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Crico/RMF-published guidelines

Effective Use of Clinical Decision Support

By Gianna Zuccotti, MD, CRICO

Related to: Ambulatory, Clinical Guidelines, Diagnosis, Primary Care, Other Specialties

Malpractice cases alleging a failure or delay in diagnosis in the ambulatory area highlight a need to optimize the availability and integration of clinical decision support tools into provider workflow to enhance consistent delivery of evidence-based care. Several current processes integrating clinical decision support in CRICO offices are highlighted below, using the CRICO Breast Care Management Algorithm as an example.

  • Maximizing use of printed copies

Challenges exist in ensuring that content of clinical decision support tools are readily available to the provider at the time of patient visit or review of test results. Printed material poses unique challenges, as there is a tendency to file or shelve guides rather than actively circulate them. To maximize provider familiarity with content and optimize availability, practices might schedule an in-service during which guideline content is reviewed and discussed. Algorithms can then be strategically placed in key locations where they can be accessed by clinicians reviewing imaging and laboratory results and determining next steps in treatment.

  • User-activated Decision Support

Electronic medical records (EMR) may have clinical support content available to be accessed by the provider. The term “user-activated” decision support describes information available within the EMR but requiring the provider to access it (usually via an extra click that pulls up a new window with the content). This type of decision support brings the content closer to the point of decision, but continues to require the provider to recognize his or her need for additional guidance and to seek out recommendations.

  • Automatic Decision Support

Reminders derived from guidelines for disease management and screening are examples of “automatic” decision support. Within the EMR used by Partners Healthcare, the CRICO Breast Care Management Algorithm has been operationalized to generate a reminder that a patient is due for mammographic screening. Combining user-activated and automatic decision support is one way to further leverage IS functionality to facilitate medical care. The Partners Results Manager module displays an automatic alert for all patients with mammogram results needing additional action. If the physician clicks the link within the alert, the CRICO Algorithm pops up, enabling the clinician to confirm what action is best taken.

A potential future enhancement to automatic decision support would allow additional synthesis of patient-specific information, such as abnormal test results or demographics. A behind-the-scenes IT process derived from clinical guidelines such as the CRICO Breast Care Management Algorithm could “run,” and the clinician would be presented with evidence-based recommendations to assist in deciding on further diagnostic work up and treatment.

Detailed description on processes related to clinical decision support can be found in CRICO’s What Works, a collection of practice-based solutions designed to ensure reliable and high quality care in the office environment. We encourage you to evaluate them and tailor them to the needs of your own practice.

The CRICO Breast Care Management Algorithm, newly revised this year, reflects the latest clinical evidence and now includes physician-patient discussion points related to cancer diagnosis and patient safety. A task force of breast care experts from the Harvard-affiliated medical institutions worked to streamline the advice to primary care providers regarding breast cancer risk assessment and screening.

June 1, 2009
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