Since the advent of computerization in healthcare, the promise of clinical decision support has been seen as a holy grail: the ability to integrate a variety of technology and knowledge/evidence based tools into the care delivery process and at the point-of-care.
HIMSS defines Clinical Decision Support (CDS) as: “A process for enhancing health-related decisions and actions with pertinent, organized clinical knowledge and patient information to improve health and healthcare delivery. Information recipients can include patients, clinicians and others involved in patient care delivery; information delivered can include general clinical knowledge and guidance, intelligently processed patient data, or a mixture of both; and information delivery formats can be drawn from a rich palette of options that includes data and order entry facilitators, filtered data displays, reference information, alerts, and others.”
This broad definition covers a wide range of tools and mechanisms available to clinicians and, for the purposes of this article, we should assume that CDS is widely implemented and successfully used in many settings. However, the question to answer is can CDS help one become a better clinician? It is important to differentiate CDS from CPOE (Computerized Provider Order Entry), which is the process of electronically entering instructions for the treatment of patients, e.g. ordering investigations or treatment protocols.
In order to be useful to clinicians, I would like to focus upon a number of high level criteria when evaluating CDS tools. Implemented successfully in one instance does not mean that a specific clinical decision support tool will be universally of value in other settings. Think of CDS in terms of the following:
- Relevance: Is the tool relevant to your practice? Many instances of CDS have been developed in hospital settings and — linked with policies, organizational change, and buy-in by staff (including clinicians) — they effectively become part of the standard of care for specific conditions, e.g. anti-coagulation therapy in a hospital setting. CDS in this instance usually involves clinical staff as well as the hospital pharmacy and changes in workflow processes. This is not something that can be easily transferred from the acute hospital setting to an ambulatory practice and is probably not relevant except in specific clinical settings.
- Efficiency: Does the tool slow you down? If you pay a significant price in terms of time taken to use CDS, is the benefit worthwhile? In some circumstances, you may be willing to forgo some efficiency for the potential benefits that accrue due to increased patient safety. But this is a judgement call that you will have to make with all of the CDS tools at your disposal. The best tools from an efficiency perspective are those that integrate seamlessly into your workflow and provide you with appropriate information at the time it is needed and in the right context. For example, when prescribing a medication, being made aware of a potential drug interaction and having an alternate medication recommended by the CDS system at the time of prescription is a highly valuable capability.
- Sensitivity: Does the decision support tool give you the right amount of information (or alternately, too much or too little information) to make clinical decisions? A good example of this is drug interaction checking during the prescribing process. If the sensitivity is set too high and you receive too many alerts and warnings that are not relevant, clinicians generally tune out and ignore the warnings and recommendations. If the sensitivity is set too low, you may be missing important interactions that are not being displayed. Fine-tuning the sensitivity of CDS systems is not a simple task, but in order to be useful and effective, it is very necessary. Some CDS systems allow clinicians (or practice administrators) to adjust the sensitivity settings of the alert systems. In situations where sensitivity cannot be adjusted, this can become a significant problem.
- Currency: How often is the CDS information updated? If the information is not current, it once again loses relevance to one’s patients. Some information needs to be updated regularly, e.g. drug information is generally updated at minimum every three months. Other information may not need to be updated as frequently, e.g. patient handouts for specific diseases. You should check and understand the currency of your CDS information.
- Usability: How does the CDS tool fit into your workflow? Usability is a significant challenge for all vendors and developing applications that “just work” requires multiple cycles of development and a very engaged group of users to ensure that usability is constantly being improved. In certain situations, if usability has been fine-tuned and has a high level of satisfaction amongst the majority of users — but does not fit into your workflow — you may want to evaluate your existing work processes to effectively take advantage of the CDS tool.
Clinical Decision Support is not just about the technology. Do not assume that you can simply plug in CDS and enjoy the benefits. There is often a steep learning curve and lots of practice required. However, once you have mastered the tool(s), you have the potential to practice better medicine and manage patients in ways that were just not possible using a paper chart.