More common in the United States and other developed countries, Primary care is a major part of the healthcare system. It deals with all patients with signs and symptoms to come up with a sound diagnosis and management. Primary physicians, after a complete history and physical examination, order a set of laboratory and imaging studies to help in the diagnosis. If the case is more complicated, the patient is then referred to specialist. In this system, primary care serves as a triage; hence, more cases are seen in primary care than a specialty clinic. With a vast possible clinical scenario, clinical decision support system comes in handy.
Clinical Decision Support System (CDSS) is an electronic system, usually embedded in electronic medical record that helps physicians in diagnosis and management of patients. According to Robert Hayward of the Center for Health Evidence, “CDSS link health observations with health knowledge to influence health choices by clinicians for improved health care”.
In one systematic review, CDSS improves process of care in 63%, however in another study, it did not reduce death. CDSS eliminates human errors caused by many human factors. These factors include limited time of consult, stressed physicians, clinical experience of physicians, and incomplete data from the patient. With CDSS, signs and symptoms gathered from consults are lumped together and all possible differential diagnoses will be available to the physician for further review. Another benefit of CDSS in healthcare is that It can avoid adverse drug reaction and medication prescription errors by prompting nurses or physician of incompatible medications that cannot be mixed together.
As a clinician myself, my clinical decision may be based on different factors. 1. Based on my clinical training. I had my 4-yr residency training and 3-yr fellowship training in the Philippine General Hospital, a premier referral center in the country. All these years, I’ve seen many cases enough to build a database of cases. 2. Local and International literature. With the shift to evidence-based medicine, many decisions and recommendations are now based on available quality literature. 3. Patient’s factors like financial, emotional and social factors. Clinical decision will also be based on what is acceptable to the patient. A particular management maybe applicable or available to a patient but he or she may not afford it, then the next possible less expensive management is the more appropriate treatment.
Community Health Information Tracking System (formerly called Child Health Injury Tracking System) or CHITS is an electronic medical record system developed by the National TeleHealth Center (NTHC) to improve health information management at the Regional Health Unit (RHU) level. It is develoed to gather data and generate reports that can be used by the RHU to improve healthcare in the area.
A 36 years old female consulted the regional health unit due to blooding vaginal discharge of 4 days duration, right lower quadrant pain and post-prandial vomiting.
BP: 140/90 HR: 90 Temp: 38.9
On abdominal examination:
The abdomen is tender at the right lower quadrant only. No palpable mass
On internal examination:
The external genitalia is normal, the vagina is smooth, cervix is smooth but tender on movement, the uterus is small, there is tenderness in the right adnexal area. There is a 6×6 cm tender mass at the right lower quadrant/ adnexal area.
Using CHITS, the complete history and physical examination is recorded.
Using the CDSS:
These clinical data are entered in the CDSS embedded in the CHITS. The pertinent data include bloody discharge, RLQ pain and vomiting with physical findings of fever, RLQ tenderness and right adnexal tenderness are entered. The CDSS gave differential diagnoses, which included, Ectopic pregnancy, acute appendicitis and Pelvic Inflammatory Disease. It suggested the following laboratory and imaging studies:
Pregnancy test: negative
AP CT Scan: 6 x 4 cm tubular mass with fluid collection within. No gestational sac noted within the tubular mass. Ovarian in origin cannot be ruled out. Uterus is small. endometrium is thin.
Based on these tests, Ectopic pregnancy was ruled out
Because of the fluid collection inside the tubular mass was noted in CT Scan, the physician interpreted it as pus collection, thus diagnostic laparoscopy was contemplated. After loading of antibiotic with polymicrobial coverage, the patient underwent diagnostic laparoscopy, which later showed the definitive diagnosis of Tuboovarian abscess. Appendix was noted to be normal.
Bates DW et al. Ten commandments for effective clinical decision support: making the practice of evidence-based medicine a reality. J Am Med Inform Assoc 2003;10:523-530. http://jamia.bmjjournals.com/content/10/6/523.full
Jaspers MW et al. Effects of clinical decision-support systems on practitioner performance and patient outcomes: a synthesis of high-quality systematic review findings. J Am Med Inform Assoc 2011;18:327-334. http://jamia.bmjjournals.com/content/18/3/327.full.pdf+html
Souza NM. Computerized clinical decision support systems for primary preventive care: a decision-maker-researcher partnership systematic review of effects on process of care and patient outcomes. Implementation Science 2011:6:87 http://www.biomedcentral.com/content/pdf/1748-5908-6-87.pdf
Ash JS et al. Recommended practices for computerized clinical decision support and knowledge management in community settings: a qualitative study. BMC Medical Informatics and Decision Making 2012;12:6 http://www.biomedcentral.com/1472-6947/12/6