A Patient's Perspective (2)- The Story of Oleg

Source: EnglishRussia.com

Oleg was born in the city of Omsk on a warm summer day in Russia twenty years ago. His parents were poor peasants who worked hard and saved some money to send their son to school. His dad worked in the lumber company in a nearby town while his mother taught in the local elementary school. He was the second child but his birth was celebrated with much pomp and pageantry in line with local customs, almost as though he were the first child. This is because he was born seven years after his elder brother. His naming ceremony was attended by almost everyone in the town and he was showered with gifts by so many well-wishers.

Oleg grew up with his mother and father doting over him, but at about the age of five years, he was sickly and was not allowed to play with the kids for fear of “catching a fever”. Everyone thought he was just spoiled silly, but his parents suspected something was wrong. They had gone to the local doctor so many times but he assured them that Oleg was fine and that he was only passing through this phase.

The Road from Omsk.
Source:omskcityblogspot

Then one cold December morning, Oleg complained of weakness of his limbs and for the entire day, could not move his legs or arms and was crying due to the excessive pain. Panic-stricken, the parents rushed him to the local doctor who was at a loss about what to do. The primary care doctor could only guess what this strange condition was- he had no way to test the child in order to make a diagnosis, he did not even have painkillers strong enough to stop the pain. He tried calling the hospital at the next town but there was nothing they could do- they had to try to bring the child to the hospital the next morning. At dawn, the parents and the family doctor set forth to go to the hospital, four hours away by road - the child cried all the way to the hospital.

At the local district hospital, the doctors succeeded in giving the child some very strong painkillers and he slept fitfully- for the first time in 2 days. Alas, the hospital did not have the necessary equipment to diagnose the condition and they had to refer to the specialist hospital in far away Moscow. Could they call the doctors over there so they could have a discussion about the case? Yes but the phone call was limited because the specialist could not see the patient- he could only rely on what the other doctors said.  Finally, they agreed to send the child to Moscow but the parents refused. They had no money. How could they fly their son to Moscow? How could they even afford his medical bills? There was simply no way. Sophia, Oleg’s mother wept bitterly.

Russian Specialist Hospital
Source:Indiabizclub

The people from the town took a collection for the family and they were finally able to send Oleg to Moscow for specialist care. The tests were done and the doctors argued bitterly over the possible diagnosis. Lou Gehrig’s disease? Amyotrophic lateral sclerosis? Guillain Barre’s syndrome? They finally had to make use of the hospital’s newly installed Clinical Decision Support System to make a final diagnosis in line with current evidence based research: Multiple Sclerosis.

The clinicians were glad that their multi-million ruble electronic medical record fitted with a state-of-the-art clinical decision support system was finally yielding dividends. However, the battle for Oleg’s life had just begun…

Patients' Perspective of IT and Quality of Care

A few of my readers have asked me to be slightly less “technical” in my writing as some of the material seemed too arcane for some readers who are non-medical or non-information technology savvy. In the light of this, I have decided to make this post a little less technical and address it to a broader audience.

What I will like to discuss this time, is essentially quality control and information technology from the perspective of a patient and not from the angle of the technicians or service providers. I want to make a case for the importance of the uptake of information technology in every sphere of the health care value chain. By this term, I mean the entire gamut of patient care from the time the patient gets sick to the time he/ she comes in contact with the service provider until the time he/she is discharged.  All the transactions that take place during this interaction are important and as we know, it affects the final outcome: basically whether the patient gets well completely, his/her condition is managed properly such that they can live comfortably with the complications or the patient gets worse (hopefully not) or dies (heaven forbid!).

Source: iStockPhoto

Every contact with care providers is thus important for the patient and also for the provider in many ways. Every patient is an opportunity for the medical personnel- nurses, doctors, pharmacists, physiotherapists, etc to learn about the case and get better- this is the idea behind teaching hospitals. In addition, every patient is a unique source of data. Even though this might sound strange to some readers, it is very true. From preventive health interventions to the first time the patient comes in, the patient supplies data- about time of entry, presenting complaint, diagnosis, drug interactions, drug efficacy, efficacy of medical interventions, infection control… the list is virtually endless. The data collected can then be utilized to improve medical processes and care for patients.

Despite these however, the average patient does not care for the various terminologies, but basically about this: “help me get well, with effective but inexpensive medical care that will help me have a better quality of life”. To the trained eye, the statement is very complicated as there is an entire range of arguable definitions like, how do you define “humane treatment”, “inexpensive”, “quality of life” etc. To the patient however, it is simple.

We will explore this through the hypothetical experiences of two patients in two different contexts: Oleg in Omsk, Russia and Sama in Bombay, India.

I will tell you their story in the next few posts.

Do Clinical Decision Support Systems Lead to Quality Improvement? (Part 4)

Before going back to the story of Oleg and Sama, I want to quickly discuss the effect of clinical decision support systems on patient care.

Open clinical, a knowledge management website, shown below, highlights a few research articles which investigate the use of clinical decision support systems and their effect on quality across various dimensions including diagnostic decision making, disease management, etc.  If you click on the picture, you can access these articles.

 After going through the literature, make up your own mind about the overall effect of CDSS on quality.

When you do, let me know what you decided.

Up next, the story of Oleg and Sama 

Do Clinical Decision Support Systems Lead to Quality Improvement? (Part 3)

Unintended Consequences of Clinical Decision Support Systems

Source:SailingScuttle

Now, I will go a step further to discuss the unintended consequences of CDSS. These can be seen as side effects or unforeseen consequences of the implementation of these systems. A lot of the information in this article will be taken from the article by Joan Ash and colleagues at the School of Medicine, Oregon Health and Science University in Portland Oregon. For the complete paper, click here.

The authors of this paper highlighted a few unintended consequences of clinical decision support systems which they found during their qualitative research in the form of observation and formal interviews. They noted that these unintended consequences were derived from either the content of the information or the way the information was presented to the health professional in question.

Source: Creative Nursing Education

Major consequences related to content included the fact that the database had to be updated pretty frequently due to new evidence and expanding knowledge in various fields. Sometimes this is not done quickly enough and can give rise to problems later on. Another related problem is that the content might just be plain incorrect due to errors in the algorithmic process or inaccurate information leading to a general mistrust and lack of use of the system in general.

Possible consequences related to the way the information is processed include the major problem of alert-fatigue,when the sheer number of alerts causes you to ignore most of the alerts which are considered superfluous but also mean some important alerts are likely to be ignored.

Other consequences can include input errors like typographical errors and mis-insertion of data like choosing the wrong option on a list as well as rigid systems which might not be configured to meet the exigencies of medical practice which is invariably more flexible.

These unintended consequences need to be factored in when designing clinical decision support systems and steps taken to remedy these problems when they arise.

Do not forget to comment on the discussion section in the previous post. Stay tuned for part 4

Do Clinical Decision Support Systems Lead to Quality Improvement? (Part 2)

Clinical Decision Support Systems (CDSS) are a part of the spectrum of the capabilities of health information systems which have a transformational effect on the way medicine is practiced. They are defined by Musen et al., as any computer program designed to help healthcare professionals to make clinical decisions.  These tools are generally divided into:

1. Tools that focus attention e.g. focus on information that might be overlooked by the physician. An example is “case 1” in my previous post
2. Tools for information management: these tools help to retrieve information like textbooks and stored personal notes in a timely manner
3. Tools for providing patient specific recommendations: these provide advice based on data that is specific to individual patients.

These systems can be used for preventive care, diagnosis, planning or implementing treatment, follow-up management, hospital provider efficiency, cost reductions and improved patient convenience according to Berner et al.

These different uses of clinical support systems are not so clearly delineated but there are many areas of overlap. However, according to Musen et al., they can also be divided into tools that help with patient diagnosis and tools that help with patient management. These two are important distinctions and the authors discussed that there are two modes of interaction with these systems viz.: the consulting model in which the program advises the physician about patient care and the critiquing model, where the system evaluates the physician’s proposed line of management and corrects the choices he makes.

Despite the various classifications, it is clear that the systems cannot stand alone like the gadget in the movie, Star Trek which could be pointed at a sick person and make a diagnosis on the spot. Rather, it works hand in hand with the physician to make more effective choices that are beneficial to the patient. Some people think however, that there might be an effect on the clinical ability of the physician in the long run. I will resist the temptation to discuss this now, but will address this in subsequent posts. I will however like to know your thoughts on the matter as I have posted in the discussion session below. The utility of these systems and potential side effects will be discussed in my next posting. Stay tuned.

Below, is a video by Tom Garithe, the Editor-in-Chief of the American Journal of Obstetrics and Gynecology describing the difference between Electronic Medical Records and CDSS:

For discussion: 

Do you think clinical support systems will reduce the clinical acumen of physicians in the long run?

Do Clinical Decision Support Systems Lead to Quality Improvement? (Part 1)

Scenario 1:
 Imagine a cancer patient with a cocktail of medication. The physician wants to prescribe another medication for a recently discovered symptom. Should she prescribe drug A or B? Will there be any interaction with the current medication? She can tell if it will interact with some of the drugs, but not all- she decides to prescribe it anyway. Immediately she places the order, the computer system gives a warning beep followed by  sign: "potential drug interaction!" the doctor is thankful- she would not have thought of that problem and the pharmacist might not even have detected it. Such is the role of clinical support systems. Consider a similar warning sign below:

Source:Journal of Medical Internet Research

Scenario 2:
A physician is seeing a rare form of a disease. He last saw a similar patient during his residency program three years ago. He decides to place the patient on a particular line of management, as was done with the previous patient. As soon as he does this, a gentle alert is shown stating that studies show that there is a better line of management available, so he should re-consider his disease management plan.
These two hypothetical scenarios highlight the importance of clinical decision support systems.


In our ongoing discussions about quality in healthcare and the role of information technology, I have decided to discuss clinical decision support systems. In general, any intervention or program that can support a physician in making a diagnosis is a clinical decision support tool. An example of this might be a clinical handbook in a physician's pocket, a pharmacopoeia or prescribing guidelines- these provide support to the physician making a diagnosis and help her make appropriate decisions about the care of the patient. You would however have noticed that these tools are only useful at the point of care. There is no point having these tools after the patient has been discharged. These tools are also only for support and should not try to supplant the clinical acumen of the physician or his "cultivated intuition".

Source: juneshlam.com

Information technology seeks to make the use of these tools more efficient and relevant. To do this, the technology  has to have the features I mentioned above and more. Clinical decision support systems were thus developed to have the functionality of all these tools and be more accessible, but more importantly, they usually ride on already established health information systems or electronic health records. Without this, they would be relegated to the background or better termed "clinical reference tools"

How are these systems used and what can they do? These will be discussed in part II of this series. In part III, I will discus potential "side effects" or unintended consequences of these tools. In Part IV, I will discuss their impact on quality and if there is any evidence in this regard.

I would be glad to read your comments.