Impact of EHR-Based Clinical Decision Support on Adherence to Guidelines for Patients on NSAIDs: A Randomized Controlled Trial

James M. Gill; Arch G. Mainous; Richelle J. Koopman; Marty S. Player; Charles J. Everett; Ying Xia Chen; James J. Diamond; Michael I. Lieberman

doi:10.1370/afm.1172

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Response to Dr. Kibbe regarding EHRs and Clinical Decision Support
James M Gill

Published on: 22 February 2016
Not automatons
Wilson D Pace

Published on: 22 January 2011
A valuable contribution
David C. Kibbe, MD MBA

Published on: 18 January 2011

Published on: (22 February 2016)
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Response to Dr. Kibbe regarding EHRs and Clinical Decision Support
James M Gill, Newark, USA
I appreciate the comment from Dr. Kibbe about our article on the impact of EHR-based clinical decision support. I am particularly pleased to have comments from someone who has been a leader in Health IT for the AAFP and other national organizations, as Dr. Kibbe has. As he points out and as this study demonstrates, EHRs by themselves don’t “magically improve care”. Even when clinical decision support (CDS) is incorpora...
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I appreciate the comment from Dr. Kibbe about our article on the impact of EHR-based clinical decision support. I am particularly pleased to have comments from someone who has been a leader in Health IT for the AAFP and other national organizations, as Dr. Kibbe has. As he points out and as this study demonstrates, EHRs by themselves don’t “magically improve care”. Even when clinical decision support (CDS) is incorporated into the EHR (as was done in this study), it does not “magically improve care”. In fact, EHR-based CDS has been inconsistent in its impact on quality of care, especially for chronic disease management. 1 We feel that the main reason is that most EHR-based CDS is not well suited to fit seamlessly into the clinician’s workflow, and does not support the Patient Centered Medical Home model. 2 One of the greatest challenges is to determine how to best do this. So it is essential that future studies examine not only impact on quantitative quality measures, but the impact on qualitative measures of the barriers and facilitators of CDS in a typical office practice. We only began to touch on that in our study.
I also want to answer one question raised by Dr. Kibbe. He asked if the intervention had an impact on longer-term outcomes such as gastrointestinal (GI) complications and hospitalizations for these complications. We actually did measure outpatient diagnoses of GI complications, but were not able to measure hospitalizations. We found that outpatient diagnoses for GI complications during the study year were actually higher for the intervention group compared to the control group (5.5% vs. 3.1%, p < 0.05). However, we were not able to determine if these were actually new problems, vs. simply a heightened awareness to symptoms.
Given the national effort to implement EHRs, the drive toward “meaningful use” (including EHR-based CDS) and the funding to support that goal, it seems logical that there would be more data on how EHR-based CDS can actually improve care. However, we are not there yet. Hopefully this paper can help to stimulate discussion such as that initiated by Dr. Kibbe, to challenge researchers, clinicians and policy-makers to develop systems that can actually move us toward true meaningful use of EHRs.
1. Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Annals of Internal Medicine. May 16 2006;144(10):742-752. 2. Bates DW, Bitton A. The future of health information technology in the patient centered medical home. Health Affairs. 2010;29(4):614-621.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (22 January 2011)
Page navigation anchor for Not automatons
Not automatons
Wilson D Pace, Denver, CO USA
Dr. Gill's group has conducted an excellent study of clinical decision support embedded in EHRs. This is a very timely article given the recent meaningful use criteria that have been published that include clinical decision support (CDS) requirements. Dr. Kibbe's comments are appreciated and I support them entirely. The CDS system as described which included options to turn off the recommendations for a single visit or pe...
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Dr. Gill's group has conducted an excellent study of clinical decision support embedded in EHRs. This is a very timely article given the recent meaningful use criteria that have been published that include clinical decision support (CDS) requirements. Dr. Kibbe's comments are appreciated and I support them entirely. The CDS system as described which included options to turn off the recommendations for a single visit or permanently indicated it is a more advanced system them many and developed by individuals with reasonable expertise in designing these systems. The article rightly points out that reminding physicians to do something that they don't clearly believe in has limited impact on their care. Perhaps this is a good sign of clinician independence from automatically following recommendations.
The ability to use centralized systems to develop and disseminate CDS algorithms is a strength of this study and in my experience the only way to move CDS along across multiple practices in an expeditious manner. That said, local adjustment of algorithms is also critical to acceptance of the recommendations. It is not clear whether these practices were allowed to adjust the algorithms or not. While this makes studying the impact of CDS more complex (response rates to recommendations versus population based changes) it may create systems that people don't ignore as frequently as they endorse the reminders.
We still have a lot to learn about providing effective CDS within the busy, primary care office visit and this article continues us down this learning curve.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (18 January 2011)
Page navigation anchor for A valuable contribution
A valuable contribution
David C. Kibbe, MD MBA, Oriental, NC, USA
I'd like to thank Dr. Gill and colleagues for performing this study and writing such an engaging and readable report of their findings. This article definitely is a contribution to the debate about, and furthers our understanding of the complexity involved with, the use of EHR- based decision support in improving the quality of the care of patients with chronic conditions.
In short, health IT is not a panacea...
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I'd like to thank Dr. Gill and colleagues for performing this study and writing such an engaging and readable report of their findings. This article definitely is a contribution to the debate about, and furthers our understanding of the complexity involved with, the use of EHR- based decision support in improving the quality of the care of patients with chronic conditions.
In short, health IT is not a panacea. EHRs don't magically improve care, even when used appropriately and with deliberate attention to detail by doctors who care enough about their outcomes to study them carefully.
As the authors point out, only about half of the physicians in the study bought into the guidelines underlying the judgment as to appropriate intervention for patients on low-dose aspirin and elderly patients, the two risk factors where there was a positive difference using the EHR. For the other risk factors, namely peptic-ulcer, on steroids or anti-coagulants, the use of the EHR decision support didn't make a difference. Apparently, good docs (and it's my opinion that the majority of physicians who participate in this kind of study are good doctors) carry the decision support needed for patients of this type around in their brains!
And the study doesn't mention the ultimate outcomes here: did any of these patients suffer negative consequences of non-guideline care, e.g. gastrointestinal bleeding requiring hospitalization? And if there were such occurrences, then what happened to the physician's behavior?
But I'm asking too much. What counts here is that the authors have shown that taking a very systematic approach to using EHR-based decision support may not make a whole lot of difference in the achievement of guideline-concordant behavioral change. And this should, and I predict will, cause many of us to pause for additional thinking.
Thank you, and very kind regards, DCK
Competing interests: None declared
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Competing Interests: None declared.