National Efforts for Clinical Decision Support (CDS)

Erik Pupo

Deloitte Consulting

Public Health as a CDS Variable

Three dominant myths in CDS usage

• Clinicians will use knowledge-based systems if the programs can be shown to function at the level of experts

• Clinicians will use stand-alone decision-support tools

• Diagnosis is the dominant decision-making issue in medicine– What does this patient have vs. what should I do

for this patient?

Applying Diagnosis to Public Health Alerts

National Focus – Standards and Knowledge Artifacts• Most existing CDS systems and their knowledge

bases have limited portability• There is a need for a universal format(s) for CDS

knowledge that can be written once and imported anywhere

• There is a need for a universal format for encapsulating and accessing CDS capabilities as a software service

National Efforts to Date for CDS

• Health eDecisions (development of HeD as a standard for rules, alerts and guidelines)

• Clinical Quality Framework– Clinical Decision Support (CDS) and electronic Clinical

Quality Measurement (eCQM) are closely related, share many common requirements, and are both in support of improving health care quality.

– Both need the ability to identify cohort of patients based on logical combinations of patient data.

• CQM measures adherence to a standard plan of care.• CDS guides a physician to follow a standard plan of care.

– Meaningful Use requires implementation of CDS rules to improve the outcomes of certain eCQMs

Public health and CDS – what’s missing

• CDS alerts need to support multiple perspectives • The standards used for the electronic representation of

CDS were not developed in consideration of public health, and use different approaches to patient data and computable expression logic.– Technical and functional usability

• It is currently difficult to share logic between a public health department and the CDS rules in a CDS system or in an electronic health record (EHR)– Lack of semantic interoperability across common CDS and EHR

data elements

Types of expected CDS inputs and outputs – CDS vs Public Health

Example Inputs Example Outputs from a CDS Alert

What would a public health alert look like?

Patient age, gender, past health maintenance procedures

List of health maintenance procedures due or almost due

Possible contamination of medical equipment in a acute care hospital

Medication identifier, age, gender, weight, serum creatinine level

Recommended maximum and minimum doses for medication given patient's estimated renal function

Possible bioterrorist attack using existing medication supply

Patient summary

Wide range of care recommendations

Analysis of symptoms and concerns

What’s missing – public health usability for EHR and CDS

• Like with the thinking on CDS, the use of public health alerting mechanisms needs to manage the usability of existing state and local public health workflows– Technical reporting– Functional usage of EHR

• National focus on public health cognition and design of EHRs to support public health functions

What’s missing – Public Health and EHR Terminology Harmonization

• Encoding allows for alerts– Granular encoding in

medication ordering allows for alerts by drug name

– Granular encoding of specific health concerns or symptoms allows for alerts by diagnosis name

• Same thinking needs to apply to public health

– More encoding of public health events and vice versa

• Harmonization of clinical quality and clinical decision support data models at the national level

Summary – Multiple Efforts on Multiple Fronts needed at the National Level

• Alerts– Standardization of EHR formats for alerts need to

include public health input• Rules

– Development of reusable rule sets to support public health

– Common modeling of clinical decision support rules using a public health “cognitive” model

• Guidelines– Development of reusable guidelines from state and

local public health best practices