Section 6.3 Optimize
Optimization Strategies for Clinical Decision
Support
Clinical decision support is a hallmark of an electronic health record (EHR) and it is increasingly
becoming embedded in certain health information exchange (HIE) services. Clinical decision support
is heralded as the key driver for EHR to be used to improve the quality, experience, and cost of
health care; it is also maligned as contributing to EHR resistance and potentially causing unintended
consequences.
Time needed: 4 hours
Suggested other tools: 2.3 Visioning, Goal Setting, and Strategic Planning for EHR and HIE
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:

Prevent errors of commission and omission

Optimize choice of treatments, improve adherence to guidelines, improve completion of
assessments and treatment plans, and optimize follow-up with people who have chronic
conditions

Improve the care process, including documentation, communication, and use of data for
quality measurement, research, and education
The most common form of CDS across all forms of EHRs is the alert to drug-allergy and drug-drug
contraindications. But there are many other forms of CDS—both active and passive:

Active CDS 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 user of the EHR, providing an update or
signal of 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
1
Reference: http://www.himss.org/ASP/topics_clinicaldecision.asp
Section 6 Optimize—Optimization Strategies for Clinical Decision Support - 1
health information exchange organization (HIO), such as an update to a medication
list or reminder that a lab test is due. This may only need to be clicked off to populate
the EHR. In many products, the user can decide whether to view the information as it
is coming in.
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 order or preparation
for administration of a common drug, such as acetaminophen, triggers 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 client was already taking a drug being considered by the
clinician, an alert to this affect would probably be well-received. The greater the
complexity or integration of information, the more intrusiveness is accepted by the
user.

Passive CDS is displayed on user request. Examples include a user setting a preference for
what information is displayed on a dashboard, whether certain information will be presented
in table or graphic format, or that the user can access additional information (e.g., training
materials for client, drug knowledge)..
Forms of CDS for LPH
In addition to alerts concerning drugs, the following are some forms of CDS that may be found in
EHRs used by LPH departments:

Documentation completion is one of the most common forms of CDS. In its simplest form,
this includes reminders to complete empty data fields, which are especially useful if
documentation must be completed over a period of time. CDS for documentation may also
use more sophisticated branching logic—such as for care plans—that directs the user to
appropriate documentation sections based on client needs. Workflow notification software
may not be considered CDS, but it helps direct users to perform certain tasks by certain dates.
For example, documentation that requires co-signature can be directed to the appropriate
individual. Adding hyperlinks to documents in a document repository is another potential
workflow support tool.

Problem list assistance. Public health nurses are encouraged to document client problems
using the Omaha System of terminology. EHRs may include CDS that helps select and
categorize appropriate problem descriptions.

Therapy critiquing and planning is software that operates much like drug knowledge
databases that supply alerts and reminders about potential drug allergies or contraindications.
These systems integrate clinical research, practice-based evidence, client preferences, and
choices the user is considering to generate recommendations for a specific client’s needs. The
knowledge database is a subscription service that is continually updated. Client preferences
may be derived from personal health records and/or documentation from client preference
interviews. A simple example is translation of client instructions to a preferred language.
It is imperative that any form of CDS be reviewed by the intended user, have a trustworthy source of
decision support, and be used only to supplement (not replace) professional judgment.
Planning for Clinical Decision Support
Take the following steps to ensure that the CDS supplied through your department’s EHR and HIE is
appropriate and useful:
Section 6 Optimize—Optimization Strategies for Clinical Decision Support - 2
 Engage stakeholders (those who will be using the system directly as well as those who use
reports to measure outcomes) in:
o Understanding their role in planning for CDS use
o Establishing goals for use of CDS
o Expressing concerns about CDS
 Translate goals with respect to CDS:
o Describe desired actions users are expected to take when receiving an alert.
o Obtain baseline performance data that demonstrates why the alert is necessary (or
why an alert may not be necessary and could be turned off).
o Anticipate desired outcomes by setting realistic quality and patient safety goals.
o Annotate rationale and potential obstacles so all stakeholders are aware and can sign
off on the approach to adopting CDS.
 Ensure EHR (and HIE, if applicable):
o Is compliant with interoperability standards (technical, semantic, and process) to
reduce errors in alert presentation.
o Supports sensitivity setting (some EHRs support different levels of alerting
depending on the user role).
o Practice guidelines, protocols, and other evidence-based knowledge supports the CDS
rules in the EHR and is 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 for billing purposes need to be refreshed
annually. Any changes in best practice recommendations should be able to be pushed
to the system.)
o Is compliant with and federal and state regulations.
 Identify, select, or build CDS support interventions needed to achieve goals at various point
in clinical workflow. Stakeholders who are being asked to use CDS support should have a
say in the nature of that support. Some EHRs support facility development or modification of
care plans. While this may seem like a good thing, there evidence suggests that too much
customization adds cost, reduces outcomes comparability, and puts a health care organization
at risk for not following evidence-based guidance. The following article addressing
customization in a behavioral health record system is applicable to any setting: Thinking
Customization? Proceed with Caution, available at:
http://www.behavioral.net/print/article/thinking-customization-proceed-caution).
 Require stakeholder review, test, validation, and approval for all CDS systems implemented,
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. 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 actions relative to alerts that are more difficult to
identify and may require a manual audit.
 Measure results, evaluate effectiveness, and refine CDS program. Users who are provided
feedback on the results of using CDS are more apt to use it appropriately. For example, the
Section 6 Optimize—Optimization Strategies for Clinical Decision Support - 3
fact that 92 percent of immunizations were given on time, compared to 73 percent without
the EHR and its CDS, 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 EHRs and HIE services for LPH departments, stakeholders will primarily be identifying and
selecting, rather than building, CDS. Not all attributes listed may be available in your EHR or HIO,
but you can have your vendors consider adding them over time.
Clinical decision support should be:
 Specific to client
 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 user
 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 CDS with the Client
There is some evidence that suggests that CDS can be a turnoff for patients.2 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
CDS. As a result, recommendations from this study include finding ways to educate clients about the
value of CDS. 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.
2
Shaffer, VA, et al. 2012 (July 20). Why Do Patients Derogate Physicians Who Use a Computer-Based Diagnostic
Support System? Medical Decision Making.
Section 6 Optimize—Optimization Strategies for Clinical Decision Support - 4
 Explain to the client why evidence in making decisions is important and how it supports upto-date care planning and care coordination.
 Adopting a client self-management model of care in which the EHR is a tool to support
shared decision making.
Copyright © 2014 Stratis Health.
Section 6 Optimize—Optimization Strategies for Clinical Decision Support - 5
Updated 03-18-14