Health Goals to Clinical Decisions (CDS)

It’s hard to reach personal health goals or solve medical problems without a plan.  Plans require decisions. Never-ending decisions (choices) in the health journey. Clinicians, researchers, and insurance companies study and use Clinical Decision Support (CDS) to help with the decision-making process. It’s a shortcut for using research (evidence) in the decision-making. Some talk about patient-centered decision support (see a definition at the bottom of this post). They’re trying to figure out how to help people to make decisions in two minutes of ten-minute visits. Yet, few patients or caregivers I’ve met ever talk about CDS.  So how can people understand the value and limitations of CDS?

Let’s look at six scenarios that illustrate the variety of decisions that health teams make:

1. Immunization – measles, flu, pneumonia, etc. Strong evidence supports protocols for childhood and adult immunization. It’s preventative for the well and the chronically ill. All clinicians will order immunizations. It’s a one-time decision for people – do it or don’t. Some people prefer not to, no matter the evidence.
2. Stop Smoking. All clinicians recommend stopping smoking. Many patients want to stop smoking as a health goal. There are protocols for different ways to stop smoking: cold turkey, patches, gum, support groups, therapy, etc. People have a choice how to stop smoking. There are decision aids available to understand the different ways. But stopping smoking is not a one-time decision. It’s a continuous, repeating action – a habit change.  The method chosen may or may not work.
3. Trouble peeing – a common topic of conversation for men of my age. For patients it’s a functional health goal – fix the trouble peeing. Usually, the prostate’s involved. There are protocols for tests, such as PSA to rule out prostate cancer. Have the test or not.  The evidence points to some concern about false positives (The test shows there’s a  problem when there isn’t a problem). It’s a choice – ultimately for the patient, but usually in partnership with their clinician.
4. High risk for cardiovascular disease (heart attack or stroke). Usually, the patient is unaware of the risk. It’s not one of their personal health goals. Yet almost all clinicians will check the risk and follow a protocol that recommends statins to reduce cholesterol if cholesterol is high. The clinician orders the med and the patient takes as ordered, intermittently, or not at all. Decision support can help make a decision but won’t affect whether or how regularly a person takes it. The statin may or may not prevent heart attack or stroke.
5. Infection prevention in the hospital. A critically ill person can easily get an infection in the hospital – catheters, intravenous lines, transmission from person to person.  Most clinicians will start a protocol to prevent infections, starting with hand washing. Decision support can help them decide risk and select actions. The evidence is strong, the protocols are clear. Often, patients and caregivers are unaware of the risk. But sometimes clinicians don’t start a protocol or follow the protocol and patients and caregivers know and insist. The actions taken involve the whole team including the patient and caregiver.
6. Antipsychotic drugs for people with dementia – The choice is to stop or continue these powerful drugs. A growing body of evidence indicates stopping. The clinician may or may be aware of the protocols about stopping the antipsychotics. The caregivers may or may not be aware.  It’s much safer to stop antipsychotics as a partnership. Decision support tools exist to help with the decision and the process.

These six scenarios show the many issues involved with healthcare decisions and decision support. The decisions can start as health goals or medical problems or both. Decisions can involve any stage of the journey. When research and decision support is available about choices, patients, caregivers, and clinicians may or not be aware. Decisions can be one-time decisions or be a habit change. Alignment of the patient, caregiver, and clinician is critical and involves communication within a relationship. And finally, the action taken as a result of evidence may or may not work. It’s hard to know if something doesn’t work because the plan isn’t being followed regularly or the action just doesn’t work. This reinforces the importance of team alignment and agreement about the plan.

Patients, caregivers, and clinicians want to reach health goals and solve medical problems. Clinical decision support helps the team make choices. The more you know about each other and the evidence the better the choices. The better the choices, the more likely that the choices will be followed and that they will work. Phew, intense isn’t it?!

A definition of Patient-Centered Clinical Decision Support (CDS):

CDS is a vehicle for clinicians to communicate and implement evidence with their patients. “Patient-centered CDS supports individual patients and their approved caregivers and/or care teams in health-related decisions and actions by leveraging information from evidence-based research (CER and PCOR) and/or patient-specific information (e.g. patient-generated health data).

Image: Metacognition wordle by Nancy Smith

YouTube of post