Ever since electronic health records (EHRs) were envisioned, nurses have anticipated their potential benefits. We expect that the use of information technology (IT) will support our documentation, provide more efficient workflow, and improve our ability to deliver safe and effective care with timely information at our fingertips. Today, the majority of healthcare organizations have EHRs in place that are constantly capturing large quantities of data and information about patients and populations. But are EHRs and related health IT systems delivering on their promise?
Optimal care delivery is dependent on reliable, accurate information made available at the point of care. Today, most of that information is delivered digitally through health IT systems, including traditional functionality such as the ability to capture a patient's medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiologic images, and lab and test results. Increasingly, health IT systems also enable access to evidence-based tools that providers can use to make decisions about a patient's care.1 These clinical decision support (CDS) tools and systems can help clinicians by taking over routine tasks, warning of potential problems, or providing suggestions for the clinical team and patient to consider.2
According to the Healthcare Information and Management Systems Society (HIMSS), CDS is “a process for enhancing health-related decisions and actions with pertinent, organized clinical knowledge and patient information to improve health and healthcare delivery.”3 Recipients can include patients, clinicians, and others involved in the patient's care delivery. The information delivered can include clinical knowledge and guidance via order entry, data displays, alerts, and references. These capabilities create a vision of a data-rich, supportive digital environment that enables each nurse to make sound, evidence-based decisions at the optimal location and time. Let's explore what must be in place to make that vision a reality.
The ideal CDS system is available at the point of care, offers real-time response, integrates into the practice workflow, and requires minimal training because it's user-friendly.4 The CDS system focuses on intelligence gathering and is designed to be used at the point of care by clinicians. CDS system tools should aid nurses in improving the effectiveness of their care delivery, determining interventions, and supporting patient safety and quality improvement activities. Although these tools can support the decision-making process, the decision maker is ultimately the clinician who can accept or reject the recommendations based on the context of the patient's current clinical situation.
CDS system capabilities also allow the clinician to initiate a request for support or query the system for additional information to inform decisions. Other options enable the system to automatically deliver an alert or reminder in response to a clinician action, such as documentation of a medication order, fall risk assessment, or pain response.
Key pillars and objectives
The “Roadmap for National Action on Clinical Decision Support” was developed jointly by the American Medical Informatics Association and HIMSS to outline a vision for next-generation CDS capabilities and suggest short- and long-term activities to advance CDS in the US.5 The roadmap identifies three pillars for realizing the promise of CDS and achieving its full benefit.
- Pillar 1: Best knowledge available when needed
- —Clinical knowledge and CDS interventions should be represented in standardized formats so users can readily understand and apply them.
- —Clinical knowledge and CDS interventions should be collected, organized, and distributed in a way that users can find the information they need and incorporate it into their own processes and workflow.
- Pillar 2: High adoption and effective use
- —Policy/legal/financial barriers should be addressed, and additional support and enablers provided, to ensure widespread CDS adoption and deployment.
- —CDS systems should be designed in a manner that's easy to deploy and use, and best practices should be identified and disseminated.
- Pillar 3: Continuous improvement of knowledge and CDS methods
- —Existing deployments should be systematically captured, organized, and examined, and the lessons learned shared in a continuous feedback loop.
- —The data available in interoperable EHRs should be leveraged to enhance clinical knowledge and improve health management.
These key pillars and their objectives should be considered when implementing CDS systems to maximize benefits and help realize positive changes in the healthcare system.
What can CDS systems do?
There are different types of CDS interventions, each of which can be used to meet specific information needs.3 (See CDS intervention type taxonomy.) Examples include checklist use during order entry, clinical documentation forms, prompts for specific information, and calculated risk scores based on specific clinical documentation. CDS interventions can serve as data filters to display a patient's immunization status; provide patient rounding or action lists; or filter a patient's physiologic parameters, such as heart rate or pain level, before medication administration.
Knowledge resources, such as an info button linking from a problem list entry, can provide evidence-based treatment summaries. Calculators can be displayed for drug dosing or updating an I.V. drip rate. General notifications can be provided for abnormal or critical test results, or to request renewal of a restraint or indwelling catheter order after a specific timeframe has lapsed. CDS interventions may be disruptive to the workflow, so they need to be carefully integrated into clinical systems. If alerts and reminders are too frequent, or inappropriate, they can contribute to “alert fatigue” and may be overridden or ignored.2
The five rights of CDS
The use of CDS to find and prevent errors related to gaps between optimal and actual practice can result in improved care quality.4 However, the availability of such information depends on how data are collected, stored, retrieved, and transformed into actionable information. The CDS five rights model states that CDS-supported improvements can be achieved if we communicate the following:3
- the right information: evidence-based, suitable to guide action, and pertinent to the circumstance
- to the right person: considering all care team members, including clinicians, patients, and their caregivers
- in the right intervention format: for example, as an alert, order set, documentation tool, data display, or reference information
- through the right channels: for example, through an EHR, personal health record, website, or mobile application
- at the right time in the workflow: when it's most needed to make a decision or take action.
These five rights can be used as a framework when planning to implement CDS interventions within a facility or practice.6
Impact on nursing practice
Successful use of CDS requires integration into the nurse's clinical workflow. Nurses have begun using CDS in their practice where additional information important to the current clinical situation can help inform better decisions. CDS can provide support to clinicians at various stages in the care process, from preventive care through diagnosis and treatment to monitoring and follow-up.7
CDS systems have been shown to speed up the decision-making process and reduce adverse events. For example, nurses use the Modified Early Warning System as a bedside CDS tool that utilizes vital signs to identify patients likely to deteriorate.8 Bar code medication administration (BCMA) tools can also leverage CDS. Upon medication administration, the nurse is required to scan both the bar code on the patient's wristband and the medication packaging. This process prompts a CDS alert if the medication is contraindicated for the patient, thus preventing a medication error and enabling the nurse to contact the physician to obtain a new order.9 However, if used incorrectly, the safety checks and balances within BCMA can be negated. Unsafe practices, including workarounds, can occur if the system doesn't support a safe workflow or if the clinician doesn't understand how to use the BCMA system correctly to improve patient safety.10
Although these capabilities can help ensure the accuracy of documentation and improve patient safety, clinicians may feel overwhelmed by administrative tasks that don't add value to patient care.11 Automation of the patient record was expected to relieve documentation burden, but health IT systems don't necessarily support clinical needs or optimal workflow. There has also been an increase in documentation requirements to satisfy payors and regulations.
Positive process and outcomes improvements have been reported with the use of CDS systems, but there's a risk that potential distractions can contribute to safety issues. Nurse informaticists and others involved with the design and implementation of CDS systems must be mindful of these challenges and solicit direct input from clinicians in the process. Machine learning tools can also be used to assist in error detection, thereby providing additional support to the user at the point of care.12
Impact on patient safety
There's significant evidence that CDS systems can positively impact healthcare providers' performance with drug ordering and preventive care reminder systems.12 A synthesis of high-quality systematic reviews found positive results for computer reminder systems that led to improvements in hypertension management, diabetes care, and asthma care.
It seems logical that CDS also has the potential to improve patient outcomes by delivering alerts and reminders to reduce adverse events. However, recent studies and systematic reviews haven't definitively demonstrated the overall positive effects of CDS on medication safety. In one synthesis of systematic reviews in which 65% of the included studies measured a patient outcome, only a small portion demonstrated positive findings.13 In a recent clinical trial with the objective to determine the effect of the Bedside Pediatric Early Warning System on all-cause hospital mortality and late admission to the ICU, the findings didn't support a decrease in all-cause mortality among hospitalized pediatric patients.14 More studies are needed to determine key factors contributing to the impact of CDS to explain these disappointing results.
The path to optimal benefits
To gain the optimal benefits of CDS, nurses must realize its value and limitations, and those responsible for implementation should understand that CDS requires careful design and integration into the clinical workflow. High-quality care is dependent on reliable, accurate information made available at the point of care and informed by the clinician. Health IT and CDS systems can improve our ability to deliver safe and effective care if used appropriately and implemented effectively. Only then can we begin to realize the promise of these emerging technologies.
3. Osherhoff J, Teich JM, Levick D, et al Improving Outcomes with Clinical Decision Support: An Implementer's Guide
. 2nd ed. Chicago, IL: Healthcare Information and Management Systems Society; 2012.
4. Kraft MR, Androwich IM. Incorporating evidence: use of computer-based decision support systems for health professionals. In: Saba VK, McCormick KA. Essentials of Nursing Informatics
. 6th ed. New York, NY: McGraw Hill; 2015: 583–590.
5. Osherhoff JA, Teich JM, Middleton B, Steen EB, Wright A, Detmer DE. A roadmap for national action on clinical decision support. J Am Med Inform Assoc
6. Campbell R. The five “rights” of clinical decision support. J AHIMA
8. van Galen LS, Dijkstra CC, Ludikhuize J, Kramer MH, Nanayakkara PW. A protocolised once a day Modified Early Warning Score (MEWS) measurement is an appropriate screening tool for major adverse events in a general hospital population. PLoS One
12. Jaspers MW, Smeulers M, Vermeulen H, Peute LW. Effects of clinical decision-support systems on practitioner performance and patient outcomes: a synthesis of high-quality systematic review findings. J Am Med Inform Assoc
13. Jia P, Zhang L, Chen J, Zhao P, Zhang M. The effects of clinical decision support systems on mediation safety: an overview. PLoS One
14. Parshuram CS, Dryden-Palmer K, Farrell C, et al Effect of a pediatric early warning system on all-cause mortality in hospitalized pediatric patients: the EPOCH randomized clinical trial. JAMA