Clinical Decision Support. The Road to Broad Adoption

888 Pages·2014·28.76 MB·English

by  Robert A. Greenes (Eds.)

Clinical Decision
Support
Clinical Decision
Support
The Road to Broad Adoption
Second Edition
Edited by
Robert A. Greenes
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Foreword
The processes by which some work achieves exponential success while others fade
into failure have long been the topic of analyses and essays in business schools,
government offices and university classrooms. In his 2000 book The Tipping Point,
Malcom Gladwell describes three factors that underpin virtually all successful mar-
ket phenomena.
The Law of the Few describes that there must be a few key champions for an
idea before it can reach the tipping point. The Stickiness Factor is the quality that
compels people to pay close, sustained attention to the idea. The Power of Context
recognizes how changes in the environment will define the likelihood that a given
idea “tips.”
The champions are here, and as you will read in the pages that follow, they tell
a very compelling story about stickiness (shifting payment objectives in the United
States toward incentivizing quality of care rather than quantity of care) and con-
text: the semantic context (never before have we had both a semantic foundation in
Health IT that has been so consistent), the technical context (never before have we
had such well defined, focused and adopted standards for CDS), and the cultural
context (physicians, focused on quality outcomes are asking for help – they expect
computers to be able to offer clinical decision support).
Clinical decision support is how we distribute knowledge from where it is to
where it needs to be. This is not unlike similar endeavors in other vertical markets
(law and transportation come to mind) or more general markets such as news and
weather information – stuff we all need to know. In all of these cases, a conflu-
ence of evangelism, technical readiness and market needs converged toward rapid
adoption of new models of knowledge syndication. The best such example is that
of RSS, an XML format for knowledge distribution, which was largely responsible
for the explosion of both professional and peer-to-peer knowledge distribution on
the Internet, sometimes referred to as “news.” In 1999, the Internet was beginning
to change how people communicated, conducted business, and share information.
Two engineers working at Netscape, a small company working to create a business
model around the Netscape Navigator web browser, developed a format initially
called RDF Site Summary – or RSS.
This format, which evolved through predictably emotion-laden iterations
not unlike the standards evolution we have witnessed with Arden Syntax (and
ArdenML), GEM, vMR, or Health eDecisions, stabilized in 2002 with the release
of the RSS 2.0 standard (re-named Really Simple Syndication) and adoption by
the New York Times as a method for publishing their content. This was the tipping
point. Any software tool that was capable of consuming RSS 2.0 was capable of
consuming the New York Times! Soon most browsers were capable of doing so, as
well as Microsoft Outlook and many 3rd-part tools. Most recently, Flipboard, Zite
and several other unique solutions, developed for portable computing devices such
as tablets and smartphones have incorporated methods of consuming RSS feeds and
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creating “mashups” of digital content for consumers that makes the experience both
meaningful and pleasurable. Such tools anticipate the needs of the user, and make it
effortless for the user to have the information they need – when they need it – deliv-
ered in a manner that is easy and aligns with their workflow.
This revolution in consumer knowledge sharing could not have happened with-
out the vision of the engineers who knew that the content must be normalized, the
semantics well defined, and the syntax predictable. It took over a decade to get
from the definition of the standards to where the capabilities those standards enable
are not just instantiated in the background of our lives – but expected to be there,
helping us quietly and inconspicuously perform better.
Where are we with clinical decision support? We’re at the tipping point, as
the news industry was in 2002. This book represents an extraordinary synopsis of
where we have been, why this “simple” problem is so complex, and what we will
leverage as a foundation as we weave these capabilities into the tapestry of health
care for our communities. These capabilities will not be an extra tool that we con-
sider using (or not using) as we provide care to our patients. Rather, clinical deci-
sion support (and the other CDS – consumer decision support) will become an ally
that is expected to be there, helping us quietly and inconspicuously perform better.
Milestones in human history: Gutenberg’s press in 1450, RSS in 2002, and clinical
decision support in 2014. Yes – it really is that big a deal. Congratulations to Dr
Greenes and the incredible team who have written such an extraordinary review of
this important topic.
Jacob Reider MD
Chief Medical Officer,
Office of The National Coordinator for Health Information Technology,
United States Department of Health and Human Services
Preface
When we published our first edition of this book in 2007, the effort to incorporate
computer-based clinical decision support (CDS) into health care had already been
pursued for more than four decades. Most of the progress had occurred in aca-
demic medical centers in the United States, and in other scattered locales world-
wide. Some of the successes had been adapted and incorporated into a variety of
proprietary electronic health record (EHR) systems, but by and large, this was
only scratching the surface in terms of what of CDS could potentially achieve, to
ensure the safety, quality, and cost-effectiveness of health care practice. It also had
provoked some backlash, based on instances in which it was not done well, was
not sufficiently patient-specific or useful, and caused interruptions of workflow or
increased effort to deal with. Further, although standards existed for exchanging
some forms of CDS or delivering CDS as a service, most implementations in EHRs
were in proprietary formats, integrated into applications in proprietary ways, and
virtually no sharing was occurring. As a result, larger health care organizations had
to develop mechanisms for handling their own (a) knowledge generation and vali-
dation, (b) knowledge management, curation, and update, and (c) adaptation and
integration into applications and workflow settings – three time-consuming and dif-
ficult life cycle processes. Smaller health care entities – community hospitals and
practices, for example – basically had no resources to do any of this.
As a result of the above situation, stakeholders were beginning to recognize the
need for larger-scale collaborative or national initiatives to promote adoption, and
to develop both shared knowledge and tools to make it easier to do so. In our first
edition, we proposed that efforts along those lines be developed.
What we did not foresee is that in the seven years since that preceding edition,
there would be tremendous changes on a number other fronts – some of which
were already occurring but the impact of which had not yet been felt – that would
bring about the situation we have today: namely, that there are many new drivers
for CDS adoption and many initiatives that are stimulating the process. Drivers
include advances in genomics and precision medicine, increasingly fine-tuning the
knowledge needed for the care of individuals; increased use of home monitors, sen-
sors, fitness trackers, and personal health records by individuals to record their own
health status; new standards and interoperability, as well as natural language pro-
cessing and image feature extraction methods, enabling us to integrate data from
multiple sources to create “big data” repositories, that can be used to provide new
capabilities for population-based prediction and management of cohorts of patients;
new understanding of cognitive processes and development of methods for visuali-
zation and management of complex data; and an increasing “app culture” in which
lightweight applications can be developed which pull data from various sources and
provide new opportunities to integrate, organize, analyze, and display data on top of
or in conjunction with existing EHR systems. Initiatives include national policies
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in a number of countries fostering EHR adoption and convergence on features that
enhance integration of data, measurement and reporting of quality, and use of CDS;
and new health care finance models for reimbursing care based on pay-for-value
rather than fee-for-service; and new care delivery models incentivizing increased
levels of care coordination, patient engagement, and emphasis on wellness, disease
prevention, and early detection of problems.
As a result of all these changes, we have added a number of new chapters, and
substantially revised other chapters to capture the multiple forces now aligning for
increased CDS adoption. This includes looking at the technical, cultural, organiza-
tional, policy, legal, and financial factors that are now at play, or beginning to come
into play. We also identify some key requirements that are starting to take shape
but don’t have organized effort behind them yet to take CDS to scale. Nonetheless,
perhaps over the next seven years or so, we will see that many of these ideas also
become reality.
The book is intended to familiarize stakeholders having the various back-
grounds and perspectives we just mentioned with the factors involved, and to equip
them to be effective in this fast-moving field.
We are very pleased to have expanded the contributed list of chapters and to
have, overall, the participation of a fantastic set of authors that are truly experts
in their respective areas. I am extraordinarily grateful to this wonderful group of
colleagues for sharing their knowledge and passion for this important activity.
Bob Greenes
November, 2013
Preface to the first edition
In looking for a way to introduce this book, I came across a speech by Admiral
Hyman G. Rickover, delivered at Columbia University in 1982, in which he said,
“Good ideas are not adopted automatically. They must be driven into practice
with courageous impatience. Once implemented they can be easily overturned
or subverted through apathy or lack of follow-up, so a continuous effort is
required.”
Several citations of this quote on the internet present a curious discrepancy,
in that the word “impatience” is replaced with “patience”. I find this variation to
be intriguing, as it seems to me that both courageous patience and courageous
impatience must be manifest for the greatest progress to occur. If one has a good
idea, one must not only be both steadfast and patient to stay the course and see it
through, but also, at the same time, one must continue to push aggressively, even
impatiently, lest the effort lose momentum and flag.
My idea for this book was based on the observation that computer-based clinical
decision support (CDS) has the potential to be truly transformative in health care
but that, despite considerable creativity and experimentation by enthusiasts over
more than four decades, and convincing demonstration of effectiveness in particu-
lar settings, the adoption of CDS has proceeded at a snail’s pace. This slow pro-
gress has not significantly accelerated even with major national and regional efforts
in a number of nations to promote the use of the electronic health record (EHR),
computer-based physician order entry (CPOE), electronic prescribing, and the
personal health record (PHR), which are important substrates on which CDS can
operate (and for which the prospect of CDS itself is a major driver). Some capa-
bilities have made their way into commercial health information system products –
examples include advice and warnings during CPOE, to ensure proper doses, avoid
harmful interactions, or warn about allergies, the provision of alerts to providers
when an abnormal laboratory result is found, and the use of order sets, or group-
ings of orders, for specific clinical problems and settings, such as coronary care
unit admission or post-operative care after a hip replacement. Nonetheless, CDS
usage remains spotty at best, most prevalent but by no means ubiquitous at aca-
demic medical centers, less so in community hospitals, and almost non-existent in
office practice. Although the public frequently now turns to the internet for medical
knowledge, automated decision support oriented to patients and consumers in terms
of reminders, alerts, and patient-specific advice is similarly largely lacking.
What’s wrong with this picture? Is CDS perhaps not really a good idea? Are
the requirements for wide dissemination and use beyond reach? Or are there initia-
tives that can be undertaken that can change the dynamic, and significantly boost
adoption? This book is an effort to address this conundrum. Our goal is to exam-
ine CDS in detail from many perspectives – its history, the motivations for it, the
technologies, the psychology and human factors concerning deployment and use
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xxx Preface to the first edition
of CDS, the sociology and organizational and management considerations that can
lead to successful deployment, the financial and economic drivers and constraints,
the marketplace and business opportunities, and lastly, the role of communal and
top-down initiatives such as standardization and creation of infrastructure and shar-
able resources.
The premise is that if CDS is truly a good idea, then the sluggish progress in
adoption and use to date can only mean that we are in need of a new approach.
But to develop a new approach to a complex, multifaceted problem, one that would
have a better chance of success than current incremental, uncoordinated efforts, the
effort will require the participation of many stakeholders representing a range of
perspectives. It is much easier in such situations to preserve the status quo, or to
introduce minor tweaks than to take concerted action – since tweakers can tinker
with an existing system without needing to build a huge consensus, but concerted
action requires a major effort to promote a shared vision. Only by finding a way for
these participants to come together with a commonality of purpose can this good
idea be driven forward with the duality of courageous patience and impatience that
it requires.
This book is thus an effort to develop a common ground for addressing this
challenge. It should be of most interest to health care organization managers, pol-
icy makers and other senior leadership, payers, government funding agencies and
foundations focused on health care delivery, medical informatics researchers and
students, information technology development managers, information systems
and knowledge product and service vendors, and clinical investigators and health
care providers more generally who have interest in the issues of health care quality,
safety, and cost-effectiveness.
Let’s look a bit more at the motivations for CDS and the challenge of aligning
them. In this book we adopt a view of CDS as decision support aimed at individual
patient-specific health care. It is advice and guidance offered by computers (more
properly, information and communication technology) to aid the problem solving
and decision making of health care providers, patients, and the public (i.e., includ-
ing those not currently patients). CDS is in most views not only a good idea but an
essential one. The most compelling reasons for CDS are to help practitioners avoid
errors, optimize quality, and improve efficiency in health care. Many pressures fuel
the need – the explosion of biomedical knowledge over the past several decades,
the multiplicity of diagnostic and therapeutic choices available for patient care, the
specialization and fragmentation of care, the time constraints on practitioners, regu-
latory and compliance demands, malpractice concerns, the increasing prevalence of
multi-system diseases as the population ages, the spiralling costs of health care, the
growing activism and involvement of individuals in their own health care, and the
emerging capabilities for “personalized medicine” through genomics, biomarkers,
and increasingly structured clinical phenotype data.
Although the descriptors used to characterize the above trends have a kind
of desperate urgency to them which collectively suggest hyperbole, the fact is
that they do reflect the reality of health care today. Because the trends and their
Preface to the first edition xxxi
consequences impact on different stakeholders in various ways, however, the com-
bined extent of the need perhaps has not been appreciated to its full degree by indi-
viduals, as a result of which there has been little impetus for a broad-based effort to
address it.
It is important to understand the differences in perspective of the various stake-
holders, and to recognize their motivations and needs. For practitioners, despite
the benefits offered, there are a number of reasons why CDS is not unequivocally
endorsed. Providers often become quite expert in their own particular subject
domains, keep up with the literature, and don’t feel a compelling need for comput-
ers to make recommendations. Despite this, they do generally accept the value of
CDS to monitor their actions especially where the aim is to help avoid acciden-
tal errors; they welcome alerts for unexpected lab results – if false positives are
kept to a minimum; they appreciate timely reminders for schedulable actions; and
they take advantage of predefined order sets for frequent clinical situations they
encounter. In general, and not surprisingly, the satisfaction with CDS by practition-
ers seems mostly related to the degree to which it is supportive, patient-specific and
relevant, and provided in a way that doesn’t interfere with care or require inordinate
additional effort and time.
In some circumstances, however, the use of CDS not only requires extra time
and effort by the practitioner, but the benefits of its use aren’t seen as accruing to
the practitioner or the patient. Examples are applications of CDS aimed at limit-
ing orders for expensive tests and treatments. This purpose has been manifested in
adoption of drug formularies, substitution of generic for brand name drugs, utili-
zation review and utilization management, and requirements for preapproval/prior
authorization from payers for imaging procedures, specialty referrals, or surgery as
a function of clinical indication. These may be tolerated by practitioners as nec-
essary evils but they are regarded primarily as interference with medical judg-
ment and are hardly embraced. Patients also exhibit disdain for and distrust of
such applications. So although a societal net benefit may be at play, it is difficult
to align support of institutions, payers, providers, and patients in cost containment
circumstances.
Difficulties such as the above have been true of many information system inno-
vations in health care. Given the frequently tenuous acceptance or tolerance of such
technologies by those who must interact with them directly, instances in which
their implementation has been poorly done have been quick to be seized on by
unhappy users and critics as examples of why the adoption of such systems should
be resisted. Before an information system innovation is introduced, careful thought
and experience with testbeds and pilot implementations are needed. Planning, both
locally and at an organizational or enterprise level, needs to be directed at issues of
how to motivate the participants, and how to make the innovation function effec-
tively, including considerations of process flow and work flow, responsibilities and
prerogatives of the users, and ease of use and perception of benefit by them.
With respect to the deployment and support of CDS, it also appears that a major
barrier to progress is a lack of recognition of how hard the problem is. On the