With our growing reliance on electronic health records (EHRs) and the need to prove to the federal government that they are being used in a meaningful way, practitioners have been struggling to meet Stage 1 regulations on Clinical Decision Support (CDS) systems.
In 2014, that struggle will be even more daunting. The Centers for Medicare and Medicaid Services says Stage 2 MU requires that providers have a system in place that checks for drug-drug interactions and allergies and that they "implement five clinician decision support interventions related to four or more clinical quality measures at a relevant point in patient care for the entire EHR reporting period."
What does that mean in practical terms? Typically it involves having a plug-in installed in your EHR that alerts clinicians to a list of important medical interventions, each of which are tied to specific quality measures. For example, Practice Fusion has CDS advisories to alert physicians to check a diabetic’s hemoglobin A1c levels, which is important because high levels indicate long-term blood glucose is poorly controlled.
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Having an alert in your system to prompt clinicians to take action would fulfill one of the five CDS interventions in the Stage 2 rule mentioned above. One of the specific quality measures from the National Quality Forum, NQF 0059, centers upon keeping track of patients with Types 1 and 2 diabetes between 18 and 75 years of age with an HbA1c above 9%. The provider who implements this properly also would meet one of the four quality measures listed in the Stage 2 rule.
Unfortunately, many hospitals and practices with CDS systems can’t handle these kinds of transactions. "Outside of four or five integrated health systems and the Veterans Administration, robust CDS use is still quite rare beyond alerts for drug-drug interactions and drug-allergy contraindications," explains David Raths in a recent Health Informatics blog post.
Fortunately, several stakeholders are doing their best to help providers get up to speed. HIMSS, the American Medical Informatics Association (AMIA) and the CDS Collaborative for Performance Improvement are working hard to improve CDS tools, building on the guidelines spelled out in HIMSS’s Improving Outcomes with Clinical Decision Support: An Implementer’s Guide.
Partners Healthcare in Boston is also getting involved. It has conducted pilot studies, offering its top-flight CDS system via a Web service to select healthcare providers that don’t have Partners Healthcare’s expertise -- or its deep pockets. These pilots have offered interoperable, remote access so that organizations can tap into a CDS library that remains current over time.
Current is the key term. One of the problems with maintaining a CDS system is that medical science is constantly advancing. "Knowledge is not static," explained Howard Goldberg, MD, senior manager at Partners Healthcare's Enterprise Clinical Informatics Infrastructure division. "Your content needs to be kept evergreen." Even keeping up to date with alerts on something as relatively simple as immunization "is an enormous challenge," he added.
Even those providers that can keep up to date have a long journey ahead before they can lay claim to truly robust clinical decision support. As I’ve mentioned before in this column, Meaningful Use really is a euphemism for minimal use. Even if a provider is capable of meeting its quotient of five interventions and four quality measures, it has only taken baby steps on the path to quality patient care.
A CDS system should do what the term implies -- improve a clinician’s decision making process. That can only be accomplished with access to in-depth reference materials from the research literature and algorithms that allow physicians to distinguish among a variety of complex diagnoses. Smart order sets, databases, and care plans from vendors like Elsevier, Zynx, UptoDate, and Wolters Kluwer will get us part of the way there, as will Web access to IBM Watson, Isabel Healthcare, and a host of other sophisticated diagnostic-assistance platforms.