• Decrease errors of omission and commission.
• Reduce unnecessary, ineffective, or harmful care.
• Promote adherence to evidence-based care.
The Final Rule on Meaningful Use Stage 2 has also raised requirements for CDS tools. In Stage 1, eligible professionals needed only to implement one Clinical Decision Support (CDS) rule relevant to specialty or high clinical priority. In Stage 2, EPs will need to use CDS to:
• Improve performance on five high-priority health conditions.
• Support querying of immunization registries.
• Identify reportable conditions.
Clearly we all must embrace CDS tools.
Building a CDS program
Key elements of a successful CDS implementation include:
• Support for the program comes from all levels of the organization.
• Key stakeholders are involved.
• A clinically oriented champion must guide the effort.
• A multidisciplinary CDS committee.
• CDS goals aligned with organizational strategic goals.
• Ongoing monitoring .
The ultimate goal of a CDS program is to follow Osheroff’s CDS Fiver Rights, which seek to provide: the right information, to the right person, in the right format, through the right channel, at the right point in clinical workflow to improve health and healthcare decisions and outcomes. The ‘CDS Five Rights’ approach is also a framework for setting up and optimizing CDS interventions to address priority objectives.
CDS implementation problems and challenges
It can be challenging to implement an effective CDS program in a clinical practice. Commercially available tools imbedded in EMRs have unreliable alerts and insufficient application of usability standards. These are all inherent problems that limit our ability to create CDS tools that are effective and efficient. Small practices do not have the required personnel to create the templates and deploy them. Most clinical practices do not have sufficient staff to accomplish this.
It would be ideal if CDS tools were standardized and a repository of them existed from which a small practice could pull. Unfortunately, there is a lack of standardization and sharing between and among healthcare organizations with respect to CDS tools. Each of our EMRs is "proprietary" with a unique database that would require customized programming in order to implement a CDS tool. Clearly we need a better solution.
The AGA is proactively trying to lead the way in this endeavor by developing CDS tools and definitions for three clinical service lines (CSLs): colon cancer prevention, inflammatory bowel disease, and management of chronic hepatitis C. We are using or creating updated guidelines, deriving performance measures, and creating standard order sets and clinical management algorithms with grades of evidence for each decision point.
The future of CDS
Clearly CDS tools will mold and shape the practice of medicine in the future. We must succeed in standardizing the process and making the information uniformly available.
This will require the creation of cloud based CDS tools that are no longer proprietary to the EMR. In addition, the providers cannot do this alone. We will need to bring the patient into the process through the development of patient specific "hovering tools" designed to provide us with information about them on a real time basis.
Real CDS tools created by a private practice
The Illinois Gastroenterology Group (IGG) has recently developed a program we call "Project Sonar". It’s an initiative designed to improve our communication with our patients with IBD. We created a cloud based repository of CDS tools that are accessible from our EMR. These are queried by our EMR and provided to physicians and staff. Patients are sent queries on a real time basis that contain an abbreviated CDAI to assess their symptom quotient. These data are then fed into our database where we are developing artificial intelligence to determine the course of action based upon the level and the rate of change in the level.
The value of Project Sonar is that it is scalable to other practices, even using other EMRs. This is the ultimate structure that will move us toward success. There is just not enough band-with in most practices to create them in house.
Conclusion
If we are to succeed and thrive in a future system characterized by acceptance of risk for both outcomes and finances, we will need to efficiently deploy our practice assets and so that we are obtaining the most they can provide. We must increase our return on assets.
In order to minimize risk, we also need to embrace our patients in a way that brings them into the process. This will require the creation of information systems that are replete with CDS tools both for the provider as well as gamefied for the patient.
