AHRQ: Integration with workflow is key to CDS success

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Clinical decision support (CDS) systems can be successfully developed and implemented, and the knowledge base can be shared across clinical sites and EMR systems, according to a recent Agency for Healthcare Research and Quality (AHRQ) report.

The report focused on the challenges and barriers to CDS design and the implementation that AHRQ experienced when the organization funded two demonstration projects in 2008 in support of the design, development and implementation of CDS systems. The projects aimed to incorporate CDS into EMRs that have been certified by the Certification Commission for Health IT (CCHIT) as well as demonstrate that CDS can operate on multiple information systems, AHRQ stated.

The Clinical Decision Support Consortium (CDSC) Project was awarded to Boston-based Brigham and Women’s Hospital and also includes Partners HealthCare System. According to AHRQ, the project’s goal is to assess, define, demonstrate and evaluate best practices for knowledge management and CDS in health IT across multiple ambulatory care settings and EHR technology platforms while focusing on chronic disease management and prevention screening.

The GuideLines Into Decision Support (GLIDES) project is a collaboration between Yale University School of Medicine, Yale New Haven Health System and the Nemours Foundation. The goal of the project, according to AHRQ, is to implement evidence-based guideline recommendations that address both preventive practices and complex management of chronic disease, deliver the guideline knowledge via electronic decision support interventions at ambulatory sites that employ CCHIT-certified EHR systems and evaluate the fulfillment of knowledge transformation goals and the effectiveness of the decision support tools in improving the quality of healthcare.

“Both contractors have successfully concluded the preimplementation phase and have completed the design phase,” the AHRQ stated. “The GLIDES project is now operating its CDS intervention at its multiple clinical sites and organizations, while the CDSC project is demonstrating its CDS intervention at its primary contractor sites and will soon be ready to share the knowledge and technical specifications with collaborators’ sites.”

According to AHRQ, the GLIDES protect team focused on the ambulatory pediatric setting, with an aim to improve the management of asthma and to prevent obesity. While distinct projects, unique in scope and purpose, AHRQ noted their similar challenges:

  • The management of the design of CDS interventions takes considerable time and effort;
  • Lack of alignment with an organization’s overall goals and incentives can affect CDS projects;
  • Clinicians do not agree on how prescriptive the CDS application should be;
  • Written guidelines were ambiguous and unclear, making it difficult to translate them to computable code;
  • Terminology and data exchange standards are still maturing and lack constrained implementation specifications;
  • Suboptimal EMR usage by clinicians diminishes the impact of CDS interventions; and
  • There are no easy solutions to gaining clinicians’ acceptance and use of CDS interventions.

“Multiple factors are believed to affect the success or failure of CDS intervention implementation,” the report concluded. “Clearly, a successful CDS intervention is dependent on the completeness and accuracy of the evidence base used to support it and the technical design of the interventional modalities…It is clear from empirical studies of CDS implementation and current recommendations for their design that integration with workflow is key to success.

“How to integrate the CDS interventions with clinicians’ workflow, however, remains a challenge, in part because there are no current standards for clinical workflow.”

According to the AHRQ, there can be lessons learned from the organization’s experience, including:

  • Guideline development committees should include individuals with programming expertise and health informaticians;
  • Updates of guidelines recommendations are needed;
  • Implementation specifications and guides should be produced that simplify existing standards and support consistent application of standards for messaging, interfacing and mapping purposes;
  • The organizational working environment should foster meaningful EMR usage, including not only software and hardware needs but also the attitudinal changes needed to support adoption;