The future of clinical decision support

张琨

<br>The picture of patient care and safety will look very different in the future. With integrated IT systems, centralised patient care records and clinical decision support, healthcare professionals will have powerful tools to assist them in providing patients with the safest and most effective medical care.
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<br>First DataBank Europe (FDBE) looks ahead to 2010 and beyond, taking us on a hypothetical journey to show how clinical decision support could work in the future.
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<br>Our patient is a 24 year old Asian female who is married, with no children. Her name is Asiya. She is a smoker and lives in London where she works as a production assistant for a media company. She has been diagnosed with epilepsy.
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<br>Asiya discusses her condition with her doctor, who prescribes phenytoin, an anti-convulsant drug. The new diagnosis and medication is recorded on her NHS Care Record using the Systematised Nomenclature of Medicine Clinical Terms (SNOMED CT) and the NHS Dictionary of Medicines and Devices (dm+d) respectively. These ensure consistency throughout the country for the recording and retrieval of medical information about the population’s health and well-being.
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<br>After the GP has prescribed the phenytoin, the clinical decision support system recommends that he discusses with Asiya the contraception she uses. She currently uses barrier methods with her husband. The GP is reminded to mention that there is an element of risk associated with phenytoin and pregnancy, so he advises on pre-conceptual care should she plan to have a family one day.
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<br>Monitoring conditions
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<br>The clinical decision support system also reminds the clinician to monitor Asiya’s drug serum levels regularly and recommends that a future phlebotomy appointment is booked with the practice nurse. Asiya chooses suitable recurring appointment dates from those proposed by the booking system and opts to receive a SMS text message close to her appointment dates to serve as a reminder.
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<br>Six months later, Asiya’s latest test result shows the serum level of phenytoin is sub-therapeutic. A SMS text message notifies Asiya of the result and prompts her to book an immediate appointment with the practice nurse.
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<br>At the appointment Asiya mentions her period is late. The nurse tests a urine sample from Asiya and the result indicates that she is pregnant. This is entered on her NHS Care Record with the relevant SNOMED CT concept(s) – patient care records are now accessible to every relevant healthcare professional in the UK.
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<br>Asiya’s GP receives an automatic urgent email communicating this news. The clinical decision support system immediately highlights to the GP that her current anti-convulsant medication is potentially contraindicated now that she is pregnant.
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<br>Managing treatments
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<br>Asiya is contacted and asked to make an immediate appointment with her GP.
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<br>During the consultation, the GP finds that whilst Asiya is surprised she is also overjoyed and wishes to proceed with the pregnancy.
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<br>Responding to the potential contraindication alert of pregnancy and phenytoin, the GP asks the clinical decision support system to suggest alternative medicines for epilepsy which might be safer in pregnancy.
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<br>The GP cross-references treatment options with recent evidence on epilepsy management in pregnancy and current National Institute for Health and Clinical Excellence (NICE) guidance – utilising all the tools around him to make the best quality decision for Asiya. Carbamazepine is selected and prescribed.
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<br>The clinical decision support system also suggests prescription of folate supplements to counter the possible risk of neural tube defects associated with anti-convulsant medication. Asiya is then recommended to make an appointment with the practice nurse to discuss an antenatal programme.
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<br>During the appointment with the nurse, the clinical decision support system provides Asiya with a tailored antenatal programme including a course of daily vitamin K supplements four weeks before the delivery date to reduce the risk of a bleeding problem in the infant during and after labour. It also fires a lifestyle alert, triggered because she smokes ten cigarettes a day. Asiya and the nurse discuss a smoking cessation programme and Asiya agrees to enrol on the course.
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<br>Asiya gives birth naturally to a healthy baby boy, weighing 7lbs 6ozs. All the birthing details, including how she is feeding her son, are recorded on her NHS Care Record using SNOMED CT terminology.
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<br>Back home, at a regular check-up visit to the GP, the clinical decision support system reminds the GP to review Asiya’s anti-convulsant medication following the birth of her son and warns that her old medication (phenytoin) is secreted in breast milk. The GP discusses breastfeeding with Asiya who confirms she is feeding her son this way. They discuss the minimal risks associated with her current anti-convulsant medication and agree that she should remain on carbamazepine. They discuss contraceptive options and the GP is reminded to advise that carbamazepine can reduce the efficiency of the contraceptive pill.
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<br>Joined up care
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<br>Six months quickly pass for Asiya and she decides to take a holiday to visit some friends in Leeds. Whilst there, she complains of light-headedness and a racing heart rate, and has to be admitted to Leeds A&E immediately. The on-call medical registrar diagnoses atrioventricular nodal re-entry tachycardia. She decides to treat Asiya’s condition with adenosine: the hospital clinical decision support system proposes a dosage range for the patient and the given indication. This clinical decision support module, entitled ‘dose range check’, is designed to ensure that the prescribed dose for a given patient is within the safe and effective range, based on the patient’s age, weight and surface area.
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<br>After successful treatment, Asiya is discharged from hospital and an electronic summary is immediately sent to Asiya’s GP detailing the incident, diagnosis and follow up recommendations. The next day Asiya visits her GP for a routine baby and mother health check and they are able to discuss her hospital admission in Leeds.
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<br>FDBE and the future
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<br>This vision of the future, showing a cohesive, real-time system being used by healthcare professionals throughout the UK, is likely to be in place by 2010. FDBE is working to enable safer prescribing, dispensing and improved patient care through effective clinical decision support.
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<br>Through its partnerships with healthcare system providers and its work with NHS Connecting for Health, FDBE sees this vision of the future as a reality, the ultimate future of clinical decision support.
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