Peter Basch, M.D., offers a succinct summary of why the 1,000 physicians he helps with IT are moving to electronic health records: "We are shifting to EHRs not to punish doctors by making them typists, but to use the value of information to improve care." That's why Basch is making clinical decision support a top priority as he heads an EHR effort in his role as medical director of ambulatory clinical systems at MedStar Health, Columbia, Md. Basch, like many other EHR proponents, stresses that offering physicians timely decision support is perhaps the most valuable component of a shift to electronic records. That's because receiving timely advice, based on sound medical evidence, when making treatment decisions can dramatically improve care quality while saving money on inappropriate treatment. Practices are taking widely varying approaches to implementing decision support, ranging from simply using an EHR to alert physicians when a patient is overdue for a test to developing sophisticated protocols that provide a step-by-step guide to treatment of a specific condition. Recognizing the value of decision support, doctors at Community Care Physicians in Latham, N.Y., recently began using evidence-based clinical treatment protocols. "This has streamlined the order process for the diagnoses that we see most frequently," says Barbara Morris, M.D., chief medical officer at the 160-physician practice. By integrating the protocols so they fit physician workflows, doctors have to make fewer clicks to order appropriate tests and medications and document treatment, she says. And that makes their lives easier, while improving the quality of care. Group practices that are pioneers in the clinical decision support arena envision a day in the not-too-distant future when they'll carefully analyze the use of protocols and other decision support aids to measure what approaches work best. "That's likely our next step," says Nancy Babbitt, administrator at Roswell Pediatric Center in Alpharetta, Ga. The group practice is using EHR templates for documenting care that include decision support functions. Many group practices with EHRs, however, are just getting started with phasing in the full clinical decision support capabilities of their systems. And some, such as MedStar, are working with consultants to build robust, tailor-made decision support functions. Of course, a majority of practices have yet to even acquire an EHR system. A variety of surveys suggests that as few as one-fifth of group practices use the technology. But Medicare and Medicaid EHR incentive payments under the federal economic stimulus program could lead more practices to take the electronic records plunge. And the pending definition of "meaningful use" of EHRs-the cornerstone of incentive eligibility-requires that practices implement at least some decision support functions. "A lot of what it's going to take to achieve 'meaningful use' is getting clinical decision support right," says Jerry Osheroff, M.D., who chairs the HIMSS Clinical Decision Support Workgroup, which has created a collaborative Web site on decision support. Osheroff is chief clinical informatics officer at Thomson Reuters, a New York-based software vendor. Osheroff points out that proponents use many different definitions of clinical decision support. The workgroup adopted a broad definition: "intelligently filtered patient data that helps inform decisions that lead to better outcomes." That definition, he says, could encompass advanced clinical systems as well as a sticker on a patient chart. Many clinics that have EHRs are starting their decision support efforts by simply turning on preventive care guideline alerts that come with the systems, says Rosemarie Nelson, principal at MGMA Healthcare Consulting Group, Englewood, Colo. These alerts offer reminders about overdue tests, such as mammograms. Beyond that, Nelson advises clinics to look for "easy first steps" that automate workflows a majority of physicians already use, rather than immediately launching into developing dozens of sophisticated treatment protocols.

At MedStar, however, Basch and his team are going far beyond the easy first steps; they are implementing robust treatment protocols. The integrated delivery system has rolled out an EHR from GE Healthcare, Waukesha, Wis., to about two-thirds of its 1,000 employed physicians. Now, it's bolting on sophisticated protocols created in partnership with Clinical Content Consultants, Concord, N.H. "This allows us to build as many or as few prompts as we wish that are tailored to the patient and the physician opening the prompt," says Basch, a practicing internist. When a doctor is using the EHR, a button glows yellow to indicate if there is a suggested protocol available, such as breast cancer screening, that's relevant to the case. By clicking on the protocol, physicians can view a series of suggestions for tests and procedures to order. MedStar is phasing in protocols gradually to avoid overwhelming physicians with information, Basch says. "I was concerned about decision support that's forced, with lots of popups in your face," Basch says. Such an approach disrupts the doctor's workflow, he contends. "With our system, I can click on the yellow button when I'm ready, such as once I hear the patient talk about why they are here." The protocol "changes the dynamic of the office visit to a two-way conversation" because the doctor can go over a list of appropriate questions that are displayed in the protocol. In the months ahead, MedStar will track which protocols are opened most often and what action is commonly taken so physicians can fine-tune the system. For now, using the protocols is voluntary. "My belief is that doctors want to do the right thing," Basch says. "If we enable them to work more efficiently, they'll use the protocols." MedStar's records system includes "a very simple screen" that shows medication history and allergies. The e-prescribing component offers alerts, such as for adverse drug interactions, as well as guidance regarding what drugs are on the formulary and covered by insurance. "But knowledge-based medication management doesn't really exist; it must be built," Basch argues. "We do not have, nor do most clinics have, a decision support system that looks at the implications for use of a drug and recommends the most appropriate and cost-effective drug for that condition." The physician is hopeful of eventually implementing a system with business intelligence to achieve that goal. Meanwhile, the protocols implemented so far include recommendations on drugs to order for specific conditions.

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