1. Decision Support for Quality Improvement
Unit 6.4: Tips for Successful Clinical Decision Support Systems
The final decision support for QI unit presents tips for successful design and implementation of clinical decision support systems in health care
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Health IT Workforce Curriculum

2. Health IT Workforce Curriculum
Objectives
Investigate strategies for successful design and implementation of decision support systems
The objective of unit 6.4 is to investigate strategies for successful design and implementation of decision support systems.
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Health IT Workforce Curriculum

3. Early Considerations Primary need and target area To whom and how
Efficiency improvement
Early detection/accurate diagnosis
Evidence based treatment
Prevention of adverse events
Primary need and target area
To whom information is delivered
How information is delivered
To whom and how
When assisting clinicians in assessing the need for clinical decision support, it is helpful to understand the primary need or target area for which the clinical decision support is being considered. Are they trying to improve overall efficiency? Identify disease early? Aid in obtaining an accurate diagnosis or implementing an evidence-based treatment protocol? Or are they trying to prevent adverse events, such as medication error? Next, it is important to know to whom the decision support is to be delivered, and how. For example, duplicate testing alerts need to go to the provider who orders the test, however, if the test is part of a nurse-initiated protocol, the alert needs to go to the nurse.
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Health IT Workforce Curriculum

4. Early Considerations User control
How much control user will have in accessing and responding to information?
User control
Automatic:
Example: calendar alarm that is automatically presented to remind user that a scheduled meeting is about to begin
The next thing you will need to know is how much control the user will have in accessing and responding to information. Is the CS displayed on demand or presented automatically to the user. Can the user choose whether to accept the information? CDS can be designed to remind clinicians of things they intend to do, but should not have to remember. Or it can be designed to provide information for clinicians who may be uncertain as to the best course. CDS can be designed to correct errors that clinicians have made or to recommend that clinicians reconsider their plans.
In order to better understand the concepts of automatic and on demand functionality, let’s look at the example of the calendar alarm. The user can set the calendar alarm to signal 15 minutes before a scheduled appointment. The calendar alarm is presented automatically to remind the user that there is someplace he needs to be in 15 minutes. When the user is in a word processing program, he may elect to access the online thesaurus when he wants to select a different word choice that has the same meaning.
On Demand:
Example: user can access the online thesaurus as needed
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Health IT Workforce Curriculum

5. Health IT Workforce Curriculum
5 Rights of CDSS
Right Information
Right Person
Right Format
Right Channel
Right Time
Osheroff suggests that there are 5 rights of CDS design. CDS should be designed to provide the right information to the right person in the right format through the right channel at the right time (that is, when the information is needed). So you will need to know whose decisions are being supported by the clinical decision support system, what information that person needs to have presented, when does the persons need that information, and how should the information be presented. The challenge is to determine how closely the clinical decision support is tied to what the clinician already intends to do. Speed and ease of access are important for clinical decision support that the user seeks out (or “on demand support). Timing is more important for automated reminders.
Osheroff JA. Improving medication use and outcomes with clinical decision support: a step-by-step guide. Chicago, IL: The Healthcare Information and Management Systems Society; 2009.
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Health IT Workforce Curriculum

6. Health IT Workforce Curriculum
CDS Design
More effective than manual decision support processes
CDS interventions most likely to be used:
Fit into clinicians’ workflow
Presented automatically
If recommends actions for users to take: more effective than if merely provides assessments
If provides information at a time and place of decision-making: more likely to have an impact.
Kawamota and colleagues conducted a systematic review and noted several design characteristics that are associated with successful clinical decision support. First, computerized processes are more effective than manual processes. Next the interventions that are most likely to be used by clinicians are those that are presented automatically (versus on-demand) and those that fit into their workflow. If the clinical decision support rule recommends actions for the user to take it will be more effective than a rule that merely provides assessments. Finally, if the rule provides information at a time and place of decision-making activity, then the rule is more likely to have an impact on care.
Kawamoto K, Houlihan CA, Balas EA, Lobach DF (2005). Improving clinical practice using clinical decision sopport systems: a systematic review of trials to identify features critical to success. BMJ 330(7494):765.
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7. Health IT Workforce Curriculum
CDS Implementation
Workflow integration
Includes structure or work system features and processes that support care
Step 1: Engage clinicians in design and implementation
Step 2: Analyze workflow and how CDS will fit into that workflow
Step 3: Determine need for process improvement
Step 4: Configure to meet users’ needs
Workflow issues are critical to take into account when designing and implementing clinical decision support systems. Workflow includes features of the work system as well as processes that support care. First, it is important to engage clinicians in all aspects of design and implementation. Next, their workflow must be analyzed and a determination must be made as to how the clinical decision support will fit into that workflow. It is important to understand that there may be many different workflow patterns, not just a single pattern, and all patterns should be taken into consideration. Only when the team has determined that there needs to be process improvement can decisions be made on how to improve processes and how the clinical decision support can aid improvement. Finally, the system must be configured with the user’s needs in mind.
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Health IT Workforce Curriculum

8. Health IT Workforce Curriculum
CDS Implementation
Data Entry and Output
Most CDS are integrated into the EHR and pull patient information from that record
Some CDS are independent of the EHR and the user may have to enter patient information twice
A consideration: who enters the data and who receives the CDS advice?
Most of the CDS that is associated with drug interaction alerts and reminders are integrated into the EHR and pull information from that EHR. Other systems are independent of the EHR, such as web-based and hand-held computer-based CDS tools. These may require clinicians to enter data twice – once into the electronic health record and once into the CDS application, causing workflow problems. Another consideration is who enters the data and who receives the advice. For example, a prescriber may write a manual prescription and a nurse may enter it into the order entry system. How would a recommendation to change the prescription be handled. A variety of approaches have been used, such as alerts to the physician’s pager), but these issues must be addressed in the planning process.
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Health IT Workforce Curriculum

9. Health IT Workforce Curriculum
CDS Implementation
Standards and Transferability
EHRs with CDS capability may not be ready for use “off the shelf”
Effective CDS implementation requires some degree of local customization
In the absence of standards for information exchange of CDS, users will need to select the rules and alerts that are most applicable to their site
Electronic health records with clinical decision support capability may not be ready for use without a significant amount of additional work. Systems usually come with sets of built in reminders. Clinicians will need to select which ones to use. These systems usually require some sort of local customization. Time and effort on the part of clinicians is often required to select and design content. Vocabulary differences, as well as different standards for medication formularies or processes of care may require additional work before the CDS can be deployed. IT professionals and clinicians will need to spend time understanding the logic of the CDS and may need to adapt it to their unique needs.
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Health IT Workforce Curriculum

10. Health IT Workforce Curriculum
CDS Implementation
Knowledge Maintenance
It is difficult to maintain the accuracy of the medical record (e.g., failure to update medications or allergies)
If information used to trigger the CDS is not accurate, the alerts will not be accurate
Knowledge imbedded in the CDS may be out-dated (e.g. clinical practice guidelines may change and the CDS will need to be updated to reflect the current standard).
It is difficult to maintain complete accuracy of the medical record. For example, providers may fail to update medication or allergies. Or a nurse may not document an intervention in the electronic record until two or three hours after he has performed the intervention. If information used to trigger the clinical decision support rule is not accurate, the alert will not be accurate. In addition, knowledge that is imbedded in the clinical decision support system may be out-dated. Clinical practice guidelines change with great frequency as clinicians and researchers gain new knowledge or as new regulatory requirements become active and the clinical decision support system will need to be updated to reflect current standards.
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Health IT Workforce Curriculum

11. Clinical Decision Support (CDS) Inpatient Case Study
A semi-rural community hospital has bought a commercial inpatient computerized order entry system (CPOE). The hospital admits patients to its inpatient units from its emergency department (ED) and from ambulatory clinics and wants to assure and measure safe and timely admission and transition of patients from the ED to the inpatient unit. The hospital sees many cases of chest pain in the ED, which has been identified as an area in which it can improve management. There is a standard protocol for working up, diagnosing, and treating patients with chest pain, and the inpatient physician group would like to assure rapid initiation of the protocol once the diagnosis of chest pain is made in the ED.
Think about the following case. A community hospital has a new CPOE system and wants to make sure that it has a safe and timely admission and transition process of patients from the emergency department to inpatient units. The focus of improvement efforts for this hospital is care of chest pain patients, who usually present in the ED and are subsequently managed in the inpatient settings. The hospital has a standard protocol for working up, diagnosing, and treating patients with chest pain and the inpatient physician group wants to assure the rapid initiation of that protocol as soon as possible after the diagnosis of chest pain is made by the emergency room physicians.
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Health IT Workforce Curriculum

12. Inpatient CDS Case Study Two Contingencies
A patient may come to the ED with clear diagnosis of a major event (heart attack) that requires immediate transfer to the cardiac intensive care unit (CICU). The cardiac care team has specific protocols for different cardiac diagnoses that depend on rapid evaluation and diagnosis in the ED, timely communication to the cardiac care team and coordination of care (diagnostic testing, interventions) and transfer of the patient to the CICU.
A patient may deteriorate acutely after arrival to the ED. Deterioration may be preceded by changes in vital signs and measures (e.g., heart rate, respiratory rate, blood pressure, oxygen saturation levels, electrocardiogram) that are tracked and recorded by patient monitors with alarms for abnormal values.
Just as real-life cases are most often complicated, let’s look at two contingencies related to our case study. In the first possibility, a patient comes to the ED with an apparent heart attack. The cardiac care team has specific protocols that depend on rapid evaluation in the ED, timely communication, and coordination of care and transfer to the ICU. In the second unforeseen event, a patient deteriorates on arrival to the ED. This deterioration may be preceded by changes in vital signs as recorded by patient monitors with alarms for abnormal values.
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Health IT Workforce Curriculum

13. Inpatient CDS Case Study Considerations for Clinicians and IT
What is CPOE and what are its functions in patient safety?
What is the role of CDS in CPOE?
What is the sequence of events that must occur in the average patient who presents to the ED with chest pain and must be admitted to the inpatient unit?
What are the sequences of events for patients in contingencies 1 & 2?
What clinical data need to be monitored, detected, and managed during the ED work-up of the patient? Does this change for contingencies 1 & 2?
What are the functions of CDS in data management to ensure quality?
In trying to decide upon the best use of clinical decision support for the current case, clinicians and IT professionals need to understand what computerized provider order entry entails and how it functions with respect to patient safety. They also need to understand the role of clinical decision support in CPOE, and the sequence of events that need to occur when the average patient presents to the ED with chest pain and needs to be admitted to the inpatient unit. How does this sequence change when either of the two contingencies come into play. What types of clinical data need to be monitored and managed during the ED work-up for the patient and does this change for either of the two contingencies. Finally, the team needs to be aware of the functions of clinical decision support in data management to ensure quality.
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Health IT Workforce Curriculum

14. Inpatient CDS Case Study Considerations for Clinicians and IT
Order sets
How do order sets help assure safety and quality in inpatient care?
How are order sets created, implemented, and maintained?
Alerts and reminders
How do alerts and reminders interact with users?
How can alerts pose problems in patient safety?
Access to drug dictionaries and patient data
What are patient safety functions that CPOE/CDS linked to patient data offer?
What patient safety functions can drug dictionaries offer to DCS and what challenges exist in implementing them?
The team will want to look specifically at orders sets, alerts and reminders, and access to supportive information that aids in decision making. It will need to understand how order sets help assure safety and quality in inpatient care and how these order sets are created, implemented and maintained. The team needs to understand the affect of alerts and reminders on users, and how these supports can sometimes pose difficulties in patient safety. Finally, they need to be aware of the patient safety functions that clinical decision support linked to patient data and drug dictionaries offer, and what challenges exist in implementing them.
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15. Clinical Decision Support (CDS) Ambulatory Care Case Study
Ambulatory practices in the community want to keep track of patients who are admitted for chest pain (especially those who are diagnosed with heart disease). They would like to improve ongoing management of heart disease in their population by being alerted to patient admission to the hospital and hospital management and disposition of these patients (new medications, management by specialists, etc.). They have a good working relationship with the hospital and some of the ambulatory practices affiliated with the hospital already have a common electronic health record that connects to the hospital information systems.
The merits of clinical decision support are not limited to the inpatient environment. Think about the following case. Several community ambulatory practices want to monitor patients who are hospitalized for chest pain. They want to improve ongoing management of patients diagnosed with heart disease in their population by receiving an alert when these patients are admitted and receiving information about the hospital management and disposition of these patients. Some of these practices have a common electronic systems with the hospital.
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Health IT Workforce Curriculum

16. Ambulatory Care CDS Case Study Considerations for Clinicians and IT
For practices with connected EHRs,
What kinds of patient data need to be made available to the ambulatory practices?
What forms of CDS will be helpful to assure continuity of care?
Information libraries
Alerts and reminders
Guidelines
At the hospital
At the practices
HIT professionals working with clinicians will need to ascertain the following information when working with practices that are fortunate enough to have connect electronic health records. What kind of data need to be made available to the practice. What forms of decision support will be helpful to assure continuity of care. The team will need to look at the potential value of information libraries, alert and reminders, and guidelines to both the practices and the hospital to which the practices admit their patients.
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Health IT Workforce Curriculum

17. Ambulatory Care CDS Case Study Considerations for Clinicians and IT
For practices without connected EHRs,
What are alternatives to implement CDS?
What are challenges and barriers?
What business strategies might be considered by the hospital and the practices to improve EHR adoption?
If preventive care is to be the emphasis, how can CDS be implemented in ambulatory EHRs to improve prevention?
Information libraries for practitioners and patients
Evidence-based care guidelines
Alerts and reminders
Analysis tools for practice data
When working with practices that do not have connected EHRs, questions such as what are alternatives, challenges, and barriers to implementing clinical decision support. What business strategies need to be considered? If prevention is to be the focus of the practices, how can clinical decision support be implemented in ambulatory EHRs to improve prevention. One would need to look at the value added by having information libraries for practitioners and patients, access to evidence-based care guidelines, alerts and reminders, and analytic tools for practice data.
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Health IT Workforce Curriculum

18. Clinical Decision Support (CDS) Public Health Case Study
The State Health Department has noticed the problem of cardiac disease in community and wants to implement programs to discover and intervene in both acute and preventive care. It would like to establish health information exchange (HIE) for cardiac care in the state. Public health policy makers would like to have decision support that would help improve cardiac care within the state. In meeting with clinical cardiologists from community hospitals and a tertiary university center in the state, public health officials are in discussion with an IT team to improve the functionalities of the local health information registries (primarily for immunizations, infant metabolic screening, and cancer).
In one final case, let’s look at use of clinical decision support in the public health arena. The state health department wants to set up cardiac management and prevention programs because they have found cardiac disease to be a problem in the community. They want to establish health information exchange for cardiac care in the state and would like to have decision support to support that effort. So public health officials meet with clinical cardiologists and IT professionals to improve how the local health information registries function by adding cardiac risk data to the current immunization, metabolic screening and cancer data.
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Health IT Workforce Curriculum

19. Public Health CDS Case Study Considerations for Clinicians and IT
What is the public health information process for cardiac health and who determines this?
Surveillance: types of data reported, by whom, and how often?
Analysis: measures of importance?
Response: public health responses?
What data do public health officials need to assess and make decisions about cardiac health in the state?
Access to information (institutional, regional, national)
Guidelines
Alerts and reminders (to public health officials, to the public)
What information standards are needed (clinical data reporting, data reporting formats?)
The team will want to find out who determines the cardiac health information process and what is entails. Team members will examine the surveillance processes, including the types of data reported, who reports the data, and with what frequency these data are reported. They will inspect both measures of importance to cardiac health and public health responses to these measures. The team will need to understand the data that public officials need to assess and make decision regarding cardiac health, including access to information at the institutional, regional, and national level; whether these decisions are governed by clinical practice guidelines, and what alerts and reminders are needed to notify public health officials and general public. Finally, the team needs to understand what information standards are needed for clinical data reporting and what format is required.
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Health IT Workforce Curriculum

20. Health IT Workforce Curriculum
Summary
When implementing CDS, IT professionals should consider the primary need and target area, to whom and how information is to be delivered, and degree of user control.
The 5 rights of CDS state that CDS should be designed to provide the right information to the right person in the right format through the right channel at the right time.
Important considerations are: workflow integration, data entry and output, standards and transferability, and knowledge maintenance.
In summary, when assisting with the implementation of clinical decision support, IT professionals should consider the primary need and target area, to whom the information needs to be delivered, how the information is to be delivered, and the degree of desired user control. The five rights of clinical decision support state that clinical decision support should be designed to provide the right information to the right person in the right format through the right channel at the right time. It will be important to consider workflow integration, data entry and output, standards and transferability, and knowledge maintenance.
Component 12/ Unit 6.4
Health IT Workforce Curriculum