Meaningful use Stage 1 is now in effect, and work has already begun in earnest to define the criteria for Stage 2. Stage 1 requires providers to implement one clinical decision support (CDS) rule, along with basic medication CDS including drug allergy and drug-drug interaction checking. Early indications are that Stage 2 requirements will include an increased emphasis on CDS, directed toward high-priority quality and safety targets. Even with the likely increase, though, the MU requirements only call for a relatively modest implementation – a “floor” to help providers get comfortable with the concept.
In fact, CDS can be used to address quality, safety, and cost needs throughout the clinical practice, as long as it is conceived and implemented wisely. Healthcare professionals can deliver on the promise of CDS if they reach beyond the basic MU requirements, and create a more visionary and strategic framework for long-term CDS implementation and use. A few guiding principles can help you establish that framework:
Choose your targets. Motivation to use CDS increases when there is a problem to solve, a metric to improve, a victory to proclaim. Start with one or two goals that are already in your strategy – such as preventing venous thromboembolism (VTE) in the hospital, improving maintenance care of diabetic patients or optimizing management of pneumonia. (Some of these are MU quality targets.) Direct your CDS focus there and be sure to measure the impact. Once you are able to show improvement, you can expand the focus to other targets.
There are many forms of CDS. Many healthcare professionals experience CDS as a series of fatigue-inducing intrusive alerts. In fact, there are several major CDS intervention types, including intelligent data displays and flowsheets, order sets and care plans, targeted references and infobuttons, analytics and performance dashboards, smart documentation tools, task-specific assistants, and more. Different intervention types are best for different objectives and different workflows; think broadly about what type of CDS can best serve your needs.
Make CDS available to multiple caregivers. Physicians aren’t the only professionals who need CDS at the point of care. True interdisciplinary care coordination requires that nurses, pharmacists and other allied health professionals can easily access quality CDS tools and resources. Nurses need timely, evidence-based content to improve decision making, reduce care variability and support care documentation. Pharmacists view CDS as a toolkit to reduce medication errors, increase productivity and enhance patient care. A CDS recommendation should be presented to the person best able to act on it. Often, the right strategy is to direct multiple CDS approaches to multiple healthcare workers at different points in the care process. For example, VTE prevention may involve a combination of assessment tools, care plan helpers and order sets.
Be a force for change. Healthcare professionals must work together to push CDS capabilities forward, to produce a world where CDS is implementable, usable, valuable and cost-effective in a wide variety of healthcare settings. Work is proceeding at regional and national levels on improving usability and streamlining implementation; connecting CDS improvement tools to quality measurement tools; understanding clinical information needs in different tasks and matching CDS tools to those needs; sharing interventions among institutions; and addressing the particular technology needs of small practices. The websites of the major HIT and quality organizations contain many useful links that can steer you to opportunities to participate in advancing the state of the art.
Jonathan Teich, MD, PhD, is chief medical informatics officer of Elsevier and a board-certified emergency physician at Brigham and Women’s Hospital.
