The Devil is in the Details: Care Guidelines and Clinical Decision Support

As many of us know in the healthcare community, clinical decision support (CDS) functionality is a meaningful use (MU) requirement for EHRs. I suppose the goal of the authors of this requirement is to enable physicians to provide quality care by following established care guidelines for appropriate screening, monitoring, etc.

Most often the EHRs do not provide the rules for the care guidelines, thus placing the burden on the provider to build it for their practice. Many of these EHRs have therefore built clinical decision support functionality for the provider to input these simple rules. Typically, they’re in an “if-then” format where if a certain set of facts are true, then the system provides the user with an alert.

Many of the EMRs that I have seen show these alerts when specific investigations are indicated based on a certain set of conditions, e.g. patient’s age, diagnosis, or lab results.

Unfortunately, such functionality falls far short of what is needed to implement even moderately complex clinical care guidelines. Take the widely respected guideline for reduction of atherosclerotic cardiovascular risk from the American College of Cardiology.

In order to follow this care guideline:

1. The provider has to first see if the patient has established atherosclerotic cardiovascular disease (ASCVD)
2. If not, then check what their cholesterol level is and if it is <190
3. Then calculate their 10 year ASCVD risk
4. Then the ASCVD risk calculation requires values for 9 different variables (systolic BP, smoking history, age, race, gender, diabetes, etc) that one must enter into a calculator based on something called pooled cohort risk equation
5. Then based on the risk, the provider then has to see if the patient is taking a recommended statin (which varies based on their risk)
6. And then if they are, check if they have had the expected response

Good luck referencing all of this information in your EHR! Realistically, the provider will need to follow all these steps themselves to come up with the answer. Doable? Certainly, but a tall order and not to mention, time consuming.

For me, a better solution would be in an application that built all these steps and rules into a single algorithm, one that takes all of these variables into account and provides me with a recommendation while I’m still in the room with my patient.

Ideally this system would use the data from my EHR that I’ve already carefully entered so that I do not have to manually input these values again. In the age of MACRA and MIPS, there is a lot of emphasis on quality of care with the onus being on providers to provide guideline-based care. Applications which can incorporate complex guidelines and enhance the ability of providers to practice at a high standard will provide a lot of value. And ultimately have the potential to save lives and improve the overall health of the community.

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