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Using Clinical Decision Support Can Decrease Care Costs

Posted on September 28, 2018 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or

A study of clinical decision support system use has found that abiding by its recommendations can lower medical costs, adding weight to the notion that they might be worth deploying despite possible pushback from clinicians.

The study, which appeared in The American Journal of Managed Care, looked at the cost of care delivered by providers who adhered to CDS guidelines compared with care by nonadhering providers.

To conduct the study, researchers reviewed 26,424 patient encounters. In the treatment group, the provider adhered to all CDS recommendations, and in the control group, the provider did not do so. The encounters took place over three years.

The data they gathered regarding the encounters included alert status (adherence), provider type, patient demographics, clinical outcomes, Medicare status, and diagnosis information. The research team looked at the extent to which four outcome measures were associated with alert adherence, including encounter length of stay, odds of 30-day readmissions, odds of complications of care and total direct costs.

After conducting their analysis, the researchers found that the total encounter cost was 7.3% higher for nonadherent encounters than adherent ones, and that length of stay was 6.2% longer for nonadherent versus adherent encounters. They also found that the odds ratio for readmission within 30 days increased by 1.14, and the odds ratio for complications by 1.29, for nonadherent encounters versus adherent encounters.

Not surprisingly, given these results, the study’s authors suggest that provider organization should introduce real-time CDS support adherence to evidence-based guidelines.

It is worth noting, however, that the researchers inserted one caveat in their conclusion, warning that because they couldn’t tell what caused the association between CDS interventions and improved clinical and financial outcomes, it would be better to study the issue further.

Besides, getting clinicians on board can be painful, with many clicking through alerts without reading them and largely ignoring their content. In fact, another recent study found that almost 20% of CDS alert dismissals may be inappropriate.

Most of the inappropriate overrides were associated with an increased risk of adverse drug events. Overall, inappropriate overrides were six times as likely to be associated with potential and definite adverse drug events.

Roche, GE Project Brings New Spin To Clinical Decision Support

Posted on January 10, 2018 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or

The clinical decision support market is certainly crowded, and what’s more, CDS solutions vary in some important ways. On the other hand, one could be forgiven for feeling like they all look the same. Sorting out these technologies is not a job for the faint of heart.

That being said, it’s possible that the following partnership might offer something distinctive. Pharmaceutical giant Roche has signed a long-term partnership deal with GE Healthcare to jointly develop and market clinical decision support technology.

In a prepared statement, the two companies said they were developing a digital platform with a difference. The platform will use analytics to fuel workflow tools and apps and support clinical decisions. The platform will integrate a wide range of data, including patient records, medical best practices and recent research outcomes.

At least at the outset of their project, Roche and GE Healthcare are targeting oncology and critical care. With a pharmaceutical company and healthcare technology firm working together, providing tools for oncology specialists in particular makes a lot of sense.

The partners say that their product will give oncology care teams with multiple specialists a common data dashboard to review, which should help them collaborate on treatment decisions. Meanwhile, they plan to offer critical care physicians a dashboard integrating data from patient’ hospital monitoring equipment with their biomarker, genomic and sequencing data.

The idea of integrating new and possibly relevant information to the CDS platform is intriguing. It’s particularly interesting to imagine physicians leveraging genetic information to make real-time decisions. I think it’s safe to say that we’d all like it if CDS systems could bring the rudiments of precision medicine to thorny day-to-day clinical problems.

But the truth is, if my interactions with doctors mean anything, that few of them like CDS systems. Some have told me flat out that they end up overriding many CDS prompts, which arguably makes these very expensive systems almost irrelevant to hospital-based clinical practice. It’s hard to tell whether they would be willing to trust a new approach.

However, if GE and Roche can pull off what they’re pitching, it might just provide enough value it might convince them. Certainly, creating a more flexible dashboard which integrates data and office workflows is a large step in the right direction. And it’s probably fair to say that nothing like this exists in the market right now (as they claim).

Again, while there’s no guaranteed way to build out useful technology, bringing a pharma giant and a health IT giant might give both sides a leg up. I wonder how many users and patients they have involved in their design process. Let’s see if they can back up their promises.

Quick Hitting Thoughts on CDS (Clinical Decision Support)

Posted on March 21, 2016 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I’m finally starting to go through all my notes from HIMSS. Part of that is because I’ve been busy after HIMSS. Part of it is because I like to recover from what I call the #HIMSSHaze. Part of it is that I like to see what still resonates a few weeks after HIMSS.

With that in mind, I was struck by a number of quick hitting comments that I noted from my interview with Dr. Peter Edelstein, CMO at Elsevier. Dr. Edelstein is a fascinating guy that I’ll have to have on a future Healthcare Scene interview. In the meantime, here are some of the quick hitting thoughts he shared about CDS (Clinical Decision Support).

One key point he made is that it seemed like many organizations didn’t have a strategy for CDS. He also aptly pointed out that the same seemed to apply to big data. I agree with him wholeheartedly. If we were to go to a healthcare organization and ask them their CDS strategy I don’t think most of them would have an answer. I think if we dug in, we’d probably find that most of them have essentially deferred their CDS strategy to their EHR vendor. Does anyone else feel like this is a problem?

When I asked Dr. Edelstein what would be his suggested strategy on adopting CDS, he suggested that he’d want to make sure that the CDS solution worked across all provider types. Next he compared the pull CDS solutions (Reference resources, etc) to wearing seat belts in a car and the push CDS solutions (Order sets, care plans, etc) to an airbag in a car. While we certainly need both sets of solutions, he suggested that we should make more of an effort to get the push CDS solutions implemented in healthcare.

I thought the analogy was a great way to look at the various types of CDS solutions. Plus, I agree that we need more push solutions in healthcare. The pull solutions are necessary for some of the most challenging problems, but we all know that when a doctor is busily going about their day they often choose not to check with the pull solutions when they should. The push solutions can be integrated into their workflow so that providers can more easily address any potential issues from within the flow of their day.

Dr. Eldestein also pointed out that Wikipedia is still the most commonly used reference resource despite many studies which have illustrated the medical errors that exist on it. Why do they use it? It’s because it’s simple to use and easily accessible. This is a great illustration of why we need the right CDS information to be more easily available to the doctor at the point of care at the moment they need it.

Definitely some great insights into CDS. What’s great about CDS is that at this point pretty much everyone is using some form of CDS. We’re also seeing CDS integrated more deeply into EHR software. I expect this trend will continue and will become much more sophisticated.

It does beg the question, what’s your healthcare organization’s CDS strategy?

CDS Technology: A Value Proposition for MU

Posted on June 19, 2014 I Written By

The following is a guest blog post by Bonnie Briggs, Director of Product Management for Wolters Kluwer Health.

As the industry turns towards Stage 2 Meaningful Use (MU) attestation with greater urgency and anticipates the forthcoming criteria for Stage 3 and beyond, healthcare providers are increasingly looking for effective ways to streamline compliance and best position for the future. With so many initiatives competing for limited dollars, the value proposition of any health IT investment is critical to meeting current and future regulatory objectives—and qualifying for attractive incentive payments that can deliver a whopping $7 million to the average 200-bed hospital for Stage 2 alone (based on the current Medicare share and transition factor).

As MU moves past the Stage 1 focus of basic data capture within an EHR, healthcare organizations need to lay a foundation to address the more advanced clinical processes and improved outcomes focus of Stages 2 and 3. Use of clinical decision support (CDS) technology at the point of care is a focal point of compliance as it sets the stage for greater adoption of evidenced-based practices to improve outcomes.

While drug reference and drug interaction data applications are obvious choices for meeting Stage 2 MU CDS requirements for drug-drug, drug-allergy and drug-disease interactions screenings, healthcare organizations need to consider that not all solutions are advanced enough to address other key MU requirements, namely patient education/engagement requirements and HL7 Infobutton capability. Specifically, the industry’s most advanced products can help fill in the gaps by providing appropriate tools for educating and engaging patients and linking clinicians to the most relevant content.

Addressing Patient Education and Limited Health Literacy

Industry research reveals that there is a considerable disconnect between the language of clinicians and the ability of patients to comprehend the relevance and importance of what is being communicated. In fact, nearly half of American adults have some level of limited health literacy when it comes to using and understanding written health information alone, according to the Institute of Medicine (IOM).

One area that has become a focal point of regulatory discussion related to patient education and health literacy is the need to accommodate non-English-speaking patients. The National Standards on Culturally and Linguistically Appropriate Services (CLAS) states that “health care organizations must make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service areas.”

While Stage 2 MU requirements call for the use of EHRs to identify patient-specific education resources, Stage 3 recommendations released by the HITPC Meaningful Use Workgroup earlier this year point to the potential of this rule being expanded to support language needs. Specifically, the recommendation calls for the “use of CEHRT capability to provide patient-specific educational material in non-English speaking patients’ preferred language.”

When considering the value proposition behind the use of CDS technology in the form of drug reference applications, the availability of consumer-level content that addresses a broad array of foreign languages should be considered to best position for compliance going forward. Industry recommendations also suggest that materials be written on a 5th to 7th grade level, using simple sentence structures and short, bulleted statements for easy reading. Other key considerations for effectively engaging patients include age-appropriate illustrations and the provision of materials in larger fonts for the visually impaired.

The Infobutton Challenge

Compliance with MU patient education standards also means that certified EHRs must support the Health Level 7 International Context-Aware Knowledge Retrieval standard, more commonly referred to as the HL7 Infobutton. This industry standard must be used to access patient-specific education materials based on relevance. It may also provide links to referential CDS as an option.

A widely accepted and adopted standard, the Infobutton essentially enables EHRs to generate a view of a patient encounter based on standard patient and provider information. From that information, an EHR application can gather appropriate patient education materials based on the specific details of that case at the click of a button.

The challenge for healthcare organizations will be identifying CDS applications that are equipped to gather patient data in this way. When advanced drug reference applications can aggregate this information from problem lists, medication lists and laboratory results and support Infobutton contextual parameters for identifying appropriate knowledge resources, the value proposition as it pertains to MU compliance is heightened.


When positioning for effective use of CDS at the point of care to meet current and future MU objectives, healthcare organizations need to be careful of making knee-jerk decisions and consider the best technological foundations for long-term success.

While a number of CDS applications on the market can address the basics of drug-drug, drug-allergy and drug-disease interactions screenings, not all are equipped for the broader patient education focus currently unfolding. Considerations should be made for addressing the bigger picture of health literacy and evolving industry standards such as HL7 Infobutton capability.

Bonnie Briggs, RPh, MBA, is the Director of Product Management for Wolters Kluwer Health. She can be reached at

Structuring for the Future of Clinical Decision Support (CDS)

Posted on May 10, 2013 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

The following is a guest post by Adam Lokeh, M.D., vice president of clinical development and informatics with Wolters Kluwer Health.

Clinical decision support tools (CDS) play an increasingly critical role in a healthcare organization’s overarching strategy to comply with federal incentive programs and succeed within the quality- and performance-based reimbursement landscape currently unfolding. When effectively aligned with physician documentation practices at the point of care, these tools can have a powerful impact on error reduction, the standardization of evidence-based practices, quality of care and ultimately saving lives.

Research reveals that a combination of advanced CDS technology working in tandem with computerized physician order entry (CPOE) solutions will be needed to successfully navigate the coming healthcare landscape. A number of CDS elements will need to be considered and integrated into existing systems to create this powerful collaboration including evidence-based order sets, alerting systems for medication management, ECA rules (event, condition, action), referential information including guidelines and care plans, smart documentation and surveillance technology to name a few. To fully leverage the advantages of these tools, it’s important to understand the different approaches to data and content and the inherent advantages and disadvantage of each.

Currently, there are two approaches to content when designing point-of-care IT infrastructures—structured and unstructured. While both have the potential to standardize care and improve decision-making, industry preference leans toward greater integration and use of structured content for its ability to lay a foundation of improved accuracy, efficiency and ability to drive clinical decision support and analytics.

Because structured content is tagged or coded data that resides in a fixed field, it can be easily located, identified and understood, simplifying the process of integrating content into existing systems and sharing between disparate systems. In contrast, unstructured content, such as free text, often results in irregularities and ambiguities that make it harder to interpret.

Unstructured data makes it more difficult for health IT systems to recognize shared data, requiring complex and largely manual conversion processes that are prone to errors, resulting in inaccurate data. When inaccurate patient information is then shared between systems, the potential for adverse events or care issues is only compounded.

While the premise of this discussion as it relates to the benefits of structured content would seem clear, it’s not that simple. Physicians want the ability to express themselves freely when documenting, and there is concern within the physician community that the full patient picture could get lost if the narrative is too highly structured. As a practicing physician, I understand the delicate balance that exists between the need for a technological foundation that promotes accurate information sharing and the desire to protect the individual patient story.

The truth is that there can be risk without allowing for flexibility in creation of narrative content.  Poorly-designed interfaces have clearly existed with some structured content frameworks historically—and still do today within some CDS and CPOE applications—that can cause pieces of the patient narrative to get lost. The use of applications lacking in flexible design and without trustworthy content that is thorough and exhaustive in nature has led to poor physician perception and even fear that the technology will marginalize patient care. Ultimately, the end result is poor physician adoption.

That is why it is so critical that vendors work with physicians to identify all essential elements as well as the factors that can hinder adoption.  The solution is new, thoughtful clinician-designed systems that are more intuitive and flexible, allowing some limited unstructured content to help flesh out the narrative.

When CDS technology is developed through this kind of high-level partnership and designed to accommodate the use of structured content where it is needed most, content can be indexed at a granular level, easing the process of mapping within systems.  It also lays a foundation for automated updating of content as industry evidence changes and provides a framework for more robust reporting due to extensive filtering capabilities.

The end result is more accurate and efficient integration of the best industry evidence at the point of care, delivering a framework for decision support that truly impacts care without compromising the patient narrative. It’s this kind of far-reaching potential—currently offered through some of the more advanced CDS and CPOE applications in the industry—that physicians need to witness to truly understand what can be accomplished. Unfortunately, the industry has not done a very good job of educating them to date.

Some are looking to the potential of natural language processing (NLP) to address the needs for mapping in free-text environments through data mining. While this path offers an alternative, it is not as powerful a foundation as structured content for improving decision making at the point of care. In fact, it’s retroactive. If data mining occurs after the patient narrative has already been input, decision support can, by definition, only be offered “after the fact.”

In essence, physician documentation that is completed in a structured-content environment —as opposed to a traditional dictation method—is, in itself, a form of CDS. Because documentation can be structured to guide and remind physicians to document important medical elements, it assures that nothing is overlooked.

Many industry initiatives point to greater incorporation of structured content into the design of IT applications for information exchange. Industry movements and organizations such as Meaningful Use, HL7, the Standards and Interoperability (S&I) Framework Health eDecisions Project and the CDS Consortium are working towards industry standards that will require use of more structured content.

The simple fact is that when data is shared, it has to be recognized across and between systems. Structured content within CDS applications allows data to be mapped to a standardized vocabulary to ensure accuracy.

That said, clinicians prefer free text. Until the industry properly educates physicians regarding the power inherent in structured content, the best approach will be a hybrid that includes avenues for both models. For maximum adoption, IT vendors should consider that critical components will need to be structured to drive CDS, reporting and quality metrics, but allowing for some amount of free text to smooth out the edges for more widespread adoption.

Patients Question Clinical Decision Support Use

Posted on January 30, 2013 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or

Using clinical decision support technology (CDS) is such a standard and helpful health IT approach – not to mention a central Meaningful Use feature — that we almost take its existence for granted. Apparently, however, patients aren’t as tolerant of computer-assisted decision making as clinicians and IT experts are, according to a new study published in Medical Decision Making.

The study suggests that patients actually distrust physicians who use CDS, labeling them as “less professional, less thorough, and having less diagnostic ability,” according to a report by EHR Intelligence.

The study, done by University of Missouri researchers, showed participants vignettes depicting an exam for an illness or injury. These participants were then asked to rate their reactions to the physicians showed in the vignettes.

The results suggest strongly that potential patients are unnerved by the notion of physicians making use of CDS.  Researchers found that the study subjects were less likely to trust computer-driven diagnoses, and moreover, less likely to be happy with a positive outcome if that outcome involved CDS use.

Perhaps the only social benefit to physicians using CDS was that subjects were less likely to blame a doctor for a negative outcome if the doctor relied on CDS to make a decision.  If a doctor used CDS, ignored its conclusions then had a negative outcome, patients felt strongly that he or she was deserving of punishment.

It’s not exactly good news for healthcare providers that patients are likely to be squeamish about their using CDS. That being said, my guess is that doctors can do a lot to make patients comfortable simply by explaining what they’re doing and making patients feel confident about the process. In the end, after all, patients care most about their relationship with the provider, computer-aided or not.