CDS
Clinical decision support has been defined broadly as “providing clinicians or patients with clinical knowledge to enhance patient care.” This includes not only the familiar reactive alerts and reminders (such as alerts for drug allergies and interactions), but also many other intervention types, including structured order forms that promote correct entries, pick lists and patient-specific dose checking, proactive guideline support to prevent errors of omission (such as ensuring that appropriate patients are placed on aspirin), medication reference information for prescribers and patients, and any other knowledge-driven interventions that can promote safety, education, communication, and improved quality of care.
A detailed treatment of clinical decision support in eRx, including practical issues of classification, usability, implementation, and evaluation, is presented as a chapter in the eHealth Initiative consensus report, Electronic Prescribing: Toward Maximum Value and Rapid Adoption. That report describes and references several ways of classifying clinical decision support intervention based on when in the process the logic is executed, how it is delivered, and the global impact it has on the process. A conceptual framework for evaluating outpatient eRx applications based on functional capabilities was is an important step towards understanding variable clinical decision support in this domain.
CDS Benefits
There are well-documented problems with the appropriate, safe, and cost-effective use of medications in healthcare. The very structure of most eRx applications – such as using standard drug dictionaries, selecting parameters from lists, and having required fields –can alleviate some of the problems associated with generating and filling medication prescriptions.However, supplementing this structure with CDS interventions, aimed at those who enter, edit, and manage prescriptions, offers greater leverage for achieving optimal patient care).
Healthcare objectives that can be addressed with CDS are:
• Reduced medication errors and adverse medical events
• Improved management of specific acute and chronic conditions
• Improved personalization of care for individual patients
• Best clinical practices consistent with available medical evidence
• Cost-effective and appropriate prescription medication utilization
• Effective professional and consumer education about medication use
• Effective communication and collaboration about medications across clinical/prescribing-dispensing-administering settings
• Efficient and convenient clinical practice and self-care
• Better reporting and follow-up of adverse events
• Compliance with accreditation and regulatory requirements
• Improved dissemination of expert knowledge from government and professional bodies to clinicians and patients.
Various efforts to enhance prescription management through CDS have been implemented and evaluated over the past few decades, but historically these efforts have been limited primarily to a small number of academic settings. More recently, CDS-enabled eRx is becoming more widespread in commercially available systems and more widely used in practice.
However, utilization of eRx itself is still at modest level as many eRx systems do not include all of the necessary and desired features for thorough, high-value, efficient CDS application. Thus, there are substantial opportunities to further realize the potential for CDS to help achieve the objectives listed above.
There are main areas where action is necessary to bring the current state of CDS closer to the desired state:
Determine and encourage core CDS functionality in all products, including knowledge, database elements, functionality and usability features, and organizational matters.
Enhance the knowledge management infrastructure for eRx-related CDS, making it possible for more providers to have access to references, rules, and guidelines that are comprehensive, high-quality, usable, actionable, and configurable. Enhancing this infrastructure will also make it possible to do broadly applicable research on the effectiveness of specific CDS methods. Closely related to this is the need to have enhanced standards and vocabularies for a variety of CDS-related eRx operations.
Provide incentives – financial, regulatory, and legal – for implementation and use of CDS-enabled eRx