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Decision Support Not an Exact Science


By Beckie Kelly Schuerenberg November 1, 2007

As more provider organizations dive into computerized physician order entry, they are finding that integrating decision support can be an extremely complex undertaking. While offering access to every type of clinical intelligence tool from the system sounds good in theory, many organizations quickly find this strategy doesn't mesh with their clinical goals or workflow.

For example, some, like Mercy Health Partners, a Toledo, Ohio-based integrated delivery system, want to ensure the decision support they offer reflects their best practices. So they develop an extensive evaluation process for each clinical intelligence tool. Others are concerned that too many alerts will disrupt physician workflow.

Because of such challenges, some provider organizations spend a vast amount of time assessing each clinical intelligence tool before offering it in a CPOE system.

"Some larger provider organizations do considerable decision support evaluation both before and after rollout," says Jonathan Teich, M.D., assistant professor of medicine at Harvard University, Cambridge, Mass., and an attending physician in emergency medicine at Brigham & Women's Hospital, Boston. "The results can be surprising for organizations to learn which types of interventions work well for their clinical staff."

Offering decision support from a CPOE system has been an imperative, yet complex process for Mercy Health Partners.

Nine months before CPOE rollout began, executives at the delivery system invited physicians to participate in a paid committee to determine the type and frequency of intelligence tools to be used in the new system. The physician design committee selected various drug interaction alerts and created about two dozen rules for the system that direct physicians to some of Mercy's clinical best practices. But Mercy had considerably more difficulty creating automated order sets-another type of decision support tool. Order sets are groups of drugs and tests that physicians commonly order simultaneously or that reflect other clinical best practices.

To develop automated order sets, the committee first had to collect paper-based order sets from physicians and nurses across Mercy's seven hospitals. Committee members spent months going from unit to unit looking for such order sets, even searching through desk drawers for some unofficial ones that were written on scraps of paper, says Kenneth Bertka, M.D., chief medical information officer. Then they had to consolidate the order sets and present them to the pharmacy and therapeutic committee at each hospital for approval to be used in the system.

Incorporating more than 700 order sets into the CPOE system was a time-consuming project, Bertka says.

"We started by implementing standard order sets, but that was more of a challenge than we thought," he says. "In some cases we went live with different order sets at different hospitals because we couldn't make the changes overnight. There was a need to find a faster way to develop order sets."

Shortly after the CPOE roll out began, Mercy changed its clinical governance structure to enable the physician design committee to implement order sets without waiting for other committees' approval. Physician design committee members now talk to various clinicians about prospective changes, then invite other committees to comment after they have been implemented.

Though Mercy has shortened the process for integrating decision support into its CPOE, the committee still hasn't unveiled all of the alerts, rules and order sets it plans for the system, Bertka says. "In an ideal world, we would have had the clinical guideline development process streamlined across our hospitals before we implemented order entry," he says. "We didn't have that. But we also made a conscious effort to go forward slowly so our clinicians wouldn't be overwhelmed by alerts."

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