Diagnostic tools ready for a test drive

As has happened with other technology, diagnostic decision-support systems are a tool physicians as a whole tend to like in theory better than they do in practice.

Clinical decision-support systems are computer-based systems that help physicians treat patients through means such as providing access to medical information or providing alerts regarding drug interaction, preventive test scheduling and other patient needs. Various surveys and studies have reported that physicians tend to believe claims that these systems can help them in their practice.

Those same surveys also note a low adoption rate. For example, a recent Commonwealth Fund survey found that only 23% of family physicians had such systems, fewer than the 28% that had electronic medical records systems. And just because physicians had them didn't mean they used them. An earlier survey that the Commonwealth Fund did in 2003, and published in the April 10, 2006, Annals of Internal Medicine, found 25% of doctors across specialties had decision-support systems, but only 6% of doctors overall used them "routinely."

Physician concerns over such systems included worries about inaccurate information, a lack of time to act on nonurgent alerts, fears of the systems resulting in so-called cookbook medicine, and the failure of many systems to interact with the office EMR.

But one of the biggest problems is one that clinical decision-support systems share with other technologies --that there isn't enough time or money to figure out which one is worth buying, and how it would fit into the practice workflow.

Fortunately, say doctors who have bought diagnostic decision-support systems, checking out a system is far easier than, say, trying to do the same with other decision-support tools or an EMR (which might or might not already come with its own support system). Many systems are available for free test drives, with 30 days being a common timetable.

Steve Furr, MD, a family physician and one of the founders of the five-physician Southwest Alabama Physicians group in Jackson, Ala., said he found out quickly while testing a system that he needed something portable, rather than something he could only use on a desktop computer.

He puts his portable system, which costs him $200 for a two-year subscription, on his handheld, and says it helps him save time he might otherwise spend going back to his office to do research, or to copy information for patients who needed assurance that their symptoms didn't match a diagnosis they suspected would come.

Dr. Furr said the efficiencies gained by having the information at his fingertips allows him more time to see patients. And he encourages physicians testing out systems to pay attention to small features.

Dr. Furr said his practice made the decision to test a handheld system because of its portability, but it was a small feature that sold him on a particular product.

The system he uses has an arrow feature that allows him to move back and forth between pages. He found other systems that did not have that feature were harder to navigate and took more time. "The little things are the most important thing, and that little back arrow is something important," Dr. Furr said.

Dr. Furr's system is not integrated with an EMR, but many systems can be. The problem, though, is getting the two systems in sync.

Michael Krall, MD, the family physician lead for the decision support and ambulatory patient safety department for Kaiser Permanente's Northwest Region, said Kaiser's EpiCare system already has several decision-support tools built in, but does not have diagnostic decision support, which allows physicians to cross-check their diagnosis by entering information into the system.

Dr. Krall said he has been interested in adding a diagnostic decision-support tool but wants one that will tightly integrate with the existing network. Right now, he said, physicians would have to re-enter data that already exist in the EMR, so it would not improve efficiencies.

Stephen M. Borowitz, MD, a pediatrician in the Division of Pediatric Gastroenterology and Nutrition at the University of Virginia Children's Hospital, said he uses diagnostic decision-support systems as a teaching tool. He said it exposes students to the physician's natural tendency to be biased towards a particular diagnosis.

For example, Dr. Borowitz routinely sees a patient with severe neurological disorders that render him unable to communicate. When he was recently admitted with a fever, Dr. Borowitz's immediate assumption was a bacterial infection because the boy has a central venous catheter. After turning to his system, which suggested possible gallbladder disease, Dr. Borowitz said he was forced to shift his thinking. As it turned out, the boy had gallstones and needed his gallbladder removed.

"In retrospect, I probably should have thought of it but didn't," said Dr. Borowitz. "It exposed my bias towards a particular diagnosis."

Dr. Borowitz said he's not sure how practical the system might be in a typical family practice. But that's the good thing about this technology, said Dr. Furr. Several systems can be test-driven for little or no money until you can figure out if a system is something you would use -- or until you find the one that makes sense for you and your practice.