Clinical decision support: Laying an effective foundation for the future of care delivery



Healthcare providers are knee-deep in Stage 2 Meaningful Use (MU) preparations as they press forward to qualify for incentives in a timely fashion. Moving past the initial Stage 1 focus on “data capture and sharing” within an electronic health record (EHR), the mission of Stage 2 points to more advanced clinical processes, laying a foundation for Stage 3’s focus on improved outcomes.

As the evolution of meaningful use unfolds in tandem with other pay-for-performance initiatives, it is imperative for hospitals to lay the most effective foundation for clinical decision support (CDS) to prepare for the future of care delivery. IT investments will need to be thoughtfully considered in terms of the way they address the bigger picture of healthcare reform, as quick fixes that address the “need of the moment” could become costly mistakes in the long term.

Since demonstrated use of CDS is a primary focus area of Stage 2 MU, there is little question that healthcare organizations will need to invest in infrastructures to support evidence-based practices at the point of care. The question becomes: How are resources best employed to meet immediate compliance deadlines while still laying the best foundation to meet future mandates?

Drug reference tools

Most healthcare organizations are providing clinician access to some form of drug reference content, and consideration should be made for leveraging these tools alongside drug interaction data applications to support Stage 2 MU compliance for CDS in both inpatient and ambulatory settings. Specifically, the industry’s most advanced products can help fill in the gaps by providing:

  • Data for drug-drug, drug-allergy, and drug-disease interaction screening

  • Data to support duplicate therapy and dose range checking for pediatric and adult patients

  • HL7 Infobutton capability

Alongside laying a foundation for meeting the above CDS requirements, applications can help healthcare organizations comply with MU rules that require the identification of patient-specific education handouts, maintenance of active medication and allergy lists, and promotion of interoperability through the ability to map to standardized vocabularies.

There are two primary types of drug data solutions: reference content that can be accessed at the point of care and integrated medication safety screening solutions that can provide decision support based on patient data. Both can support Stage 2 MU in various ways, but a number of considerations come into play when you are choosing appropriate applications. In particular, two areas of compliance offer particular challenges:

  • Drug-drug and drug-allergy screening

  • HL7 Infobutton access to CDS and patient education

The challenge of alert fatigue

Alert fatigue refers to the tendency for clinicians to miss important (“signal”) alerts among a barrage of less important (“noise”) alerts. While alert fatigue can be problematic across many areas of EMR workflow, it is particularly prevalent with drug-drug and drug-allergy alerts within medication order entry. In fact, research reveals that drug safety alerts may be ignored in 49% to 96% of cases[1].

Alert fatigue heightens clinician skepticism about technology. Alerts may appear to be irrelevant because the physician knows more about the patient’s history than the alerting system does.

For example, an alert may point to a possible drug allergy cross-sensitivity, but the physician knows the patient has tolerated that particular drug without any problems in the past. The physician is left in the position of managing workflow by either disregarding alerts that may be irrelevant and running the risk of missing something important, or suffering workflow slowdown caused by attention to potentially irrelevant alerts. Both outcomes can be problematic and frustrating for a clinician.

User control and customization

When you are considering applications to support the CDS component for drug-drug and drug-allergy MU requirements, one approach is to seek out solutions that support user control and customization of alerts on an individual basis.

While site-level alert management can also be useful, it is often a time-consuming process. User control, on the other hand, can be readily embedded in the clinician’s workflow, for example with a checkbox saying, “Don’t show me this alert again” or “Don’t show me this alert again for this patient.”

Since physicians differ on which alerts they consider clinically significant, user control allows them to make their own choices and keep some autonomy over the process. From a liability perspective, some organizations may wish to put boundaries around what users can customize, but still allow customization within those boundaries.

In the meantime, the industry as a whole is working to make alerts smarter, meaning the alerting system would consider more and more patient context and therefore be much more patient-specific. The design of alerts is also important; one study showed that the quality of the alert display was the most important factor in physician acceptance of CDS systems[2].

The infobutton challenge

Stage 2 MU rules require certified EHRs to support the use of the HL7 Infobutton standard for access to patient-specific education materials. The rules also require certified EHRs to provide linked referential CDS, optionally using this same standard.

The Infobutton requirement for patient education represents a positive step forward because it helps patients receive the most relevant educational materials possible. The challenge for healthcare organizations will be to identify applications that are equipped to gather patient data in this way at the click of a button and to identify knowledge resources that can accept a variety of Infobutton contextual parameters. Advanced drug reference applications should be able to provide both CDS and patient education materials based on patient data from problem lists, medication lists, and laboratory test results.

To lay a foundation effectively for the future, providers also need to consider the broader picture of patient education initiatives and movements on the national landscape - particularly the focus placed on language support. Applications that support direct access to patient education materials should support the HL7 Infobutton standard and provide the educational materials in multiple languages. Patient education should cover general information on the nature of the disease or condition, possible causes, signs and symptoms, and standard means of care and support.

Positioning for the future healthcare landscape

The race is on as healthcare organizations strive to meet Stage 2 MU deadlines to qualify for incentives. While the road to get to Stage 2 on its own will be complex for many organizations, it’s also important to consider Stage 3 MU and other initiatives when choosing health IT applications to address the CDS requirements.

The long-term value proposition of any IT investment is critical, and choosing the best drug reference and drug interaction data applications will lay an effective foundation for significantly reducing errors and promoting evidence-based practices at the point of care. Physician adoption is a make-or-break element in this equation, so consideration should come into play for addressing alert fatigue when choosing solutions for the long-term.

Also, patient education will continue to be an important factor for reducing both the number and severity of adverse events and slowing down the revolving door effect in healthcare. Reference applications that identify and provide the best patient education materials to address the needs of the future regulatory landscape should be a priority.

Howard Strasberg, MD, MS, is Vice President, Clinical Informatics, Clinical Solutions, with Wolters Kluwer Health.

[1] Van der Sijs H, Aarts J, Vulto A, et al. Overriding of drug safety alerts in computerized physician order entry. J Am Med Inform Assoc. 2006;13:5-11.

[2] Seidling HM, Phansalkar S, Seger DL, Paterno MD, Shaykevich S, Haefeli WE, Bates DW. Factors influencing alert acceptance: a novel approach for predicting the success of clinical decision support. J Am Med Inform Assoc. 2011 Jul-Aug;18(4):479-84.


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