1. Hess, Cathy Thomas BSN, RN, CWOCN

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Recently, I have had many questions regarding the use of clinical decision support (CDS). The Centers for Medicare & Medicaid Services (CMS) released a document in July 2014 titled, "Clinical Decision Support: More Than Just 'Alerts' Tipsheet" (last updated July 2014).1 The "CDS Tipsheet" is chock-full of useful information. I have taken the liberty to provide you with highlights directly from this document and encourage you to download to read it in its entirety.1


Clinical Decision Support Is a Key Functionality

Clinical decision support is a key functionality of health information technology that, when effectively applied, contributes to increased quality of care and enhanced health outcomes, error and adverse event avoidance, improved efficiency, reduced costs, and enhanced provider and patient satisfaction. Recognizing this potential to improve care, the US Congress included CDS as a centerpiece of the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs ("Meaningful Use").


Clinical decision support is not simply an alert, notification, or explicit care suggestion. It encompasses a variety of tools including, but not limited to, computerized alerts and reminders for providers and patients, clinical guidelines, condition-specific order sets, focused patient data reports and summaries, documentation templates, diagnostic support, and contextually relevant reference information. These functionalities may be deployed on a variety of platforms (eg, mobile, cloud-based, installed). Clinical decision support is not intended to replace clinician judgment, but rather is a tool to assist care team members in making timely, informed, higher-quality decisions. The "Five Rights" concept provides a best-practice framework that providers may consider in choosing the CDS options appropriate for their practice.


The Five Rights concept states that in order to provide these benefits, CDS interventions must provide


* the right information (evidence-based guidance, response to clinical need),


* to the right people (entire care team, including the patient),


* through the right channels (eg, EHR, mobile device, patient portal),


* in the right intervention formats (eg, order sets, flow sheets, dashboards, patient lists),


* at the right points in workflow (for decision making or action).



What Does Meaningful Use Require for CDS?

In Stage 2, eligible providers must implement 5 CDS interventions related to 4 or more clinical quality measures, if applicable, at a relevant point in patient care for the entire EHR reporting period, and have enabled the functionality for drug-drug and drug-allergy interaction checks for the entire EHR reporting period.


The Stage 2 Meaningful Use Final Rule states "CDS is not simply an alert, notification, or explicit care suggestion" and goes on to describe nonalert CDS examples, including disease-specific order sets and documentation forms/templates. The rule also defines CDS as "HIT (Health Information Technology) functionality that builds upon the foundation of an EHR to provide persons involved in care processes with general and person-specific information, intelligently filtered and organized, at appropriate times, to enhance health and healthcare." Moreover, the Stage 2 Meaningful Use Final Rule replaces the term "clinical decision support rule" with "clinical decision support intervention" in order to "better align with, and clearly allow for, the variety of decision support mechanisms available to help improve clinical performance and outcomes."


Clinical decision support is frequently an integrated part of the provider's EHR system but may also present in a variety of other mechanisms, including, but not limited to, pharmacy systems, patients' personal health records, or portals provided by the practice. Some providers use certified EHR technology (CEHRT) to drive (or, for example, to receive or trigger) CDS in an external system, for example, by sending data to a registry or immunization forecaster that provides CDS. For Meaningful Use, such systems must interact with CEHRT in the normal course of the care delivery workflow, ensuring that decision support interventions are delivered at the right point in the workflow, based on relevant patient information (even if the appropriate point in workflow is not during a patient encounter).


The remaining portion of the CDS Tipsheet incorporates the following:


* What kinds of things constitute CDS?


* Evaluating eligible providers use of CDS for meaningful use


* Questions and answers


[white circle] Q: How is CDS defined for purposes of the meaningful use program?


[white circle] Q: How should an auditor evaluate noninterruptive CDS?


[white circle] Q: Must the CDS be "fired" during the reporting period?


[white circle] Q: Can screenshots be used to demonstrate CDS?


[white circle] Q: Does CDS directed at support staff, patients, or caregivers "count" for purposes of the meaningful use program?



This column has provided a sample of the "CDS Tipsheet," but please take the time to read this document in its entirety. It is very important to stay up-to-date on CMS guidance.




1. Centers for Medicare & Medicaid Services. Clinical Decision Support: More Than Just 'Alerts' Tipsheet. Last accessed August 25, 2014. [Context Link]