Using Commercial Knowledge Bases for Clinical Decision Support: Opportunities, Hurdles, and Recommendations

Using commercial knowledge bases for clinical decision support: opportunities, hurdles, and recommendations. Gilad J. Kuperman, Richard M. Reichley, and Thomas C. Bailey

JAMIA 13(4):369-371, Jul/Aug 2006

Using e-prescribing as focus and example, this editorial commentary describes the opportunities and hurdles in using commercial knowledge bases for clinical decision support systems, and makes recommendations for knowledge base vendors and clinical information system (CIS) developers in working towards realizing the benefits of clinical decision support (CDS) and accelerating the availability of clinically useful knowledge bases. Two seemingly contradicting words flash in my mind as I read this article: customization and standardization.

This review is useful for clinical information system developers, information technology professionals and administrators who are concerned about implementing improving health care quality and safety.

Introduction

In this article, the authors assert that “the quality and safety of health care leaves much to be desired” by citing two published reports on quality of health care. [1,2] Given the complexity of health care system and barriers to implementing the practices and policies needed to improve safety of patient care, using commercial knowledge bases for CDS is one way towards improving quality and safety of health care.

Opportunities

Reports of studies have shown that computerized medication ordering process using pharmaceutical knowledge bases can reduce medication errors. [3] However, most organizations do not have the expertise or resources to crate such knowledge bases themselves. The solution to this problem of access to medication-related knowledge is to buy a commercially produced knowledge base that contain drug-drug, drug-disease interactions, minimum and maximum dosing suggestions, drug-allergy cross-sensitivity groups, and groupings of medications by therapeutic class.

Hurdles

CDS with commercial knowledge bases are not well received because they generate excessive number of alerts. This causes clinicians to have decreased confidence in CDS and to ignore all alerts (i.e. the unhelpful, nonsense, overly sensitive alerts as well as clinically relevant ones). The authors fear that this decreased confidence in the alerting system and CDS can lead to clinicians’ dissatisfaction with clinical information system and impede the nation’s progress towards the goals of the health IT strategic framework set forth by NIH.[4]

Recommendations

The authors of this article recommend that developers of clinical information systems and vendors of knowledge bases work together to:

1. Design knowledge bases that are customizable, modifiable, and browsable
2. Enable the local customizations be retained and not be affected by the updates
3. Describe for the users how the knowledge base and the clinical system interact
4. Make the customizations made by one user can be exported to another user
5. Adopt standards for knowledge base representation and concept identifiers.
6. Facilitate sharing and evaluation of customization efforts and results.

References

1. McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. The quality of health care delivered to adults in the United States. N Engl J Med. 2003 Jun 26, 348(26):2635-45.
2. Leape LL, Berwick DM. Five years after To Err Is Human: what have we learned: JAMA. 2005 May 18; 293(19): 2384-90.
3. Hunt DL, Haynes RB, Hanna SE, Smith K. Effects of computer-based clinical decision support systems on physician performance and patient outcomes: a systematic review. JAMA. 1998;280:1339-46.
4. Department of Health and Human Services. Goals of the Health Information ?Technology Strategic Framework. http://www.os.dhhs.gov/healthit/goals.html. Accessed May 18, 2007.

Beshia Popescu