Purpose: Prescribing medications and ordering laboratory tests are key elements in clinical decision process (CDP). However these decision junctions are usually one-dimensional and focus primarily on medical personnel. We suggest integrating multidisciplinary synchronized decision support teams into these processes, thus reducing risk while improving financial outcome.
Method: The prescribing pathway and laboratory test ordering patterns were studied and analyzed in details in order to identify potentially problematic issues in these processes. The results of this analysis were used to create structured decision-rules and intervention algorithms:
- Drug related problems algorithm (DRPA) – prescriptions arriving at the pharmacy from 3 internal medicine wards were preemptively screened and clinically checked according to pre-determined criterion. The results were communicated to the medical teams in the department.
- Macrocytic anemia algorithm (MAA) - requested vitamin B12 and folic acid test orders were inspected by hematology laboratory personnel and only executed according to predetermined clinical rules.
- DRPA: during 2010 pilot study approximately 1000 potential errors were identified, this is in comparison to traditional voluntary error reporting which was approximately 15% of the total number of intervention see with DRPA. The acceptance rate of intervention was 98%. The most frequent interventions were: incorrect dosing, therapeutic duplication, drug interactions and dispensing mistakes.
- MAA: 70% percent decrease of total hospital vitamin B12 and folic acid tests was recorded when comparing semiannual number of these tests performed prior and after to initiation of MAA (approximately 6000 and 2000 respectively). Furthermore there was statistically significant increase in detection of patient suffering from anemia when compared to pre MAA period (70% p<0.005). This indicates an increase in test yield with substantial direct cost savings.
Conclusion: Many electronic decision support systems are available commercially, however there is an increased body of evidence indicating that such systems are expensive to implement, labor consuming and are not well integrated into daily prescriber activities. The design and implementation of a preemptive human operated intervention algorithm concentrating on the CDP can be a successful strategy. This may be achieved, as seen in our study, by utilizing existing medical support human resources and synchronizing them into decision junctions leading into substantial quality improvement, risk reduction and substantial savings. Accordingly the Hospital management expanded the DRPA to 5 additional wards.