As a geriatrician, Paula Rochon’s job was to improve the health of the elderly patients and residents at the Baycrest Institute in Toronto. As the former senior scientist of that institute, she’s helped build the technology that makes doing that job easier.
(Rochon has since left Baycrest and is now VP of Research at Women’s College Research Institute.)
Baycrest completed a rollout of both a computerized order entry system (CPOE) and an electronic clinical decision support (CDS) system back in 2004. It was Rochon’s answer to a growing and disturbing trend – the overmedication of many seniors in nursing homes.
As the elderly face down a number of health problems and find themselves juggling many multi-coloured, drug-filled capsules, they are at more risk of suffering from an adverse reaction. It can be hard for doctors writing prescriptions to know what medications might conflict, and what dosage is safe in every circumstance. Computerized CDS systems are designed to help fix that.
“Because older people, who are often quite frail, require different doses of drugs, the system makes it so amounts are appropriate for the kind of patient you’re prescribing for,” Rochon says. The system, she says, offered “a way to improve the way we did things.”
CDS existed before computers found their way into hospitals. Any system that takes information about a patient and makes it accessible to a doctor in order to help improve the care received can be described as CDS.
“Colour-coded reminders and post-it notes are all examples of clinical decision support in the paper world,” says Anwar Mohammad Sirajuddin, the CDS lead in Information Systems Division at Memorial Hermann Healthcare System, based in Texas.
Sirajuddin says many hospitals are now upgrading their processes to make use of computerized CDS. But the implementation of such a sophisticated system requires a hospital to already have a superior technology infrastructure. It’s also not a cure-all for ineffective work flows, but it can help make a well-run health care facility an even better one.
It’s not the type of software one is just able to buy and install either. Many U.S.-based vendors offer CDS tools in software suites tailored for hospitals, but the tools require a high level of customization with the hospital’s electronic health records (EHR) to be of value.
Rochon notes that no vendor had created a CDS system for a long term care facility, so Baycrest had to build it from the ground up with the help of Meditech.
“Developing the whole system required a big input from all sorts of areas in the organization,” she says. “Not only is the physician writing the order, but the pharmacy is receiving it, and the nurse is processing it and administering the drugs.” It really requires an entire group “to come up with a process that makes sense for the computer.”
The hard work has paid off for Baycrest. The system has helped streamline the process of ordering drugs – the order is now instantly transmitted from doctor to pharmacy. It’s resulted in doctors prescribing lower dosages of drugs, and helped to avoid drug-related health problems.
“It’s made people feel a lot more comfortable about their prescriptions,” Rochon says. “The doctors get some more input to make their decisions. They’re not doing it in isolation, but in a whole context.”
The Chicago-based Healthcare Information and Management Systems Society recently released a guidebook designed for health care facilities making use of an electronic CDS. Sirajuddin was an associate editor on the journal, alongside Dr. Ferdinand Velasco, chief medical information officer at Texas Health.
Texas Health began rolling out its CDS system two-and-a-half years ago. The project is expected to be completed by around 2011. That sort of timeline is typical of large hospitals putting a complex CDS system in place, Velasco says.
“It’s almost a philosophy rather than a specific technology set,” he says. “Those who aren’t as sophisticated in their understanding of decision support think it is just something you can buy and install. But it’s not.”
Hospitals can’t be too aggressive in rolling out a CDS system because there is a danger of overwhelming staff with the information being made available, he adds. It is wise to make sure that your operations are running well, and then introduce different tools and components of the complex system, one phase at a time.
“If users feel they are getting too many alerts or reminders, they are not really integrating the information,” he says. “Physicians may start to ignore the alerts at the expense of patient safety.”
Baycrest had a similar approach when introducing its system. Coming up with the appropriate rules to alert physicians and then making sure they only appeared when needed was a long process, Rochon says, but worthwhile.
Baycrest, she says, didn’t want to create a system that bombarded doctors with messages everytime they sought to do something. “Then people won’t pay very much attention to what you’re telling them to do.”
The system was thought out soit works in the background as much as possible, she adds. For example, instead of alerting a doctor who has prescribed too high a dose of a drug, the system just calculates the appropriate amount to give.
All that, and the system has solved the long standing problem of illegible doctor handwriting on prescriptions, too.