Using commercial knowledge bases for clinical decision support

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Medication ordering and management is an aspect of healthcare delivery that is plagued with quality and safety issues. These issues could be alleviated by medication-related clinical decision support (CDS) embedded in Computerized Provider Order Entry (CPOE) or Electronic Health Record (EHR) systems. Representing medical knowledge in information systems has been a challenge but this knowledge acquisition bottleneck can be eased by utilizing knowledge bases developed by commercial vendors. Such knowledge bases are cost-effective and can be incorporated into Clinical Information Systems (CIS) to display alerts highlighting drug-drug and drug-disease interactions, inappropriate medication doses, drug allergies, and duplicate medication orders. In spite of their apparent benefits, such knowledge bases have not gained wide acceptance mainly due to their propensity for excessive and clinically unhelpful alerts. Such nuisance alerts not only degrade a clinician’s performance but also his confidence in the alerts and ultimately lead to dissatisfaction with the clinical information system.

Allowing healthcare organizations to customize behavior of CIS by filtering unnecessary alerts can improve the value of alert functionality of a CIS. But healthcare organizations face several challenges in this effort: • Lack of management processes to decide on customizations to knowledge-base or CIS functionality

• Closed architecture for CIS and knowledge base

• Unsustainability of customizations as they may be overwritten by subsequent CIS or knowledge-base upgrades

• Inability to share customizations across multiple healthcare entities

• Liability concerns regarding inadvertent suppression of critical alerts

• Complications in legal agreements between healthcare organizations, CIS, and knowledge-base vendor.

To meet these challenges, the authors make several recommendations: • CIS and knowledge base vendors should provide tools to allow end-user customizations for filtering clinically unhelpful alerts or supplementing it with additional checks.

• Vendors should develop better tools to browse the knowledge-base

• Vendors should provide information about system architecture to facilitate customizations

• Product design should allow sharing of customizations across organizations

• Standards should be developed and adopted for knowledge base representation

• HCOs should implement specific policies and procedures regarding knowledge editing Comments Allowing healthcare organizations to customize their medication-related knowledge base and clinical information systems would help align the CIS to organizational preferences. It would also allow clinicians to control the system behavior and filter out clinically unimportant alert. Only when the knowledge bases and clinical information systems support and add value to healthcare delivery, the full potential of CDS systems can be realized.