What Clinical Decision Support Can Offer

By Nancy Zimmerman, RN, BSN

Advanced clinical decision support (CDS) systems are playing an increasingly important role in promoting quality and safety in patient care, especially in diagnostic assistance. While arriving at a correct diagnosis will always be a mixture of art and science, with physicians ultimately responsible for all clinical decisions, CDS systems support the science by adding key data points of which the clinician may otherwise be unaware. This data can include:

• Clinical details documented in the patient’s medical history, but not in easily accessible parts of the electronic health record (EHR), e.g., buried in long, free-text notes from a visit several months ago
• Evidence of serious, developing conditions that is not readily apparent through clinical observation
• Considerations regarding potentially harmful diagnostic procedures, especially imaging
• Recent evidence-based best practices for reaching certain diagnoses

 

CDS bases alerts on a holistic clinical patient view

Advanced CDS systems ride on top of EHRs, reading and interpreting all details in patients’ records. That includes data contained in free-text notes extracted using screen-reading technology, as well as readily obtainable structured data recorded with menu selections. The CDS system completes its clinical view of the patient by similarly reading data from systems such as ambulatory EHRs in external facilities and the information systems of laboratories and emergency and radiology departments. While these systems rarely share their electronic information directly with each other, all can share information with the CDS system through standard HL7 interfaces.

When a clinician enters a diagnosis into the inpatient EHR, the CDS system matches the diagnosis to relevant data points concerning the patient’s past and current clinical situation in these systems, and to information about best practices stored in its knowledge base. When CDS detects a potential issue, it sends an alert to suggest a change in diagnosis, a new diagnosis, or a less harmful or invasive approach to diagnostic procedures.

The following use cases illustrate some of the ways in which CDS systems perform an essential role in advancing quality care and patient safety.

 

Use case #1: CDS alerts based on information from diverse systems

Patient safety issues can arise when a clinician is following standard procedures but has limited information available at the point of care. For example, standard protocol may call for a lumbar puncture (LP) to facilitate diagnosis for a patient with unresolved headaches. The patient could have normal platelet values at the time the LP is scheduled, with no immediate indications of potential safety issues. But if pharmacy records tell the CDS system the patient has a prescription for heparin, and data from an outpatient EHR reveals the patient’s current reading represents a drop in platelet value, the CDS system can alert the physician to a potential case of heparin-induced thrombocytopenia. If this condition exists, it would put the patient at risk for bleeding during the LP due to a clotting factor issue. Once alerted, clinicians can ensure patient safety by addressing the thrombocytopenia before proceeding with an LP, or by drawing another platelet count immediately before performing the LP to confirm the patient’s platelets have not dropped to an unsafe level. Either measure will ensure the patient is not harmed by an LP.

 

Use case #2: CDS alerts based on “silent deterioration”

Many post-admission clinical events involve separate, serious conditions that require diagnosis as soon as possible, yet can’t be easily observed by clinical staff. One of the most common examples—and the leading cause of death in hospitals—is sepsis, as when a patient presents to the emergency department with acute appendicitis and develops severe sepsis while hospitalized.

Though the symptoms of sepsis are hard to spot visually, the mathematical nature of sepsis progression makes it readily identifiable to CDS systems. CDS can note trends such as a slow rise in white blood cell counts over time in lab tests or evidence that, while vital signs remain relatively constant within the normal range, the patient is slowly becoming hypotensive or developing a slightly elevated fever.

While a clinician may note such changes in more routine care if actively seeking them, the clinician who is already laser focused on treating appendicitis may not observe them until the patient is suddenly septic and develops organ failure. With CDS monitoring and alerting, the clinician remains focused on appendicitis until alerted to the need to focus on developing sepsis—early enough to address it.