Clinical decision support (CDS) has the ability to significantly impact improvements in quality, safety, efficiency, and effectiveness of health care. The Agency for Healthcare Research and Quality (AHRQ) has long supported efforts to develop, adopt, implement, and evaluate the use of CDS to improve health care decisionmaking.
To date, AHRQ has funded several research projects involving CDS, including the new Patient-Centered Outcomes Research (PCOR) Clinical Decision Support (CDS) Initiative, two demonstrations supported by a panel of technical experts, the development of white papers, and outreach efforts to develop consensus in the health care field around the use of CDS to promote safe and effective health care. These research efforts work to engage relevant stakeholders, including patients, clinicians, provider organizations, guideline and quality measurement developers, and information technology professionals, in the ongoing work to improve health care decisionmaking using CDS systems.
AHRQ has launched a new initiative to disseminate and implement patient-centered outcomes research (PCOR) findings through clinical decision support (CDS). This initiative, announced through a Notice of Intent published in 2015, will promote the dissemination and implementation of PCOR CDS findings, and develop tools to help CDS artifacts become more shareable, health IT standards-based, and publicly available. The PCOR CDS Web site, which will host all the information related to this initiative, was launched in February 2017.
Plans for the PCOR CDS initiative include the following components:
- Engage stakeholders to catalyze the development and use of PCOR-based CDS throughout the health care system and provide CDS developers and stakeholders with constructive advice and feedback;
- Develop and test resources (“artifacts”) for CDS implementation based on PCOR findings, including coded clinical knowledge and implementation guides;
- Develop a publically accessible repository of PCOR findings suitable for CDS development and the infrastructure for sharing PCOR-based CDS; and
- Evaluate the overall initiative.
For the first component, AHRQ recently awarded a cooperative agreement to Research Triangle Institute (Principal Investigator Barry Blumenfeld). This project team will develop a PCOR Clinical Decision Support Learning Network (PCOR CDS-LN), which will bring together multiple public and private stakeholders to collectively pursue the following aims:
- Accelerate collaborative learning opportunities by convening, implementing, and initiating operation of a multistakeholder CDS learning network.
- Identify barriers and facilitators to the incorporation of PCOR findings in CDS, and develop recommendations for implementing PCOR findings in clinical workflows via CDS.
- Monitor and measure the dissemination and use of PCOR findings in vendor-based and open source CDS tools, evaluate the effectiveness of the PCOR CDS-LN, and adapt its activities to increase effectiveness based on these findings.
- Develop a sustainability plan for ongoing operations of the PCOR CDS-LN.
For more information about this initiative, email PCORClinicalDecisionSupport@ahrq.hhs.gov.
CDS Connect is a project to demonstrate how evidence-based care can be more rapidly incorporated into clinical practice through interoperable decision support. The CDS Connect Repository follows AHRQ’s mission of focusing on evidence based care, by identifying and codifying new evidence based standards of care as CDS artifacts, with an initial focus during FY-17 on cholesterol management. During FY-18, the focus will shift to pain management and opioids misuse disorders. These artifacts will be piloted in a live clinical setting to refine and evaluate the effectiveness of the Repository and its processes around artifacts and their development. 30+ organizations and individuals participate and guide development of the Repository.
The CDS Authoring Tool is a component of the CDS Connect Repository. Along with the CDS Connect Repository, the CDS Authoring Tool is designed to promote the creation and use of CDS in everyday clinical settings, connecting high-quality CDS to the U.S. healthcare community. The CDS Authoring Tool provides an interface for creating CDS logic using simple forms and exporting it as Health Level Seven (HL7) Clinical Quality Language (CQL) 1.2 artifacts using the HL7 Fast Healthcare Interoperability Resources (FHIR) DSTU 2 data model. Currently, the CDS Authoring Tool has a focus on the domain of cholesterol management, but development is underway to broaden its applicability to pain management and opioid misuse disorders and other domains.
In 2008, AHRQ awarded two 5-year demonstration contracts focused on the development, adoption, implementation, and evaluation of clinical decision support (CDS). The contracts were awarded to the Brigham and Women's Hospital in Boston, MA (Project Director: Blackford Middleton, M.D.; Clinical Decision Support Consortium) and Yale University in New Haven, CT (Project Director: Richard Shiffman, M.D.; Guidelines Into Decision Support).
While working with a Technical Expert Panel, these projects were to advance our understanding of how best to incorporate CDS into the delivery of health care. The projects explored how the translation of clinical knowledge into CDS can be routinized in practice and taken to scale in order to improve the quality of health care delivery in the United States. An early report, Challenges and Barriers to Clinical Decision Support (CDS) Implementation (PDF, 254 KB), describes the challenges and barriers that the contractors encountered as part of their CDS demonstration project.
After 5 years, both projects demonstrated the ability to translate evidence-based knowledge into useful, actionable guidance for clinical care through CDS. Available below are links to a comprehensive report detailing the approach, methods, and lessons learned for each project as well as further research questions and policy considerations for the field and accompanying videos about each project.
- Findings and Lessons From AHRQ’s Clinical Decision Support Demonstrations Projects (PDF, 2.61 MB)
- Clinical Decision Support Consortium project video (6 min., 53 sec.)
- Guidelines Into Decision Support project video (7 min., 50 sec.)
Translating clinical guidelines into clinical decision support (CDS) rules has been an active area of research for many years. A key barrier to doing so has been the need to translate narrative recommendations from prose to unambiguous, coded formats that can be implemented by various clinical information systems and care settings. The AHRQ eRecommendations project addressed this barrier and laid the groundwork for further CDS advancements by formalizing the translation process and developing an “eRecommendations” format.
This project developed structured, coded logic statements called "eRecommendations" for 45 A- and B-graded recommendations of the U.S. Preventive Services Task Force, and 12 recommendations relevant to the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. These eRecommendations leveraged standard data elements, coding systems, and value sets developed for performance reporting. Pilot testing was conducted at Memorial Hermann Health System and with the Louisiana Health IT Regional Extension Center.
To advance the understanding of incorporating clinical decision support (CDS) into ambulatory health care delivery, the Agency for Healthcare Research and Quality (AHRQ) sponsored a series of white papers. The series begins with a concise, but comprehensive overview of CDS and its current state, including evidence of its potential impact and its use in clinical settings today. This overview is followed by a thought-provoking piece that explores the use of electronic CDS to improve clinical workflow in ambulatory and hospital-based settings through user-centered design approaches.
Below are highlights from the two papers in the series:
Clinical Decision Support Systems: State of the Art (PDF, 184 KB).
Eta S. Berner, Ed.D., University of Alabama at Birmingham
- CDS, when well-designed and implemented, holds great potential to improve health care quality, increase efficiency, and reduce health care costs.
- Failure to attend to CDS alerts and recommendations poses challenges for those developing, implementing, and using CDS.
- Researchers and vendors alike should address cognitive, informatics, structural, and workflow issues to optimize CDS design, implementation, and integration into clinical workflow.
Clinical Practice Improvement and Redesign: How Change in Workflow Can Be Supported by CDS (PDF, 634 KB).
Ben-Tzion Karsh, Ph.D., University of Wisconsin-Madison
- The goal of widespread use of CDS in ambulatory care has not yet been realized.
- Successful integration of CDS into clinical workflow requires effort and user involvement.
- There are a range of techniques available to researchers to define and measure workflow fit that will lead to innovations in CDS design and implementation.
- User-centered design approaches can be used by developers and implementers to ensure that CDS works for a range of users, their diverse needs, and in a range of contexts of use.
To further its mission of supporting the use of health information technology (IT) to drive improvements in health care outcomes, the Agency for Healthcare Research and Quality (AHRQ) is providing online access to the first chapter of Improving Medication Use and Outcomes with Clinical Decision Support: A Step-by-Step Guide, which is designed for implementers of clinical decision support (CDS) tools. Chapter 1 of this new guide outlines foundational elements for applying CDS to medication management, including:
- The 'CDS Five Rights' approach (getting the right information to the right stakeholder, at the right point in workflow, through the right channel, and the right format).
- Steps in the medication management cycle and opportunities for applying CDS to improve medication use and outcomes.
- Current and desired future states of CDS use for medication management.
- An overview of the CDS medication management literature.
To read the first chapter, visit http://healthit.ahrq.gov/cdsguide.
In November 2008, the American Medical Informatics Association (AMIA) convened a CDS Town Hall Meeting at the request of AHRQ. The meeting aimed to stimulate a discussion of the current CDS environment and options for future efforts to promote CDS adoption.
A summary report on the meeting and its outcomes is available for download. (PDF, 112 KB).