1. Penetration and Availability of Clinical Decision Support in Commercial Systems Clinical Decision Support - The Road Ahead Chapter 7

2. Overview A summary of the progress of availability of commercial Clinical Decision Support systems and their usage in health care organizations Focus on the usage of “complex CDS” from 2002 to 2005 These are rule-based. No machine learning/ data mining methods is involved

3. KLAS KLAS Enterprise is a research firm, specialized in independent monitoring of Healthcare Information Technology (HIT) Performs confidential interviews with officials in 4500 hospitals and 2500 clinics Has targeted the use of CDS since 2001

4. Status of CDS in 2002 KLAS interviewed 72 healthcare professionals, for the definition of CDS. The definitions by respondents were grouped into three types 1. Reminders e.g. reminder that patient needs an immunization 2. Simple Alerts e.g. drug-drug and drug-allergy conflicts 3. Complex Rules A reminder or an alert based on multiple parameters from different clinical systems

5. Status of CDS in 2002 (cont) Virtually every hospital had at least one software application that provided a minimal level of CDS Most common CDS: Pharmacy Information Systems Drug-drug interaction alerting CDS in laboratory Abnormal result checking Duplicate order checking

6. Status of CDS in 2002 (cont) Of the healthcare professionals interviewed: One-third reported use of some alerting and excitement in doing so Most alerts, while designed and developed, were not active, and have not yet benefited the organization The alerts most heavily in use focused on administrative and financial (business) side

7. Obstacles to CDS in 2002 Two reasons cited by most hospitals for not having complex CDS implemented: 1. Extreme difficulties physicians had in electronic ordering and interacting with electronic records 2. Lack of alerting viability in the software products

8. CPOE Inquiries 2002-2005 Computerized Physician Order Entry (CPOE) One of the areas where rules, alerts, and knowledge- based actions comes heavily into play KLAS has performed an in-depth inquiry of CPOE activities in USA, since 2002 There is a close linkage between usage of CPOE and CDS

9. CPOE Inquiries 2002-2005 (cont) Changes from 2002-2003 Some growth in complex CDS Still very limited Only 25 out of 125 live CPOE sites were doing any complex CDS with their software Changes from 2003-2004 Increase in number of CPOE sites doing complex CDS

10. CPOE Inquiries 2002-2005 (cont) Changes from 2004-2005 Increase in percentage of hospitals doing CPOE with a commercially available software 2003  1% of hospitals 2004  2% of hospitals 2005  4% of hospitals Sizable jump in the number of physicians doing CPOE 2003  45,000 physicians 2004  69,000 physicians 2005  113,000 physicians Growth of Complex CDS is not as universal It is one thing to go live with CPOE. It is entirely another to do complex CDS

11. Challenges of Complex CDS Ineffective rules (e.g. false alerts) Acceptable response to an alert is still undefined No normative set of “decisions” acceptable to healthcare and legal community Effective CDS is difficult when orders and discrete results are not mapped accurately Issues of one-to-many and many-to-one relationships Tied to database design and health data dictionary

12. Comments from Users  “We have a rule and alert oversight committee of physicians, nurses and pharmacist from across the system. They monitor alerts, so we look at them periodically to see how many of them are being overridden, if they are written the way they should be, and if they are giving the type of benefit that we hope to get from them.”

13. Comments from Users (cont)  “Physicians satisfaction is kind of a mixed bag. They understand the importance of it so they are happy about the evidence-based order based, and the lack of interpretation of handwriting. Fro ma safety standpoint, they are happy with the system.We are starting to experience a little alert fatigue at one site. We are revisiting some of the alerts that are in the system”

14. Comments from Users (cont)  “We have had to abandon doing any rules or alerts beyond the most simplistic ones. It takes a lot of concurrence to get anything out and live and we do not have the time to work on it right now. If we had something off the shelf, it would be a different story, like what they use for the standard drug interactions in the pharmacy system.”