6 Optimization Strategies for Clinical Decision Support

Section6.3 Optimize

Section 6 Optimize—Optimization Strategies for Clinical Decision Support - 1

Optimization Strategies for Clinical Decision Support

Clinical decision support is a hallmark of an electronic health record (EHR) and it is increasingly becoming embedded in certain health information exchange (HIE) services. Clinical decision support is heralded as the key driver for EHR to be used to improve the quality, experience, and cost of health care; it is also maligned as contributing to EHR resistance and potentially causing unintended consequences.

How to Use

1.Gain an appreciation for the nature of clinical decision support.

2.Understand challenges in clinical decision support development and use.

3.Ensure that steps are taken to ensure that alerts are appropriate and useful.

Clinical Decision Support

Clinical decision support (CDS) refers broadly to providing clinicians or patients with clinical knowledge and patient-related information, intelligently filtered or presented at appropriate times, to enhance patient care. Clinical knowledge of interest could range from simple facts and relationships to best practices for managing patients with specific disease states, new medical knowledge from clinical research and other types of information.[1] Clinical decision support is intended to:

• Prevent errors of commission and omission
• Optimize choice of treatments, improve adherence to guidelines, improve completion of assessments and treatment plans, and optimize follow-up with people who have chronic conditions
• Improve the care process, including documentation, communication, and use of data for quality measurement, research, and education

The most common form of CDS across all forms of EHRs is the alert to drug-allergy and drug-drug contraindications. But there are many other forms of CDS—both active and passive:

• Active CDS is displayed automatically, generally as an alert, reminder, required field or field edit, and message. Attributes include:
• It is essentially a just-in-time notice to the user of the EHR, providing an update or signal of potential issue.
• It generally requires the user to accept or decline the support. For example, a pop-up box may appear that there is new information about the client being received from a health information exchange organization (HIO), such as an update to a medication list or reminder that a lab test is due. This may only need to be clicked off to populate the EHR. In many products, the user can decide whether to view the information as it is coming in.
• It must be important and relevant, or it will be ignored (i.e., declined without consideration as to whether it is important or not). This is often referred to as “alert fatigue” and is generally a consequence of poor design and lack of stakeholder input into the clinical decision support system. For example, if every order or preparation for administration of a common drug, such as acetaminophen, triggers an alert that it could have an adverse effect on the liver, the alert will be considered an annoyance by most users. However, if a client was already taking a drug being considered by the clinician, an alert to this affect would probably be well-received. The greater the complexity or integration of information, the more intrusiveness is accepted by the user.
• Passive CDS is displayed on user request. Examples include a user setting a preference for what information is displayed on a dashboard, whether certain information will be presented in table or graphic format, or that the user can access additional information (e.g., training materials for client, drug knowledge)..

Forms of CDS for LPH

In addition to alerts concerning drugs, the following are some forms of CDS that may be found in EHRs used by LPH departments:

• Documentation completion is one of the most common forms of CDS. In its simplest form, this includes reminders to complete empty data fields, which are especially useful if documentation must be completed over a period of time. CDS for documentation may also use more sophisticated branching logic—such as for care plans—that directs the user to appropriate documentation sections based on client needs. Workflow notification software may not be considered CDS, but it helps direct users to perform certain tasks by certain dates. For example, documentation that requires co-signature can be directed to the appropriate individual. Adding hyperlinks to documents in a document repository is another potential workflow support tool.
• Problem list assistance. Public health nurses are encouraged to document client problems using the Omaha System of terminology. EHRs may include CDS that helps select and categorize appropriate problem descriptions.
• Therapy critiquing and planning is software that operates much like drug knowledge databases that supply alerts and reminders about potential drug allergies or contraindications. These systems integrate clinical research, practice-based evidence, client preferences, and choices the user is considering to generate recommendations for a specific client’s needs. The knowledge database is a subscription service that is continually updated. Client preferences may be derived from personal health records and/or documentation from client preference interviews. A simple example is translation of client instructions to a preferred language.

It is imperative that any form of CDS be reviewed by the intended user, have a trustworthy source of decision support, and be used only to supplement (not replace) professional judgment.

Planning for Clinical Decision Support

Take the following steps to ensure that the CDS supplied through your department’s EHR and HIE is appropriate and useful:

Engage stakeholders (those who will be using the system directly as well as those who use reports to measure outcomes) in:

• Understanding their role in planning for CDS use
• Establishing goals for use of CDS
• Expressing concerns about CDS

Translate goals with respect to CDS:

• Describe desired actions users are expected to take when receiving an alert.
• Obtain baseline performance data that demonstrates why the alert is necessary (or why an alert may not be necessary and could be turned off).
• Anticipate desired outcomes by setting realistic quality and patient safety goals.
• Annotate rationale and potential obstacles so all stakeholders are aware and can sign off on the approach to adopting CDS.

Ensure EHR (and HIE, if applicable):

• Is compliant with interoperability standards (technical, semantic, and process) to reduce errors in alert presentation.
• Supports sensitivity setting (some EHRs support different levels of alerting depending on the user role).
• Practice guidelines, protocols, and other evidence-based knowledge supports the CDS rules in the EHR and is periodically refreshed as new knowledge becomes available. (Many EHRs include a subscription to a drug knowledge database that may be refreshed monthly or quarterly. Code sets for billing purposes need to be refreshed annually. Any changes in best practice recommendations should be able to be pushed to the system.)
• Is compliant with and federal and state regulations.

Identify, select, or build CDS support interventions needed to achieve goals at various point in clinical workflow. Stakeholders who are being asked to use CDS support should have a say in the nature of that support. Some EHRs support facility development or modification of care plans. While this may seem like a good thing, there evidence suggests that too much customization adds cost, reduces outcomes comparability, and puts a health care organization at risk for not following evidence-based guidance. The following article addressing customization in a behavioral health record system is applicable to any setting: Thinking Customization? Proceed with Caution, available at:

Require stakeholder review, test, validation, and approval for all CDS systems implemented, changes made to these systems, and revision/update maintenance. It should be obvious that the acetaminophen example described above contributes to alert fatigue. But turning that rule off should be a stakeholder decision. Pros and cons should be weighed as any such decision is made. Train users and monitor use. Ignoring alerts is commonplace and can be monitored through an audit logging process (if available in the EHR). However, misinterpreting an alert or making an erroneous selection are actions relative to alerts that are more difficult to identify and may require a manual audit.

Measure results, evaluate effectiveness, and refine CDS program. Users who are provided feedback on the results of using CDS are more apt to use it appropriately. For example, the fact that 92 percent of immunizations were given on time, compared to 73 percent without the EHR and its CDS, is strong evidence of value.

Factors for Appropriate/Useful Alerts

Use the checklist below to help stakeholders identify, select, or build clinical decision support. For most EHRs and HIE services for LPH departments, stakeholders will primarily be identifying and selecting, rather than building, CDS. Not all attributes listed may be available in your EHR or HIO, but you can have your vendors consider adding them over time.

Clinical decision support should be:

Specific to client

Relevant and important

Accurate

Clear and unambiguous

Show justification for use

Concise

Provide alternative actions

Make additional information accessible, if applicable

Generated for all dangerous cases

Directed to the right user

Knowledge/credential-specific

Tied to previous performance of user to avoid repetition of alerts

Designed to make it difficult to overriding a “fatal” or “critical” alert

Built to require a reason for overriding the alert (at least through a simple drop-down menu)

Delivered to promote action rather than stop intended action

Easy to see and use, not obstructing the primary view of the underlying information and not requiring multiple clicks, scrolling, page visits, or narrative typing

Using CDS with the Client

There is some evidence that suggests that CDS can be a turnoff for patients.[2] One study reported that patient attitudes vary—and that patients whose providers have more positive attitudes about EHRs, and who have a high locus of control about their own health care situation—were more supportive of CDS. As a result, recommendations from this study include finding ways to educate clients about the value of CDS. These might include:

Learning how best to use the EHR at the point of care—with respect to positioning, communicating with the client during data entry, using the EHR to validate the accuracy and completeness of data being collected, and providing information to the client via the EHR.

Explain to the client why evidence in making decisions is important and how it supports up-to-date care planning and care coordination.

Adopting a client self-management model of care in which the EHR is a tool to support shared decision making.

Copyright © 2014 Stratis Health.Updated 03-18-14

Section 6 Optimize—Optimization Strategies for Clinical Decision Support - 1

[1] Reference:

[2] Shaffer, VA, et al. 2012 (July 20). Why Do Patients Derogate Physicians Who Use a Computer-Based Diagnostic Support System? Medical Decision Making.