Clinical decision support: improving access to improve patient care

BMJ Best Practice is a clinical decision support tool that works at the point-of-care. BMJ Best Practice offers continually updated, evidence-based and practical content to all healthcare professionals. It is accessible on any device - both online and offline via an app.

In this short article, Professor Siang-Hiong Goh and Dr. Kieran Walsh discuss how clinical decision support can enable access to clinical knowledge that will improve patient care.

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Prof Siang-Hiong Goh, Senior Consultant Emergency Physician, Accident & Emergency Department, Director Medical Education, Changi General Hospital, Singapore & Dr. Kieran Walsh, Clinical Director, BMJ  

According to Sackett, and colleagues, “evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” (1) The term evidence-based medicine was coined over twenty years ago but there is still some way to go before we can be sure that it is a part of everyday clinical practice and has a consistent and positive effect on patient care. There are a variety of reasons for this – from the misappropriation of the evidence-based “quality mark” by vested interests to an unmanageable volume of evidence. (2)

There can also be issues regarding the currency of evidence. Guidelines that are curated or evidence that is studied and put into a summary should, of course, be as current as possible. However, it is important to recognize that, when it comes to new treatments and diagnostic tests, such evidence may still be in its infancy. It is important therefore that evidence-based guidelines are not automatically and blindly followed – but rather that clinical judgment should be exercised at all times. For well-established treatments with a strong evidence base, clinical decision support should help clinicians to practice safely with effective and cost-effective treatments. In fact, from a patient safety standpoint, clinicians may be on stronger ground if they can show that they are adhering to the latest evidence-based recommendations.

Another problem is that developed countries now have a “silver tsunami” of rapidly aging patients, who need more care despite a limited care budget. Evidence-based clinical decision support tailored for the care of such patients and that is aimed at community practitioners (including nurses and nurse practitioners) can help ensure that care is carried out in the right place. This will result in patients staying in the community rather having to be admitted to a tertiary care center.

This need is also linked to the need to control healthcare costs. With a view to controlling costs, many hospitals and clinical departments in all parts of the world now have to adhere to government block-funding for diagnosis-related group codes. An effective way of achieving this is to have a bundled system of care, commonly known as a clinical pathway. Evidence-based clinical decision support resources may offer well-designed clinical pathways and algorithms. These will save busy clinicians’ time and effort in designing clinical pathways.

Another problem is that doctors and other healthcare professionals often complain that they cannot access the evidence when and where they need it. Increasingly they need it at the point of care and yet that is often exactly where they most struggle to access evidence-based medicine resources. This can be because of a lack of internet access or evidence-based resources that are too long to read or resources that do not work well for modern media (for example on mobile devices).

However, advances in technology mean that we are getting closer to the ultimate goal – evidence-based medicine continually at your fingertips. This often means evidence-based clinical decision support resources that are accessible on mobile. Mobile technology has certainly improved but the content must be responsive to the device. Even then a poor WiFi or internet environment might mean that the best content in the world might not get to the user. So, an app version of the content is often needed. The content on the app must be continually updated alongside the live version. It is also essential that the app is quick to download and that it uses minimal storage. And that it has sophisticated and advanced search functionality, including autosuggest options. Then for the context of a busy ward-round, the content must be practical, actionable, and easy to read.

Automatic tracking of searches can also make a real difference. On an average ward, round doctors will have many unanswered questions—it is impossible to remember them all. Automatic tracking of searches means that they don’t have to. The tracking of searches can then be used by the physician to claim CME/CPD credits. In the past, a problem with apps has been that users can feel that they are not getting the full version of the service. However, once again improved technology means that apps can now host images and videos and interactive content including medical calculators.

Some features required of apps are unique to healthcare – for example, a bright screen might disturb patients on the ward at night. But once again new technologies such as night mode features can reduce the brightness of the screen and so enable usage in whatever environment is necessary.

A busy clinician on the go needs information that is tightly linked to their office or hospital electronic medical record system. They would not want to have to toggle between two different “computers-on-wheels”, or between two medical devices. Preferably, evidence-based clinical decision support should be embedded into the electronic health record system as well as laboratory and radiology order sets, so that it is convenient and easy to use, and so that real-time information feed is achieved.

One difficulty with electronic health record systems is that, invariably, the system needs to go down every few months for maintenance and system updates. This may last as long as half a day. Clinicians would also like such applications to be able to update silently in the background - without the interruption of clinical work.

Ideally, compliance with guidelines should be consistent between different departments. For instance, in trauma, the trauma surgeon might favor whole-body scans, while the emergency physician and radiologist might favour a more selective regional scanning protocol based on physical examination. There are merits in both points of view. Evidence-based clinical decision support should enable as much agreement between such departments as possible, emphasizing logic and rational usage.

Nurses and allied health professionals often long to be a more active part of the healthcare team. Having an evidence-based computerized order entry system, which will objectively guide nurse practitioners, pharmacists and radiographers in the ordering of tests and treatments are likely to be a good way of enabling this.

Lastly, the ideal clinical decision support tool should be cost-effective. Funding models should be tailored to the area of practice. An Academic Medical Centre with a large staff and a complex case mix of patients will definitely use advanced clinical decision support a great deal. By contrast, a small office practice in the community or a regional community hospital or nursing home will have less of a need. The cost of clinical decision support resources should reflect factors such as these. This will undoubtedly promote the attractiveness of these resources to a wide range of institutions.

References

1. Sackett DL, Rosenberg WM, Gray JM, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ 1996; 312:71
2. Greenhalgh T, Howick J, Maskrey N. Evidence based medicine: a movement in crisis? Bmj. 2014 Jun 13;348:g3725.

Conflicts of interest

Kieran Walsh works for BMJ Best Practice - the clinical decision support tool of the BMJ.