By: John Alex, Senior Clinical Consultant
As you contemplate purchasing and implementing systems with Clinical Decision Support (CDS) functionality, consider factors that can make implementations succeed or fail.
The decision to implement CDS interventions must be based on a number of factors, including impact on patients and workflow, cost, availability of reliable data, difficulty of implementation, and acceptability to clinicians and patients. Improving care needs to be the primary reason for using CDS, and should be looked at as a potential benefit and cost reduction tool.
Considerations for implementing CDS interventions:
1. Trust and Acceptance
User trust and acceptance is paramount and can be negatively affected by many different variables. Poor design elements can plague users and sabotage the best effort. Users need to buy into the concept, feel in control as a user and trust that the design and implementation of CDS interventions will be articulate, meaningful and disciplined.
Alert fatigue is a term used to describe Aesop’s “the boy who cried wolf” phenomenon within the CDS world. The user devalues the process and becomes numb to the interventions. Interventions should be used judiciously and present clear paths to actions or resolutions. Trust in the inferences should not be blind, rather it should be built into the system by offering references from which the inference was derived (such as established guidelines and best practices etc.). Alert fatigue can exacerbated by:
- Does not fit in user’s workflow
- Too many alerts
- Non-obvious presentation of alerts
- Lack of prioritization based on clinical significance and context
- Contextual irrelevance
- No clear path to resolution
- Irregular presentation of alerts
- Significantly slowing down workflow
- Interventions that are not distributed prudently to the right users of the systems
2. System Rigidity
New guidelines, expert knowledge databases, and best practices are constantly evolving in healthcare delivery. Choosing solutions that allow for these evolutions is important to long term success. Some solutions allow limited flexibility, some provide tools for limited user configuration changes, and others require vendor support. Flexibility in creation of CDS interventions and how they are distributed in your workflow should be in your control.
3. Investment of Resources
The implementation of solutions that provide CDS requires commitment and support from leadership and the dedication of clinical champions to promote the cause. The upfront costs of such solutions might be more obvious than the long term costs. The difficulty and associated costs to keeping content current and appropriate will require formal processes to be implemented and should be considered as part of the QA/ QI teams responsibilities. Clinical effectiveness, utility, acceptance, and future needs have to be captured, collated, and reviewed periodically using an adapted change management process.
What are the risks of non-action?
“If all you have is a hammer, everything looks like a nail”…Experience breeds biases. Without the help of CDS tools, you are constrained to basing your decisions on your current knowledge and past practices.
Staying current to all new guidelines and best practices is a monumental task. Change is constant in the medical field, and the rate of change and amount of new knowledge required to stay current seemingly grows faster as time goes on. Without CDS, change mitigation becomes onerous and potentially inconsistent across clinicians and patients. Fostering the greater use of evidence-based medicine principles and guidelines requires teaching and benefits from reinforcement. Gentle prodding, questioning or suggestions can provide a safety net to clinicians and their patients.
Physicians are now seeing more patients, spending less time with them, and are expected to know their full medical history, current problems, and risk factors as they interpret data and plot next steps in the treatment plan. The ability for a clinician to aggregate, weigh and interpret all available information accurately and consistently for every patient every time is unlikely and can expose patients to risk.
Implementing CDS is one of the core objectives of MU but offers much more than just a checkmark in the box, if it is well thought-out and executed.
Challenges to a successful implementation include proper evaluation, planning and execution as well as a significant investment in long term maintenance. Understanding these considerations and knowing how to navigate your way through them will affect acceptance and overall success.