Jon Keevil, MD
CEO and Founder, HealthDecision

Clinical decision support (CDS) takes on many forms. These range from the simple (showing a pick list of medication doses to avoid the error of prescribing simvastatin 25 mg) to the sublime (artificial intelligence systems that can read x-rays and pathology slides) and everything in between.

Sometimes, too much input hampers the decision process. At a farmer’s market, a table with 35 varieties of jams and jellies generally will sell fewer jars than a table with just 6 options. So too in medicine, too much input can be confusing or overwhelming which defines a role for CDS as well.

Guidelines are generally written to be relatively comprehensive. Committees of experts work to squeeze the best available information out of published literature and their own experience. What can result are large compendiums of guidance that can require smaller summary documents to help clinicians make sense of them. The 2013 ACC/AHA guideline to reduce blood cholesterol for example, was 49 pages long and included 10 tables and 5 branching diagrams. An important contribution to medical care to be sure, but not an easy reference for the clinical encounter.

Similarly, the 2014 Clinician’s Guide to Prevention and Treatment of Osteoporosis is 23 pages long and offers a set of general recommendations for all patients regarding calcium, vitamin D, weight-bearing exercise, and others. It also includes 28 different recommendations that are specific to particular patient subgroups defined by sex, age, menopausal status, bone mineral density T score, FRAX® calculated risk of fracture, and patient historical features. For the clinician in the office, this functions a lot like a table of 28 jams and jellies, increasing the resistance to actually making a selection.

HealthDecision’s osteoporosis tool offers a very particular CDS in this context. All 28 different recommendations are built into the logic, but for any particular patient, a single recommendation is appropriate. For the clinician, the most valuable component of CDS is not the one recommendation shown, but rather the 27 potential recommendations that are not shown. A table with a single jar of strawberry-rhubarb jam that the patient and clinician can consider together whether this recommendation seems appropriate to them.