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Integrating Clinical Decision Support Into Workflows

Monday, June 20, 2011   (0 Comments)
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Submitted by SuccessEHS (NWRPCA Member)

Clinical Decision Support (CDS) Systems are needed for compliance with Stage 1 meaningful use.  Additionally, CDS can:

  • Assist with accurate diagnoses, disease prevention, adverse event alerting, lowering costs of care, improving operational efficiencies, and reducing patient inconvenience.
  • Align Providers with legislation and health care policymaking
  • Position providers for compliance with quality guidelines necessary for reimbursement in the future

Contained in this White Paper

  • What is Clinical Decision Support?
  • The 5-Rights of Implementing CDS Systems
  • CDS use in Clinical Workflows
  • The Future of CDS in the U.S.

Author:   Adele Allison, National Director of Government Affairs

Historical Perspective

Decision-making:  The Hunch vs. Dexter

Before discussing the history of clinical decision support (CDS), readers should recognize that clinicians are cognitive individuals that come to the medical field with established decision-making habits.  Anyone who has taken a Myers-Briggs personality test knows that by adulthood the psychological tendencies people receive at birth or learn over a lifetime form one’s natural thought processes for decisions and problem-solving.  Clinicians are people, too, and cognitive decision-making is a natural behavior.

According to Pat Croskerry, MD, PhD, Professor of Emergency Medicine at Dalhousie University in Halifax, Nova Scotia, the human psyche expends tremendous cognitive effort with distractions and interruptions.   Having to continually shift one’s attention to refocus on the task at hand requires quite a bit of mental agility that can be confounded by fatigue.  Croskerry states that in the last 3 or 4 hours of a night shift in an emergency room, physicians are functioning at 70% capacity.[1] Given the demands of the clinical practice in the U.S. and the speed and comfort a provider can have with reflective decision-making, moving to analytical conclusions can seem to be a nuisance or even an affront to diagnostic acumen.

What is Clinical Decision Support?

According to the Office of National Coordinator (ONC), Clinical Decision Support (CDS) “provides clinicians, staff, patients or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care.”  CDS systems deliver tools electronically in such forms as alerts and reminders for care, clinical guidelines, order sets, data, documentation templates, diagnostic support, reference information, portals, and much more.  Practices that weave CDS technology into their workflows will ultimately realize benefits in patient quality of care, outcomes, safety, efficiency, cost-savings, and provider and patient satisfaction.

The U.S. is on the brink of wading into the waters of improving clinical decision making through the use of technology at the point-of-care and within the practice design.  Legislation supports it.  Patient-center medical home supports it.  Health policy supports it.  More and more, practices are adopting it – and, wisely so since compliance with quality guidelines will likely affect reimbursements in the future.

Evolution of Clinical Decision Support Systems

The concept of decision support arose as early as the 1960’s with punch-card driven systems to analyze and predict diagnosis.  Since that time the architecture of CDS systems has grown from standalone systems to EHR-based clinical decision support delivered at the point-of-care, based upon record content and evidence-based guidelines.  (See Diagram 1) MYCIN, developed at Stanford University in 1975, was able to identify bacteria causing severe infections and associate a recommended antibiotic, complete with weight-based dosing to the clinician, for such problems as bacteremia and meningitis.  Later engineered at the University of Pittsburgh, a solution called Internist was released in 1981 that supported rules-based diagnosis of complex problems in internal medicine.

Rules-based logic continued development and by the mid-2000s, CDS systems could automatically prompt appropriate CDS in the form of alerts.  In 2005, a study of effectiveness of CDS systems on clinical performance and patient outcomes was published.[2] This research report concluded that clinician performance had been improved by 64% and patient outcomes by 13% as a result of electronic prompting as compared to systems requiring the user to self-prompt or activate the CDS.

With the enacting of the American Recovery and Reinvestment Act of 2009 (ARRA), adoption of interoperable electronic health records (EHR) has been launched creating swift market movement to avoid Medicare penalties by 2015.  This key legislation has also triggered rapid shifting in health care policymaking.  Through CMS, the Secretary of HHS has created a three-phased roadmap for implementation and Stage 1 includes the implementation of 1 CDS rule for purposes of outreach, research, and/or disparity reduction.

Stage 1 rules also require reporting 6 of 44 defined clinical quality measures that in turn will be used for comparative effectiveness research.  In the government’s mission to define “quality” in terms of clinical guidelines for wellness and chronic disease management, ARRA earmarks $1.1B for this detailed investigation. U.S. providers may soon see national guidelines emerge based upon data collected and studied, and suddenly realize a shift in the reimbursement models from pay-for-service to pay-for-quality and accountability.  Based upon the clinical outcomes, a provider or perhaps even a community of providers through “Bundled Payments” will experience adjustments or non-payment or reduced value or poor performance, healthcare acquired conditions, and missing the mark on nationally defined standards for patient safety and quality of care.[3]

Following evidence-based guidelines and the demand for strong CDS systems is emerging.  The electronic health care technology market is responding to this call with ever more intuitive tools.  CDS can be embedded in the provider’s workflow by way of “computerized alerts and reminders to care providers and patients, clinical guidelines, condition-focused order sets, patient data reports and summaries, documentation templates, diagnostic support, and other tools that enhance decision making in clinical workflow.”[4]

Download the full white paper with original charts and tables.



[1] “Conversation with … Pat Croskerry, MD, PhD,” http://www.webmm.ahrq.gov/perspective.aspx?perspectiveID=87 , June, 2010.

[2] Garg AX, Adhikari NK, McDonald H, Rosas-Arellano MP, et al, “Effects of computerized clinical decision support systems on practitioner performance and patient outcomes:  a systematic review,” JAMA, 2005, http://jama.ama-assn.org/content/293/10/1223.long

[3] See the Patient Protection and Affordable Care Act of 2010, Creation of Advance Payment Models (§3022), Newly created Center for Medicare and Medicaid Innovation (CMMI), for more information, link:  http://innovations.cms.gov/news/events-archive/

[4] Office of National Coordinator for Health Information Technology, June, 2011,http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__cds/1218


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