Taking Clinical Decision Support to the Next Level: A Standards-Based Approach

Clinical decision support (CDS) is one of the “hot terms” in healthcare that means many different things to many different people. Typically, CDS provides timely information at the point of care to help inform decisions about a patient’s care.  When viewed from an ePrescribing perspective, CDS has been part of a clinician’s workflow for years in the form of drug-drug and drug-allergy interaction checks.  Now, due in large part to MU2, EHR vendors are enabling the required 5 CDS interventions in a variety of ways, - and sometimes without actual content.  This poses challenges on multiple levels that could be addressed if the healthcare industry used a standard-based approach to CDS. 

 Given that CDS is critical to improving outcomes, I’m pleased to share a special guest post below from Pooja Babbrah, who provides key insights about how the industry can take CDS to the next level.

Pooja is Point-of-Care Partners’ Practice Lead for PBM Services.  A senior healthcare information technology consultant and specializes in product management, strategic planning and go-to-market strategies and execution.  With more than 20 years’ experience in various healthcare services and health care IT companies, Pooja understands the perspectives of all stakeholders including PBMs, health plans, patients, physicians, ePrescribing and EMR vendors and hospitals/health systems.

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Taking Clinical Decision Support to the Next Level: A Standards-Based Approach

Clinical decision support (CDS) is a set of valuable tools providing specific clinical knowledge and patient-related information at the point of care so as to improve patient safety and quality of care. To realize the true benefits of CDS within electronic health records (EHRs) and electronic prescribing (ePrescribing) systems, additional work must be done. 

First and foremost, clinicians using the system must find that CDS and the information it provides are clinically relevant and useful in impacting patient outcomes. Despite its benefits and required use under meaningful use stage 2 (MU2), CDS has not realized the uptake that’s been expected because it is still in its formative stage of development and lacks consistent rules in EHRs. What can be done to take CDS to the next level? Adopting a standards-based approach is a major part of the solution.

CDS is in its infancy. While it can be argued that CDS is still in its infancy, when viewed from an ePrescribing standpoint, CDS in the form of drug-drug and drug-allergy interaction checks has been a part of a clinician’s work flow for years. MU2 raised the bar by requiring EHR vendors to implement 5 CDS interventions related to clinical quality measures at a relevant point in patient care. These include problem list, medication list, allergy list, demographics, laboratory tests and values/results, and vital signs. At the same time, however, not all providers are required to use the rules provided by the vendors. Despite CDS being a core measure of MU2, eligible providers  that do attest to Stage 2 only have to attest whether they’ve used CDS on a yes/no basis. Moreover, there is no calculation for this measure. In other words, providers do not have to apply these rules to a specific number or percentage of patients. As a result, MU2 is simply a “baby step” toward true CDS.

Lack of consistent implementation of CDS rules in EHRs. Another issue impacting CDS and its lack of uptake among physicians is the lack of consistency in how CDS rules are implemented by EHR vendors, who don’t consider themselves to be rules creators. They provide the technology platform for the clinical rules but, for the most part, do not provide the actual content. EHRs have therefore approached the implementation of CDS in a variety of ways, including:

• Hosted rules: CDS rules stored and hosted at a central location and pushed to the practice/EHR.
• Customizable rules: Standard rules that are available through the EHR, which can be modified or customized by the practice.
• Bolt-on engines: Separate rules engine and editors that run along the main components of the EHR, typically provided by a third-party vendor.
• Web services: Web-hosted rules engine stored and hosted at a central location.

When EHR vendors outsource the actual content of the rules, their integration and interface into the EHR and clinical work flow vary significantly, in addition to the type of information that is being pushed to the provider. In most cases, practices are unable to customize what is being pushed to them in terms of alerts, reminders and practice guidelines. In those cases in which a practice can customize the rules, the process is extremely complicated and can take hours of staff training by the vendor in order to understand how to do it. For this reason, a “one size fits all” approach to CDS has been used to date. Clinicians are essentially locked in to the rules provided by the EHR, and any custom work can be very time consuming and costly. This is a big reason why there has been limited uptake of CDS within the physician community.

The impact of MU. So, what can be done to take CDS to the next level? Will finalization of MU stage 3 (MU3) help push this along or will CDS continue to be a government-imposed “requirement” that’s never really been adopted and soon may become outdated?

The shift from volume- to value-based payment will in itself provide a natural movement toward use of CDS because it is in the best interest of providers to use all available tools that improve patient care and positive outcomes. In fact, the current draft of the proposed MU3 rule encourages innovation of CDS:

We encourage innovative efforts to use CDS to improve care quality, efficiency, and outcomes. HIT functionality that builds upon the foundation of an EHR to provide persons involved in care processes with general and person-specific information, intelligently filtered and organized, at appropriate times, to enhance health and health care. CDS is not intended to replace clinician judgment, but rather, is a tool to assist care team members in making timely, informed, and higher quality decisions. – CMS 80 FR 16731; Medicare and Medicaid Programs; Electronic Health Record Incentive Program-Stage 3; Proposed Rule [RIN 0938-AS26]

How standards can take CDS to the next level. However, this encouragement from the Centers for Medicare and Medicaid Services (CMS) and the natural progression seen from a shift in payments may not be enough to take CDS to the next level. The use of standards will help provide a targeted approach for CDS. Implementation of standards and the encouragement of innovation may seem like an oxymoron, but use of standards, in terms of a framework for the integration and interface with EHRs, will provide that extra incentive necessary for increased adoption and use of CDS. 

The role of standards development organizations (SDOs) is to provide an environment in which all stakeholders can collaborate to ensure the mutual end goal of better patient care. SDOs have been instrumental in pushing forward standards that ultimately fostered adoption of ePrescribing and ePrescribing technologies. Examples include ePrescribing of controlled substances, electronic prior authorization, formulary and benefit information, and, more recently, enhanced standards to accommodate the growing use of specialty medications.

Regarding CDS specifically, EHR vendors, content providers and clinicians should ensure that content providers standardize a format in which rules, alerts and protocols are integrated into an EHR while still allowing for customization of these rules by a practice. Standardization of the interface’s format would provide a huge leap forward in the usefulness of CDS in the practice work flow.

It has yet to be seen whether CDS will move in the direction that is so greatly desired by stakeholders. However, working with standards organizations will continue the dialogue among stakeholders, which will further the advancement and uptake of CDS functionality in EHRs.