Decision Support Made Practical
MANAGED CARE October 2002. ©MediMedia USA
Staying current always has been a challenge for physicians due to the time required to read journal articles and studies, whether printed or electronic. Automation may bring journals to the desktop, but a physician still has to search for the right information.
Making all the necessary information easily accessible is the motivation behind today's decision-support products. Most of them are called clinical information systems or primary care information systems and are designed for practicing physicians. They combine diagnostic and treatment guidelines with evidence-based research. Some also include patient information and drug data.
A closer look
An early system was UpToDate, started in 1992, «www.UpToDate.com». Burton Rose, MD, its founder and editor-in-chief, explains that UpToDate is designed to assist practicing physicians in making the right decisions for their patients. "Doctors want specific pieces of information at any one time," says Rose.
For instance, rather than writing a comprehensive chapter on diabetes, UpToDate includes a series of monographs about diabetes, based on questions that might arise during patient care. The information is organized to allow quick access to sections of interest, as well as more intensive exploration of a topic — what Rose calls "two-minute and 20-minute consultations." References to pertinent studies are included, and a mouse click brings up the abstract.
UpToDate can use the "What would a doctor want to know?" format, because all its writers and editors are doctors, and, in a sense, they write for themselves. According to Rose, UpToDate has 3,000 physician authors who continuously review and revise information. The system is updated three times annually, with special updates for breaking news. Further reviews of the original material come from the various medical societies that have endorsed UpToDate to their members.
PDxMD «www.pdxmd.com» was launched in July. Originated in 1999 by physicians and medical editors and writers, PDxMD was bought and revamped by Elsevier, the medical publishing company that owns the electronic reference tool MDConsult. Today's product uses structured templates to offer "a guided choice navigation system," according to Steven Merahn, MD, vice president for general medicine for Elsevier Science.
The system prompts doctors to categorize a problem before using PDxMD. A user may begin with a chief complaint, a condition, or patient information needs. Templates using familiar clinical categories were designed for the differential-diagnosis tool (1,500 disorders) and the comprehensive medical conditions files (450 conditions) The format is consistent throughout the system to enable doctors to locate information and customize patient information materials. In addition to embedded evidence and references, PDxMD links to MDConsult for more information. Merahn sees it as a tool doctors can use anytime by clicking on an icon on the computer desktop.
PDxMD also is on a rolling review schedule, with files updated quarterly or, when urgent changes are necessary, within days. Physician and nonphysician writers develop templates, on which up to five doctors will sign off.
EBM Solutions «www.ebmsolutions.com» is another company providing an evidence-based decision-support tool for physicians through its program, EBMdesktop. EBM Solutions was formed by physicians and is affiliated with six major academic medical centers in the United States. Other programs that provide information but not necessarily decision support are: Skolar, eMedicine, Merck Medicus, Praxis, ACP Pier Online, ClineAnswers, RxCentric, and the Micromedix group of products.
The American Academy of Family Physicians (AAFP) will announce an affiliation with PDxMD at this month's annual conference. Joetta Melton, the director of publications for AAFP, says, "The academy wants to make members aware of the evidence-based options that are available to help guide clinical decisions." Melton adds that this is not an exclusive agreement and that the academy is talking with other companies that sell similar products.
Academic and teaching institutions have been the heavy users of decision-support systems, a useful resource for interns and residents. The systems are also available to doctors at individual subscription rates. This means that doctors can have the latest information synthesized for them in a readily useable format with decision-support guidelines for diagnosis and treatment. Doctors who do not have computers in their examining rooms will be able to take the information with them on handheld devices. UpToDate is about to introduce its system on a Pocket PC. PDxMD is designed to work on both the Palm and the Pocket PC. Other products also have handheld versions.
The systems tend to be designed for primary care practitioners and cover internal medicine, women's health, and pediatrics, with material being added continually to broaden coverage.
Take a demo
I urge physicians who haven't seen these products in action to test them at their web sites: One demo is worth a thousand words.
PDxMD's Merahn sees real benefits for a practicing physician: It helps physicians to "get to the definition of best practices quickly;" it expedites patient work-ups; it "affects outcomes, because it is evidence based;" the "clinical documentation helps record keeping; and it "affects the relationship between doctor and patient."
Patricia Hale, PhD, MD, is a Gansevoort, N.Y., internist who has been using UpToDate for about four years. She likes it, because "it seems to cover the specific topics I most often want, in a brief format that is quick to use." She can now "look up topics in the office that I would normally not have bothered with or waited until evenings or weekends to research." It is also a good tool for patient education.
Mike Rakotz, MD, a solo practitioner in Lyons, Colo., has been using UpToDate since last December. He says, "It has changed the way I look up current information for treating medical conditions that I see in my office and at the hospital. Having access to the information on UpToDate makes the medicine I practice more current, so my patients get better care."
Each tool discussed here offers something different. These systems do not dictate how doctors should treat patients; they assist them in making optimal treatment decisions. As Merahn points out, decision-support systems reduce variability by offering a consistent reference platform across practitioners, and that leads to error reduction." These systems offer the promise of raising the level of medicine practiced, regardless of geographic location. Physicians, you will be hearing a lot about this. I guarantee it.