Clinical Decision Support: No Substitute For Doctors' Opinion

Study finds little improvement in how doctors with access to computerized alerts treat elderly patients with cognitive impairment.
5 Key Elements For Clinical Decision Support Systems
5 Key Elements For Clinical Decision Support Systems
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Clinical informatics professionals and health IT software developers need to reassess how they develop clinical decision support (CDS) tools. That's the advice from the lead author of a new study questioning the benefits of computerized CDS systems in geriatric populations.

"The entire industry of clinical decision support is going in the wrong direction," geriatrician Dr. Malaz Boustani, associate director of the Indiana University Center for Aging Research and a research associate at the Regenstrief Institute in Indianapolis, told InformationWeek Healthcare.

Boustani and several colleagues, who authored a study in the May issue of the Journal of General Internal Medicine, found no statistically significant benefits to the home-grown CDS system at Wishard Memorial Hospital in Indianapolis, in terms of treating elderly patients with cognitive impairment (CI). About 40% of all hospitalized patients over the age of 65 have some form of cognitive impairment, according to the study.

The researchers found no real differences in how physicians order consultations with geriatric specialists or discontinue certain treatments that could be dangerous for patients lacking full mental capacity, whether the doctors had access to computerized CDS or not. The CDS system also had no significant effect on outcomes, including length of hospital stay, development of complications, readmissions within 30 days of discharge, and death within 30 days of initial hospitalization.

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"A simple CDS [system] to alert the physicians of the presence of CI and provide recommendations to reduce the use of anticholinergic medications did not significantly change physician prescribing behavior," they wrote. Patients with CI are not supposed to be given certain anticholinergic drugs, which treat muscle spasms and certain other neuromuscular conditions.

"Additionally, the CDS [system] was not sufficient to increase the referral to geriatric consultation services or reduce potentially harmful procedures such as Foley catheterization and physical restraints. The CDS [system] also had no impact on health outcomes and did not improve recognition of CI at hospital discharge," the article continued. Restraints and catheters can be dangerous for patients lacking full mental capacity.

The journal article concluded: "Despite the success of CDS [system] tools in other populations and practice environments, our results suggest that human interaction may play a significant role in the acceptance of recommendations aimed at improving the care of hospitalized older adults with CI."

Boustani, who also directs the Healthy Aging Brain Center at Wishard Health Services, recommended against the traditional "top-down" approach to CDS, in which the computer pushes information out to physicians whether they want it or not. "They haven't asked for help, and we come in and intrude on them and tell them how they should take care of patients," he told InformationWeek Healthcare.

A better way, according to Boustani, is to provide CDS "on demand," such as when the doctor indicates he or she is seeing a patient with cognitive impairment, and also combine artificial intelligence with human intelligence.

Regenstrief now has a trial underway to see whether patients in intensive care can be taken off sedatives, Boustani explained. In the trial, a pharmacist personally reviews medication orders and potential CDS alerts twice a day. "The doctor doesn't see the alert until the pharmacist verifies it," he said. "That's what the doctors told us they wanted."

But pharmacists must not delay, either. At least 20% of the patients in the study group did not get screened for CI until they had been in the hospital for 48 hours.

"In summary, we recommend development of a new and enhanced CDS [system] capable of integrating the strength of both the human and computer resources to deliver early, clinically relevant, validated, and easy to implement recommendations that may lead to reducing the exposure of the vulnerable hospitalized elders to potentially harmful anticholinergics and thus enhance their hospital care," the study said.

"We want computerized decision support to start working in the same way as a diagnostic tool or a diagnostic order," Boustani added. For example, if a patient comes to an emergency room with heart failure or emphysema, the system should help guide the physician to order a chest x-ray, not tell the doctor what should and should not be done. Many physicians perceive CDS alerts as a judgment upon how they practice medicine.

"I think that's a fatal flaw," Boustani said.

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