PracticalDermatology

Integration of clinical decision support (CDS) into the electronic health record is a required capability for federal reimbursement through the Health Information Technology for Economic and Clinical Health Act. Yet, many physicians do not know what decision support is or how it can help their clinical practice. Unlike aviation, where all pilots follow standardized training in their cockpit instruments and tools, in medicine there is huge variability in knowledge, interest, and use of clinical information systems, including a broad range of physician perception and understanding of CDS. Some believe that CDS is limited to drug-drug interaction or automated dosage checking. Others believe CDS can be defined as reading about the disease process at the point of care. While a majority of physicians use, for example, Epocrates on the mobile phone and referential databases such as UpToDate and MD Consult on the desktop, we are just now scratching the surface of the potential of advanced CDS embedded into the medical record and use of the tools on mobile tablets and phones.

The good news is that powerful, excellent applications will evolve to improve care and empower dermatologists as we work. And while from a federal reimbursement perspective, mobile point-of-care knowledge tools have taken a back seat to the electronic health record discussion, CDS is being used more and more at the point of care whether embedded in the record or not. The ease of having “knowledge in your pocket” on your phone and iPad is changing the way we practice. As the use of health information technology continues to progress, clinicians need to be aware of the full capabilities and benefits of what the available tools can do and how they can be used most efficiently.

CDS BENEFITS

CDS systems can offer value to dermatologists in many diverse ways:

• CDS tools, unlike medical textbooks, can be indexed and searched by multiple patient factors to more closely match a physician's thoughts on signs, symptoms, and diagnoses.
• CDS systems can be integrated with teledermatology, empowering the referring physician with richer information while reducing the amount of time spent by the consulting dermatologist writing the consult.
• CDS can be integrated into the electronic health record, such that patient data from the record can be entered into the CDS, and patient-specific diagnostic and treatment information from the CDS can be added to the record.
• Many CDS tools now offer point-of-care CME, which is sometimes referred to as “performance improvement CME,” and this trend will likely accelerate. The idea is that physician learners retain knowledge when questions are asked and answered about specific problems with their own patients. So rather than sitting in a conference or studying a topic on a computer or in a journal and answering topic questions, point-of-care CME users search for clinical answers to a patient-specific problem at the point of care and then receive CME credit for each search.
• CDS systems can resolve complex medical information to positively impact diagnosis, testing, therapy, and patient management.

In our work, we have focused on enhancing point-ofcare diagnosis, patient management, and patient education through clinician use of CDS during the patient encounter. Lowell Goldsmith, MD, MPH, dean emeritus of the University of Rochester School of Medicine and Dentistry, and I founded the Rochester-based health care publisher and technology company Logical Images, Inc. before smartphones and tablets were widely used—and, in fact, before Google existed! In the 90s, we envisioned a redesign of the medical atlas so clinicians could pattern match and search in new ways. This effort resulted in VisualDx, which brings diverse pattern recognition assistance into one unified platform. The system is problem oriented, in contrast to specialty oriented, so diagnoses of ophthalmology, oral mucosal medicine, radiology, and other specialties bring a comprehensive richness to VisualDx. Merging the pattern recognition skills of dermatology with a rich findings-based search (symptoms, signs, past medical history, etc.) is a key benefit of CDS. As opposed to online textbooks, CDS systems such as VisualDx are designed to reveal the spectrum of each disease by aggregating thousands of actual patient presentations from multi-center and multi-physician image collections and then displaying the variants in relation to unique user-defined search entries.

CURRENT AND FUTURE TRENDS

Mobile information access and computerized records are now on a steep adoption slope. As more physicians are embracing handheld knowledge sources and other “e-health” tools, the number of computer-savvy physician users of health information technology is approaching the “tipping point.” In partnership with a malpractice liability insurer, we have integrated point-of-care CME accreditation within the VisualDx CDS system. Physicians can not only receive CME credit for their patient-specific searches but will also receive a discount on their medical malpractice insurance for incorporating point-of-care CDS and CME into their practice. Some states require risk management CME, and these types of integrated programs will change the way we think about continuing education. In addition to continuing education, medical student and resident education is being transformed by mobile health information technology access and the iPad. At several medical schools, all incoming first-year students are given iPads loaded with point-of-care reference and other interactive tools. It is not uncommon for medical students and residents to be using knowledge sources as they are on rounds and at the bedside. Many students and residents are teaching their teachers who are late to the mobile transformation of health care information.

In the past, physicians questioned whether they would use these tools in front of the patient, due to concern that the patient might think the doctor was admitting a lack of knowledge by using these tools. Now with patients persistently using the Internet for health information before and after their visits with their physicians, they are pleased to see their physicians using professional tools and checking literature evidence when needed—looking up evidence communicates to the patient that you are taking the time to solve their problem and are focused on their unique concerns. There is no doubt this is an exciting time. We are moving away from the educational and care paradigm of memorized facts, sometimes faulty recall, and expedient care, and using better information and evidence when needed to guide improved care for our unique and individual patients.

Dr. Papier is co-founder and Chief Medical Information officer of VisualDX.

Art Papier, MD, is an associate professor of dermatology and medical informatics at the University of Rochester School of Medicine and Chief Executive Officer of Logical Images, Inc.