Forget to prescribe that flu shot? Let your computer remind you
Forget to prescribe that flu shot? Let your computer remind you
One study shows 400% increase in adherence
A growing number of physicians have a new medical assistant to help them improve outcomes: their computers. While simple patient care reminders have long been a part of practice management systems, more sophisticated software can help physicians avoid drug interactions or inappropriate dosing, increase preventive care, and follow well-established clinical guidelines.
Such computer tracking can provide dramatically positive results for patients, health care computer experts say. (For information on how one physician uses computer-based records, see related story, p. 27.)
"In one of our studies, we had as much as a 400% improvement in the adherence to guidelines," says Clement McDonald, MD, distinguished professor of medicine at Indiana University and co-director of Indianapolis-based Regenstrief Institute, which focuses on medical informatics and health services. "There’s a tremendous potential [for outcomes-based computer technology], especially for preventive care."
McDonald and others say they hope research will encourage more physicians to make use of the emerging technology, which is now predominantly used by academic centers or large health systems. The Agency for Health Care Policy and Research (AHCPR) in Rockville, MD, and the National Library of Medicine in Bethesda, MD, recently provided $4.6 million to fund studies of computerized decision-support systems.
Health care has lagged behind other industries in its use of computer technology, says J. Michael Fitzmaurice, PhD, director of the Center for Information Technology at AHCPR. He notes that his local junkyard proprietor can locate a hubcap using a computerized inventory, but some physicians must order duplicate tests because they can’t locate the patient’s prior report.
"As information technology speeds up and expands, why can’t health care take advantage of it like the grocery store, the airline industry, or the junkyard where I take my Volkswagen Rabbit?" he says.
Start with computerized orders
To begin to use computers to improve outcomes, physicians need some computer-based data although the entire patient record does not necessarily need to be on line. "If you’re going to have the computer give reminders, what you probably want is computer-based ordering systems," says McDonald. In other words, physicians need to enter their lab test, prescription, or treatment orders on the computer. A reminder system could then alert the physician to drug interactions or suggest alternatives.
Yet even basic patient data such as age can provide the information needed for some prompts, says McDonald. For example, age data alone may tell the physician that a patient is over 65 and should have a flu shot. Many medical billing systems offer simple preventive care reminders.
Each layer of computer-based information allows for more alerts: medications, patient problems, vaccinations.
McDonald and his colleagues studied the use of computer-generated reminders for influenza vaccination of patients at high risk of pulmonary disease over three winters. The study group totaled 4,555 patients.
Physicians who received a printed reminder report when a target patient came for a scheduled appointment were twice as likely to give the vaccine as a control group who received no such reminder. Patients of physicians who received the reminders also had significantly fewer winter emergency room visits and hospitalizations.1
In a two-year, randomized trial of 12,467 patients testing an extensive reminder system, McDonald and his colleagues found that "computer reminder messages had a strong and persistent effect on patient care." Physicians receiving reminders increased their use of certain suggested preventive care interventions by 400% during the study period, compared with an increase of 150% among those without reminders. In general, the use of preventive care was twice as high for those with reminders.2
PC power: 2,000 docs on line
The Regenstrief Medical Record System provides an example of the enormous potential use of computer technology in medical care. It began in 1972 with the records of 35 patients at the Regenstrief Health Center Diabetes Clinic of Wishard Memorial Hospital in Indianapolis. Now, the system operates at three Indiana University Medical Center hospitals, more than 30 affiliated clinics, and sites in Texas and Virginia. More than 2,000 physicians and other health care providers use the computerized system, encompassing some 1.3 million patient records. Physicians even use portable PCs at 12 remote sites serving the homeless to record visit notes.
Physicians enter their order, problem lists, and discharge notes at workstations, and some data, such as lab results, can be received electronically. Office or hospital staff enter other patient information, such as history and physical information provided by obstetrics patients. Alert (and cost) information appear on the screen as the physician enters orders.
The computer sorts through hundreds of reminders that are based on established guidelines, targeting such issues as preventive care, drug dosing and interaction, new abnormalities, and undertreated diseases. For example, the system calculates the Framingham Cardiovascular Risk Index and suggests interventions when the patient’s risk level is high, and calculates ideal weight and makes suggestions about diet.2
The computer proposes pre-composed orders to physicians when they begin their order writing. Physicians may alter their advice or treatment regimens for patients based on these prompts. The computer also scans patient records before their scheduled visits and prints out reminders for the physicians.
Alerts detect drug events
Physicians and hospitals with less extensive computer-based data still can take advantage of the benefits of alerts and reminders. The two hospitals of the Barnes Jewish Hospital health system in St. Louis are using and evaluating two computerized drug monitoring systems one that checks dosing against age, weight, and other patient data, and one that provides alerts regarding possible adverse drug events.
"We believe we’re getting value from the [alert] system even though we know we could do better if we had more [computer-based patient] data," says Michael Kahn, MD, PhD, assistant professor of medicine and head of the section of medical informatics at the Washington University School of Medicine in St. Louis.
"If you have to wait for it all, you’re never going to do anything," he says. "You have to pick your opportunities carefully, and you have to be willing to accept a [computerized alert] performance of less than 100%."
In the Barnes Jewish Hospital program, the hospital pharmacist receives the drug alerts and reviews the patient chart to determine if there are any extenuating circumstances, says Kahn. The pharmacist agrees with the alerts about 75% of the time and sends the information on to the physician, who may then decide to alter the medication dosing, he says. The program is being expanded to four community hospitals affiliated with the health system, he says.
Program receives positive response
The physicians have responded positively to the program, including the pre-screening by pharmacists, Kahn says. "We have been noticing over time that there’s a decrease in the number of alerts we’re getting," he says. "We think that’s a learning effect. If this program goes out of business, I couldn’t be happier, because that means patients are getting appropriate dosing."
Reminders are sometimes a sophisticated form of checklist for physicians. Ideally, they should be immediate, something the physician can react to while the patient is still in the office rather than a monthly printout of patients who need a certain preventive test, says David Rind, MD, an internist and senior associate at the Center for Clinical Computing at Harvard Medical School in Boston.
Rind, who uses a computer-based patient record and regularly receives reminders about preventive care for his patients, also cautions against creating "information overload" with too many reminders for physicians.
Still, his research at Beth Israel Deaconess Medical Center in Boston showed clear benefits, such as alerts that helped physicians prevent serious kidney failure by halting certain medications among patients with rising creatinine levels.3
"There’s tremendous benefit [of computer alerts] from preventing easily preventable mistakes and from helping people remember to do things that everyone agrees they should do," Rind says.
While physician acceptance of computerized reminders and alerts is growing, a number of obstacles remain. Data from outside sources, such as radiology centers, laboratories, and hospitals, should be formatted in standard coding so computer systems can interface, says McDonald. For example, medical labs have adopted a uniform system that allows for the electronic transfer of data.
While there are many medical practices and guidelines that are widely or universally accepted, such as flu shots for high-risk patients, more work needs to be done toward developing clear and valid standards, says McDonald.
"The limitation on the potential [of computerized alerts and reminders] is the limit on scientifically determined rules," he says. "[For example,] we don’t know the very best drug for high blood pressure. We don’t know which patients would get the most benefit from it."
If physicians don’t believe in a standard, McDonald notes, "reminders don’t help at all."
Physicians also need to wrest control of computer technology from the administrative side of medicine, says Warner Slack, MD, associate professor of medicine and psychiatry at Harvard Medical School and editor-in-chief of MD Computing journal.
"The emphasis has been on financial computing in medicine, not on clinical," he says. "My dream for the future is that the "M" in the acronym MIS [management information systems] will stand for medicine, not management."
[Editor’s note: MD Computing is a bimonthly medical journal focusing on research and application of computers in medicine. It publishes a buyer’s guide in each November-December issue. For subscription information ($59 annually), contact Springer-Verlag, 333 Meadowlands Parkway, Secaucus, NJ 07094. Telephone: (800) SPRINGER.]
References
1. McDonald CJ, Hui SL, Tierney WM. Effects of computer reminders for influenza vaccination on morbidity during influenza epidemics. MD Computing 1992; 9:304-312.
2. McDonald CJ, et al. The Regenstrief Medical Record System: 20 years of experience in hospitals, clinics, and neighborhood health centers. MD Computing 1992; 9:206-217.
3. Rind DM, et al. Effect of computer-based alerts on the treatment and outcomes of hospitalized patients. Arch Intern Med 1994; 154:1,511-1,517.
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