Decision Support Systems: Silver Bullet or Lead?

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silver bullet - 4160817135_a925e3f61f
Photo by eschipul

You might have seen the Jeopardy! episodes in 2011 where Watson, an IBM computer system, beat the biggest all-time human money winner, and also beat another record holder for the longest championship streak. Watson’s creators have aspirations of it eventually becoming your physician’s assistant, but are these type of computer assisted tools really ready for prime time?

Fans of Ray Kurzweil, the noted technology futurist and entrepreneur, would chalk this up as just one more inevitable notch on the progression towards real and practical artificial intelligence. Kurzweil has noted the exponential growth of computing power, which began, he says, with 1890 U.S. census, and has continued practically unabated since — leading up to the current wonder, Watson.

The folks at IBM’s DeepQA project have set even higher hopes for Watson than just uncanny gameshow trivia — they want to revolutionize the way healthcare providers make critical decisions by having Watson serve as a high-end clinical decision support (CDS) system.

There’s no doubt of the need for some sort of intelligent assistance when it comes to healthcare decisions. Dr. Herbert Chase, a Columbia University medical school professor, has said that for at least 30 years, doctors have been unable to keep up with the information overload . “Every day, doctors have questions they can’t find the answers to. Even if you sit down at a search engine, it’s so labor intensive and it takes so long to find answers.”

Futurists forecast that a mobile-accessible, cloud version of Watson is in the works, which would be a game changer. Think Siri + + MEDLINE.

Instead of waiting for Watson, many providers have turned to home-grown, or commercially available CDS solutions. But are these tools really viable for novice and experienced healthcare providers?

The medical research studies attempting to answer this question have returned with a mixed bag of results. We’ve dug through more than 40 studies conducted within the past ten years and have found that the answer is both yes and no — or a definite maybe.

All waffling aside, the majority of studies reporting positive impacts of current CDS seem to be for those systems that are very narrow and targeted in their application. Concerned about adverse drug events within a hospital or clinic setting? A couple of studies1 indicate a positive impact of utilizing these tools. Want automated real-time pneumonia and heart failure decision support? One study2 shows promise.

But, widen your net of what you want from decision support and the current crop of solutions don’t seem to be making much of an impact. One research project3 hypothesized that CDS functionality would result in higher-quality outpatient care compared with electronic health record (EHR) use without CDS. The results? Not even close. Neither EHRs nor CDS was associated with ambulatory care quality.

Many of the studies cautioned that CDS’s are not silver bullets, and urge decision makers to employ multiple factors before embarking on this path. Get buy-in from key, experienced staff. Try to envision unanticipated effects that the CDS introduction might cause — for example, one study referenced the ability for nurses to routinely override the CDS recommendations, which could lead to an increase rather than a decrease in variation or errors4.

Whatever your approach, wise counsel is always advisable. Need some help? Give us a call.

Research Study References:

  1. [Drug Saf] Drug Safety: An International Journal Of Medical Toxicology And Drug Experience 2011 Mar 1; Vol. 34 (3), pp. 233-42.;              [Am J Health Syst Pharm] American Journal Of Health-System Pharmacy: AJHP: Official Journal Of The American Society Of Health-System Pharmacists 2012 Feb 1; Vol. 69 (3), pp. 221-7.
  2. [Am J Health Syst Pharm] American Journal Of Health-System Pharmacy: AJHP: Official Journal Of The American Society Of Health-System Pharmacists 2009 Feb 15; Vol. 66 (4), pp. 389-97.
  3. [Arch Intern Med]. 2011;171(10):897-903. doi:10.1001/archinternmed.2010.527.
  4. [J Clin Nurs] Journal Of Clinical Nursing 2009 Apr; Vol. 18 (8), pp. 1159-67.


Wall of Shame

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Wall of Shame
(Photo by Sarah G...)

Since 2009, almost 21 million patients have had their medical records stolen, unlawfully disclosed, or just lost, according to the Office for Civil Rights (OCR) of the U.S. Dept of Health and Human Services (HHS). The result is a “wall of shame” (and possible fines) for these healthcare organizations — a wall your organization should avoid getting posted on at all costs.

The wall is a by-product of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 — part of the umbrella of the American Recovery and Reinvestment Act (ARRA). HITECH fulfills a promise made by President Obama with the goal of modernizing portions of the American healthcare system.

During a speech at George Mason University, President Obama said:

“To improve the quality of our health care while lowering its costs, we will make the immediate investments necessary to ensure that, within five years, all of America’s medical records are computerized. This will cut waste, eliminate red tape and reduce the need to repeat expensive medical tests…But it just won’t save billions of dollars and thousands of jobs; it will save lives by reducing the deadly but preventable medical errors that pervade our health-care system.”

There are a number of carrot and stick incentives inside HITECH to encourage rapid adoption of Electronic Health Records (EHR) by hospitals. Due to these incentives, the Congressional Budget Office (CBO) has increased its projected EHR adoption rate from 65% to an estimated 90% among physicians by the year 2019. This increased projection estimate is a direct result of HITECH.

EHR is a fantastic idea, but as with most things digital, ease of use/access within EHRs means that electronic health record information can also be easily copied, stolen or disclosed in an unauthorized manner. So provisions are needed to protect the privacy and security of patient information.

HITECH addresses some of this by giving HHS some enforcement teeth. Via section 13402 of the Act, HHS is required to issue regulations (and possible fines) for breach notification by entities subject to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and their business associates. Via section 13402(e)(4) of HITECH, the HHS Secretary must post a list of breaches of unsecured protected health information affecting 500 or more individuals. So, 21 million breaches may be a conservative estimate.

How can you avoid getting your organization on the “wall of shame”? Stay tuned here for a future follow-up with suggestions, or contact us for more information.