Commentary: A new CDS standard for meaningful use stage 3 and beyond

By Howard R. Strasberg, MD
09:10 AM
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There are two fundamental objectives driving trends on the national healthcare stage today — the need to increase quality and decrease costs. From meaningful use (MU) to new pay-for-performance initiatives, all efforts are aimed to work synergistically to deliver better outcomes through more accountable and efficient care delivery.

The use of clinical decision support (CDS) at the point of care has been identified as a foundational component to successfully attaining the aggressive quality goals laid out in federal initiatives. Consider that MU Stage 2 rules require the use of electronic tools to enhance and support decision-making based on the latest medical evidence. Expectations for how these tools are incorporated into care delivery will increase as MU Stage 3 comes into focus.

For many healthcare organizations, the question is no longer “when” to consider investing in CDS applications but “how” efficiently can the most effective tools be deployed and adopted. As the industry moves towards more accountable care practices, developing standards that will help increase the momentum for adoption and mainstream use of these tools will be paramount to success.

For decades, the medical informatics community has been working toward a widely-adoptable standard for CDS artifacts to ease the challenges associated with deployment and integration of tools such as rules, order sets and care plans. While some standards do exist, they have generally seen only modest adoption.

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Now, with the recent ballot of a new Health Level Seven (HL7) draft standard, new opportunities may be on the horizon that will help move the industry closer toward the end-goal of optimum quality and patient safety. The standard comes as part of the Health eDecisions Project (HeD), which aims to develop standards that will promote ease of deployment, delivery and update of CDS interventions.

The need for a standard
For CDS interventions to be effective, computable biomedical knowledge must be available in tandem with patient-centric data and a “reasoning” component that combines these elements to aid with decision-making. In order to fully leverage the power of CDS, these interventions must also be easy to acquire and deploy.

Evidence-based, electronic order sets and care plans have already been singled out by KLAS research and other leading institutions as the CDS tools of choice for standardizing care practices and promoting evidence-based practices at the point of care. The overarching value of these tools has also been proven in the field time and again, with a number of case studies pointing to very high year-over-year returns; in the case of Southeast Alabama Medical Center, IDC Health Insights identified returns greater than 400 percent (PDF) and notable quality metrics improvements.

While few would dispute the effectiveness of these tools, a number of studies point to EMR integration as one of the greatest challenges to deployment and use. The 2011 and 2012 CDS reports issued by KLAS both cited integration as an ongoing challenge. Similar results were reported in a 2012 review of clinical content vendors conducted by The Advisory Board Company.

While some order set vendors have advanced capabilities allowing for exportation of clinical content to a variety EMR formats, there are limitations. Currently, no vendor is able to address every integration need because the format for order sets is unique to each EMR. As such, vendors currently have to export content in multiple formats.

Evolution of a new standard
Beginning in the second half of 2012, the Office of the National Coordinator’s Standards and Interoperability Framework began work on HeD with the primary goals of identifying (1) standards for sharable CDS artifacts and (2) standards for providing clinical decision support as a service. The outcome of this first approval process has focused on sharable CDS artifacts specifically supporting:

• Event-condition-action rules (on event, if condition is true, do action)
• Order sets (predefined groups of orders related to a particular clinical condition)
• Documentation templates (structured forms for recording patient information)

It is not the first attempt at creating a national standard for order sets. Under HL7 International, the CDS workgroup developed a standard specific to order sets, which was published in September 2012. While the new HeD standard builds off of this effort under the HL7 umbrella, the scope of the new project encompasses a broader domain of CDS content types.

The base level of the HeD knowledge artifact schema is referred to as a knowledge document, which has the following components:

• Metadata (e.g. title, description, author, publisher)
• External data (fetching information from a patient’s medical record)
• Expressions (defining expressions that can be referenced within the artifact)
• Triggers (defining a list of triggers to activate the artifact, if applicable)
• Conditions (determining the applicability of the artifact)
• Action Groups (the main content of the artifact, such as the content of an order set)

Specific to order sets, the new HL7 draft standard provides a model for representing an order set as an XML document. Armed with the capabilities of the HL7 infrastructure, order set technology can now overcome the challenge of integration with EMRs that has long been a thorn in the side of content publishers and vendors.

Under the new model, order set content can be purchased from a CDS vendor and then customized to the unique needs of the healthcare organization. Upon importation into a computerized physician order entry (CPOE) system, physicians can make patient-specific decisions regarding which orders to include, exclude or modify. The CPOE system screens the set of orders against the patient’s profile using medication safety screening software and the set of orders is then submitted for processing.

Overcoming the ongoing mapping challenge
The new HeD HL7 standard is a great step forward toward addressing one of the primary challenges to deploying CDS technology at the point of care — integration. But while this standard will move CDS initiatives forward, it is important to point out that the new standard does not address the ongoing issue of mapping that exists for many order set content vendors. The ability to map content efficiently and effectively ultimately equates to more accurate and efficient integration of these tools within CPOE systems.

Currently, there are two approaches to content — structured and unstructured. While both have the potential to standardize care and improve decision-making, structured content provides a foundation for ensuring improved accuracy, efficiency and flexibility within order set technology.

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Structured content is tagged or coded data that resides in a fixed field where it can be easily located and identified. In contrast, unstructured content, or free text, often results in irregularities and ambiguities that make it harder to interpret.

When content can be indexed at a granular level through content that is structured, it eases the process of mapping order sets within EMR and CPOE systems. It enables easy updating of order sets in response to new evidence and best practice guidelines, and allows for robust reporting due to extensive filtering capabilities.

While the new HL7 standard diminishes some of the roadblocks to the initial deployment and integration of CDS content, the industry as a whole still faces many challenges to ongoing maintenance and updating of evidence-based content at the point of care. Strides have been made within some vendor communities to address this issue, but healthcare organizations need to be forward-looking.

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