Clinical decision support in electronic prescribing: recommendations and an action plan: report of the joint clinical decision support workgroup
In functional terms, clinical decision support (CDS) is defined as: “providing clinicians or patients with clinical knowledge and patient-related information, intelligently filtered and presented at appropriate times, to enhance patient care.” This includes reactive alerts and reminders as well as other intervention types such as medication reference information for prescribers and patients, patient- specific dose checking etc. Some of the healthcare objectives that can be addressed with CDS are; reduced medication errors and adverse medical events, cost-effective and appropriate prescription medication use, and compliance with accreditation and regulatory requirements.
CDS in eRx can improve the safety, quality and efficiency of care. To realize the full impact of CDS on health care, new mechanisms to provide access to current knowledge, accelerated implementation of standards and coding systems, and appropriate incentives for use are all required. While benefits can be obtained from standalone eRx systems, progression to a more comprehensive electronic health record is necessary to reap the full spectrum of benefits.
This consensus white paper sets forth recommendations and action plans in three critical domains: (1) database elements; (2) uniform standards, vocabularies and centralized knowledge structures; and (3) appropriate financial and legal incentives to promote adoption. It provides an overview of the current state of CDS-enabled eRx, describes barriers of adoption and provides probable solutions to these barriers. Some of the recommendations address:
- Features and elements needed for eRx systems to provide effective, high-value CDS with target implementation dates.
- A listing of components that should be available in basic and advanced CDS systems for eRx in 2006 ad 2008.
- Standards and vocabularies that must be developed at a national level in order to efficiently support dissemination and sharing of CDS interventions and also to adopt the research findings into practice.
- Incentives and structures that could be developed at a national level in order to efficiently support dissemination and sharing of CDS interventions.
Clinical decision support(CDS): providing clinicians or patients with clinical knowledge and patient-related information, intelligently filtered and presented at appropriate times can improve the safety, quality, efficiency, and cost effectiveness of care when applied to electronic prescribing systems. However, these potential benefits CDS applied to E-prescribing have not been fully realized.
Recommendations and action plans were given in three critical domains: (1)advances in system capabilities, including basic and advanced sets of CDS interventions and knowledge, supporting database elements, operational features to improve usability and measure performance, and management and governance structures; (2) uniform standards, vocabularies, and centralized knowledge structures and services that could reduce rework by vendors and care providers, improve dissemination of well-constructed CDS interventions, promote generally applicable research in CDS methods, and accelerate the movement of new medical knowledge from research to practice; and (3) appropriate financial and legal incentives to promote adoption.
A number of barriers impede the optimal adoption and effectiveness of CDS interventions for medication management.Some include:- 1) functionality: limited CDS feature and usability problems. 2) data: lack of integration to important data from the EHR. 3) knowledge: uneven availability, standards, and management of best-practice CDS knowledge. 4) costs: for implementation and ongoing use, as well as perceived liability concerns.
Core Features to Support Clinical Decision Support
Certain features of e-prescribing systems can help ensure that knowledge and data are effectively used for safe, high-quality, cost-effective medication management. These recommendations fall into four areas: 1) Knowledge base: the types of rules, content, and interventions that are available in the system. 2) Database: necessary data elements needed to permit targeted, patient-specific, event-specific CDS. 3)Functionality and usability: aspects of the day-to-day operation of the e-prescribing system that must be considered and implemented to make it acceptable, implementable, and efficient. 4)Organizational: governance, communication, policy, and management structures and processes that are essential for effective, appropriate use of CDS on an ongoing basis.
Impact of CDS increases as more types of data and workflow are combined together in a single system or interoperable set of systems. Benefits can be obtained from standalone e-prescribing systems but progression to a more comprehensive electronic health record is necessary to reap the full spectrum of benefits of these systems.
Further work is needed to accelerate development of the structures and enablers, to make use of the above recommendations in determining eligibility for government programs and incentives, and to consider the application of these recommendations to other clinical workflows outside of E-prescribing.