Quick quiz:
How many times does the phrase “clinical-decision support” appear in the health information technology, or HITECH, section of the American Recovery and Reinvestment Act of 2009?
Charles Friedman stumped a couple hundred physician informaticists when he asked that question Wednesday during the opening session of the 18th Physician-Computer Connection Symposium in Ojai, Calif., sponsored by the Association of Medical Directors of Information Systems.
Friedman is the deputy national coordinator in the Office of the National Coordinator for Health Information Technology at HHS. He joined by phone an AMDIS panel called “Moving the Nation towards Meaningful Clinical Decision Support.”
Friedman's answer: Clinical-decision support is found only once in the 700-plus pages of the stimulus law, but it is a fundamental function nevertheless. CDS, as it was referred to throughout the session is one of five criteria an electronic health-record system must have to meet the definition of a “qualified” EHR under the law, Friedman explained. (To be deemed as qualified systems, EHRs also must be capable of storing demographic and clinical health information, support physician order entry, capture and query information relevant to healthcare quality and exchange and integrate healthcare information from other sources.)
Only qualified EHRs can be certified as meeting the requirements of the stimulus law for provider subsidy payments, so clinical-decision support “is a precondition” to being a certified EHR, Friedman said. Additionally, implementing systems with clinical decision-support capabilities will “very likely work its way into our considerations of the workforce that is needed” to carry out government programs to boost EHR adoption and use, including the work of proposed national and regional health IT extension services. The office of the national coordinator has “actively supported CDS since 2006 and helped form a CDS government collaborative in 2008 to foster cross-agency cooperation in developing decision-support systems within federal healthcare organizations, he said.
Friedman said that ONC is planning a two-day workshop in late August on clinical-decision support as part of the criteria physicians must meet to achieve “meaningful use” of an EHR and qualify for payments under the stimulus law.
AMDIS will host a second session on clinical-decision support Thursday. Why all the attention on one function of an EHR system?
William Bria
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The influence of clinical-decision support on healthcare could be “tremendous,” said AMDIS Chairman William Bria. “CDS is the most important intersection between medical knowledge and medical information technology,” Bria said. “That interface is one that holds the greatest promise for actually improving quality of care and safer care.
“Unlike whether you're doing computerized physician order entry, CPOE, CDS is not one thing,” Bria said. Alerts, such as warnings to drug-related allergy, are CDS, but so is a patient's medication history if it is readily provided by an EHR system as part of a physician's workflow. But it is also decision support if a physician is given a recommendation on a specific antibiotic at the time of prescribing. “So, the idea of using our information tool to apply best known medical practice is not just one step. It's an incremental series of steps. There is no plug and play, no Web services where it's all done. Medicine is nowhere near that standardized. There is no such thing as unimpeachable evidence.”
So, merely saying “I'm going to import the medical literature into my decision-support system” won't be enough. A decision-support system also needs to help sort or rank that information and, best practice will require hospitals and physician groups to “measure the effects of decision support,” Bria said.
“If you do not measure the results of whatever decision-support system you introduce, you will have no insight to what the value is of applying that medical evidence,” he said.
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