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In Pursuit of the Holy Grail: Scalable, Interoperable Clinical Decision Support

November 8, 2013
by David Raths
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Consortia making progress on standards, tools, and strategies for implementation

When the physicians in the ambulatory clinics of Wishard Health Services in Indianapolis get an alert or reminder in the computerized physician order entry (CPOE) module of their homegrown electronic health record (EHR), they may not be aware that the alert was generated at Partners HealthCare System in Boston, and sent to Indiana as a Web service.

The project extracts a limited data set about a patient, including labs and allergies, in the form of a Continuity of Care Document (CCD), which is sent to Partners. Its system adjudicates the rules against that data, and sends back information on which reminders or alerts fire.

Although there was a considerable amount of technical and policy work behind the scenes to make it happen, “the physicians’ experience is that the alerts are not a whole lot different than homegrown ones — and that is the goal,” explains Brian Dixon, a research scientist at the Regenstrief Institute in Indiana. “By demonstrating that clinical decision support (CDS) can work as a Web service, we are not trying to do something magically different. The value is in the economies of scale.”

Brian Dixon

The meaningful use incentives are not enough money for all hospitals, especially community hospitals, to create their own systems for decision support, says Dixon, who is also an assistant professor of health informatics at the Indiana University-Purdue University Indianapolis School of Informatics and Computing. “They cannot form the committees or have knowledge management and informatics people to decide on 300 rules.” Then there are the IT requirements that stem from those decisions, and getting the rules into Epic, Cerner, or whatever EHR you are using, he adds. “That is time-consuming and costly.” 

Having academic health centers provide CDS as a service is one potential solution. “The idea of a service is that it can be robust content at a reasonable cost that multiple health systems on a regional or national level could take advantage of,” Dixon says, “and a small group could maintain the knowledge base. That is the dream.”

It’s easy to find discouraging statistics about CDS. Outside of four or five leading integrated health systems and the Veterans Administration, robust CDS use is still quite rare beyond alerts for drug-drug interactions and drug-allergy contraindications. Stage 2 of meaningful use requires that providers implement five clinical decision support interventions related to four or more clinical quality measures at a relevant point in patient care.

Yet most providers know they are nowhere near where they need to be on CDS, claims Jerry Osheroff, M.D., principal at TMIT Consulting in Cherry Hill, N.J. “Even the ones held up as beacons of light realize they have a long way to go,” Osheroff says.

Regenstrief’s Dixon adds that although vendors offer tools for drug-drug interactions, “there really isn’t anything comprehensive you can buy off the shelf in one place. You still have to do a lot of configuration, maintenance and updating.” Smaller providers will have to rely on EHR vendors to provide out-of-the-box rules or order sets that they can quickly implement, just to get something in place, he says. “Unfortunately, just as in Stage 1,” he says, “we will see some people focusing on checking the box, rather than what will actually improve healthcare.” 

Osheroff agrees there are ways people can find to check the box to do five interventions, but adds that, “to really attack this systematically and follow the spirit of meaningful use and improve information flow is going to take a lot more effort.”

Yet despite the difficulty provider organizations and vendors have had in designing CDS interventions that don’t annoy physicians or lead to “alert fatigue,” there is a lot of exciting work taking place in CDS research, and many health informaticists see themselves in the early stages of an important journey.

Osheroff himself is working diligently to get more CIOs and CMIOs working together on CDS. He heads up the Collaborative on CDS for Performance Improvement, a nationwide volunteer initiative encompassing more than 130 individuals representing dozens of hospital organizations and numerous EHR vendors. The collaborative is an outgrowth of work on the second edition of a book called “Improving Outcomes with Clinical Decision Support: An Implementer’s Guide,” published by HIMSS. In the last year, Osheroff also has worked as a subcontractor to Deloitte on worksheets and implementation guides the Office of the National Coordinator will offer on for CDS-enabled performance improvement to help providers with meaningful use, Stage 2.

Osheroff says wider use of CDS will require both enhancements to technical standards and more process improvement work. “You need both tools and strategy,” he says. “You need a rich marketplace of high-quality interventions and you also need a rich ecosystem of providers working on performance improvement together in a sharing environment to get better faster.”

Clinical Decision Support Consortium 2.0