By Jonathan Teich, M.D., CMIO, Elsevier (Editor's Note:  See end of article for list of resources) As providers consider how to qualify for federal incentives connected to the adoption and use of electronic health records (EHRs), as specified in the American Recovery and Reinvestment Act (ARRA), committees appointed by the Office of the National Coordinator for Health Information Technology (ONC) are drafting and vetting required criteria for demonstrating meaningful use of EHRs, and selecting quality objectives and measures for inclusion in those requirements.  Clinical decision support (CDS), as an essential component of technology-enabled quality measurement and improvement, has emerged as a critical component in this important national initiative. The role of CDS in meaningful use grows larger as the requirements advance from 2011 to 2013 to 2015.  In mid-July 2009, the HIT Policy Committee approved a set of quality objectives for the 2011 meaningful use criteria; this set includes a requirement to “implement one decision rule relevant to a specialty or clinical priority,” along with more specific CDS requirements such as drug-allergy alerts. By 2013, providers must drive performance as they “provide clinical decision support at the point-of-care.” And by 2015, providers will zero in on outcomes improvement as they fulfill the objective to “implement clinical decision support for national high priority conditions.” Providers can expect to use CDS on high priority targets such as mammograms and cholesterol screening, particularly relevant to the Medicare primary-care population that is a prime target of meaningful use.  The criteria also extend to inpatient care – such as preventing venous blood clots in surgical patients – and for specialists, the set of quality or outcome measures will likely be defined in the rule-making process. It’s also quite possible that other payers may set up similar criteria, eventually expanding the focus of meaningful use and CDS beyond Medicare patients to other populations, with their own particular priority quality targets. The healthcare industry knows that CDS can achieve results. Hospitals with automated CDS systems have lower costs, fewer complications and lower mortality rates, according to a study in the January 26, 2009 issue of the Archives of Internal Medicine. While everyone in healthcare—payers, providers, government and vendors—remains excited over the value and potential of CDS, some CDS implementations have been fraught with complications and disappointments.  Many physicians still regard CDS with skepticism, concerned about cost of implementation, effect on practice efficiency, alert fatigue and uncertain effectiveness. According to the Archives report, hospitals may not realize the full benefits of CDS due to inadequate user training, system usability issues and lack of alignment between the organization and care providers. To be truly effective, CDS systems must meet multiple requirements of implementability, usability, functionality and value.  In choosing an EHR system to meet meaningful use requirements, consider these questions relative to its CDS capability:

• Implementation: Is the CDS system feasible, practical and workable?  Can it be implemented through a cost-effective process that includes planning, promotion, testing, go-live, training, monitoring and evaluation? What types of team-building, training and education programs should the organization introduce to ensure care team endorsement and use?
• Provider acceptance: Is the system easy to learn, usable, customizable? How likely is it that the CDS system will be understood, accepted and used by clinicians?  How might clinical champions contribute to CDS buy-in, acceptance, use and ongoing evaluation?
• Flexibility for providers: Does the CDS system meet the needs of the particular specialties and providers in your organization?  If you are serving multiple specialties, is the system flexible enough to give value to the pediatrician, orthopedist, or radiologist as well as to the internist?  Can the system be customized to meet the needs of other specialties and disciplines such as pharmacy, nursing and allied health?
• Flexibility for patients: Can the CDS system meet the needs of diverse groups of patients?  For example, does it deliver equal benefits to children diagnosed with obesity, middle-aged men with hypertension, seniors with Type 2 diabetes, and younger women with post-partum depression?  Can it adjust to patient characteristics obtained from the EHR?
• Flexibility for healthcare settings: Will the CDS system deliver value and benefit within the variety of healthcare settings that it must cover?  Depending on your needs, can it be adapted to inpatient care, ambulatory care, ED care, long-term care and home care?
• Breadth and depth of content: Are the CDS system’s recommendations justified by evidence and recognized guidelines?  Does the system explain its recommendations with evidence-based clinical content integrated into the clinical workflow?  How frequently is this content updated?
• Integration: Does the CDS system easily integrate with other products and services, such as those focused on regulatory reporting, predictive analytics, outcomes analysis, care planning, e-prescribing and e-learning?
• Sharing: Does the CDS system facilitate or enable CDS sharing to streamline new additions and maintenance?  Can CDS interventions developed at other institutions be readily incorporated?

Optimizing Your Relationship with CDS CDS is more than alerts. Clinicians must adapt to and make the most of CDS’ growing function and scope.  Instead of simply using a single type of CDS (such as alerts) for all situations, clinicians must learn how and why to use different types of CDS, at different stages of the workflow, for maximum effect.  With practice and commitment, clinicians can become equally adept in using other types of CDS—from drug interaction alerts and references to infobuttons, care plans and procedure guides. Learn from others’ experience. Rather than focusing on the inevitable snafus and bumps that accompany the launch and installation of new technologies, clinicians would do well to review case examples and empirical studies of CDS successes.  “CDS, when well-designed and implemented, holds great potential to improve health care quality, increase efficiency, and reduce health care costs,” according to a white paper sponsored by the Agency for Healthcare Research and Quality.  The whitepaper calls upon researchers, developers and vendors to “address cognitive, informatics, structural, and workflow issues to optimize CDS design, implementation, and integration into clinical workflow.” In short, CDS promises to improve outcomes, streamline workflow and enhance patient care – but attention to both good system capabilities and good implementation management is vital to fulfilling this promise. Think about CDS systematically. CDS will more easily achieve its goals of better outcomes, enhanced care and streamlined workflow when every healthcare stakeholder – especially care providers – comes to view CDS as a reusable and renewable engine and standard resource, rather than as a disconnected set of discrete tasks to be performed at each patient encounter.   Ultimately, clinicians will address objectives such as engaging patients and families to follow preventive care guidelines by using tools such as flowsheets at the outset of a patient encounter, information resources and order sets during the encounter, and patient education and results management tools afterward. Learning More About CDS Clinicians interested in learning more about CDS can consult a variety of resources (listed at the conclusion of this article).  It is likely that new resources, such as the HIT regional extension centers called for in ARRA, will play an important role in collecting, disseminating and promoting best practices, making the implementation of meaningful CDS more predictable and stable. Additionally, clinicians can facilitate adoption and use of CDS within the context of meaningful use by studying and visiting existing CDS implementations.  Among the questions clinicians may want to ask are these:

• What was the initial target: the problem, challenge or opportunity that drove the implementation of CDS?
• How did the organization prepare for implementation through needs assessment, planning, education, communication, task force development and team building?
• How effectively did the organization mobilize financial, human, technological, clinical and business resources?
• What types of roadblocks or barriers did the organization face and how were they overcome?
• What results were achieved—both in operations and patient care?
• What were the lessons learned and how could they be applied to the experiences of other organizations?

CDS provides clinicians with timely, consistent, accurate information for enhanced diagnostic and treatment decision making.  All clinicians, including physicians, nurses, pharmacists and allied health professionals, stand to benefit from tools that support better coordinated care, more engaged patients and families and improved healthcare quality, safety and efficiency. By adopting and using CDS in the support of meaningful use, physicians can introduce innovations that will improve the the health of patients, families and local communities. Resources Clinical Decision Support Roadmap (American Medical Informatics Association) http://www.amia.org/inside/initiatives/cds Health IT Investments that Improve Healthcare: Critical Information Policy and Technology Attributes and Expectations (Markle Foundation) http://www.markle.org/events/20090113_transition/20090113_health_it_investments.pdf A Shared Roadmap and Vision for IT http://www.nationalehealth.org/uploadedFiles/Home/News/A%20Shared%20Roadmap%20and%20Vision%20for%20Health%20IT%20-%20Feb%2010%202009%20FINAL3.pdf Clinical Decision Support Demonstrations—Clinical Decision Support Consortium (AHRQ) http://healthit.ahrq.gov/portal/server.pt?open=514&objID=5562&mode=2&holderDisplayURL=http://prodportallb.ahrq.gov:7087/publishedcontent/publish/communities/a_e/ahrq_funded_projects/cds_projects/cds_projects/clinical_decision_support_consortium.html Improving Outcomes with Clinical Decision Support: HIMSS Clinical Decision Support Guidebook Series http://www.himss.org/ASP/topics_cds_workbook.asp?faid=108&tid=14 “Effects of Computer-based Clinical Decision Support Systems on Clinician Performance and Patient Outcome: A Critical Appraisal of Research” http://www.annals.org/cgi/content/abstract/120/2/135 Jonathan Teich, M.D., is Chief Medical Informatics Officer for Elsevier and an attending physician and professor in emergency medicine at Harvard's Brigham and Women's Hospital. Obtain Medical Specialty Own-Occupation Disability Insurance On-line