Chapter 1  -  Approaching Clinical Decision Support in Medication Management

As noted previously in this chapter, each step in the medication management process is fraught with opportunities for suboptimal outcomes, even with the best trained/educated/intended participants. The current state of affairs is roughly described as follows:

• The most common form of CDS applied to medication management is typically DDI and drug-allergy checking modules. Alert fatigue and general dissatisfaction with these interventions is common.
• Relatively limited diffusion of advanced CISs, such as CPOEs and EMRs, further limits the opportunities for fully optimizing the CDS Five Rights. Even when organizations have these systems in place, interoperability barriers across systems—for both patient data and CDS interventions/knowledge—frustrates successful implementation.
• Standard terminologies for clinical information, such as LOINC®, ^[13]  SNOMED-CT®, ^[14]   and RxNorm ^[15]  are still underutilized across CIS, and further limit data and knowledge interoperability across pertinent systems.
• Medication-error reporting channels exist but capture only a small fraction of errors.
  • USP-ISMP ^[12]  , MEDMARX®, and Federal (MedWatch) are prominent examples among others. There has been progress in standardization and terminology (defining contributing factors, nodes, NCC MERP error categories) and electronic submission into large databases at national, regional, and hospital levels. However, federal mandatory error reporting only contributes a relatively few reportable sentinel events. Hence, there is still dependency on voluntary reporting mechanisms that are highly variable, with reporting volume depending on the care quality and culture across different delivery organizations.
• Sharing information about successful strategies for applying CDS to improving medication-related outcomes is relatively limited.
• Many institutions customize their CDS assets, such as DDI databases, to address current problems with excessive alerting; however these customized—and potentially more practical—solutions are not readily available to other institutions due to lack of interoperability standards and other barriers.
• The lack of widespread, plug and play interoperability of CDS interventions with CIS typically makes CDS deployment more difficult than it should be and slows the pace of innovation. These factors exacerbate the potential workflow difficulties that arise when CIS and CDS and systems are not developed and deployed with end-user needs and constraints in mind.
• Historically, misaligned financial incentives, an unclear business case, low capital availability, and/or fragmentation between quality/medication efforts and CDS activities have prevented a coordinated and systematic approach to CDS and medication management.
• In some cases, clinicians resist use of medication decision support tools for fear they will reduce autonomy or increase liability, or because of the perception (often justified) that the interventions (typically unsolicited alerts) are more annoying than useful.
• Conflicts between guidelines from multiple sources regarding appropriate medication use are not infrequent, which creates challenges for implementers attempting to facilitate guideline-based care with CDS.

© 2009 Healthcare Information Management Systems Society (HIMSS)