10 Innovative Clinical Decision Support Programs
What provides the smarts behind an advanced implementation of electronic health records? Clinical decision support systems. It may be time to revisit your CDS vendor options.
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Clinical decision support is the brains behind an advanced implementation of electronic health records. EHRs, e-prescribing systems, computerized physician order entry, and medication reconciliation systems all are strengthened by some form of clinical decision support. CDS can help physician reach proper diagnoses, ask the right questions, and perform appropriate tests on the front end of the decision-making process--preventing errors of omission--as well as stop errors of commission on the back end, during treatment and procedures.
The Stage 1 criteria for Meaningful Use of EHRs to qualify providers for Medicare and Medicaid bonuses require but a single rule for clinical decision support, down from the five previously proposed. Expect the minimum to rise to at least five rules during Stage 2, which will likely start in 2014. Clearly, federal officials expect CDS to be part of a complete EHR.
KLAS Enterprises has identified five elements of clinical decision support: order sets, multi-parameter alerting, nursing care plans, reference content, and drug information databases. Different vendors take different approaches to their CDS products, but they have one thing in common: a deep clinical knowledge base that helps promote patient safety. Here is our look at 10 CDS developers and vendors. If you have a CDS system in place but are not seeing a significant return on investment, it may be time to shop around.
Clinical decision support system Archimedes IndiGO, which stands for "individualized guidelines and outcomes," is the commercialization of the Archimedes Model. The scientifically validated model, developed by Kaiser Permanente physician-mathematician and Archimedes founder Dr. David Eddy, applies a series of mathematical equations to analyze stores of clinical, administrative, or physiological data, then feeds the results into a computer model that simulates actual healthcare processes and human physiology.
Created with the help of a five-year, $15.6 million grant from the Robert Wood Johnson Foundation awarded in 2007, IndiGO takes patient-specific data from more than 30 different variables to create "individualized guidelines" based on each person's unique risk factors, history, treatments, and, when available, biomarkers across multiple morbidities. The personalized guidelines also can analyze insurance coverage to factor in the costs of recommended treatments.
IndiGO interfaces with electronic health records (EHRs) and disease registries, drawing on those databases to help identify at-risk patient populations and suggest appropriate interventions. In addition, the system can put together patient-specific care plans for better disease management. San Francisco-based Archimedes says that this is exactly the kind of data payers will be looking for as providers evolve into Accountable Care Organizations and adopt the patient-centered medical home model.
Autonomy Health, which has roots at Cambridge University in the U.K. and now is a subsidiary of Hewlett-Packard, approaches clinical decision support from the diagnosis side, rather than the more common strategy of applying clinical knowledge to treatment or medication decisions.
Autonomy's year-old CDS product, Auminence, relies on a platform called "Meaning Based Healthcare" to analyze patient history, presenting symptoms, and physician knowledge. The system looks for patterns in the data to produce a checklist, with statistical probabilities, for physicians to go through while making a differential diagnosis. Results are displayed in a dashboard view.
Interestingly, Autonomy brought in Dr. Joseph Britto, formerly of another diagnostic decision support company, Isabel Healthcare, as head of medical technologies to lead the 2010 launch of Auminence. (Britto has since become an independent consultant in clinical informatics.)
DiagnosisOne features a platform called smartPath, which includes components for clinical decision support, order sets, analytics, and public health recording and surveillance, built on a Microsoft, Oracle, and Red Hat architecture. The smartConsult CDS module scans all available patient data to help identify gaps in care, with an emphasis on developing effective treatment plans.
The smartConsult dashboard simulates an EHR view, updating patient information during the patient encounter when the doctor enters a diagnosis. The system is designed to improve physician productivity and meet Meaningful Use requirements for CDS, patient education, and health information exchange, according to the Lowell, Mass.-based vendor.
Developed at the Laboratory of Computer Science at Massachusetts General Hospital in Boston, DXplain has been in use since 1986 and marketed nationally since 1987. Over the years, the knowledge base has grown from about 500 diseases in the first release to more than 2,400 diseases, 5,000 clinical findings, and 230,000 data points, according to Mass General, which still holds the distribution rights.
Users enter clinical information into a text box, then the diagnostic decision support system looks for appropriate medical evidence in its knowledge base, looking for synonyms and correcting misspellings to account for the wide variations that free-text entry presents. DXplain offers a list of possible diagnoses based on symptoms, physician observations, test results, and other factors. Physicians can click a "Focus" button to emphasize some findings over others in reaching a diagnosis.
Elsevier Clinical Decision Support, a subsidiary of Anglo-Dutch publishing giant Reed Elsevier Group, draws heavily on its parent company's massive stable of medical journals, books, and online medical reference tools such as MD Consult. The CDS division is a combination of home-grown technology and content, plus several Elsevier acquisitions. Notably, Elsevier bought drug database developer Gold Standard in 2006, nursing care plan provider CPM Resource Center in 2007, and clinical analytics firm MEDai in 2008.
The extensive Elsevier CDS product line is divided into four categories: analytics and reporting; drug reference and decision support; evidence-based guidelines, clinical content, and tools; and learning and performance management. Well-known Elsevier CDS brand names include Mosby's, Gold Standard, Pinpoint, and First Consult.
Diagnostic decision support vendor Isabel Healthcare grew out of a distinctly different culture in the U.K. After his three-year-old daughter Isabel nearly died from a missed diagnosis at a London hospital in 1999, Jason Maude didn't sue for malpractice. He joined with attending physician Dr. Joseph Britto to develop a system that could prevent similar errors.
The Isabel system offers a Web-based checklist to help clinicians process symptoms and test results to arrive at an accurate diagnosis, offering possibilities that are so uncommon that a physician might only see it a couple of times during a career. (Maude's daughter Isabel had necrotizing fasciitis, the same rare, flesh-eating bacterial disease that Dr. Atul Gawande famously described in his book, "Complications: A Surgeon's Notes on an Imperfect Science.")
Isabel, which has a database of more than 100,000 documents and "knowledge kernels," works as a standalone app or it can be integrated with an EHR to draw data directly from the patient's record.
PKC, which stands for problem-knowledge coupling, is the brainchild of Dr. Lawrence Weed, creator of the problem-oriented medical record and the subjective, objective, analytical, and planning (SOAP) approach to clinical progress notes. Weed has never been a fan of evidence-based medicine because it still relies on probabilities. Instead, he prefers the computer-aided "coupling" of medical knowledge to a specific patient's set of problems, based on the theory that the human brain could possibly recall and apply all relevant learning to the patient's current condition at the point of care.
Weed has left the company he founded, but his philosophy remains in PKC's products, though the Burlington, Vt.-based vendor does call its recommendations evidence-based. Advisor, a CDS system for clinicians, helps with differential diagnoses and care plans. A consumer-focused version called Profiler is an interviewer, gathering medical history and other information directly from the patient and presenting questions based on each response. This program can create the subjective portion of the SOAP note for export to an EHR or personal health record.
While Thomson Reuters has announced plans to sell its healthcare holdings, no deal has been consummated, so the global media conglomerate remains a major provider of clinical decision support content, via its Micromedex division. In fact, Thomson Reuters introduced version 2.0 of the Micromedex point-of-care CDS suite just a month before the divestiture announcement.
More than 3,500 hospitals in 83 countries use Micromedex's clinical evidence for medication safety, health and disease management, patient education, and toxicology, according to Thomson Reuters. Micromedex offers iPhone and iPad apps for its drug reference guide and medication interaction checker. Users can gain access to other aspects of the Micromedex 2.0 knowledge base on other mobile platforms, including Android and BlackBerry.
Wolters Kluwer Health has two brands in the CDS realm: the UpToDate knowledge base and ProVation Order Sets, offering evidence-based clinical content and software for care plans.
Founded in 1992 and sold to Wolters Kluwer in 2008, UpToDate now indexes 9,000 topics in 19 medical specialties, including a recently released module for general surgery. Still run as a semi-autonomous company, UpToDate claims to have more than 450,000 clinician users in 149 countries.
ProVation is the software that puts medical evidence into clinical practice. As previously reported by InformationWeek Healthcare, ProVation has "done most of the legwork so that the order sets and UpToDate content can be integrated into your hospital's [EHR and CPOE] systems, using standards such as HL7 and InfoButton API, and the right terminology, including SNOMED CT, RxNorm, LOINC, CPT, and ICD-9."
Zynx Health has well-developed platforms for hospital and ambulatory care, incorporating more than 500 clinical decision support rules and 1,100 templates for order sets into its various software packages. An online resource, ZynxEvidence, provides nearly 150 modules of evidence-based clinical content for computerized physician order entry.
When integrated with an EHR, the Zynx system produces clinical reminders that include detailed care plans based on each patient's condition.
Co-founded by UCLA internist Dr. Scott Weingarten, director of health services research at Cedars-Sinai Health System in Los Angeles, and Dr. Nancy Greengold, now president of the related Zynx Health Device Network after a stint at Wolters Kluwer Health, Zynx Health has been owned by publishing giant Hearst since 2004.
Zynx Health has well-developed platforms for hospital and ambulatory care, incorporating more than 500 clinical decision support rules and 1,100 templates for order sets into its various software packages. An online resource, ZynxEvidence, provides nearly 150 modules of evidence-based clinical content for computerized physician order entry.
When integrated with an EHR, the Zynx system produces clinical reminders that include detailed care plans based on each patient's condition.
Co-founded by UCLA internist Dr. Scott Weingarten, director of health services research at Cedars-Sinai Health System in Los Angeles, and Dr. Nancy Greengold, now president of the related Zynx Health Device Network after a stint at Wolters Kluwer Health, Zynx Health has been owned by publishing giant Hearst since 2004.
Clinical decision support is the brains behind an advanced implementation of electronic health records. EHRs, e-prescribing systems, computerized physician order entry, and medication reconciliation systems all are strengthened by some form of clinical decision support. CDS can help physician reach proper diagnoses, ask the right questions, and perform appropriate tests on the front end of the decision-making process--preventing errors of omission--as well as stop errors of commission on the back end, during treatment and procedures.
The Stage 1 criteria for Meaningful Use of EHRs to qualify providers for Medicare and Medicaid bonuses require but a single rule for clinical decision support, down from the five previously proposed. Expect the minimum to rise to at least five rules during Stage 2, which will likely start in 2014. Clearly, federal officials expect CDS to be part of a complete EHR.
KLAS Enterprises has identified five elements of clinical decision support: order sets, multi-parameter alerting, nursing care plans, reference content, and drug information databases. Different vendors take different approaches to their CDS products, but they have one thing in common: a deep clinical knowledge base that helps promote patient safety. Here is our look at 10 CDS developers and vendors. If you have a CDS system in place but are not seeing a significant return on investment, it may be time to shop around.
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