Do No Harm

Clinical decision support , a first cousin of performance support , is helping doctors reduce medical errors and save lives.



Eight-year-old Ben Kolb died during minor ear surgery because he was given the wrong drug. Boston Globe health reporter Betsy Lehman died after receiving a chemotherapy overdose. Libby Zion, an 18-year-old college student, died when a drug she was taking reacted with another drug doctors gave her.



Unfortunately, they're not alone. A November 1999 report from the Institute of Medicine (IOM), a non-profit branch of the National Academy of Sciences, estimates that anywhere from 44,000 to 98,000 Americans die each year as a result of medical errors. Even the smaller figure is higher than the number of people who die because of either car accidents, breast cancer or AIDS. The institute's researchers also found medical mistakes that don't result in death cost $17 billion to $29 billion annually.



The report's findings weren't much of a surprise to the medical community , the IOM used previously published studies as the basis of its research , but the public outcry following its release was a wake-up call for physicians, health care administrators and patients. Although the report warned that there's no "magic bullet" that will easily solve the problem of medical errors, many physicians and hospital administrators believe certain types of technology can go a long way toward reducing them.



"People are now more eager to embrace technology. They're starting to see that computers can save lives," says Jonathan Teich, corporate director for clinical systems research and development at Brigham and Women's Hospital in Boston, part of the Partners Healthcare System. He is also a practicing physician there.



Among the ways computers save lives, he says, is by providing clinical decision support, another name for what we in the e-learning industry refer to as electronic performance support. The basic idea behind these systems is that they give users relevant information exactly when they need it, prompting them to respond in a certain way.



For instance, using a performance support tool, a repair technician who works on copy machines could enter the model number of the machine, follow the prompts through a series of diagnostic options, and repair the copier without needing to page through thick manuals. Or a call-center employee who helps customers solve computer problems could use a performance support tool to walk through questions that would pinpoint likely solutions. In both of these examples, the people doing the work don't need to memorize and carry around massive amounts of data in their brains; the computer does that for them.



Of course, fixing paper jams and helping customers figure out why their computers are on the fritz is entirely different than dealing with the life-and-death situations doctors face every day. But the technology works in a similar way.



Since the days of Hippocrates, doctors have followed what are known as "clinical pathways," which are a series of appropriate decisions based on accepted rules. "If the kid sitting in front of you has spots on his chest and a temperature of 102 degrees, you think to yourself, "Hmm, could be chicken pox,?" says Charlene Marietti, a medical technologist and editor of Healthcare Informatics magazine. "You've already started down a clinical pathway. With decision support, those rules are simply codified into an algorithm."



Say a doctor is treating a 50-pound child and accidentally enters a prescription for a drug dose that's appropriate for a 150-pound adult. In a paper-based system, that error might go undetected, resulting in injury or death. But if the doctor prescribed that same dose using a computerized system, the software would point out the error.



Decision support can be even more powerful when it's linked with a patient's medical history, says John Halamka, associate dean of Harvard Medical School and chief information officer for the CareGroup health care system in Boston. This digital connection between individual records and medical rules is especially helpful for detecting allergies and drug interactions, he says. For example, the system might tell a physician, "Warning! This patient has renal dysfunction and is allergic to penicillin. We recommend that you choose this other drug instead."



Not only do such computerized systems keep mistakes from happening, but they may also help doctors learn in the long run, says Teich. "On one hand, clinical decision support prevents errors and changes care plans for the better. That's its most immediate effect," he says. "But in the process, it also educates the person doing it. In fact, we call this just-in-time education. It gets deep into your memory because it's happening at a critical moment for you."



Some decision-support systems even link doctors to studies that relate to the case they're handling, allowing them to bookmark the information for future reference.



Teich and his team are currently doing research to determine whether these systems actually change doctors? behavior in the long term. "It's really a fundamental question in education: Do computerized clinical decision support systems improve or hinder the education of doctors?" he says. "On the one hand, they could improve it, because you keep getting these reminders that are very focused and germane. On the other hand, they could hinder it because they could make people dependent on the computer system."



Although he doesn't have any solid results from the study yet, Teich says computerized order entry , a system that allows doctors to order everything from lab tests to X-rays to medications online , and decision-support technology have reduced serious adverse events by 55 percent at Brigham and Women's Hospital. (In the study, an adverse event is anything that prolongs the patient's hospitalization for one day or more or that reduces the patient's capabilities when he or she is discharged.) The systems have also saved an estimated $5 million to $10 million per year at Brigham and Women's by eliminating redundant tests and unnecessary prescriptions, he says.



A more controversial and less common type of clinical decision support is diagnostic support, which actually guides physicians through the process of figuring out what's wrong with a patient. According to Halamka, these systems have been widely criticized as being far less accurate than a doctor's own knowledge and experience. "The New England Journal of Medicine did a review of these systems and found that the best of them is no more than 50 percent accurate," he says. "It's like flipping a coin, so why bother?"



But others point out that while diagnostic support systems may not be reliable enough to take the place of a physician's own know-how, they can help doctors identify certain rare diseases they don't see on a regular basis. "Physicians normally encounter the same types of conditions, day after day, week after week," says Marietti. "They don't necessarily think to ask a patient, "Have you been traveling in Africa?" Those kinds of questions may be very critical to an end diagnosis, but since it's not part of their normal process they don't really think of them."



Edward Septimus, medical director of infectious diseases at Houston-based Memorial Hermann Healthcare System, says his hospital system hopes to implement some sort of diagnostic support in the next two or three years. "We may want to put some of this information on the computer just to make sure physicians don't forget anything," he says.



Despite decision support's role in reducing medical errors, these systems haven't yet enjoyed widespread use. That's partly because they're often tied to electronic medical records (EMR), a technology that allows doctors to enter and view computerized patient records. Only 5 percent of U.S. doctors are currently using EMRs.



The slow rate of adoption has several explanations: concern about who has access to patient data, a lack of standards among EMR vendors, the high cost of the technology and resistance on the part of physicians to learn a new system. Septimus, who enters all of his orders electronically, says many doctors complain that electronic entry takes too much time. "Writing is still quicker," he says.



Good decision support is also difficult when a patient's primary care physician has one set of records, his podiatrist has another, and his dentist has still another. Even if most of those records are digital, there's no quick way for one physician to check a patient's complete set of records, especially if they reside on different computer systems that may not be compatible with each other. Instead, they must be laboriously copied and faxed from one place to another.



Even in ahead-of-the-curve organizations like CareGroup, which was described by InformationWeek as being one of the most Web-enabled health care systems in the country, there's still the challenge of making the technology fit seamlessly into physicians? daily lives and routines. "You have to show doctors that [these systems] will shave time off their day and make patient care much safer," says Halamka, who's currently rolling out a computerized order entry system that will go live on April 1. "Just putting it out there and saying, "Use it. You'll like it? doesn't work."



When it comes to integrating decision-support technology into doctors? routines, wireless devices may hold a great deal of promise. "The last two years were about the Web. The next year is about wireless computing," Halamka says.



According to an October 2000 report from research firm WR Hambrecht and Co., 15 percent of U.S. physicians are using handheld devices for reference purposes, such as storing phone numbers and looking up drug information. Barely 1 percent are using them for "transactional purposes" , writing prescriptions, ordering lab tests and accessing patients? medical history. That number is expected to jump to 20 percent by 2004, the report says.



The advantages of handheld wireless devices over desktop computers , or even laptops , are obvious. Most doctors don't spend a lot of time sitting at their desks; instead, they're constantly running from one appointment to the next. Wireless devices would allow them to check patient records, schedule appointments and enter prescriptions on the fly, without having to go out of their way to use a desktop computer in a set location. And since handhelds are lighter than laptops, physicians are more likely to want to carry them around.



Physicians at Beth Israel Deaconess Hospital, part of the CareGroup

system, are already using Palm Pilots to access records in the emergency department. Previously, they used a white board in the emergency room to keep track of patients? progress. But the writing on the board was often illegible and the information outdated. And because the board was located in a public area, everyone could see the information on it, thus violating patient confidentiality, Halamka says.



The white board has since been replaced by Palm Pilots. "Our emergency physicians can look at their Palm devices to see that we have 23 patients, and Mrs. Smith just rolled in with chest pain and is in bed 1-A," says Halamka. "All the patient management is done wirelessly."



But the technology still has a way to go before physicians embrace it wholeheartedly, Halamka says. Battery life is an issue, and user interfaces are still too clumsy for most time-pressed physicians. "Try taking notes on a Palm Pilot. It's not so easy," he says.



Memorial Hermann's Septimus uses a Palm Pilot to look up drug interactions and receive updates from pharmaceutical companies, but that doesn't necessarily mean the system is wireless. In order to send a prescription to a pharmacy, he has to enter the information into the palmtop, go to the docking station, print out the prescription and fax it to the pharmacy. Although the computerized entry cuts down on potential errors, the system remains paper-based at its core. Septimus says he's about six months away from introducing truly wireless capabilities, in which a doctor could beam a prescription directly from a Palm Pilot to the pharmacy using a secure Internet connection.



That type of instant convenience is the key to integrating technology into doctors? lives, Marietti says. "One of the biggest problems with decision support is that physicians often have to go outside of their normal working environment , be that physical, or even just another screen , to get to it," she says. "It can't be that difficult. It has to be there for them when they need it."



-Amy Sitze (asitze@onlinelearningmag.com) is editor of Online Learning Magazine.



COPYRIGHT Bill Communications Inc. 2001. All rights reserved.