Over the past few weeks, I've seen a convergence of emerging ideas that suggest a new path forward for decision support. Application Service Providers offer remotely hosted, high value Software as a Service applications at low cost. I believe we need Decision Support Service Providers (DSSP), offering remotely hosted, low cost knowledge services to support the increasing need for evidence-based clinical decision making.
BIDMC has traditionally bought and built its applications. Our decision support strategy will also be a combination of building and buying. However, it's important to note that creating and maintaining your own decision support rules requires significant staff resources, governance, accountability, and consistency. Our Pharmacy and Therapeutics Committee recently examined all the issues involved in maintaining our own decision support rules and you'll see that it's an extensive amount of work. We use First Data Bank as a foundation for medication safety rules. We use Safe-Med to provide radiology ordering guidelines based on American College of Radiology rules. Our internal committees and pharmacy create and maintain guidelines, protocols, dosing limits, and various alerts/reminders. We have 2 full time RNs just to maintain our chemotherapy protocols.
Many hospitals and academic institutions do not have the resources to create and maintain their own best practice protocols, guidelines, and order sets. The amount of new evidence produced every year exceeds the capacity of any single committee or physician to review it. The only way to keep knowledge up to date is to divide the maintenance cost and effort among many institutions.
A number of firms have assembled teams of clinicians and informatics experts to offer these kinds of knowledge resources. UptoDate maintains world class clinical information with thousands of authors reviewing literature and providing quarterly revisions. Safe-Med has a large team of experts codifying decision support rules and building the vocabulary tools needed to make them work with real world clinical data. Medventive provides the business intelligence tools needed to create physician report cards and achieve pay for performance incentives.
However, none of these firms can plug directly into an electronic health record in a way that offers clinicians just in time decision support.
Here's a strawman for the way a Decision Support Service Provider should work:
a. A hospital or clinic selects one or many Decision Support Service Providers based on clinician workflow needs, compliance requirements and quality goals
b. Electronic health record software connects to Decision Support Service Providers via a web services architecture, including appropriate security to protect any patient specific information transfered to remote decision support engines. For example, an EHR might transfer a clinical summary such as the Continuity of Care Document to a Decision Support Service Provider along with a clinical question to be answered.
c. A clinician begins to order a therapy or diagnostic test. The patient's insurance eligibility and formulary are checked via a web service. The patient's latest problem list, labs, and genetic markers are compared to best practices in the literature for treating their specific condition. A web service returns a rank ordered list of desirable therapies or diagnostics, based on evidence, and provides alerts, reminders, or monographs personalized for the patient.
d. Clinicians complete their orders, complying with clinical guidelines, pay for performance incentives and best practices.
e. The decision support feedback is realtime and prospective, not retrospective. Physicians get CME credit from learning new approaches to diagnosis and treatment.
In order to do this, EHR vendors must work with Decision Support Service Providers to implement the uniform architecture and interoperability standards needed to integrate decision support into EHR workflow. I would be happy to host a Harvard sponsored conference with all the stakeholder companies to kick off this work.
Of course, some may worry about the liability issues involved in using a Decision Support Service Provider. What if clinicians comply with flawed guidelines or fail to comply with suggested therapies and bad outcomes occur?
Based on my review of the literature, I believe decision support liability is a new area without significant case law. The good news is that there are no substantive judgments against clinicians for failing to adhere to a clinical decision support alert. As a licensed professional, the treating clinician is ultimately responsible for the final decision, regardless of the recommendations of a textbook, journal, or Decision Support Service Provider. However, as Clinical Decision Support matures and becomes more powerful and relevant, I believe that there could be greater liability for not using such tools to prevent harm.
This blog entry is a call to action for EHR vendors and emerging Decision Support Service Provider firms. It's time to align our efforts and integrate decision support into electronic health records. Working together is the only affordable way for the country to rapidly implement and maintain high quality decision support.