Clinical Decision Support: Meaningful Rules of Engagement

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Among the many differences between the proposed regulations for “meaningful use” of electronic health records and a draft circulated last summer is that the Centers for Medicare & Medicaid Services (CMS) now wants hospitals and physician practices to implement clinical decision support (CDS) for a minimum of five high-priority conditions in order to qualify for federal subsidies in 2011. The earlier draft called for just a single CDS rule during the first year of the EHR incentive program. So what's a hospital to do to comply?

If the more stringent requirement holds when CMS finalizes the definition of meaningful use this spring, it will, of course, mean more work for CMIOs and their charges. “I think some people aren’t thrilled that it perked up from one to five,” says Gerard A. Burns, MD, CMIO of Columbia, Md.-based MedStar Health, surely echoing the sentiments of many of his peers.

“This really puts a laser focus on needing to work together to embrace positive change,” says Robert Murphy, MD, CMIO at Memorial Hermann Medical Center in Houston.

Not just any CDS rule will do. Relatively simple forms of CDS, namely drug-drug and drug-allergy interaction checking, would not qualify based on the current proposal, Burns notes. What likely will qualify are rules that relate to the quality measures that CMS proposes hospitals be able to report on as part of meaningful use. “There’s a strong suggestion [from CMS] that hospitals should link these five rules to some of the quality measures,” says Benjamin Kanter MD, CMIO of Palomar Pomerado Health, a two-hospital system outside San Diego. Indeed, CMS specifically says rules must be “relevant to specialty or high clinical priority, including for diagnostic test ordering, along with the ability to track compliance with those rules.”

When deciding which five CDS rules to choose, both Kanter and Murphy believe a good place to start is with the quality measures themselves. In the CMS plan, take a look at Table 20, titled “Proposed Clinical Quality Measures for Electronic Submission by Eligible Hospitals for Payment Year 2011-2012,” which spells out about three dozen quality measures that CMS proposes hospitals be able to report on.

For hospitals that choose to participate in the Medicaid incentive program rather than seek Medicare bonus payments, Table 21 is the place to start. To be eligible for Medicaid bonuses, a provider must have at least 30 percent of its patients on Medicaid, the lone exception being pediatrics, where the threshold is 20 percent.

Both the Medicare and Medicaid tables include many measures endorsed by the National Quality Forum (NQF) and that are part of the current Medicare Physician Quality Reporting Initiative. A large number of these elements occur at the time of discharge or relate to a patient’s problem list.

“The problem is, they’re not always easy interventions to put in place,” says Murphy. The Memorial Hermann CMIO is a member of the Healthcare Information and Management Systems Society’s CDS Task Force, which has set up a wiki at for health IT professionals to share information on the subject.

CMIOs do understand that clinical decision support and quality go hand in hand. “There has got to be a tight linkage between the two,” Kanter says. “They can’t work in silos.” He cautions against equating CDS with pop-up alerts, saying that decision support needs to be tied into computerized physician order entry (CPOE) so alerts lead to action. Palomar Pomerado Health—geographically the largest hospital district in California—has an EHR content committee with a CDS subcommittee. The primary nurse responsible for quality compliance and the chief medical quality officer are on the subcommittee, Kanter says, because it’s important to have both nursing and quality leadership for CDS.

If a clinical department has a request for a new rule or alert, the EHR content committee hands off the work to the CDS subcommittee, which has expertise about regulatory requirements, the knowledge to use the EHR to deliver support and the wherewithal to build the technology, according to Kanter.

Kanter calls CDS the “secret sauce” of EHRs and CPOE that actually leads to improved patient care.

The Palomar Pomerado IT department is building out CPOE this year to augment its Cerner Millennium EHR, with a target go-live date of January 2011. Kanter expects clinical decision support to be in place to support order entry, featuring