Using Commercial Knowledge Bases for Clinical Decision Support: Opportunities, Hurdles, and Recommendations

Abstract

The quality and safety of health care leaves much to be desired.1,2 Automated clinical decision support (CDS) tools embedded in clinical information systems (CISs) such as computer provider order entry (CPOE) and electronic health records (EHR) applications have the potential to improve care and should be part of any comprehensive approach to improve quality.3,4,5,6 Medication prescribing is a component of health care with well documented quality and safety problems that can be improved by CDS.7,8,9 Medication-related CDS requires that pharmaceutical knowledge be represented in a computable, explicit and unambiguous form. Creating an automated representation of medical knowledge often is the most time consuming step in the development of a CDS system and is known as the “knowledge acquisition bottleneck.”10 For a time, it was hoped that the move toward explicit guidelines in medicine would decrease the knowledge acquisition effort,11 but that has not happened.12 Experiments on data sharing from over a decade ago have not progressed.13 As a result, just a few organizations, primarily academic medical centers, are creating rules and benefiting from CDS,14 but most health care organizations do not have the expertise or resources to create such knowledge bases themselves. One potential solution to the problem of access to automated medication-related knowledge is the set of commercial vendors that supply medication-related knowledge bases for pharmacy and prescribing applications. These vendors' products contain such knowledge as drug-drug and drug-disease interactions, minimum and maximum dosing suggestions, drug-allergy cross-sensitivity groupings, and groupings of medications by therapeutic class. Developers of CISs (either vendor-based or “homegrown”), with appropriate licensing, can incorporate commercial knowledge bases into their products. The knowledge base vendor receives a licensing fee for each CIS implementation and can amortize the …