The Centers for Medicare and Medicaid services five rights of clinical decision support: What’s really required for effective decision support

Although there is no true definition of what constitutes clinical decision support (CDS) – which can include virtually any tool for automated alerts, clinical guidelines, diagnostic support and more – Congress has included CDS as a centerpiece of the Medicare and Medicaid electronic health record (EHR) Incentive Programs.

To add clarity, the Centers for Medicare and Medicaid (CMS) has developed the concept of the "Five Rights" of CDS, a framework that suggests what CDS systems should deliver:

• The right information (evidence-based guidance, response to clinical need);
• to the right people (entire care team – including the patient);
• through the right channels (e.g., EHR, mobile device, patient portal);
• in the right intervention formats (e.g., order sets, flow-sheets, dashboards, patient lists);
• at the right points in workflow (for decision-making or action).

While the basic elements of these rights are useful, the parenthetical suggestions above are essentially just a wish list for all possible capabilities. Conceivably, it is more useful to focus on the key elements that determine whether a CDS system succeeds in providing meaningful decision support that clinicians will truly value. Therefore, that primarily comes down to the system's ability to deliver critical information that would otherwise be elusive at the point of care, and to deliver that information at the time at which it most effectively guides intervention. This is what the first and last Five Rights of CDS are all about.

Delivering the right information
Delivering the right information is a matter of relaying important facts to clinicians that are not readily observable and that, if overlooked, can compromise care quality or patient safety. To fulfill this mission, it is important the CDS system have a complete clinical picture of the patient's current condition, a relevant medical history, and is able to analyze that information relative to evidence-based best practices.

Having a complete clinical view of the patient requires the CDS system be able to interpret an electronic medical record's (EMR's) free text information – which comprises the majority of clinical documentation – along with clinical details from the systems of labs, radiology departments and others. The greater the amount of potentially relevant patient information the system has available for its analysis, the greater its ability to deliver the right information.

A CDS system that analyzes all facts about the patient can assist with diagnoses of life-threatening developments that can otherwise go undetected. For example, by continuously monitoring a patient for signs of silent deterioration – such as noting that lab tests show a slow rise in white blood cell counts and that while vital signs remain within normal ranges, the patient is slowly becoming hypotensive or developing a slightly elevating fever – CDS can detect at the earliest possible stage the development of sepsis, and alert clinicians to the immediate need for intervention. The CDS system should also deliver the "right information" in the form of reports regarding adherence to alerts. Offering clinical leadership insight into clinicians ignoring alerts enables dialogs to improve adherence, as well as the fine-tuning of the system to make alerts even more useful.

Delivering information at the right points in workflow
Clinical decision support alerts are often based on specific diagnoses, and can contribute to alarm fatigue if not fully synchronized within clinician workflows. This is especially true in emergency departments (EDs), where care is typically guided by initial assessment and chief complaint, and diagnoses are documented as the patient is being readied for ED discharge. When CDS systems issue alerts according to checklists – i.e., for all patients with fever – clinicians may ignore the CDS system because of an overabundance of alerts for issues they are already in the process of addressing.

If, however, the CDS system monitors which EMR screens clinicians are currently working in, it can synchronize its alerts to provide useful information at the correct step of clinical decision-making. It can also issue accurate alerts as the care episode is concluding for needed action that was skipped. In fact, 10 months after a CDS solution implementation, one health system in particular noticed significant results in its ED including a 58 percent decrease in the total number of alerts given, a 22 percent decrease of non-compliance and an 80 percent decrease in total alerts bypassed.

The key is for as few alerts as possible to be based on mistakes made by the CDS, and for as many alerts as possible to call attention to actual clinician mistakes that are in process or about to happen – the antidote to alarm fatigue.

Bringing together information and overcoming interoperability issues
Only when a CDS system gets the first and last CDS "rights" correct can it deliver value through the remaining rights – delivering information to the right people through the right channels in the right format. If it fails in delivering the right information at the right time, the rest is just noise.

Today's more advanced CDS systems deliver their value by reading and interpreting all patient data, both structured and unstructured, and delivering accurate and meaningful alerts to clinicians in synch with, rather than disrupting, established workflows. Add to that the capability to issue performance reports to further maximize efficiency and increase compliance, and these systems can enable health systems to achieve more uniform care quality across the enterprise while simultaneously improving patient safety.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

Although there is no true definition of what constitutes clinical decision support (CDS) – which can include virtually any tool for automated alerts, clinical guidelines, diagnostic support and more – Congress has included CDS as a centerpiece of the Medicare and Medicaid electronic health record (EHR) Incentive Programs. To add clarity, the Centers for Medicare and Medicaid (CMS) has developed the concept of the “Five Rights” of CDS, a framework that suggests what CDS systems should deliver:

 

·         The right information (evidence-based guidance, response to clinical need);

·         to the right people (entire care team – including the patient);

·         through the right channels (e.g., EHR, mobile device, patient portal);

·         in the right intervention formats (e.g., order sets, flow-sheets, dashboards, patient lists);

·         at the right points in workflow (for decision-making or action).

 

While the basic elements of these rights are useful, the parenthetical suggestions above are essentially just a wish list for all possible capabilities. Conceivably, it is more useful to focus on the key elements that determine whether a CDS system succeeds in providing meaningful decision support that clinicians will truly value. Therefore, that primarily comes down to the system’s ability to deliver critical information that would otherwise be elusive at the point of care, and to deliver that information at the time at which it most effectively guides intervention. This is what the first and last Five Rights of CDS are all about.

 

Delivering the right information

Delivering the right information is a matter of relaying important facts to clinicians that are not readily observable and that, if overlooked, can compromise care quality or patient safety. To fulfill this mission, it is important the CDS system have a complete clinical picture of the patient’s current condition, a relevant medical history, and is able to analyze that information relative to evidence-based best practices.

 

Having a complete clinical view of the patient requires the CDS system be able to interpret an electronic medical record’s (EMR’s) free text information – which comprises the majority of clinical documentation – along with clinical details from the systems of labs, radiology departments and others. The greater the amount of potentially relevant patient information the system has available for its analysis, the greater its ability to deliver the right information.

 

A CDS system that analyzes all facts about the patient can assist with diagnoses of life-threatening developments that can otherwise go undetected. For example, by continuously monitoring a patient for signs of silent deterioration – such as noting that lab tests show a slow rise in white blood cell counts and that while vital signs remain within normal ranges, the patient is slowly becoming hypotensive or developing a slightly elevating fever – CDS can detect at the earliest possible stage the development of sepsis, and alert clinicians to the immediate need for intervention. The CDS system should also deliver the “right information” in the form of reports regarding adherence to alerts. Offering clinical leadership insight into clinicians ignoring alerts enables dialogs to improve adherence, as well as the fine-tuning of the system to make alerts even more useful.

 

Delivering information at the right points in workflow

Clinical decision support alerts are often based on specific diagnoses, and can contribute to alarm fatigue if not fully synchronized within clinician workflows. This is especially true in emergency departments (EDs), where care is typically guided by initial assessment and chief complaint, and diagnoses are documented as the patient is being readied for ED discharge. When CDS systems issue alerts according to checklists – i.e., for all patients with fever – clinicians may ignore the CDS system because of an overabundance of alerts for issues they are already in the process of addressing.

 

If, however, the CDS system monitors which EMR screens clinicians are currently working in, it can synchronize its alerts to provide useful information at the correct step of clinical decision-making. It can also issue accurate alerts as the care episode is concluding for needed action that was skipped. In fact, 10 months after a CDS solution implementation, one health system in particular noticed significant results in its ED including a 58 percent decrease in the total number of alerts given, a 22 percent decrease of non-compliance and an 80 percent decrease in total alerts bypassed.

 

The key is for as few alerts as possible to be based on mistakes made by the CDS, and for as many alerts as possible to call attention to actual clinician mistakes that are in process or about to happen – the antidote to alarm fatigue.

 

Bringing together information and overcoming interoperability issues

Only when a CDS system gets the first and last CDS “rights” correct can it deliver value through the remaining rights – delivering information to the right people through the right channels in the right format. If it fails in delivering the right information at the right time, the rest is just noise.

 

Today’s more advanced CDS systems deliver their value by reading and interpreting all patient data, both structured and unstructured, and delivering accurate and meaningful alerts to clinicians in synch with, rather than disrupting, established workflows. Add to that the capability to issue performance reports to further maximize efficiency and increase compliance, and these systems can enable health systems to achieve more uniform care quality across the enterprise while simultaneously improving patient safety.

© Copyright ASC COMMUNICATIONS 2017. Interested in LINKING to or REPRINTING this content? View our policies by clicking here.

 

Top 40 Articles from the Past 6 Months