Chapter 1  -  Approaching Clinical Decision Support in Medication Management

The future state outlined next is adapted from the Roadmap for National Action on CDS. ^[16]

• The most current and applicable evidence and best practices for proper medication use underpin guidance throughout the medication management cycle. This guidance is easily accessed and accurate and is used appropriately as needed.
  • Clear, evidence-based information about treatments that work best for specific patients and circumstances is readily available. ^[17]
  • Widely used, standardized, and practical formats are available for expressing specific health-related knowledge and medication-specific interventions in both human and machine-readable form. These formats are used to create a plug-and-play environment wherein CDS guidance is readily deployed in CISs and sharable across systems and organizations. ^[18]
  • Knowledge is readily customizable for location and facility-specific needs.
  • Data needed for medication-related CDS (for example, drug terminologies, and patient drug sensitivities, allergies, clinical problems, and the like) are managed using richly expressive and widely adopted standards. ^[19]
  • Repositories make CDS knowledge more readily accessible for incorporation into CDS interventions and information systems (IS).

• Certified CISs and related tools that support medication management are widely implemented throughout the medication management cycle with high adoption rates by clinicians and patients. ^[20]   This use provides a rich substrate for deploying CDS interventions that drive desired outcomes, such as eliminating preventable medication-related harm.
  • Principles of user-centered design are fully applied by developers in producing CIS and CDS systems, fostering more rapid and successful workflow integration and high end-user acceptance.
  • Electronic prescribing functionality is widely adopted. A 2005 white paper ^[21]  has outlined a current state and future state related to electronic prescribing and environmental changes — standards, certification requirements, etc. — that need to be implemented to realize the future state for e-prescribing systems. These include:
    • Accurate, complete, patient medication list available at all times in all settings.
    • Accurate, complete, allergy list with associated reactions readily available.
    • Implementation of standard medical vocabularies across all systems and data assets.
    • Drug of choice suggestion or lookup function tied to diagnostic impression Benefits and formulary confirmation.
    • Use of TALLman lettering and predefined order strings to prevent transcription and interpretation errors.
    • Drug of choice refinement based on other diagnoses, problems, age, weight, physiologic status (renal, cardiac, pulmonary, cognitive function), and medications.
    • Drug-interaction checking (for example, drug-drug, drug-lab, drug-food, etc.).
    • Monitoring activities (such as recommended surveillance of laboratory parameters) suggested by system and initiated at time of prescription.
    • Electronic prescription transmission to pharmacy.
    • Patient education communicated at encounter with clinician review, at prescription dispensing with pharmacist review, and via online link to further information and educational resources.

• CDS functionality — especially within ISs that underpin workflow — provides a favorable return on investment (ROI) for system purchasers and is welcomed and widely used by all pertinent recipients.
  • The Five CDS Rights are optimized to ensure this information delivery is workflow/user-friendly and supports improved outcomes.
  • Such effective deployments produce data that demonstrate the ability of CDS to reduce medication errors, increase user efficiency and satisfaction, and improve other key outcomes of great interest to stakeholders. This further drives the business case for, as well as uptake and adoption of, effective approaches.
  • Local implementations are characterized by a variety of key elements for success, including:
    • Organizational structures to provide governance and gain clinician buy-in.
    • Robust knowledge assets, such as evidence-based content, rules, and order sets, etc. that are explicitly focused on addressing priority targets.
    • Rich knowledge management (KM) processes and tools to manage these assets and ensure their appropriateness (currency, evidence base, consistency, etc.) and value.
    • Substantial attention to end-user needs and constraints to optimize acceptance and usability.
    • Rigorous attention to measuring deployed CDS performance, including rich feedback loops with affected stakeholders, and to seeking opportunities for program enhancement.

• A continuous-improvement cycle of knowledge related to medication management and corresponding CDS deployment — within and across many institutions nationally/globally — drives rapid and widespread CDS-supported advances in desired outcomes.
  • Anonymous reports of medical errors and near-misses are used to identify points at which medication-focused interventions should be applied.
  • Medication errors are reported and stored in databanks to monitor for error spikes that can trigger appropriate responses, including new or modified CDS interventions that could be applied locally where spikes occur, or more widely as indicated.
  • Experiences from deploying CDS (including incorporating these interventions into CISs) to improve medication-related outcomes are systematically tracked and synthesized, further adding to the dynamic body of best implementation practices. These best practices are widely disseminated and continually enhanced, for example through mechanisms such as this book and extensions of this work as outlined in the preface.

A Peek at the Literature on Medication Use and CDS - - >

© 2009 Healthcare Information Management Systems Society (HIMSS)