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Medical Decision Support in the EMR

Posted by Dan Mazanec, MD on Mar 9, 2016 9:42:22 AM

Physician engagement is key

Our primary objective at Dorsata is to develop and build technology which assists clinicians in delivering optimal patient-centered care. An important part of this process is the integration of clinical decision support (CDS) into the workflow. CDS is based on symptom or disease specific pathways built from the best available medical evidence. Published clinical practice guidelines for common medical problems abound but evidence they actually influence clinical decisions in daily practice is poor. Time-pressured practitioners need real-time access to a decision support system, ideally during the patient visit itself.

A new study highlights the importance of involving the front line care providers in the development of guideline-based workflows with inline  support. Almost 250 physicians who were experienced EMR users were surveyed about factors influencing their use of computerized clinical guidelines. (BMC Medical Informatics and Decision Making 2016; 16:3) Four key variables influenced adoption and of the guidelines:
  • Attitude toward computerized CDS
  • Perceived usefulness to achieve work goals
  • Support from colleagues
  • Organizational support

Attitude was by far the most important and embodied the physicians’ knowledge, familiarity, and recognition of the clinical guideline. At Dorsata, we believe the best way to ensure a positive attitude is to involve the users, i.e., the front line clinicians, in the development of the guideline and ultimately its integration into the workflow of the practice. This commonly means adapting a national guideline to the local practice environment . In designing the spine carepath in Cleveland, we quickly realized we needed multiple clinician-stakeholders at the table. For spine, that meant providers along the full spectrum from primary care to specialists. As a spine specialist, I didn’t anticipate many of the clinical and operational issues of concern in the primary care setting.   Including clinicians from day one in development of the pathway facilitates the transition to building decision support into the clinical workflow in the EMR. Perceived usefulness and support from colleagues follow directly from “attitude,” increasing the likelihood practitioners in the organization will actually use the CDS provided.

An earlier study ( Ash et al, BMC Medical Informatics and Decision Making 2012; 12:6.) surveyed a wide range of ambulatory practices and hospitals across the country which had experience in implementing CDS in various settings. A key finding was that any CDS system needs to fit the local workflow of the users as closely as possible. Decision support was most helpful when available during the actual encounter, typically in the exam room. Clinicians wanted the CDS when most actionable. Again, these findings reinforce Dorsata’s methodology of building CDS technology into the clinical workflow by working directly from day one with the clinicians who will use the product. Working together with practitioners to build a user-friendly interface for documentation with seamless integration of decision support is the best way to ensure evidence-based guidelines actually influence clinical decision making in daily practice.

- DM

About Dan Mazanec, MD

Prior to joining Dorsata in 2016, Dan Mazanec, MD was the Associate Director of the Center for Spine Health at the Cleveland Clinic. Board certified in internal medicine and rheumatology, he has been a leader in the development of the emerging specialty of Spine Medicine. A frequent lecturer at international and national meetings, he has authored more than 70 book chapters and papers. He is an active member of the North American Spine Society with a particular focus on the development of evidence-based clinical guidelines as a member of the Clinical Guidelines Committee and the role of non- surgical care as chairman of the Rehabilitation Interventional Medical Spine Committee. Dan led the development of the Cleveland Clinic Spine CarePath which merges evidence-informed clinical management of spine disorders with patient-entered clinical outcome data focusing on optimizing value. He was the clinical lead for technologic enablement of the CarePath in the EMR and the implementation of the Spine Carepath across the entire Cleveland Clinic Health System.

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