Driving Better Decision-making: Clinical Knowledge Support Integrated into the EMR
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Whether the goal is quickly searching for best practices or facilitating patient education, clinical decision support (CDS) has the power to take a clinician's toolbox to the next level—provided it is immediate, accurate and in-depth. Atrius Health, a five-medical-group nonprofit alliance headquartered in Newton, Mass., stepped up to the CDS plate a year and a half ago by integrating Wolters Kluwer Health's UpToDate, an evidence-based clinical knowledge resource, into their EMR.
Atrius Health's physician groups, including Dedham Medical Associates in Dedham, Mass., are experiencing CDS as they never have before by accessing peer-reviewed, evidence-based recommendations via the web at the point of care.
By integrating a one-click access button from their Epic EMR into UpToDate, clinicians now have more than 9,000 topics in 17 medical specialties at their fingertips. With more than 77,000 pages of text, graphics, videos and images, links to Medline abstracts and a drug database, clinicians can better answer complex clinical questions such as how to treat a patient with essential hypertension who's responded favorably to thiazide diuretic monotherapy but has not attained goal blood pressure.
"As a clinician, you want the best evidence, but you can't always remember it all," says Atrius' Director of Clinical Informatics Michael A. Lee, MD, MBA. As a pediatrician, Lee says he knows what the guidelines for strep throat are but might not know how to evaluate all of the complications of strep throat. "For example, if a patient has strep throat and has blood in his or her urine, UpToDate helps me grab evidence to guide my decision on how to proceed with the patient."
With more than 460 journals monitored by editors and authors, all of the 1,200 clinicians at Atrius Health are assured they are getting timely, current clinical information, as UpToDate continuously reviews and updates topics for accuracy and completeness. More than 7,700 treatment recommendations also are now graded, so clinicians can assess the quality of the evidence more quickly.
Accessing the system is easy for clinicians. Atrius' clinical users underwent a one-time registration to create an UpToDate user account, bypassing the need to later remember their UpToDate account password as they access the system via the web or mobile devices, says Lee. This "one and done"-click access makes entering the system a breeze and cuts down on log-in time, he says, in comparison to when clinicians had to input a password and user name. Along with this easy access has been a skyrocketing of physician use. According to Lee, UpToDate received 500,000 webpage views in 2010 from Atrius' clinical staff. "When you look at that volume, it tells you that you're delivering something that caregivers need to use."
Atrius Health got a taste of how valuable UpToDate really is to clinicians last year when an Epic upgrade temporarily removed the one-click access button on some caregivers' EMRs. Help desk calls and urgent email requests that day were "substantial," says Lee, showing how critical UpToDate access is to Atrius clinicians' day-to-day practice.
From a user's perspective, Lee says that UpToDate removes the fear that the computer will be the awkward third wheel in the patient-provider relationship. "If patients or parents have a question like what symptoms should I be looking for, I can pull up evidence-based results in the room and go over the clinical guidelines as well as examples of what I think the patient might have."
Looking forward, Lee sees the need for even more targeted clinical decision support—for example, the ability to look up treatment guidelines on hypertension in patients with known diabetes instead of starting out with general hypertension guidelines. As the demand for this level of knowledge increases, and health information systems evolve to meet it, Lee is confident that UpToDate will continue to be a critical tool providing Atrius Health clinicians with the knowledge to make the best patient care decisions.