Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions
Alan H. Morris, Brian C. Stagg, Michael J. Lanspa, James F. Orme, Terry P. Clemmer, Lindell K. Weaver, Frank Thomas, Colin K. Grissom, Ellie Hirshberg, Thomas D. East, C. Jane Wallace, Michael Young, Dean F. Sittig, Antonio Pesenti, Michela Bombino, Eduardo Beck, Katherine Sward, Charlene Weir, Shobha Phansalkar, Gordon R. Bernard, Bruce Thompson, Roy G. Brower, Jonathon D. Truwit, Jay Steingrub, R. Duncan Hite, Douglas F. Willson, Jerry J. Zimmerman, Vinay Nadkarni, Adrienne G. Randolph, Martha A. Q. Curley, Christopher J. L. Newth, Jacques Lacroix, Michael S. D. Agus, Kang H. Lee, Bennett P. deBoisblanc, R. Scott Evans, Dean Sorenson, Anthony Wong, Michael V. Boland, David W. Grainger, W. Dere, Alan S. Crandall, Julio C. Facelli, Stanley M. Huff, Peter J. Haug, Ulrike Pielmeier, Stephen Edward Rees, Dan Stieper Karbing, Steen Andreassen, Eddy Fan, Roberta M. Goldring, Kenneth I. Berger, Beno W. Oppenheimer, E. Wesley Ely, Ognjen Gajic, Brian W. Pickering, David Schoenfeld, Irena Tocino, Russell S. Gonnering, Peter J. Pronovost, Lucy A. Savitz, Didier Dreyfuss, Arthur S. Slutsky, James D. Crapo, Derek C. Angus, Michael R. Pinsky, Brent C. James, Donald M. Berwick
Abstract
Clinical decision-making is based on knowledge, expertise, and authority, with clinicians approving almost every intervention-the starting point for delivery of "All the right care, but only the right care," an unachieved healthcare quality improvement goal. Unaided clinicians suffer from human cognitive limitations and biases when decisions are based only on their training, expertise, and experience. Electronic health records (EHRs) could improve healthcare with robust decision-support tools that reduce unwarranted variation of clinician decisions and actions. Current EHRs, focused on results review, documentation, and accounting, are awkward, time-consuming, and contribute to clinician stress and burnout. Decision-support tools could reduce clinician burden and enable replicable clinician decisions and actions that personalize patient care. Most current clinical decision-support tools or aids lack detail and neither reduce burden nor enable replicable actions. Clinicians must provide subjective interpretation and missing logic, thus introducing personal biases and mindless, unwarranted, variation from evidence-based practice. Replicability occurs when different clinicians, with the same patient information and context, come to the same decision and action. We propose a feasible subset of therapeutic decision-support tools based on credible clinical outcome evidence: computer protocols leading to replicable clinician actions (eActions). eActions enable different clinicians to make consistent decisions and actions when faced with the same patient input data. eActions embrace good everyday decision-making informed by evidence, experience, EHR data, and individual patient status. eActions can reduce unwarranted variation, increase quality of clinical care and research, reduce EHR noise, and could enable a learning healthcare system.