There’s No CDS Like the New CDS

It has certainly been a big year for healthcare information technology (HIT) – possibly the single most game-changing year that many of us in the informatics field will see in our lifetimes – and, consequently, a big year for clinical decision support.  The HITECH provisions of the economic stimulus act have brought billions of dollars in support and incentive funds for HIT, and we are already seeing a noticeable rise in acquisition of electronic health records and related systems.  As you surely know by now, access to much of that funding depends on achieving that magical phrase, meaningful use – reaching and documenting milestones in quality, safety, patient involvement, care coordination, public health, and privacy protection.  In order for your use of the EHR to be meaningful, the EHR has to be more than a filing system; it has to give active support to the practice, providing information to assist your decisions and actions in the direction of more consistent quality and reduced errors – in medication prescribing, test ordering, managing chronic conditions, providing preventive care, and more.

At a recent workshop (http://healthit.hhs.gov/cds) held at the Health and Human Services headquarters in Washington, Paul Tang, director of the committee that formulates proposals on meaningful use for the Office of the National Coordinator, pointed out that the use of CDS is both explicit and implied in many of the meaningful use recommendations.  According to the meeting summary of Dr. Tang’s remarks, “without CDS, measures of health priorities as defined by meaningful use are less likely to meet quality targets or improve over time.”

 I’m extremely pleased to see this great opportunity for CDS to affect care and health outcomes for the better, for a much larger segment of the population.  But that also means it’s time to take a 2009 look at a question we all think we knew the answer to years ago – what is CDS?  More specifically, do we need to rethink what we know about CDS, if we really want to turn all of this increased technology into better results?  CDS has been very successful in improving quality measures and reducing errors in many institutions, but not all.  What CDS will make the greatest positive difference in the greatest number of practices?

For many, CDS equals alerts – most commonly, alerts about drug allergies and interactions, but also alerts about a variety of potential hazards and opportunities.  Yet, alerting is one of the most intrusive forms of CDS, and not always one of the most useful.  In a recent editorial in Pediatrics (http://www.pediatrics.org/cgi/content/full/124/1/375 ) Dean Sittig of Memorial-Hermann Health (and three others, including me – but the major credit has to be given to Dean) pointed out a number of circumstances under which alerts would likely be ineffective and/or poorly accepted, “compared to other intervention types such as facesheet displays, order sets, patient education handouts, and end-of-visit forms.”  Depending on the clinical objective and where you are in the workflow of care, different CDS intervention types might fit the job best, including intelligent data displays, guideline helpers, context-sensitive reference information, smart documentation forms, procedure guides, performance dashboards, and more.

Given all of this, I have had to broaden the definition of CDS that I use when lecturing, to “provision of information to the healthcare professional, patient or family, filtered for the current situation and presented for greatest impact on the task at hand.”  The ideal CDS intervention helps you get through your current task, answer your current question or need, as correctly and efficiently as possible.  In many cases, the best CDS is something nontraditional – perhaps a video on your iPhone to refresh your memory about that procedure you’re about to do, or a predictive report of your hospitalized patient’s risk of falling. The best CDS is often  something that would not have immediately come to mind if someone asked “what is CDS”?