National Efforts for Clinical Decision Support (CDS)

1. National Efforts for Clinical Decision Support (CDS) Erik Pupo Deloitte Consulting

2. Public Health as a CDS Variable

3. 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?

4. Applying Diagnosis to Public Health Alerts

5. 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

6. 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

7. 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

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

9. 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

10. What’s missing – Public Health and EHR Terminology Harmonization • Encoding allows for alerts • Granular encoding in medication orderingallows 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

11. 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