EMR Physician Builder Day 3 - Best Practice Advisories

Gates of Hell - location? (photo by Rob Schertzer)

We left Voyager through a secret underground passage to Andromeda, passing the gates of hell on our way to Heaven. We climbed the Stairway to Heaven together then, knees up to our chests, one by one, we zipped down the slide. A fitting way to end three days of intense course work in which zoning out for more than 30 seconds was enough to get completely lost. The walking tour of campus sounds like it could have been a metaphor for this three day Physician Builder course. Today we touched upon Best Practice Advisories (BPA) and Dynamic Order Sets. Let's discuss...

In December 2006, I wrote an opinion piece in the Canadian Journal of Ophthalmology about a vision of electronic medical records of the future. [Article pre-dates on-line journals; will scan a printed version and embed here.] I wrote that we would be dictating our findings into our lapel microphones and when it came to formulating our assessment and plan, the findings would trigger a browser to open with relevant evidence based literature. Although this is not quite what we are doing, there is actually a way to build this rather seamlessly into our EMR; it's the Best Practice Advisories.

Best Practice Advisories are standards of care. In medicine, this would include recommended medications based on current evidence. This includes such things as anyone with diabetes who is between 40 and 75 years of age to be on a cholesterol lowering drug.  An EMR can be programmed to help identify patients who meet these criteria who might otherwise not get the recommended standard treatment. It is very impressive when you see the message in the patient's chart and in the same pane you can place the order. This is EMR programming done right but it requires a lot of behind the scenes work to check the diagnosis registry for the patient, verify the age, check their current medications for all the drugs in this category, then trigger the BPA to appear and to not display anything if the patient would not qualify. As discussed in Prose out of buttons from day 2 of the course, this type of behaviour can be extended into other aspects of the patient record. 

Going one step further, it is even possible to have the EMR query across multiple criteria to produce an order set based on the diagnosis, relevant allergies, lab results searching back over the past few months. It might even check what medications they are already taken to avoid duplication and which ones didn't work in the past to make sure neither are prescribed. This means a dynamic order set, one that "automatically" changes what medications and/or tests even appear on the order set for any given patient. 

There is so much that we can be achieving with our EMR. The problem is it does NOT do this automatically at all. It can only respond to logical queries that we program into them. The BPA for prescribing statins is an important one but what about the hundreds of millions of patient visits each year that are not for patients not already on statins who have diabetes and are between 40-75 years of age? We have a lot of work ahead of us. The journey still has barely begun.