The mother of invention. A physician owned medical group builds its own clinical decision support tool and brings it to the open market

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Decision Support

Willey,C. The Mother of Invention. A physician-owned medical group builds its own clinical decision support tool and brings it to the open market. Health Management Technology 2007,Aug:28(8):12-5.

Question: What is involved in the development of successful clinical decision support (CDS) for primary care, and what are the impacts and outcomes of that CDS?

Data Source/Setting: Dr. Charles Willey,CEO of Esse Health, a “progressive physician-owned medical group in St. Louis”.

Intervention: The paper reviews the development of Purkinje, a clinical decision support(CDS) system company offering Care Series, an electronic practice management and health record solution. The author presents the background for a product that initially began on paper and has now morphed into a Web-based CDS product founded by Esse Health and marketed to physicians, hosting the software on behalf of each practice. In 1996, a practicing internist frustrated by his lack of ability to make good cost/quality tradeoffs in his prescribing behavior in practice developed a paper-based prescribing guide that he shared with his colleagues. By 1998, 10 other physicians and pharmacists were contributing, and the decision was made to build an electronic CDS “by doctors for doctors” by this group. The electronic CDS was diagnosis-driven and allowed all relevant material to be presented each and every time a physician prescribed. It also includes extensive patient education materials that present a balanced view of drug therapy options and promote self-care. The system stores and manages patient problem lists.

Main Outcome Measures/Results: The group commissioned a study to determine the actual impact of the software on patient care, safety, and cost, and found significant impact in all areas. There was a 12% savings in the costs of new prescriptions and refills, generic prescribing rates climbed to 75%, there were more rapid notification of physicians when drugs were withdrawn from the market for safety issues In addition, Esse Health was at the top of plans in Missouri for patient satisfaction by the latest CAHPS study. Also of note is that Esse physicians have twice the incomes by industry standards.

Conclusion: By following a mantra “by doctors, for doctors” and gathering feedback on how CDS works best for physicians, Esse Health has established Care Series, a CDS system that has had a positive impact on patient care, safety, and cost within their healthcare group. Their system was designed to 1)eliminate the cost barrier, 2)not disrupt workflow, 3)eliminate risk by making evaluation transparent, Web-based and convenient, and 4)achieve rapid and non-disruptive implementation.

Comments: This clearly progressive medical group in St. Louis successfully demonstrates the positive impact of a CDS system. There was clearly universal support by the physicians in the group for the system, which may not at all be the case outside a group of this size, and certainly not in small physician practices which comprise 70% of healthcare in the U.S.(author’s figure). There is no discussion of any problems with implementation of the software, workflow reengineering, and physician resistance, which are inevitable with changes to the use of electronic health records and CPOE. The paper does point out, however, the importance of “all politics being local”, and their success with a locally grown system. A successful CDS software system must be able to incorporate local nuances to algorithms, and it is unclear if Care Series has that capability, or if this may preclude its ability to be franchised farther than a regional system.

Sandy Mendel

Introduction: The small, 60-physicians primary care provider created a new way to “challenge the status quo related to patient care, cost and physician reimbursement.” They came up with decision support software at the point of care --- at the point of decision making.

Objective: To reduce medical errors in small and medium-sized practice groups. Specifically, to resolve the problem related to their being “little time to keep appraised of the latest information on various medications, their efficacy and how much they actually cost.”


12 percent savings in the costs of new prescriptions and refills.

Generic prescribing rates had all climbed to about 75 percent.

Esse Health's (their subsequently formed company) came up with diagnosis-driven (4000 diagnoses included) electronic prescribing software called Purkinje that guides clinicians’ prescribing decisions by presenting prescription costs, efficacy, and “adverse effects and short- and long-term outcomes of treatment strategies for common problems in pharmacotherapy.”

Comments: One of the doctors that used the system had said it helped him by preventing him from harming patients. Another doctor had saved his patient saved 1800 per year in prescription costs. This system clearly increases the quality of healthcare while lowering cost. --Crawford 14:56, 1 November 2007 (CDT)