|The Health Record Review
by Dr. Robert Hitchcock
Posted on Mon, Nov 28, 2011 - 08:33 am
High-acuity patients and surging patient volumes combine to make the emergency department (ED) a care setting with high variability and potential for medical error.
The ED clinical team can be greatly helped by electronic health record (EHR) tools with embedded or add-on clinical decision support (CDS) that supports both patient safety as well as throughput efficiency to reduce such risks.
Following are five key reasons why CDS should be used in the hospital ED:
1. Reduce the risk of medication errors. Determining accurate medication doses can be daunting — and especially critical for infants and children in emergency situations. Calculations involving complex formulas are often difficult to memorize, and mathematical errors can still occur even when the formulas are accurately recalled. Varying dosing regimens based on indication and pharmacokinetics represent additional opportunities for error. In fact, more than 37 percent of harmful pediatric medication errors are caused by an improper dose or quantity.1 In the ED, CDS can give physicians and nurses easy and quick access to drug-specific dosing calculators, full drug monographs with age, weight, disease and renal adjustment dosing, and much more. Accurate medication information and dosing calculators, easily accessible within the clinical workflow, can provide a significant reduction in errors.
2. Reduce misdiagnoses. Approximately 10-30 percent of medical errors are diagnosis errors.2 Cognitive errors, atypical presentations, provider bias and uncommon disease processes are some of the common causes of misdiagnosis. Decision support can drastically improve the margin of diagnostic error. For example, key information from 50 challenging Clinical Pathology Conference cases reported in The New England Journal of Medicine was entered in a CDS tool, and Isabel Healthcare provided the accurate diagnosis 96 percent of the time. When the diagnosis is not immediately obvious during a care crisis, ED professionals can use differential diagnosis support tools as an aid to rapidly identify diagnostic possibilities.
3. Provide the entire care team with consistent, reliable information. Finding the most relevant evidence-based knowledge can be a difficult task, especially when time is critical. Internet search engines can return thousands of results with varying degrees of relevance and reliability. Medline can provide access to article abstracts, but it often cannot provide the answers clinicians need at the point of care. By arming providers with trusted resources, it is less likely that unreliable information will be used in clinical decision-making.
4. Improve efficiency and patient throughput. The Institute of Medicine estimates that $17-29 billion is spent annually on unnecessary or inaccurate patient care due to misdiagnosis. If clinicians can rapidly determine the correct dose, calculation or diagnosis, they can order relevant tests and make appropriate referrals, saving time and eliminating unnecessary costs for the patients and the ED. Of course, CDS is most effective when it is built into the clinician’s workflow, which minimizes interruptions and dangerous distractions. It is also important for CDS to be incorporated into providers’ workflow in such a way that minimizes alert fatigue.
5. Access all information in one place. Reference textbooks are generally outdated by the time they are published, take up valuable space in the ED and often cannot be found when needed. In contrast, electronic CDS systems can be continually updated and validated. The ability to access the most current medical resources in a central location eliminates the need for multiple logins or investment in additional resources.
While clinical decision support should not replace a provider’s knowledge, experience, intuition or judgment, it can complement the clinician’s skills and enhance the quality of care provided. The ED is an ideal setting for tools that help reduce the incidence of preventable medical errors and adverse events.
1. U.S. Pharmacopeia's MEDMARX database records from 2006-2007
2.Agency for Healthcare Research and Quality, 2005
Robert Hitchcock, M.D., F.A.C.E.P., is vice president and CMIO, T-System, Inc.