise patient safety.

While we don’t typically think of gap-closing as being a primary clinical decision support (CDS) function, CDS systems do exactly that. Its success in informing decisions depends largely on the ability to analyze information from multiple systems, closing gaps in real-time. As a result, CDS is emerging as an essential tool for improving quality of care.

Decision-making support built with a more complete view of the patient

CDS systems run on top of EMRs, analyzing documentation as it is being entered and issuing alerts in EMR windows when conditions indicate the possibility of a medical error or compromised patient safety. This is often a matter of giving clinicians information of which they were unaware.

To fully inform alerts, advanced CDS systems supplement the structured data in EMRs and pull information retrieved from other systems such as those in labs and imaging departments. CDS leverages its comprehensive patient view by applying rules-based analysis regarding diagnoses and courses of care. By augmenting a physicians’ expertise with real-time information retrieval and gap-closing, CDS systems play a key role in promoting patient safety.

Closing gaps in clinical documentation over time

Hospitals gather an enormous amount of information on patients that is stored among systems that don’t communicate directly with each other. Undetected information gaps that occur over time can have serious repercussions, including during a single episode of care.

Consider the onset of sepsis during hospitalization. A physician may correctly diagnose appendicitis for a patient at admission and begin the correct course of treatment. As that treatment is underway, systems continuously monitor the patient’s temperature and blood pressure, and information such as white blood cell counts is collected in ongoing lab tests.

While lab results and other devices continue to flow into the EMR during patient care, attending clinicians are still responsible for making correct correlations by reviewing information from various sources including the EMR and other numerous systems. In order for these direct connections to be made, clinicians need to properly acknowledge data for it to be permanently charted, though even if a clinician isn’t watching results in real time, the CDS system is. However, it is important to remember that the system usually alerts clinicians if a new abnormal result has arrived or if there is any abnormality in the monitoring devices.

Because CDS systems do connect with these information resources, they can detect, well before anyone could otherwise, a slow rise in white blood cell counts, slightly elevating body temperature and gradually falling blood pressure. By properly correlating these three factors, the CDS system can alert clinicians to the early onset of sepsis. This can enable an intervention far earlier than would have been possible had the gaps not been automatically closed – critical for patient safety when time to diagnosis is of the essence.

Closing gaps in clinical documentation across care teams

In many cases, patient safety can be compromised because various members of a care team have different sets of clinical documentation. These gaps can occur simply because multiple clinicians and various care team members treat the same patient and vital information may be unavailable for the right clinician at the right time. This is especially true in the ordering of medical imaging and ordering of duplicative tests. This is one reason why starting January 1, 2018, CMS will reimburse imaging claims only when accompanied by proof of CDS involvement in ordering.

Eliminating duplicate imaging improves patient safety by reducing unnecessary exposure to radiation. Because CDS analysis can detect even more complex safety compromises, CDS systems promote imaging safety in important ways that go beyond issues with duplicate testing.

In one recent example, an Emergency Department physician at a hospital with a CDS platform ordered an MRI for an elderly patient who had just been admitted. This patient had received a pacemaker at the same hospital two weeks earlier. While the implant had been documented as a procedural note in the EMR, it had not yet been documented in an EMR discrete field. The physician ordering the MRI was unaware of the implant, but the CDS system identified it and issued an alert. The physician immediately canceled the MRI order, avoiding disaster.

CDS systems can also help patients to be better prepped for imaging tests. For example, alerts can ensure proper hydration before tests for patients with low glomerular filtration rate (GFR) levels. This avoids the common situation of radiology having to reschedule tests when the need for hydration is discovered too late.

Strengthening clinician’s documentation, CDS can prompt for any contradictions recorded in documentation, creating a coherent clinical chart. CDS systems can also invalidate data that was documented by using more accurate live data that was accumulated. 

For example, a clinician documented sepsis at 16:00, but the CDS system identified it much earlier via vitals and lab results, making the onset time of sepsis from the CDS much more accurate than the onset time the clinician documented it. This led to improved patient care and resulted in a much earlier treatment phase.

Achieving one of the key aims of interoperability

The reason there is much discussion regarding the need for interoperability is that we could eliminate many medical errors and greatly increase patient safety if everyone were operating with a complete clinical view of the patient. The examples presented here are just a few of the many ways in which CDS serves to achieve those goals today.

The healthcare industry will likely eventually reach the point at which various healthcare IT resources freely share information. Until then, many providers are finding that CDS is an essential tool for closing gaps in clinical information and achieving one of the primary goals of interoperability in advance.

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