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Live From HIMSS: The Waterfront of CDS issues embedded in ARRA

April 8, 2009
by Joe Bormel
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Live From HIMSS: The Waterfront of CDS issues embedded in ARRA
"There's a 10% chance we know what we're talking about"

We all share a vision that HCIT in general, and EMRs in particular, are more than just data in, data out. When the users are clinicians, there's a tendency to call this added value "Clinical Decision Support" or CDS. It's become used so broadly that, without following up with the question, "What do you mean by CDS?" you really can't know what the speaker is talking about.

The first distinction for me? Are we talking about, 1) CDS that's concurrent with care, or 2) retrospective of care? If you follow that with, a) what are the goals and b) who is the intended audience?, the picture starts to form. It's well recognized that the history of monitoring the effects of CDS is unsatisfying.

So, in this, my last rant, ... I mean blog ... from HIMSS, I'm bulleting out some observations on the topic of CDS that emerged from this year's event:

1. My friend, Jerry Osheroff has a new book coming out:

Improving Medication Use and Outcomes With Clinical Decision Support: A Practical Step-by-step Guide by Jerome Osheroff (Paperback - Jun 15, 2009)

Jerry was kind enough to let me see the galley proof at HIMSS. This is clearly going to be a "must have" for clinically savvy CIOs and other leadership committed to this critically important topic.

I have a bias to acknowledge. I was one of hundreds of contributors to one of his previous publications on implementing CDS. You won't find anything more pragmatic that that book:

"Improving Outcomes with Clinical Decision Support: An Implementer's Guide" (Jan 1, 2005) by Jerry Osheroff MD FACP FA, Eric Pifer MD, Jonathan Teich FACMI FHIMSS , et al.

(Out of Print?)

2. There was an outstanding private meeting I was invited to, hosted by the AMA and NQF, focused on getting vendor input (HIMSS-EHRA) to reporting measures. CDS, combined with reporting measures, forms the basis for learning, management and improvement cycles. I walked away extremely impressed and considerably more confident about the likely reporting requirements of components of ARRA. I'm not saying that this space is simple or easy. I'm also even more aware of the dimensions.

That said, the large AMA staff that is working on this were phenomenal. My experience with this side of that organization was relatively impoverished. It's fashionable to blame their marketing department. As a physician, I have been inundated with mail (the paper kind) for twenty years, where the term AMA was always followed by the word "Insurance." Most of the educational and scientific publishing from the AMA wasn't branded with AMA, it was branded with JAMA. Funny how we humans respond to years of subtle conditioning!

I also had an opportunity to review some really detailed and necessary work on the part of the NQF. Their analytic work and thought leadership has always been exemplary. It's sobering and predictable that their work to harmonize healthcare quality measures is inexorably in tension with power struggles.

We will have follow-up meetings and the materials resulting will, no doubt, be made publicly available. On an optimistic note, they (the stakeholders making the substantive policy recommendations) are down to a specific number of well-defined, candidate measures for including in the ARRA public comment draft coming out within weeks. Obviously, these will be baked in the certification requirements.

3. I attended another of many AMDIS events, this one focused on reviewing the draft of their CDS white paper. It was presented by Harris Stutman to the internal AMDIS group, and is about to go through their internal comment process. This has been constructed by the most experienced group of CIOs, CMIOs, and community stakeholders that exists, focused mainly on deployment at hospitals and clinics. (This is not academic; I attended a few of those meetings as well. Given the new light, heat and monies available, the academic world has been more translationally focused of late.)

The sections of the white paper are governance strategies, deployment issues, and metrics/outcomes. Medical directors, directly or partially responsible for rolling out EMRs, will need to be conversant with this topic if they hope to be effective and credible leaders in their hospitals. For example, acknowledging the following will go a long way to the facilitated dialogues necessary to get meaningful buy-in:

CDS models and artifacts: Rules/Reminders, Order Sets, Flowsheet Views, Daily Reports (data-populated rounds lists, medication reconciliation instruments, discharge process-related instruments, etc.)

For each of these, there are valid maturity and verification steps that physicians need to own or co-own:

a. Is there justifiable disagreement? What's the process and timing around agreement?

b. More education and agreement necessary?

c. Background and issues clear, but alternative options incomplete or unclear?

d. Insertion of these artifacts into work problematic? "Just-in-Time" often sounds better than it is.

e. Are physicians being asked to do non-clinical documentation? Requires thorough vetting.

There were comparable lists around deployment issues, policy and override process for alerts.

One very interesting debate was not a debate at all. There was unanimity that decision support associated or triggered by a medication order needs to be presented to anyone who saw that order. Wow. That's contrary to what most non-clinicians I know think is appropriate.

There was an off-color humorous quip: If a user overrides a warning that is associated with a lethal reaction that the patient has previous experienced with a specific drug order, should decision support reflexively offer to place orders to consult the resuscitation team and pathologist? One hospital has even developed a skull-and-cross bones icon to get the user's attention. Does anyone remember the dark humor from the TV show M*A*S*H ?

I don't want to steal the thunder or intellectual property of the AMDIS group, so I need to close this section with a tease. The whitepaper ends with six take-home messages that need to be explicitly reviewed with physician communities before and during roll-out any EMR. You'll want to follow to get this paper when it's published.

4. The dialogues about the above CDS topic contained some very profound short observations worth sharing (all paraphrased and anonymized to protect the innocent):

"pay attention to both the scientific method and its absence"

"we need to make sure policy makers don't cast CDS as a panacea ... dangers and unintended consequences."

"The issue of physicians defining their own (individual) rules has important considerations."

"The issue of letting individual physicians subscribe to alerting/reminder rules of their choosing can be a powerful way to introduce and drive adoption."

Humans Need A Degree of Autonomy - this is one way of providing it.

"There's a hazard to be aware of - trial attorney's subpoena, summoning logs of all alerts that fired, along with the response to them."

"CDS requires different skills sets than implementation; measurement, for example, is far more difficult and nuanced than most implementors are trained to do."

"Learn about the GRADE system"

The Grading of Recommendations Assessment, Development and Evaluation (GRADE ) approach provides a system for rating quality of evidence and strength of recommendations that is explicit, comprehensive, transparent, and pragmatic and is increasingly being adopted by organisations worldwide. (

Cartoon from the BMJ article cited above.

In summary, congratulations! The political process has legitimized and funded HCIT and Medical Informatics. We now have the public spotlight ($40B) and a short runway.

HIMSS-2009 was like no previous HIMSS. Forget about whether the traffic was lighter or heavier than before. Forget about whether the talks about ARRA were redundant. Forget about whether you agree or disagree with George Halverson. HCIT has been written into the book of life for 2009 and beyond. The story will be grounded in CDS. The timelines are like nothing we've seen before ... very, very short. Fortunately, there are a lot of smart people, from AMDIS, AMA, NQF, EHRA, and many others, who have earned the right to lead or, in some cases, to be the earliest of followers (which is a form of leading!). I learned a ton at HIMSS, some abstracted above. I expect that we'll all need to do a lot more reading in 2009 than we did in 2008. HIMSS-2009 for me was just a kick off. This is all very exciting.

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