Difference between revisions of "Integrating Best of Care Protocols into Clinicians’ Workflow via Care Provider Order Entry: Impact on Quality-of-Carte Indicators for Acute Myocardial Infarction"

Revision as of 03:57, 5 November 2006

This study at Vanderbilt University Medical Center sought to review physician response to acute coronary syndrome. The American Heart Association guidelines for acute myocardial infarction (AMI) include prescription of aspirin and a beta blocker during the first 24 hours of care. The authors note that despite the fact that these interventions are well-documented, adherence to these evidence-based practices are inconsistent with substantial regional variation.

WizOrder is the Vanderbilt CPOE system integrated with decision support. The authors of this study developed ‘Admission Advisor’ as a component of decision support related to physician ordering in the case of patients presenting with acute coronary syndrome. The study separated findings between 1) persons who met the criteria of ‘sensitive for AMI’ upon admission and 2) persons who ultimately had confirmed discharge diagnosis of AMI.

The study followed 540 patients. 313 presented during the pre-intervention phase (prior to initiation of ‘Admission Advisor’) and 227 followed during the intervention phase. Of these 540 patients, 180 had confirmed diagnosis of AMI—105 in the pre-intervention phase and 75 in the intervention phase. During the pre-intervention phase, 60% of patients received the recommended medication regimen. With the addition of ‘Admission Advisor,’ this increased to 70%. When the reviewers looked specifically at the group who ultimately had confirmed discharge diagnosis of AMI, there was no significant change in ordering patterns among physicians. Translate: MD’s were no more likely to prescribe aspirin and beta-blockers to the patients who needed them the most regardless of decision support prompts.

A total of 135 physicians admitted these 540 patients. This fact seems to underscore the value of clinical prompts, since the care of these patients was not pooled into a very small group of specialists who would likely have made aspirin and beta-blockers a routine part of their orders.

Discussion: The authors seemed concerned that this seemingly easy-to-order and easy-to-administer medication regimen has not been universally adopted by practitioners. They acknowledge that there are some patients for whom this regimen is contraindicated: persons with active peptic ulcer, allergy to aspirin, or persons with severe asthma or chronic obstructive pulmonary disease which would preclude using beta-blockers.

If the reader is disheartened about the potential of being treated for an AMI at Vanderbilt, some cautions related to the decision-support design should help ease your anxiety. Prompts from ‘Admission Advisor’ were only given to the identified primary physician. In an acute coronary care presentation, many physicians may be involved in writing orders—and not all of these were prompted about ASA and beta blockers. In some cases, the medications were ordered by an alternate physician, including emergency room staff. Thus, the patient received the recommended care, and the attending physician’s ignoring the ‘Admission Advisor’ prompt was because the patient had already received the medication. From a decision-support-design point of view, it is important to build the system so that the right practitioners get the right information based both on the patient’s presentation of illness and the provider’s specialty.

The hospital had initiated an entirely separate campaign to improve compliance with the AHA guidelines prior to this study. Thus, compliance likely had improved prior to the pre-intervention phase of the study, and there was less opportunity to make a ‘significant’ change in ordering practice through ‘Admission Advisor.’

This study validates several general trends found in other studies. Clinical decision support prompts at the time of order entry do improve the likelihood that practitioners will follow recommended practice. On a percentage basis, it still seems that about half of the time, the recommendations of clinical decision support are ignored or overruled. Sometimes this is due to the fact that the clinician has more information at his/her fingertips than the decision support system has. Sometimes the clinical support is not sufficiently detailed or complex to address real-life clinical situations. The trend of including clinical decision support in electronic health records is expanding, and with it, the likelihood that the decision support recommendations will be followed. As with many innovations, it takes time for systems to provide solid clinical information, and for practitioners to become accustomed to following best practice prompts.

David Schanding, M.A., M.M.