Section 6.4 Optimize
Optimization Strategies
for Clinical Decision Support
Clinical decision support is a hallmark of an electronic health record (EHR) and increasingly
becoming embedded in certain health information exchange (HIE) services. It is important to
thoroughly plan for clinical decision support, keep the software current, and take steps to ensure
alerts are appropriate, useful, and used within the context of clinical judgment.
Time needed: 4 hours
Suggested other tools: Section 2.4 Visioning, Goal Setting, and Strategic Planning for EHR and
HIE, Section 4.7 System Build
How to Use
1. Gain an appreciation for the nature of clinical decision support.
2. Understand challenges in clinical decision support development and use.
3. Ensure that steps are taken to ensure that alerts are appropriate and useful.
Clinical Decision Support
Clinical decision support (CDS) refers broadly to providing clinicians or patients with clinical
knowledge and patient-related information, intelligently filtered or presented at appropriate times, to
enhance patient care. Clinical knowledge of interest could range from simple facts and relationships
to best practices for managing patients with specific disease states, new medical knowledge from
clinical research and other types of information.1 Clinical decision support is intended to:
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Prevent errors of commission and omission
Optimize choice of tests and therapies, improve adherence to guidelines, improve completion
of assessments and plans of care, and optimize treatment of chronic conditions
Improve the care process, including documentation, communication, and use of data for
quality measurement, research, and education
The most common form of clinical decision support across all forms of EHRs is the alert to drugallergy and drug-drug contraindications. But there are many other forms of clinical decision support-both active and passive:
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Active clinical decision support is displayed automatically, generally as an alert, reminder,
required field or field edit, and message. Attributes include:
o It is essentially a just-in-time notice to the clinician using the EHR to provide the user
with an update or signal a potential issue.
o It generally requires the user to accept or decline the support. For example, a pop-up
box may appear that there is new information about the client being received from a
health information exchange organization (HIO), such as an update to a medication
1
Reference: http://www.himss.org/ASP/topics_clinicaldecision.asp
Section 6 Optimize—Optimization Strategies for Clinical Decision Support - 1
list or reminder that a lab test is due. This may only need to be clicked off to populate
the EHR, but should also be viewed. Another example may be that data has prepopulated an assessment and only certain fields need data entered. The user can
complete the entries or ignore until a later date.
o It must be important and relevant, or it will be ignored (i.e., declined without
consideration as to whether it is important or not). This is often referred to as “alert
fatigue” and is generally a consequence of poor design and lack of stakeholder input
into the clinical decision support system. For example, if every time a common drug,
such as acetaminophen, is ordered or prepared for administration there is an alert that
it could have an adverse effect on the liver, the alert will be considered an annoyance
by most users. However, if a less common drug has an adverse effect on the liver,
such an alert would generally be well-received. The greater the complexity or
integration of information, the more intrusiveness is accepted by the user.
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Passive clinical decision support is displayed on user request. Examples include a user setting
a preference for what information is displayed on a client dashboard, whether certain
information will be presented in table or graphic format, or that the user can have access to
additional information (e.g., training materials for client, drug information) upon request.
Planning for Clinical Decision Support
Take the following steps to make sure that the clinical decision support supplied through your
agency’s EHR and HIE is appropriate and useful:
 Engage stakeholders (oversight physicians, nurses, and administrators) in:
 Understanding their role in planning for clinical decision support use
 Establishing goals for use of clinical decision support
 Expressing concerns about clinical decision support
 Translate clinical goals with respect to clinical decision support:
 Describe desired actions users are expected to take when receiving an alert.
 Obtain baseline performance data that demonstrates why the alert is necessary (or
why an alert may not be necessary and could be turned off).
 Anticipate desired outcomes by setting realistic quality and patient safety goals.
 Annotate rationale and potential obstacles so all stakeholders are aware and can sign
off on the approach to adopting clinical decision support.
 Ensure EHR (and HIE as applicable):
 Is compliant with interoperability standards (technical, semantic, and process) to
reduce errors in alert presentation.
 Supports sensitivity setting (some EHRs support different levels of alerting
depending on the user role).
 Has decision support rules that are compatible with practice guidelines, protocols,
and other evidence-based knowledge t that are periodically refreshed as new
knowledge becomes available. (Many EHRs include a subscription to a drug
knowledge database that may be refreshed monthly or quarterly. Code sets need to be
refreshed annually and changes in best practice recommendations should be able to
be pushed to the system when applicable.)
 Is compliant with regulations both for Center for Medicare & Medicaid Services
(CMS) and state requirements.
 Identify, select, or build clinical decision support interventions needed to achieve goals at
various point in clinical workflow. Stakeholders who are being asked to use clinical decision
support must have a say in the system that will be used.
Section 6 Optimize—Optimization Strategies for Clinical Decision Support - 2
 Require stakeholder review, test, validation, and approval for all clinical decision support
systems, changes made to these systems, and revision/update maintenance. It should be
obvious that the acetaminophen example described above contributes to alert fatigue. But
turning that rule off should be a stakeholder decision. Pros and cons should be weighed as
any such decision is made. Consider both the probability and nature of harm that could occur,
as well as the likelihood that retaining such alerts could mean important alerts are ignored.
 Train users and monitor use. Ignoring alerts is commonplace and can be monitored through
an audit logging process (if available in the EHR). However, misinterpreting an alert or
making an erroneous selection are more difficult to identify and may require a manual
 Measure results, evaluate effectiveness, and refine clinical decision support program. Users
who are provided feedback on the result of using clinical decision support are more apt to use
it appropriately. For example, if 92 percent of assessments were completed on time,
compared to 73 percent without the EHR and its clinical decision support, is strong evidence
of value.
Factors for Appropriate/Useful Alerts
Use the checklist below to help stakeholders identify, select, or build clinical decision support. For
most home health agency EHRs and HIE services, stakeholders will primarily be identifying and
selecting, rather than building, clinical decision support. Not all attributes listed may be available in a
home health EHR or HIE, but you can have your vendors consider adding them over time.
Clinical decision support should be:
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Specific to patient
Relevant and important
Accurate
Clear and unambiguous
Show justification for use
Concise
Provide alternative actions
Make additional information accessible if applicable
Generated for all dangerous cases
Directed to the right person
Knowledge/credential-specific
Tied to previous performance of user to avoid repetition of alerts
Designed to make it difficult to overriding a “fatal” or “critical” alert
Built to require a reason for overriding the alert (at least through a simple drop-down menu)
Delivered to promote action rather than stop intended action
Easy to see and use, not obstructing the primary view of the underlying information and not
requiring multiple clicks, scrolling, page visits, or narrative typing
Using Clinical Decision Support with the Patient
Some evidence suggests that clinical decision support can be a turnoff for patients. One study
reported that patient attitudes vary—and that patients whose providers have more positive attitudes
about EHRs and who have a high locus of control about their own health care situation were more
supportive of clinical decision support. As a result, the authors recommend finding ways to educate
patients about the value of clinical decision support systems. These might include:
 Learning how best to use the EHR at the point of care—with respect to positioning,
communicating with the client during data entry, using the EHR to validate the accuracy and
completeness of data being collected, and providing information to the client via the EHR.
Section 6 Optimize—Optimization Strategies for Clinical Decision Support - 3
 Explaining to clients why evidence is important and how it supports up-to-date treatment
regimens.
 Adopting a patient self-management model of care in which the EHR is a tool to support
shared decision making.
Shaffer, VA, et al. 2012 (July 20). Why Do Patients Derogate Physicians Who Use a Computer-Based Diagnostic Support System?
Medical Decision Making.
Copyright © 2013
Section 6 Optimize—Optimization Strategies for Clinical Decision Support - 4
Updated 03-18-14