5 Key Elements For Clinical Decision Support Systems

Healthcare providers are frustrated with some clinical decision support (CDS) tools provided to them by third-party vendors, partly because they don't integrate well with their electronic health record (EHR) systems, according to a new survey by KLAS Research.

The survey asked 249 providers about their use of electronic order sets, care plans and drug databases. These tools are supposed to be embedded within EHRs to achieve their primary goal of promoting evidence-based medicine and limiting the amount of variations in care. But KLAS found that about half of providers used third-party order sets for reference only, because they couldn't integrate the prebuilt order sets with their EHRs. In contrast, only a fifth of providers using care plans from third-party vendors were using them for reference only.

Neither drug database vendors nor EHR vendors are doing a good job of making medication alerts useful to physicians, the respondents told KLAS. Providers often have difficulties in adjusting the level of alerts, which can lead to "alert fatigue" among clinicians.

[ EHR adoption by care providers may be slow, but it is happening. See Meaningful Use Slowly Increases EHR Use In Hospitals. ]

KLAS suggested that the CDS vendors were only partly to blame for these difficulties: "All EMR [electronic medical record] vendors need to become more active in enabling providers to leverage evidence from third-party solutions. Too many providers struggle to get evidence-based data into the EMR and then use it effectively once it's embedded."

Order sets are used in computerized physician order entry (CPOE), which is required to show Meaningful Use. Some healthcare organizations try to create their own order sets, which increases physician buy-in, but this is very hard to do. It's also difficult for providers to maintain order sets as the evidence base changes. Consequently, the report noted, many respondents are purchasing prebuilt order sets from third-party vendors such as Wolters Kluwer ProVation, which has around 150 clients, and Zynx Health, which has several hundred customers.

As a result of the poor integration between these tools and leading EHRs, only about half of ProVation and Zynx clients said they used the tools to develop their order sets. The others built content directly in their EHR and used the third-party content as a reference.

The other big challenge was how well various EHRs presented the order set content to physicians at the point of care. KLAS found that on a scale of 1 to 5, Siemens was a 4.6, Allscripts was a 2.8, and Cerner, Epic, McKesson and Meditech fell somewhere in between on this score.

The type of EHR also had an effect on respondents' experiences with care plans, which are designed to support the work of clinicians such as nurses, respiratory therapists, and physical therapists. For example, care plan vendor Elsevier's partnership with Allscripts and Epic helped deliver a better user experience in organizations that used those vendors' EHRs. Zynx achieved similar results with its partners Epic and Siemens, but it didn't perform as well with other EHRs.

Another vendor, CPMRC, received praise from its clients for its interdisciplinary capabilities in areas of the hospital outside of nursing, such as social work and respiratory, physical and occupational therapy.

KLAS looked at the performance of drug databases from Cerner Multum, First Databank and Wolters Kluwer Medi-span. As in past studies, alert fatigue was cited as the biggest problem with drug databases. Providers say that most alerts are unnecessary, and managing them is labor- and resource-intensive. One executive of a medium-sized hospital told KLAS, "It takes 1.5 FTEs to stay on top of managing the alerts."

What providers want is a more concerted effort from the database vendors to make the alerts meaningful, and from EHR vendors to make the alerts patient-specific. A quarter of respondents cited the ability to turn off low-severity alerts and to manually configure alerts as ways to make drug warnings more meaningful.

"Most providers were only moderately successful in managing medication alerts," the report said. "Making meaningful changes to drug alerts at a vendor level has been a challenge, and providers would like more control to customize alerts."

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