Managing Clinical Decision Support
By John Glaser and Tonya Hongsermeier, M.D.
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| John Glaser | Tonya Hongsermeier, M.D. |
Clinical decision support (CDS) is a critical contributor to efforts to improve the quality and efficiency of medical care and patient care operations. But to achieve CDS’s promise, an organization must establish management structures and processes that enable it to identify priorities, develop and maintain the required content, and evaluate the technology’s impact on care.
CDS management structures and processes should accomplish several objectives, many of which revolve around the technology’s logic. CDS logic refers to real-time, computer-based rules and algorithms that guide a clinician’s treatment of a patient, such as drug-drug interaction checking during the entry of a medication order into a computerized provider order entry system.
For CDS to function properly, designated teams or committees need to be in place to identify new types of logic that should be incorporated into the organization’s clinical information systems. These groups also must ensure that CDS logic can be clinically defended through review of the literature or consensus-based decisions by appropriate clinical staff while ensuring that existing logic is reviewed at an appropriate frequency. Finally, these groups must provide direction on priorities for incorporating or modifying CDS logic.
The organization also must establish structures to facilitate and encourage clinician use of the system, including educating clinical staff on the rationale for a CDS rule. The organization needs to assess the impact of CDS on provider decisions and practices to determine if the desired outcomes are being achieved, and review strategies to improve the effectiveness of existing CDS uses. Two other issues to explore: whether computer-based intervention impedes workflow and whether the application interface confuses rather than informs the user.
Finally, the IT staff or application vendor needs guidance to ensure that appropriate specifications have been developed and testing has been performed.
There is no best way to organize these responsibilities. However, there are several commonalities that can guide the development of CDS management structures and processes.
Leverage Existing Committees
The use of existing care-oriented committees can help address several aspects of CDS management. For example, an existing pharmacy and therapeutics committee could be asked to manage medication-centric CDS logic, while a committee already devoted to improving cardiac care should be asked to oversee CDS logic related to hypertension and congestive heart failure guidelines.
These committees possess the expertise necessary to determine the clinical utility of a specific decision support recommendation. And because decision support must be maintained by regularly reviewing and updating content, this logic maintenance is best handled by a committee already familiar with current content. The committee also will be most effective at educating clinicians about the value of decision support.
A care-oriented committee is in the best position to prioritize CDS requests. For example, a patient safety committee will have the best organizational perspective on major patient safety issues and the priorities for developing and implementing CDS logic, such as whether work on chemotherapy dosing logic should be given higher priority than logic that adjusts dosing given a patient’s renal function. In addition, because of their care-specific expertise and understanding of the organization’s care practice deficiencies, these committees are most likely to “discover” new logic or new opportunities to deploy existing logic. These discoveries can be based on the experiences of the organization or upon review of the advances of others.
Examine Committee Composition
CDS logic often spans domains, such as when medication-centric logic is relevant to a committee focusing on cardiac care. To the degree that there is likely to be a significant set of CDS logic that is relevant to several committees, there should be cross-committee representation. In general, this cross-committee representation is already in place; the boundary-spanning issues were present before the introduction of clinical information systems.
Cross-representation should not only account for clinical discipline, but overall perspective. For example, it is important that clinicians representing the strategic concerns of the health system be balanced by those representing usability and efficiency concerns. Respected clinical champions can be those in management positions as well as the clinicians in a community practice who are greatly respected by their peers.
It’s important to place an information technology staff member on each of these committees. This person can help the committee members focus on the most feasible and effective IT strategies to address a particular challenge, such as alerts at the time of ordering and the use of defaults and options for incorporating decision support into the workflow.
Ensure IT Review and Assessment
Because the clinical information system will have limitations--some of which may mean that certain proposals cannot be practically implemented--CDS proposals must be examined from an IT perspective. Both clinical and IT staff must understand the effort required to implement a new proposal. Additionally, the IT staff that must “codify” and test the decision support will have a backlog that needs to be prioritized.
Define Oversight Group
The individual committees that manage portions of the CDS technology will require oversight, and an existing group can be tapped for this responsibility. Many organizations have committees that have broad authority over care improvement; for example, an integrated delivery system may have a chief medical officer’s forum. In other cases, an oversight group has been formed to provide overall direction for the implementation and management of the organization’s clinical information systems.
The actions of individual committees often will conflict. These conflicts can center on the definition of appropriate clinical decision support logic, for which committee members have different opinions on best practices. The committees also will face tradeoffs between practicing best care and working within operational realities, such whether health maintenance reminders for harried primary care physicians will fall on deaf ears. Another common clash is the prioritization of scarce organizational resources--budget limitations mean that not all ideas can be implemented. In addition to the need for resolving conflicts, an oversight group can ensure that different committees don’t independently embark on duplicative CDS strategies.
The oversight group is responsible for seeing that CDS use conforms to the organization’s medical policy. At times, a decision support idea may lead to a need to alter policy. It also may indicate the need to examine organizational roles, such as who should respond to an asynchronous panic lab value alert. This committee must have members who can work with other groups, such as the compliance committee, and determine when it is appropriate to move some issues to those other forums.
Organizations need management structures and processes to ensure that clinical information system and CDS investments achieve desired organizational goals. These goals include CDS linkage to organizational strategies, prioritization of resources and determination of the impact of clinical decision support.
John Glaser is vice president and CIO of Partners HealthCare in Boston, senior advisor, Deloitte Center for Health Solutions, and a regular contributor to Most Wired OnLine. Tonya Hongsermeier, M.D., is the corporate manager, clinical knowledge management and decision support, for Partners HealthCare.
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This article first appeared on March 21, 2007 in HHN's Magazine online site.
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