From cheeseburgers to chinos, other industries have embraced technology tools that health care organizations are still considering.

Michael J. Beller, M.D.

During the last several years working for a health care information company, I’ve observed an increasing interest among clinicians in computerized provider order entry and the role decision support can play in improving the safety and quality of health care. Health care organizations, however, aren’t quite keeping pace. According to HIMSS Analytics, only 4.3 percent of hospitals participating in a rating process have achieved levels that include CPOE and some form of decision support.

Outside the hospital, clinic or physician office, we encounter decision support every day. The first time I truly understood how pervasive it was, I was in the drive-through lane at a fast-food restaurant. Beneath the outdoor menu was an order verification screen. As I placed my order, the screen displayed the following message: “Please order here. This screen helps ensure order accuracy and prompt service.” Each item I ordered appeared on the screen along with its price.

A fast-food restaurant is worried that I might get the wrong size of French fries while most hospitals continue to rely on written orders interpreted by hospital staff. I can’t count the number of times I’ve heard nurses discussing a written order and voting on what they thought the physician meant. If you drove home with a chicken sandwich instead of a cheeseburger because of a similarly broken process, chances are you’d never visit that drive-through again.

Clearly, fast-food restaurants see the value in taking the guesswork out of order entry and making sure the order is accurate. With all the interest in decision support in health care, I got to wondering: What if the expert systems we now expect in health care were available in our everyday encounters with restaurant drive-through lanes and online merchants?

The next logical step for restaurants is to connect to the electronic health record. Imagine the next time you order lunch, this alert appears on the drive-through menu: “Based on your most recent cholesterol levels and body mass index, we suggest you forgo the deluxe cheeseburger and large fries and instead order the fruit cup and a salad. Please check the box to indicate you would like to cancel the original order and accept the alternative.”

Online, Yet Personalized

In presentations to prospective and current clients during the last several years, I’ve asked audiences how many preferred to order clothes, books and other items online instead of using paper catalog order forms. Invariably, a majority preferred online order entry for a number of reasons: item availability is up to date; users can place orders from work or home; the orders submitted are legible to all parties; the user is notified when the order ships; the retailer provides access to other resources such as size charts or an alternate language; users can save personal and billing information for use in future orders; and users can access previous orders if needed.

The reasons for giving up paper orders were no surprise: illegible handwriting; the order sheet was missing; there was no way to know if the item was in stock, if the order was received or when it would arrive; having to complete forms, including personal and billing information, from scratch for every order; the difficulty of canceling or changing an order once the form had been faxed or mailed; and no access to previous orders to make sure you weren’t ordering a duplicate.

The reasons for CPOE and decision support are similar. Access to commonly used orders and order sets; links to evidence-based references; and real-time alerts for drug conflicts can all enhance order accuracy, patient safety and the quality of health care.

Online retailers provide fairly sophisticated decision support. After entering a user name and password, Amazon, Buy.com, Lands’ End and others recommend items based on my order history. And for many of these online sites, once I enter my contact and billing information, I gain access to one-click order entry to expedite the purchase process. These retailers also store personal information such as sizes, credit card information, and addresses for family and friends to further streamline the order entry process.

What if the online retailers also had access to customers’ entire wardrobes and other key information? Say the next time you placed an order for the Men’s Buttondown Oxford Dress Shirt, the following alert fired: “Based on your recent purchases, your known inability to iron a shirt and the condition of your ironing board, we suggest the Men’s Buttondown No Iron Pinpoint Dress Shirt as an alternative to your current order. Please check the box to acknowledge the alert and order the alternative.”

Google’s Expertise

One final way health care can learn from the outside world is by considering the success of iGoogle. iGoogle is a customizable Web page from the search engine company. The user controls how and which data is displayed, resulting in a logical display of information based on preferences rather than a blizzard of disorganized data. When you log in to your personal page, you can choose from a number of “gadgets” including a clock, news or sports headlines, stock tracking, e-mail, local weather and activities, and other items you organize.

A common request I hear from physicians who have used an electronic health record is that the systems present too much data and not enough relevant information. Many want an iGoogle-like experience in which they can select the information they view and the sequence in which they view it.

Many of the latest-generation health information systems are now offering the flexibility so clinicians can act on information instead of being overwhelmed by data. Information presented in a logical, user-defined way itself provides better decision support than in the past.

While we readily accept decision support outside health care, broader adoption of CPOE and decision support using the same technology we find online could improve efficiency and offer the advantages we have come to expect when we place retail orders electronically.

Don’t be surprised if your next fast-food meal comes with more advanced ordering methods and decision support than the average clinical order. We’ve got a lot to learn.

Michael J. Beller, M.D., M.M.M., is a vice president and chief medical officer with Cerner Corporation, Kansas City, Mo.

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This article first appeared on December 10, 2008 in HHN's Magazine online site.

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