Understanding the current state of clinical decision support systems

Clinical decision support (CDS) systems have been hailed for their potential to reduce medical errors and increase healthcare quality and efficiency; therefore, it is critical for physicians to consider implementing a CDS system at their practice.

A CDS system is not simply an alert and notification or care system; CDS systems have evolved and provide a variety of assistance tools such as diagnostic support, clinical guidelines, condition-specific order strategies, documentation templates and automated patient and physician reminder alerts.

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CDS systems are not intended, to replace clinicians’ judgments. However, a CDS system should be used as a semi-automated system to assist and provide tools to all care team staff in making timely, informed and quality decisions.

Types of CDS Systems

There are two types of CDS systems. Each should be evaluated on individual merit and the needs of your medical operations:

Data mining systems may be configured to examine a patient's medical history in combination with trusted clinical research. This type of system might help foresee potential incidents, which can range from drug interactions, adverse outcomes to illness and disease indicators.

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Knowledge-based systems apply reasoning standards to analyze clinical data. The input data is analyzed against its rules and allows the program to display positive and/or negative outcomes.

Using a CDS System

Healthcare providers may use a CDS system to focus on clinical needs, ensure accurate diagnoses, provide timely and efficient screenings for preventable diseases and/or adverse drug events. Nonetheless, CDS systems can theoretically lower costs, improve efficiency and improve patient convenience-or it may address all areas simultaneously. For more complicated tasks, such as diagnostic decision-making, the purpose of a CDS system is to assist the clinician. The CDS system may offer suggestions, but the clinician must screen the information, review the suggestions and decide whether to take action or, what action to take.

Next: Implementing a CDS system with your EHR

Implementing a CDS Systemwith your EHR

Integrating CDS systems into your electronic health record (EHR) system may be cumbersome and challenging. Facility workflow integrations may require organizational policy and procedure enhancements, including retraining all users on different data collection processes and additional data entry fields. EHR templates may need adjustments to accommodate additional fields on which the CDS system can report. There may be some interoperability conflicts in software that could cause some data to be lost, overlooked or altered to fit the parameters in your current software. For example, ICD-9 versus ICD-10, a simple code on one system, needs to match the other or have an automatic conversion table.

Do you already own a CDS?

Prior to purchasing a CDS system, consult your current EHR vendor; you may currently have the software built into your system. Or it may be offered at a lower price from your EHR vendor than purchasing a stand-alone system.

CDSSystem Cautions

CDS systems have been in use since the mid-1980s in hospitals, managed care organizations, medical groups and stand-alone physician offices. As the technology has expanded, so too has its oversight by governmental agencies, quality assurance programs, insurance companies and specialty review boards. Key questions still arise, such as whose decisions are being supported, what information is presented to the user, and how. Whatever the features of any CDS system, the delivery of information, the quality of the information and the underlying evidence are the major determinants of the effect of CDS systems on patient safety and quality improvement.

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Improperly using a CDS system may be more detrimental than not using one at all. Facilities must partake in a risk assessment system to identify any problems. The CDS system must provide continuous feedback to users and identify errors when users override alerts that may affect patient outcomes. Also, it must be certain that no matter how many systems are used, the data must work bi-directionally-systems need to talk to each other in real time.

Challenges arise when implementing a CDS system in a way that safeguards all alerts, decision trees and outcomes but without causing user fatigue. Questions for CDS system implementation teams are which decision is being supported, what information is revealed and how is it presented to the user.

CMS and Meaningful Use

Clinical decision support systems have expanded after the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act, which requires providers to demonstrate the meaningful use of health IT or face the possibility of a reduction in Medicare reimbursements. In addition, providers enrolled in the meaningful use incentive programs must implement a clinical decision support rule including, at minimum, one diagnostic test ordering and the ability to track compliance with the rule. The rule must apply to a specialty or condition.

After the above decision trees and decision support systems are in place and appropriate user training is accomplished, a practice may move safely toward an efficient automated system allowing all physicians, nurses and other healthcare professionals quality time with their patients.

Allan Ridings is a senior risk management and patient safety specialist at the Cooperative of American Physicians Inc. (CAP), which offers medical professional liability protection and risk management services to nearly 12,000 California physicians. In 2013, CAP organized CAPAssurance, a risk purchasing group, to bring liability insurance coverage to member hospitals, health care facilities and large medical groups.