How decision support tools help define clinical problems
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1) The document discusses using informatics resources like decision support tools to consider issues beyond a patient's presenting problem during a clinical consultation, including management of continuing problems, opportunistic health promotion, and modification of help-seeking behaviors. 2) It provides an example of how these tools could help in the consultation of a patient, Mr. Evans, who presented with headaches and sleep issues but was also found to have high blood pressure and undisclosed alcohol use, which are relevant to understanding his overall health situation and treating his depression. 3) The document examines how electronic prompts can help bring hidden issues to light and make both doctors and patients aware of all factors that could impact the patient's health, though clinical judgement
How decision support tools help define clinical problems
- 1. Clinical review ABC of health informatics How decision support tools help define clinical problems Frank Sullivan, Jeremy C Wyatt The patient, Mr Evans, presented with headaches and early This is the fourth in a series of 12 articles morning wakening (dealt with in article of 24 September) as the A glossary of terms is available at http://bmj.com/cgi/ main reason for his consultation. This article, however, discusses content/full/331/7516/566/DC1 how informatics resources can be used to consider issues other than the presenting problem. The Stott and Davies model of the consultation indicates that three other areas of the Mr Evans is a 49 year old, recently unemployed, interaction should be considered. pharmaceutical company representative who has x Management of continuing problems—The patient’s diabetes presented with low mood, poor appetite, and sleep may be contributing to the overall picture. disturbance. He drinks two bottles of whisky per week, x Opportunistic health promotion—Ask screening questions but he does not volunteer this information initially. He about alcohol use and measure the patient’s blood pressure. has type 2 diabetes. A blood pressure check shows x Modification of help seeking behaviours—Discuss issues 178/114 mm Hg, and Mr Evans is asked to return to the practice nurse for follow-up relevant to self care and when to attend for health checks for established or potential problems. Management of Modification of help Management of continuing problems presenting problems seeking behaviours Awareness of problems Management of Opportunistic continuing problems health promotion Sometimes doctors and patients are not aware of relevant problems. Issues that are apparent to one person may not be apparent to the other. In Mr Evans’s case the diabetes is known Exceptional potential in each consultation. Adapted from Stott NCH, Davies RH. J Roy Coll Gen Pract 1979;29:201-5 to doctor and patient. The alcohol problem is, perhaps dimly, apparent to Mr Evans. The high blood pressure reading is something that only the doctor is aware of initially. Neither Known to Not known patient to patient doctor nor patient is aware of the depression at the beginning of the consultation, but information conveyed before, or during, Known to the consultation may alter that. Open Blind clinician When a health professional realises that he or she is aware of an issue that the patient is not, the matter can be remedied. It Not known Hidden Unknown to clinician is more difficult if the patient is aware of an issue that is relevant, but is unwilling to divulge it. Even more difficult is a situation where neither patient nor doctor is aware of a The Johari Window shows situations where one or both individuals in the consultation may not be aware of all the relevant information problem that may be relevant to the patient’s problems (see Johari Window). Electronic prompts to bring up such hidden Baseline Odds ratio Post-exposure issues are being incorporated into clinical systems, and are probability probability increasingly effective. 0.01 0.99 Problems underlying depression 0.02 0.98 Depression is common and often associated with anxiety, 0.03 1000 0.97 500 cognitive impairment, and substance misuse. 0.05 0.95 0.07 0.93 It is important to detect alcohol misuse because failure to do 100 0.1 0.9 so may mean that treatment for the presenting problem is 50 ineffective. Several screening tools with different characteristics 0.2 0.8 10 for various clinical settings are available. When the CAGE 0.3 5 0.7 questionnaire is used on its own in primary care, a positive 0.4 0.6 response to two or more items on it has a sensitivity of 93% and 0.5 1 0.5 0.5 a specificity of 76%. Different questionnaire screening tests for 0.6 0.4 0.7 0.3 alcohol misuse, such as the fast alcohol screening test (FAST), 0.1 may detect problems at an early stage, when intervention may 0.8 0.05 0.2 be more effective than later on. Other clues can help the doctor, 0.9 0.01 0.1 including comments from family members and the nature of 0.01 0.07 0.005 past consultations—for example, injuries that were only partially 0.93 0.05 explained. 0.95 0.001 0.03 When the baseline probability of a condition and the odds 0.97 0.02 ratio of a modifying factor are known, then the effect of any 0.99 0.01 new information can be calculated by using Bayes’ nomogram. Unfortunately, key items of information needed for such When estimates of the odds ratio and baseline probability calculations are often unavailable. For the foreseeable future, are known, Bayes’ nomogram can be used to calculate interpreting the results of most investigations still relies heavily post-exposure probability BMJ VOLUME 331 8 OCTOBER 2005 bmj.com 831
- 2. Clinical review on (according to Feinstein) “the judgements of thoughtful Highest scoring diabetes indicators in UK GP Quality and people who are familiar with the total realities of human Outcomes Framework 2004* ailments.” Apart from depression, there are other situations in which Maximum harmful alcohol use may be important, and an electronic alert Indicator Points threshold may be useful in a consultation. Although it is not the main Records reason for consulting, Mr Evans also has type 2 diabetes and Practice can produce a register of all 6 today’s consultation is an opportunity to deliver proactive care. patients with diabetes mellitus Ongoing management Problems complicating diabetes Percentage of patients with diabetes in 16 50% The microvascular and macrovascular complications of type 2 whom the last HbA1c is 7.4 or less (or diabetes need to be monitored regularly. Guidelines are equivalent test/reference range incorporated into local clinical governance structures to ensure depending on local laboratory) in past that all necessary care is given to patients. Organisations are 15 months responsible for providing different elements of the care Percentage of patients with diabetes in 11 85% recorded in electronic patient records. Integrated services (such whom the last HbA1c is 10 or less (or as health maintenance organisations or the managed clinical equivalent test or reference range depending on local laboratory) in past network) share responsibilities, using electronic health records 15 months across primary, secondary, and tertiary care. Percentage of patients with diabetes 5 90% Mr Evans’s only abnormal physical test result is a blood who have a record of retinal screening pressure of 178/114 mm Hg. The raised blood pressure is in the previous 15 months potentially important, and the practice’s decision support Percentage of patients with diabetes in 17 55% software gives advice on what to do next. Most of the advice on whom the last blood pressure is 145/85 checking for secondary causes of hypertension (such as mm Hg or less excessive alcohol ingestion and end organ damage) is familiar Percentage of patients with diabetes 6 60% to the doctor, as is the advice to repeat the examination on whose last measured total cholesterol several occasions before starting treatment. Grade 1 evidence within previous 15 months is 5 or less from meta-analyses or large randomised controlled trials may *In total, 1050 quality points are available, of which 550 points are for clinical targets. The most important areas are coronary heart disease, hypertension, and be available for straightforward clinical problems (for example, diabetes, which account for 325 (59%) of the 550 points for clinical indicators starting antihypertensive drugs), but this is not always the case. Clinical decision support tools are being refined to provide the information that clinicians require without overloading them with unnecessary data. This is difficult as the amount of Revised grading system for recommendations in evidence information needed and the sources from which information is based guidelines* obtained varies. Levels of evidence 1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias Guidelines 1+ Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias Field and Lohr describe clinical practice guidelines as 1– Meta-analyses, systematic reviews or RCTs, or RCTs with a high “systematically developed statements to assist practitioners and risk of bias 2++ High quality systematic reviews of case-control or cohort studies patient decisions about appropriate health care for specific or high quality case-control or cohort studies with a very low risk of circumstances.” One role of guidelines is to ensure that all confounding, bias, or chance and a high probability that the relevant issues are dealt with during clinical encounters. relationship is causal Individual guideline organisations have their own websites and 2+ Well conducted case-control or cohort studies with a low risk of other organisations, such as the Turning Research into Practice confounding, bias, or chance and a moderate probability that the (TRIP) database, integrate several guideline sources and other relationship is causal evidence based resources. 2– Case-control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not Computerised guidelines provide evidence based causal recommendations for, and can automatically generate 3 Non-analytic studies—for example, case reports, case series recommendations about, the screening, diagnostic, or 4 Expert opinion therapeutic activities that are suggested for a specific patient. Grades of recommendations The advantages of computerised guidelines over written A At least one meta-analysis, systematic review, or RCT rated as 1++ guidelines are that they: and directly applicable to the target population or x Provide readily accessible references and allow access to A systematic review of RCTs or a body of evidence consisting knowledge in guidelines that have been selected for use in a principally of studies rated as 1+ directly applicable to the target population and demonstrating overall consistency of results specific clinical context B A body of evidence including studies rated as 2++ directly x Show errors or anachronisms in the content of a guideline applicable to the target population and demonstrating overall x Often improve the clarity of a guideline consistency of results or x Can be tailored to a patient’s clinical state Extrapolated evidence from studies rated as 1++ or 1+ x Propose timely decision support that is specific for the patient C A body of evidence including studies rated as 2+ directly applicable x Send reminders. to the target population and demonstrating overall consistency of results or Extrapolated evidence from studies rated as 2++ Knowledge from unfamiliar sources D Evidence level 3 or 4 or Extrapolated evidence from studies rated as 2+ In the post-genomic world, clinicians will have to integrate their *Guidelines of the Scottish Intercollegiate Guidelines Network Grading Review understanding of patients’ phenotype with new information Group. RCT = randomised controlled trial 832 BMJ VOLUME 331 8 OCTOBER 2005 bmj.com
- 3. Clinical review from genomics, proteomics, and metabonomics. These new modes of inquiry about patients’ underlying genetic status help to explain older, empirical observations. For example, the relative ineffectiveness of aspirin in preventing thromboembolic disorders in 25% of the population may be caused by several common gene variants that affect platelet glycoprotein function. The challenge to clinicians is to integrate this new knowledge into their diagnostic and therapeutic approaches during consultations. Modifying help seeking behaviours Some patients with long term health problems do not attend review appointments. This is a particular problem when the individual has multiple comorbidities. A patient with depression may not think it is worthwhile spending scarce health service resources on themselves because they have low self esteem, which is often associated with depression. Electronic patient records summarise health problems and, potentially, prompt when reviews have not been undertaken. Some services, like review of the patient’s self monitoring, can be provided Definitions immediately. Others, such as retinopathy screening, may have to be scheduled for another date and place. An electronic health x Electronic patient record—Records the periodic care provided record shared between colleagues in different professions and mainly by one institution. Typically, this information will relate to the health care given to a patient by an acute hospital parts of the health services makes scheduling easier. x Electronic health record—A longitudinal record of patients’ health and health care: from cradle to grave. It combines the information about patient contacts with primary health care as well as subsets of Electronic clinical information information associated with the outcomes of periodic care held in systems the electronic patient record The principal function of electronic clinical information systems is to facilitate patient care. This involves identifying, classifying, understanding, and resolving problems to the satisfaction of the patients. Clinical records are also required to recall observations, to inform others, to instruct students, to gain knowledge, to monitor performance, and to justify Further reading intervention. Electronic clinical information systems are x Brief description of Johari Window on practice: becoming integral components of healthcare services, and in www.freemaninstitute.com/johari.htm many industrialised countries they are replacing the established x Bodenheimer T, Grumbach K. Electronic technology: a spark to paper based system of records. Combining the electronic revitalize primary care? JAMA. 2003;290:259-64 x McCusker, MT, Basquille J, Khwaja M, Murray-Lyon IM, Catalan J. patient records of different organisations creates a single Hazardous and harmful drinking: a comparison of the AUDIT and electronic health record. The challenge for many health services CAGE screening questionnaires. Quart J Med 2002;95:591-5 is to provide “cradle to grave” information. Effective integration x Page J, Attia J. Using Bayes’ nomogram to help interpret odds of records depends on establishing a workable unique patient ratios. Evidence Based Med 2003;8:132-4 identification system such as the community health index. x Feinstein AR. The need for humanised science in evaluating medication. Lancet 1972;297:421-3 x Field MJ, Lohr KN, eds. Guidelines for clinical practice: from Summary development to use. Washington DC: National Academy Press, 1992 x TRIP database: www.tripdatabase.com Individuals in most industrial societies who are, or believe x Bray PF. Platelet glycoprotein polymorphisms as risk factors for themselves to be, ill can turn to a variety of sources of advice thrombosis Curr Opin Haematol 2000;7:284-9 x Smith R. The future of healthcare systems. BMJ 1997;314:1495-6 other than health professionals. However, these sources will x Wyatt JC. Clinical knowledge and practice in the information age: a probably only help with the problems that a person deals with handbook for health professionals. London: Royal Society of Medicine that day. A doctor is often needed to provide additional Press, 2001 information, and to interpret and individualise advice for all the x Community Health Index (CHI) in Scotland. www.show.scot.nhs.uk/ problems brought to the consultation by the patient, not just ehealth/ the presenting problem. Frank Sullivan is NHS Tayside professor of research and development in general practice and primary care, and Jeremy C Wyatt is professor of health informatics, University of Dundee. The series will be published as a book by Blackwell Publishing in spring 2006. Competing interests: None declared. BMJ 2005;331:831–3 BMJ VOLUME 331 8 OCTOBER 2005 bmj.com 833