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t qualities Wha m a ke a n cellent RN ex an exper t? • treatment protocols, or "critical care paths" (adapted from "critical path analysis" in manufacturing), recommending a particular course of treatment or care. The CDSS is an "expert system"—that is, one designed to perform the functions of professionals—adapted for use by RNs and doctors from systems used in manufacturing. It's generally interoperable (that is, it can communicate) with or is incorporated into EMRs. Evidence-based medicine is promoted by hospitals and some health professionals as the medical gold standard. A current, complete medical library accessible from the bedside would be an advantage for RNs and doctors, who can evaluate the quality and relevance of research. But EBM guidelines delivered by CDSS are not unfiltered research findings, and they can potentially harm patients. What's Wrong with Support? How ca n y ou know if yo ur patient fit s the model? e Have you secn re a treatment or use withheld becaered it was consid too expensive? CDSS are designed to serve the institution before the patient, putting profit above patient care. • CDSS don't produce a neutral description of the patient's condition. Diagnostics are tailored to restrict patient admissions, speed up "patient cycle time," and favor higher reimbursement. • Protocols remind doctors to think of cost at every turn. In the HMO context, they restrict treatment and care. CDSS prescribe formulary drugs and erect electronic hurdles for doctors to clear before they can order tests and treatment. In the fee-for-service context, doctors are prompted to provide more expensive treatment than they think necessary. • The prognostic, or risk-assessment, function of clinical decision support systems may be their most disturbing. Prognostics make the likelihood of patient mortality a self-fulfilling prophecy. When advised by the CDSS that patients are unlikely to benefit from treatment, physicians are more likely to withhold it. But a patient to whom CDSS attributes a 95% chance of dying regardless of treatment isn't the same as a patient whom treatment can't help. CDSS can't determine whether a statistical model has any relevance for an individual patient. That patient is unknown to the statistical model because that patient is absolutely unique. Only practitioners, using their professional judgment, can determine whether a patient is sufficiently similar (in ways that matter) to the patients on whom the model was based. If CDSS have their way in such a situation, patients who might be helped by treatment will not get it. CDSS threaten to make the withdrawal of treatment a purely economic decision rather than a medical one. CDSS enable the surveillance, routinization, and deskilling of the work of skilled practitioners. Their name is deceptive; they don't "support" the professional judgment of RNs and doctors, but pressure them to give it up. • When practitioners want to deviate from protocol, they have to document their reasons, making themselves legally vulnerable. © Copyright IHSP 2009. All rights reserved.