"Effective CDSS Implementation" By Gordon D. Brown et al...

The University of Illinois Hospital and Health Sciences System (UI

Health) has been a leader in adopting health information technology.
When the hospital was built in 1982, a light pen–based computerized
physician-order entry (CPOE) system was deployed—decades before
CPOE use was incentivized through the Centers for Medicare &
Medicaid Services’ meaningful use program. UI Health was one of the
first to deploy a modern commercial electronic health record (EHR)
system in 1997, for which it won the Healthcare Information and
Management Systems Society's Nicholas E. Davies Award of Excellence.
Work on decision support rules began shortly after the EHR was
deployed and, over the ensuing decades, resulted in hundreds of
custom-built decision support rules. Creation of so many rules can lead
to challenges in maintenance requirements and unintended
consequences if not managed properly. Over the years, a clinical
decision support system (CDSS) governance committee structure was
formed at UI Health (exhibit 6.4) to help ensure the creation of
evidence-based, highly effective CDSS rules. Researchers at UI Health
have published many articles on the effectiveness of such rules in
facilitating problem identification, reducing contraindicated
medications, and improving venous thromboembolism prophylaxis and
warfarin dosing, among other findings (Falck et al. 2013; Galanter,
Didomenico, and Polikaitis 2002, 2004, 2005; Galanter, Liu, and
Lambert 2010; Galanter, Thambi, et al. 2010; Galanter, Heir, et al. 2010
Nutescu et al. 2013). Despite all the research and expertise, not every
rule gets implemented smoothly. For example, a study by Lui and
colleagues (2016) pointed out the need to appropriately identify
psychiatric patients who are at risk for metabolic syndrome, which can
be exacerbated by second-generation antipsychotic medications. The
psychiatry department requested a new CDSS rule around the use of
antipsychotics and the potential development of metabolic syndrome.
This rule was then published into the UI Health production
environment. After this CDSS rule was created, a primary care provider
(PCP) updated a patient's medications list because the patient's outside
psychiatrist changed her antipsychotic medication dose. The patient
was a 50-year-old woman who had long-standing diabetes,
hypertension, obesity, and bipolar disorder. A CDSS rule fired,
indicating that the patient was on an antipsychotic and qualified for
metabolic syndrome because of her abnormal girth, her systolic blood
pressure (which was greater than 130), her triglyceride level (which was
greater than 150), her HDL cholesterol level (which was less than 40),
and her glucose level (which was greater than 110). Clinically, most
consider metabolic syndrome to be a precursor to the diagnoses of
hypertension, obesity, and diabetes, all of which the patient already
had—and all were documented in her medical record. The rule
suggested that the PCP add “metabolic syndrome” to the patient's
problem list, but no link to do so was present. Recognizing that the rule
was not firing as intended, the CDSS governance committee performed
a root-cause analysis. The following lessons learned and opportunities
for improvement were identified: The rule was firing every time a
medication reconciliation (a required task for any care transition) was
performed on patients who had an antipsychotic on their medication
list and met the criteria for metabolic syndrome. As a result, an alert
went out to providers even when they were just acknowledging a
patient's current medication regimen. The rule was firing in all clinical
settings—inpatient, outpatient, surgicenter, urgent care, and
emergency department—and for providers who did not typically
address conditions such as metabolic syndrome. The rule was designed
by a psychiatrist and the CDSS committee's information systems staff
and was not vetted by the committee's other clinical members. The
creation and maintenance of the rule was outsourced to the EHR
vendor and staffed by technical specialists who had little to no clinical
expertise. All of this contributed to the confusion when reports of
problems with the rule were being submitted. The rule was firing for all
medications in the antipsychotic drug class, not just second-generation
antipsychotics shown to significantly contribute to metabolic syndrome.
Despite a lot of testing in nonproduction domains, creating a CDSS rule
takes a lot of time and requires an iterative agile process to adequately
address problems and improve the rule. Acknowledging that a patient
may already have clinical conditions (e.g., diabetes, hypertension,
obesity) documented in the problem list can help make a CDSS rule
“smarter” and increase its level of credibility—and thus increase the
receiving clinician's trust in the rule and its purpose. Attaching
guidelines and literature to a CDSS rule request can help the
development team ensure the rule is evidence based. A rule that
recommends an action can be made more convenient if the action is
available inside the alert. The information provided is then a
convenience rather than a burden