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Chapter 1  -  Approaching Clinical Decision Support in Medication Management

The medication management cycle just described defines the "when," or workflow step, and the "who" for applying CDS; the palate of available CDS intervention types addresses the "how," or format for delivering information to support decisions.

Table 1-1 outlines several major CDS intervention types and subtypes along with their benefits. These categories are not meant to be rigid or entirely mutually exclusive. Rather, the intent is to paint a rich picture of opportunities for guiding decisions through targeted information delivery. In practice, CDS interventions often combine several elements from these basic types. For example, an order set might highlight—through a non-interruptive alert—an essential intervention that should routinely be ordered and provide an infobutton link to more detailed reference information that supports the clinical recommendation.

Table 1-1: Clinical Decision Support Intervention Types

	Subtypes	Examples
Documentation forms/templates Benefits:  Provide complete documentation for care quality/continuity, reimbursement, legal requirements; reduce omission errors by displaying items for selection; reduce commission errors by ensuring critical data—such as allergies—are captured; provide coded data for other data-driven CDS. Provide prompts to acquire specific information in the format desired (for example, displaying “kg” for weight to ensure capture in the metric system as needed for subsequent dose calculation).	Patient self-assessment forms	Pre-visit questionnaire, for example, that outlines health problems and current medications Health risk appraisal
	Clinician patient assessment forms	Inpatient admission assessment Assessment of medication-related parameters, such as pain, bleeding, blood glucose, blood pressure, breathing difficulty and the like, pre- and post-medication administration (possibly pre-populated with pertinent data)
	Clinician encounter documentation forms	Structured history and physical examination template Problem-specific assessment template Intelligent referral form
	Departmental/multidisciplinary clinical documentation forms	Emergency Department (ED) documentation Ambulatory care documentation Combinations of the above
	Data flowsheets (usually a mixture of data entry form and relevant data presentation, see next entry)	Immunization flowsheet Health maintenance/disease management form Pay-for-performance form (such as for tracking pertinent quality measure parameters for individual patients)
	Subtypes	Examples
Relevant data presentations Benefits: Optimize decision making by ensuring all pertinent data are considered; organize complex data collections to promote understanding of overall clinical picture and to highlight needed actions.	Relevant data for ordering, administration, or documentation	Patient allergies, relevant lab test results, formulary status, and/or drug costs when ordering a medication Key parameters such as heart rate, pain level prior to medication administration Patient rounding or action lists organized to highlight items needing attention, such as abnormal or new values Longitudinal display of key patient information to highlight trends and issues requiring attention
	Retrospective/aggregate reporting or filtering	Data on patient adherence to prescribed medication regimen Physician practice audit and feedback/physician report cards; for example, outlining rates at which highly indicated drugs are used in specific situations, such as treating heart attack List of all patients overdue for a key preventive care intervention List of all patients in disease management program with abnormal test results indicating poor disease control Adverse drug event (ADE) tracking List of all patients currently prescribed a medication newly withdrawn from the market
	Environmental parameter reporting	Recent hospital antibiotic sensitivities
	Choice lists	On-formulary display for a drug class, sequenced with preferred items listed first Suggested dose choice lists, possibly modified as needed for patient’s kidney or liver function and age
	Practice status display	Operating Room (OR) scheduling and status display ED tracking display
	Subtypes	Examples
Order/prescription creation facilitators Benefits: Promote adherence to standards of care by making the right thing the easiest to do.	Single-order completers including consequent orders	Prompts for appropriate orders and documentation (for example, for additional meds when only one drug from a medication cocktail is selected or for reasons when ordering certain highly toxic drugs) Suggested drug and/or dose choice lists integrated into ordering function—possibly modified by patient’s kidney or liver function and age Consequent order suggestions (for example, for drug levels when ordering certain antibiotics or for premedication when ordering certain drugs or procedures)
	Order sets	General order sets (for example, for hospital admission or problem-oriented ambulatory visit) Condition-specific order sets (for example, for heart attack) Pre- or post-operation order sets Order sets containing orders that are fully specified (order sentences), contain parameter choices, have "fill-in-the-blank" fields for user-specified components of a recommended order, or a combination of the three Active guidelines [3]
	Tools for complex ordering	Guided dose algorithms based on weight, body surface area (BSA), kidney function, etc. Total parenteral nutrition (TPN) ordering forms with built-in calculators
	Subtypes	Examples
Protocol/pathway support Benefits: Provides support for multistep care plans, pathways, and protocols that extend over time.	Stepwise processing of multi-step protocol or guideline	Tools for monitoring and supporting inpatient clinical pathways (for example, for pneumonia admissions) and multiday/multi-cycle chemotherapy protocols in the inpatient or outpatient setting
	Support for managing clinical problems over long periods and many encounters [4]	Computer-assisted management algorithm for treating hyperlipidemia over many outpatient visits
	Subtypes	Examples
Reference information and guidance Benefits: Addresses recognized information needs of patients and clinicians.	Context-insensitive	General link from EMR or clinical portal to a reference program (at table of contents or general-search level)
	Context-sensitive	Direct links to specific, pertinent reference information (which can be mediated using the HL7 infobutton standard [5]); for example, link from medication order screen to display of side effects and/or dosing for that medication; link from problem-list entry to recent evidence-based treatment overviews for that problem Link from immunization flowsheet to table of standard immunization intervals Link within patient-messaging application to relevant patient drug information leaflets Calculators/nomograms, such as for drug dosing Diagnostic decision support driven by patient-specific data
	Subtypes	Examples
Alerts and reminders (typically unsolicited by patient or clinician recipient) Benefits: Provide immediate notification of errors and hazards related to new data or orders entered by CIS user or the CIS itself (such as when abnormal lab result is posted) or passage of a time interval during which a critical event should occur; help enforce standards of care. Effectiveness requires careful attention to workflow, high value of information to end user, and other factors as discussed in subsequent chapters.	Alerts to prevent potential omission/commission errors or hazards	Drug allergy alert Drug interaction alert, for example, with drugs, pregnancy, laboratory, food Under/overdose alert (single dose, total dose, frequency, etc.; general, or specific for age, weight, laboratory results) Wrong drug route alert Patient-specific contraindication for a medication or other clinical intervention, such as due to pregnancy or genetic test result Inappropriate therapeutic duplication Incorrect test or study for an indication or inappropriate testing interval, such as for drug-level monitoring Potential omission error detection, such as checking for a result from a follow-up test that is indicated after a medication is given Critical lab test result notification High-risk medication, such as chemotherapy agent or intravenous cardiovascular drug triggers reminder to nurse to obtain second witness before administration User-requested notification when lab result is available or other key event has occurred
	Alerts to foster best care	Disease management, for example, alert for needed therapeutic intervention based on guidelines/evidence and patient-specific factors Wellness management, for example, alert for patient needing flu shot Risk Management, for example, alert to document patient risk factor and/or obtain consults/interventions to address documented risk for suicide, physical abuse, falls, nutrition or smoking-related problems, etc. Medication order triggers display of more cost-effective drug, regimen, or formulary-compliant option Suggestion to add patient to a medication study or protocol

Table 1-2 illustrates how the material discussed in the previous sections on the CDS Five Rights, the medication management loop, and CDS intervention types can provide a framework for developing a CDS intervention strategy to improve medication outcomes. Information in the table is not intended to be comprehensive and include every CDS option and objective but rather serves as a strawman to consider as you develop your approach to aligning CDS interventions with targeted goals (as discussed in Chapters 2 through 5).

Table 1-2: Using CDS to Improve Medication Use and Outcomes

© 2009 Healthcare Information Management Systems Society (HIMSS)