The Benefits of Clinical Decision Support
Technology has become a significant part of pharmacy practice and advancements in technology have helped to improve patient care and healthcare as a whole. Many of these advancements are incorporated into a health information technology system called clinical decision support (CDS).
According to Healthcare Information and Management Systems Society (HIMSS), clinical decision support is a process for enhancing health-related decisions and actions with relevant clinical information, as well as patient-specific information, to improve health and healthcare delivery1. CDS provides information at the point-of-care in order to improve patient therapy.
Clinical decision support and its respective tools are part of a highly automated clinical system that can be used by hospital pharmacists to improve patient safety and possibly decrease operational costs3. For example, many hospital pharmacies utilize an intravenous-to-oral conversion program that is specific to their formulary and health system which helps to ensure the safest drug therapy route based on patient-clinical criteria while decreasing drug expenditures3. A review of computerized records at the John Hopkins Hospital in Baltimore found an estimated savings of more than $1.1 million within the Department of Medicine alone by replacing four commonly prescribed intravenous (IV) medications (listed below) with their oral equivalents4.
The information at the point-of-care is provided through the electronic health record (EHR) system used by a hospital or health system. According to the American Society of Health-System Pharmacists (ASHP), the following are essential CDS capabilities that should be available within an EHR system2:
- Ability to configure and/or customize “drug groups” that can be triggered by alerts.
- Warnings should be available in real time and tailored to the specific patient situation using available patient information. The patient’s information should be combined with drug database information in order to create inclusion and exclusion criteria that make alerts more effective.
- Medication-order-specific information, such as dosage forms, frequencies, and dose, should be available for alert inclusion and exclusion criteria.
- Ability to customize how an alert looks in order to emphasize the importance or type of warning and offer response options that are based on the characteristics of the potential harm.
- Ability to configure the information displayed in the warnings so that alert messages can be patient specific.
- Be able to configure whether a warning can be bypassed by documenting a valid reason (“soft stop”), cannot be bypassed (“hard stop”), or bypassed without documenting a reason.
- EHR users should be able to take action from the alert presentation window.
- EHR systems should be able to handle logic rules that determine how an alert can be transmitted and which end users are to receive the alert.
- Capability to allow practice settings to determine whether end users can customize the conditions in which they must respond to specific alerts.
- Alerts system should allow a short response time for the warning notification and filing user response.
- Capability to configure and record when an alert notification displays, which indicates when the checking occurs.
- Easy access to the supporting data available, with citations, for each alert displayed within the EHR. The references should be displayed along with links to external databases or documentation.
- The EHR should provide a means of easily accessing additional information that is relevant to the alert, such as allergy information.
- Access to synchronous and asynchronous checking from the database based on different system transactions, such as the entering of patient information, laboratory test values to the patient chart, and medication administration.
- Ability to log all alert warnings and user actions taken in response to the alert.
- All responses to alerts should be available to subsequent users who view the order or alert during an inquiry or other transactions related to the order.
- Data related to user actions in response to alerts and messages must be available through the CDS and transferable to an external database or spreadsheet to support retrospective auditing.
- Outcome documentation should be consistent throughout the health system so that healthcare organizations can compare and benchmark database-driven CDS outcomes among organizations.
- Easy identification of any facility-specific custom data that will be affected by modifications to data or functionality made by a vendor.
- CDS rules must be easily exportable to a text file.
- Batch import of CDS rules from standalone files of prespecified types and formats, including options to overwrite existing rules and add new rules.
- Allow users to flag alerts for usefulness or intrusiveness in order to create a mechanism to provide immediate feedback to the CDS team.
Medication-related CDS functionalities can be categorized as either basic or advanced5.
The examples of medication-related CDS above are associated with reduced morbidity rates, improved prescribing practices, facilitation of preventative-care services, improved patient monitoring, reduced healthcare costs, and reduced ADE rates5.
Technology is advancing faster every year and this will likely have a significant impact on clinical decision support. The use of data analytics and access to big data has been incorporated into many industries including healthcare. Current CDS tools will be improved upon and new tools will be introduced and implemented regularly. Improvements and advances in CDS will help assure the safe and effective use, transparency, and ongoing refinement of these tools6. Ultimately, improved CDS development and utilization within CPOE systems will lead to further reductions in medication errors and improvements towards medication therapy for patients.