healthcare technology

A fundamental question about any (Clinical Decision Support System) CDS is just how good is it, i.e. does it get the right answer for generic and specific patients? If it doesn’t this may be the result of one or more issues such as flawed information having been used to build the system, flawed programming, or the patient being outside of an often undefined or ill defined population when for another population the CDS does actually provide the right answer

A common CDS disclaimer is that it is always up to the practitioner to second guess the CDS as necessary, or in other words, the CDS is not actually supposed to be relied upon. Depending on the complexity of the underlying theory and data, the practitioner may or may not in reality have the ability to do this, or they may not have a more rational basis for doing so than “I don’t think that is right”. Such a conclusion would put the practitioner outside of what might be considered a practice guideline. On the other hand if a CDS is easy to second guess, then it might not be very valuable in the first place.

In this context comes the recent controversy over the new cholesterol and statin on line “risk calculator”. As first reported in the New York Times, it was determined that an online risk calculator overestimated patient specific risk by an average of 100% (100 here is not a typo). If action were based on this erroneous calculator, statin therapy would be substantially over-prescribed. In this regard the Times cites a statement from the organizations that published the guidelines that will continue to be a CDS classic: patients and doctors should discuss treatment options rather than blindly follow a calculator. Or, in other words, it is not to be relied on.

Apparently the problem with the risk calculator is at least in part that the risk data on which it was based was decades old and therefore did not apply to the current US population which in at least some ways has actually gotten healthier. In addition the mathematical model used was one of linearly increasing risk which has not been demonstrated to be correct. Thus the flaws in the calculator were a result of the inappropriateness and lack of justification of the knowledge bases used to build it. Despite these fundamental issues, no plans to remove or revise the calculator were identified.

This risk calculator was not imbedded within an EHR, and it requires manual input of multiple patient parameters. And of course there are additional potentially relevant patient parameters that are not part of the calculation. However something like this certainly could be part of an EHR either by direct integration, or by pointing the EHR user to it and perhaps automatically using relevant patient information that might already be in the EHR. 

more at http://www.hitechanswers.net/lesson-clinical-decision-support/

Patient engagement, defined as the process of placing patients at the center and in control of their own healthcare, is becoming a chief healthcare priority

Concurrently, a number of national information infrastructure initiatives are targeting increased patient engagement and the design of health information systems that improve the availability of health information and integrate it in meaningful ways for patients.  So far, these technology goals have been advanced primarily through the design of personal health records (PHRs), patient portals, electronic health records (EHRs), and health information exchanges (HIEs).  However, we remain far from achieving the goal of truly engaging patients in their care.

Generation and exchange of health data with patients is a requirement for Stage 3 EHR meaningful use incentives. Patients are entitled to an electronically generated copy of the record of their encounters with providers. 

Sharing provider-generated data with patients is expected to promote patient engagement and accountability, but our own experiences suggest that the data that are being shared are currently a mixed blessing.  For example, one encounter report took the form of a 6-page document in which the vast majority of information was copied and pasted from previous encounters and in which there were several factual errors. The errors will be discussed with the provider during the next visit.

Certainly the report got our attention; whether empowerment will result remains an open question.  On another occasion, although the visit itself had included making decisions about future treatment, the plan was not mentioned in the document, leaving the patient to rely on her own memory and notes.