Supporting clinical decisions for physicians

Clinical decision support software can be invaluable in a triage service: it will remind staff of conditions that fit the symptoms a caller is describing and prompt them to ask the relevant questions to check on the possibilities, or propose sensible actions.

Isn’t that exactly what we want for doctors too? Shouldn’t they be prompted to consider all possible explanations of a patient’s condition? Might they not also need an occasional reminder?

Things, sadly, are not that simple. As long ago as 1999, the Journal of the American Medical Association carried an article on ‘Why don’t physicians follow clinical practice guidelines?’ They found a number of barriers to the use of guidelines (that’s guidelines in general, irrespective of whether they’re drawing on software support). They may not be aware of their existence. They may be put off by the sheer volume of guidelines out there. They may, quite simply, not have the time to consult them.

Systems should support delivery of patient care, not distract from it

That last objection is one I’ve heard from General Practitioners (family physicians) in Britain. On average, they have ten minutes for each patient consultation, which means the useful time is around seven and a half minutes. Pulling a book out to check on a guideline simply takes too high a proportion of the available time. “I would never consult a guideline,” one GP told me.

Most British GPs use a computerised system these days. Even then, though, they don’t want to have to call up their decision support system and work through it to see whether it has anything to suggest. “I don’t want to have to check my system to be told that a patient coughing blood needs to be checked for possible cancer. If I didn’t know that, I shouldn’t be in this job.”

They also don’t like it if their screen is full of popup alert windows. They need their screens to contain the information that’s useful to them. They don’t want it cluttered.

Despite all that, we all know that diagnoses are sometimes missed. Recently, it was announced that heart attacks are missed in one-third of British women who have had one. Why? Because it’s with men that physicians first think of heart attacks. With women patients, the first thought is much more likely to be cancer. That’s despite the fact that experts point out that women are as likely to suffer a heart attack as men are.

So what’s the answer for a clinical decision support supplier?

First of all, although there does have to be an alert to doctors concerning the presence of decision support information, it needs to be discreet – it mustn’t take up too much space on screen. It just has to be eye-catching enough for the physician, whether a GP or in a hospital, to realise that the system has something to suggest. He or she can then choose to consult it.

Secondly, once the physician has gone into the decision support system, it should not require him or her to select a specific pathway – say lung cancer rather than congestive obstructive pulmonary disease. Instead it should be assembling the symptoms and findings already recorded and, if they are compatible with either condition, propose further questions to ask, or tests to carry out, in order to eliminate one or other of the possibilities.

Thirdly, it has to be constructed to as to save the physician time, not cost more. So as well as supporting the clinical decision, it should also support the process itself. For example, for a GP, does a letter have to be produced for a referral to hospital care? Then the system should produce it. That way the physician doesn’t have to flick between systems and, if anything, the use of it will save time that can be used for the consultation itself, listening to the patient or providing advice.

What does that all mean? That there is indeed a vital role for a clinical decision support system to play in supporting physicians. But it needs to be highly intelligent in design, to ensure that while it benefits patients it does not do so by distracting physicians from their main purpose: helping in every way possible to alleviate suffering and reduce ill health.

That’s one of the most exciting and satisfying challenges that healthcare information work provides today.

Supporting clinical decisions for better triage

Most of us understand the need to keep healthcare costs low. On the other hand, when we become patients, we’re not keen to see savings made at the price of increased risk. When it comes to avoiding the avoidable in healthcare, we like to think that costs are unavoidable if they ’re incurred ensuring our safety.

The Netherlands have an out-of-hours service patients can call when their GP practice is shut. The aim is to reduce visits to emergency departments in lieu of family practitioners. Nurses take callers through guidelines, asking a series of questions to establish what care the patient needs and with what urgency.

An out-of-hours call centre at work

A 2007 study set out to find out how well the service was performing. The results were disturbing. In 19% of cases, nurses underestimated the urgency of the patient’s condition. The study’s authors conclude that the service was “possibly not safe,” which feels like an understatement.

Denmark’s out-of-hours service gives evidence of the opposite effect: excessive caution by nurses. The Danish service is principally staffed by GPs, but there’s pressure to use nurses as an economy measure. However, a 2013 investigation found that nurses might be too inclined to refer a case for a GP to see instead of taking a decision themselves. The result? On top of the cost of employing the extra nurses needed, the service, far from reducing calls on GP time, might increase them. Costs could rise instead of falling.

What’s the answer? How can we reduce expenditure by having nurses or, even better, non-medical staff, take responsibility for triage, without either increasing risk to patients or incurring higher costs?

The 2007 Dutch study came up with one answer: it found that the more training nurses had received in the use of the call centre guidelines, the less frequently severity was underestimated. Certainly, telephone triage isn’t simply another application of already acquired skills. It’s a legitimate healthcare service in its own right, needing its own knowledge and expertise.

There is, however, another way in to  improve services. That’s the field in which I’m currently spending much of my time: clinical decision support.

What we’re talking about here is software that helps nurses or non-clinical call handlers work their way through guidelines. At the most trivial level, such software can ensure that nothing’s forgotten. A question might be mandatory, so the handler simply can’t move on until it’s asked. That would ensure essential information isn’t missed. Even with optional questions, their mere appearance on a screen would at least prompt the handler to ask them and might trigger a new line of enquiry.

That, however, is far from enough. There has been research (not enough, yet, but what there has been is telling) into the impact of clinical decision software. A revealing article showed that a call handler might be pushed down the wrong line by the software itself. It cites the example of a handler, a nurse, who had begun to explore what the software offered on the subject of nausea, while the caller had moved on to talk about back pain. With one line of questions already under way, the call handler failed to pick up the second symptom, however important it may have been.

Again, on some occasions, the lack of an appropriate response to certain questions led to a distorting effect: the patient was saying that she felt sick each time she ate, but the software hadn’t allowed for that reply, imposing instead quantitative entries – once a day, three times a day, and so on.

That’s what makes the search for effective software design such an interesting challenge. It’s not enough just to list all possible questions, in a fixed order. It’s vital to take all the information concerning any particular patient into account, without deciding too soon that one item has overriding importance or letting the software itself drive the direction of the investigation. In fact, the system has to:

1. take into account all the information about the patient, entered in whatever order. In other words, as in a real, face-to-face medical consultation, the patient should be able to describe all his or her symptoms without making a judgement about which is the most important 
2. suggest questions to the call handler based on all the symptoms, not just one of them 
3. drop irrelevant questions but propose all the others 
4. handle unquantified information, such as “I feel sick each time I eat”

That would be the kind of clinical decision support software that can really make a difference, because it emulates what happens in a medical consultation: the patient describes symptoms as they come to mind, not in an orderly or pre-filtered way. Alongside the kind of comprehensive training we’ve already seen is needed, such support software could bring us closer to the goal we seek: a triage service that delivers a reduction in costs without an increase in risk.

In fact, it would be valuable for far more than triage. It can make a major contribution to managing medical pathways in general. But that’s the subject of my next post.