A Case Study of Visit-Driven Preventive Care Screening Using Clinical Decision Support: The Need to Redesign Preventive Care Screening

Introduction: In the traditional model of care, an annual visit was dedicated to the task of assessing and delivering preventive care. With the move away from annual physicals, primary care physicians are addressing preventive services at every clinic visit often aided by electronic clinical decision support (CDS) systems.

Methods: We conducted a case study of a visit-driven CDS system in use at a primary care clinic. Steady-state performance was assessed via control charts of quality metrics, data regarding completion of recommendations, and an analysis of screening intervals achieved with patient visits.

Results: Under this visit-driven CDS system, quality metric performance was poor and declining. Almost half of the patients were not screened (46.5%), and the other half were overscreened the majority of the time (83.3%). Recommended preventive services were ordered less than half the time (42.6%), despite CDS reminders.

Discussion: Various barriers and systematic inefficiencies combined to produce ineffective screening in this visit-driven CDS preventive service delivery system. As a result, we conclude a visit-driven system cannot produce optimal results. In order to improve performance, preventive services should be delivered separately from clinical visits, perhaps by a "preventive service ranger" (PSR) utilizing the CDS system to review each patient once annually. Under such a system, patients would receive preventive services in an organized and efficient fashion, potentially leading to better continuity, higher quality metrics that are mathematically predictable, and improved satisfaction.