Clinical decision support preferable to subsidized EMRs

December 1, 2008

Managed healthcare executives should take a new look at diagnosis decision support, which is less expensive than EMRs

Many health policy experts believe that "if you subsidize it, they will come." While that approach has worked in persuading people to take mass transit, it hasn't lured many physicians into using EMRs.

Employers and hospitals will face financially more difficult times in 2009, and is time for managed healthcare executives to take a new look at diagnosis decision support (DDS), which will align physicians and hospitals in the shared goals of improving patient outcomes and reducing clinical risk This technology also comes at a much lower cost and can be rolled out much more quickly than EMRs.

DDS technology is not new. It has been available in various forms since 1986, but as computer hardware has become vastly more powerful, the newer versions of the systems have become faster and more practical for physicians to use. Many hospitals have adopted DDS in the past two years, as medical executives realize the importance of getting to the right diagnosis as fast as possible because of its effect on length of stay, appropriateness of testing and subsequent treatment and clinical risk.

Early versions of DDS technology were frustratingly slow. At the heart of these early systems was a crude form of artificial intelligence (AI). The software required the input of multiple experts to provide semi-probabilistic relationships between thousands of clinical features and hundreds of diseases.

Physicians also spent a considerable amount of time interacting with them, answering a hierarchy of questions. Published trials reported that it took physicians 20 or 30 minutes to enter the data and arrive at a final set of decision options.

Dr. Robert Wachter is Associate Chairman of the Department of Medicine at the University of California, San Francisco and author of two books and a blog on hospital medicine. He has written of the frustrations and "overhyping" of the early diagnosis decision support programs.

According to Dr. Wachter, "the disappointment over the ineffectiveness of the early programs led to widespread skepticism that any DDS could help physicians be better diagnosticians."

Today's computer systems are thousands of times more powerful than those of the 1980s. This vastly improved performance has enabled a variety of different clinical decision support systems to be adopted in hospitals, large and small, across the country. DDS systems today provide clinicians with prescribing decision support, image recognition and interpretation, therapy planning and patient alerts.

One of the key reasons physicians have been reluctant to adopt EMRs in their practices is the hassle factor. Many medical groups have found that installation of an EMR shifts the burden of inputting patient medical information from nurses and clerical personnel to the physicians themselves and may reduce their patient flow (and potential income).

The new DDS systems largely avoid this problem. The physician might enter a few patient demographics (e.g. age, gender) and a few key words about the symptoms, and a list of likely diagnoses is often generated in seconds.

In addition, DDS systems have another key advantage, they reduce the rate of diagnostic error. Although rarely discussed, diagnostic error is a serious problem. A report in the May 2008 American Journal of Medicine found that diagnostic errors occur in 15% of all clinical medicine cases.

Dr. Wachter notes that until we resolve the issue of diagnostic errors, we face a fundamental problem in patient safety: A hospital can be seen as a high quality organization because for example, all of its pneumonia patients receive the correct antibiotics-even if every one of the diagnoses was wrong.

Joseph Britto, M.D., is chief executive officer of Isabel Healthcare in Falls Church, VA.