Commentary

Decision Making and the New Technologies in Clinical Practice

Clinical decision-making is a fundamental part of everyday practice.  It has never been an easy task.  It carries with it the burden of responsibility for a patient’s health and wellbeing.  The facts of the patient’s case have to be gathered, prioritized and then acted on.  The important issues that come into play are clinical circumstances, experience and judgment, scientific evidence, and patient preferences.  At the end of the process the clinician will also need to use his intuition in bringing all the factors together in a way that serves the patient.  Most doctors frequently ask themselves ‘Am I doing a good job?”, or “Could I do better?” Some doctors are better than others at making clear, balanced decisions.  Those with leadership skills seem to function at a higher level.  There is much written about what makes a good clinician but none of the accounts give a clear answer.  Nurses often provide a useful insight.  They place a lot of emphasis on doctors who are approachable and readily turn up when asked to review a patient.  They like doctors who systematically gather the clinical facts, and then make reasonable balanced decisions.  Another positive characteristic is doctor who returns to review the patient unprompted.  A further additional ask is that the care the doctor provides is evidence based.

Evidence based practice is an increasing challenge even for doctors with good generic skills.  The physician can’t know or remember it all.  The sheer volume of medical information is daunting. Things frequently have to be looked up.  In the past this amounted to a furtive glance at the Oxford Handbook and other white coat references such as the Merck Manual.  For much of the last century it was thought a medical education equipped the doctor for life.  That concept is long gone.  It is universally accepted that medical education should continue to grow and evolve after graduation.Nowadays the universal availability of apps and smart mobile devices has generated clinical decision support tools (CDS).  A CDC is an information-based technology system.  CDS tools have the potential to improve clinical diagnostic decision-making and patient safety1.  CDCs are helpful in stream lining data in a manageable fashion so that information overload doesn’t occur.

The use of CDS tools requires a change in the doctor-patient relationship.  The previous, perceived culture has been that doctors who look up material in the presence of the patient are less knowledgeable.  There is evidence to support this assumption.  Arkes2 found that doctors who didn’t look up things were viewed as having greater diagnostic skills. They favoured clinicians who made decisions without diagnostic help.  They also preferred doctors to seek help from another expert colleague rather than a computer aid.  At the time when the study was undertaken patients were apprehensive of the non-human sources of health information.  These sentiments do reflect the reality in daily practice.  Many studies have reported that physicians frequently have questions during patient encounters, most going unanswered.However, the rapidly advancing technology is changing attitudes.  Patients now readily look up Google both before and after a consultation.  What they have read on-line frequently forms part of the conversation that they have with their doctor.  It would appear that the traditional ways are changing.  Patients no longer mind their doctor looking something up as long as it is done in a professional way.  They do not want the doctor to stay on the screen throughout the consultation.  They do not want it to occur around every decision.  They do appreciate being told what is being looked up and why. It is important to explain to the patient that the use of the mobile device is in relation to their care and not some social or non-work related issue. They positively like it when the doctor checks on-line about a new treatment or test.  Patel et al3 confirm many of these sentiments.  Their study found that the use of CDS tools was considered to be a positive as part of everyday clinical practice. 

CDS tools come in a variety of formats and complexity.  A simple exercise is a reminder system when immunisations or mammograms are due4.  Warnings when a test result is outside the normal range,  prescribing systems that alert the doctor about drug interactions, dosage errors, or allergies or other CDSs can aid in formulating the prognosis for a specific disorder in a patient.  An ideal CDS should include high quality assistance with the differential diagnosis, appropriate management, aspects of usability and more.  There are readily available comprehensive information sources such UP-To-Date.

The development of CDS tools is strongly aided by the introduction of an Electronic Healthcare Record (EHR).  The whole programme requires a strong commitment and is costly and technically challenging.  In addition there is significant human factor.  This referred to as the ‘diffusion of innovation’.  Many will start with downright rejection of the new technologies followed by slow acceptance.  There is a generational factor.  Commonly on a ward round the senior doctor works out the differential diagnosis from memory with the junior doctors checking it on their devices.  Lack of time is commonly quoted in relation to slow introduction of innovation.  This is completely true.  Too often new technologies are introduced into the workplace without sufficient time and training being set aside for the workforce.

However EHRs are the way of the future for the healthcare industry.  Their have great potential in providing real time data to the care of patients.   In 2016 the HSE announced that it is to spend €875m on rolling out a national EHR.  The aim is to create a shared healthcare record that is the primary source for all professionals looking after the patient5.  The current system of paper based patient notes siloed within organisations is no longer acceptable.  It leads to poor collaboration between healthcare settings and impairs the provision of high quality care.  The Maternity HER has already been introduced into Cork and Tralee and will be extended into other Units later this year.

In summary a new rapidly changing interface between medicine and technology is evolving.

JFA Murphy
Editor

References:

  1. Walsh K. Clinical decision support – being worried is nothing to worry about. BMJ 2017
  2. Arkes HR, Shaffer VA, Medow MA. Patients derogate physicians who use a computer-assisted diagnostic aid.  Med Decis making 2007;27:189-202
  3. Patel R, Green W, Shahzad MW, Larkin C. Use of mobile clinical decision support software by junior doctors at a UK teaching hospital: identification and evaluation of barriers to engagement.  JMIR Mhealth Uhealth 2015;13:e80
  4. Moore M, Loper KA. An introduction to clinical decision making support systems.  University of Miami Scholarly Repository 2011.
  5. National Electronic Health Record, Vision and Direction. Aug 2015
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