Clinical decision support: It's about more than technology

'This transformation is just kicking into high gear'
By Mike Miliard
04:37 PM
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It's natural to frame thinking and discussion about clinical practice in terms of technology.

But when it comes to clinical decision support, that's the wrong approach, says Jerome Osheroff, MD, a former chief clinical informatics officer and editor-in-chief of HIMSS' CDS guidebook series and the principal and founder of TMIT Consulting, which aims to help providers, agencies and vendors improve processes and outcomes.

To do so, he says, "presumes that clinical decision support is a tool, or an EHR-based intervention." That's not accurate.

Osheroff has been making the case for years that a more inclusive vision of CDS was necessary to ensure it's deployed properly, and that the improved outcomes it promises are realized.

Way back in 2009, as the industry eagerly awaited the transformative arrival of the Federal EHR Incentive Programs, he wrote an article for HIMSS titled "Achieving Meaningful Meaningful Use."

He topped it with an epigraph from then-National Coordinator for Health IT David Blumenthal, MD:

"By focusing on 'meaningful use,' we recognize that better healthcare does not come solely from the adoption of technology itself, but through the exchange and use of health information to best inform clinical decisions at the point of care."

That quote, wrote Osheroff, "highlights clinical decision support as a central requirement for meaningful use and for improving care. Organizations often struggle to deploy CDS successfully; nonetheless, there’s convincing evidence when executed well, significant performance benefits can be realized.

Best practices include "clearly defining priority improvement goals and objectives, taking into account external drivers and internal circumstances," he wrote. "Developing and executing a thoughtful improvement plan that fully leverages available resources" is also critical – "doing this with those whose activities underpin better outcomes, not to them."

Also key? "Paying very careful attention to evaluation and measurement," according to his paper. "What is the baseline performance targeted for improvement? What improvement strategies have been implemented? How have these affected work processes? Stakeholder satisfaction? Outcomes?"

But when the Stage 1 rules were finally released, Osheroff was sorely disappointed by the  technology requirement imposed on eligible hospitals: "Implement one clinical decision support rule related to a high priority hospital condition along with the ability to track compliance with that rule." (For EPs, the rule is only slightly different – "relevant to specialty or high clinical priority. …")

"CMS did a huge disservice by saying clinical decision support is really important for meaningful use because meaningful use is about using EHRs for quality and CDS is at the center of that – and that therefore you have that one CDS rule," says Osheroff.

"CMS and ONC went a long way toward reinforcing a completely wrong and counterproductive notion in the Stage 1 rules," he adds – "the notion we set out to dispel more than a decade ago, where people think narrowly about CDS, focusing especially on interruptive alerts."

Instead, CDS "is "a process," says Osheroff. "And that's a really, really, really important point.

It's not an alert, it's not a computer-based intervention, it's "a process for enhancing health-related decisions and actions with clinical knowledge and patient information to improve health and healthcare delivery," he says. "That's a very broad definition. And very different from what you'd think clinical decision support is by looking at meaningful use Stage 1."

As if recognizing its role in unnecessarily constricting many providers' conceptions of decision support, CMS has since worked to open some folks' minds on the topic.

It published a tip sheet titled, "Clinical Decision Support: More Than Just 'Alerts,'" (PDF) for instance: "CDS is not simply an alert, notification or explicit care suggestion," the agency intones. "CDS encompasses a variety of tools including, but not limited to: Computerized alerts and reminders for providers and patients; clinical guidelines; condition-specific order sets; focused patient data reports and summaries; documentation templates; diagnostic support; contextually relevant reference information."

Those functionalities, meanwhile, "may be deployed on a variety of platforms (e.g. mobile, cloud-based, installed)," according to CMS – adding that "CDS is not intended to replace clinician judgment, but rather to provide a tool to assist care team members in making timely, informed, and higher quality decisions."

Crucially, according to the tip sheet, "While many providers may associate CDS with pop-up alerts, alerts are not the only, or necessarily the best, method of providing support."

"There's been a tremendous over-reliance on technology for many years. I think CMS made things a lot worse when they published the Stage 1 Final Rule, and they're still trying to shuffle their way out of that mistake," says Osheroff. "They felt compelled to say CDS is more than just alerts; they emphasize it's a key functionality of health IT – when it's applied effectively, it's good for everything that ails healthcare: quality, outcomes, errors, efficiency, cost and provider/patient satisfaction."

Another critical point was CMS' emphasis of the “CDS Five Rights” concept – which Osheroff helped developed back in 2009. The idea is that interventions must provide:

  • The right information (evidence-based guidance, response to clinical need) to
  • The right people (entire care team – including the patient) through
  • The right channels (e.g., EHR, mobile device, patient portal) with
  • The right intervention formats (e.g., order sets, flow-sheets, dashboards, patient lists) at
  • The right points in workflow (for decision making or action).

"If you want to improve care delivery and processes, to make all these good things happen in healthcare, a best practice for approaching that is the CDS Five Rights," says Osheroff.

Clinical decision support, properly deployed, has a huge role to play in driving care improvement in this country. But it's about so much more than mere IT: "We keep saying over and over again: it's all about people, process and technology – in that order of importance."

Rather than aggravating clinicians – and potentially adversely impacting patient care – by "popping up alerts that aren't really helping anybody," a smart, structured approach to CDS can work wonders," he says.

"It never fails to happen when an organization documents in this structured way what they're currently doing, the information flow and workflow to improve a particular target – it always happens that a whole lot of ideas pop to mind: Our processes would get a lot better if we did less of these stupid things and more in these other areas."

Thankfully, that's starting to happen on a much more widespread basis.

This transformation is just kicking into high gear," says Osheroff. "The focus has been too much on technology. I'm very optimistic that with the proper focus, the transformation that people must go through to survive can and will be successful."