What Are Barriers to Physicians Adopting Clinical Decision Support Systems? A Literature Review

AHRQ Releases Report on "Challenges to Clinical Conclusion Support (CDS) Design and Implementation"
"A new report" produced for AHRQ  National Research Centre for Health IT dated March 2010 and released on Apr 14, 2010, "examines the challenges and barriers to implementing clinical decision support (CDS) and found workflow, design and clinician'southward level of support are just some of the problems that can touch successful CDS implementation. Challenges and Barriers to Clinical Conclusion Support (CDS) Implementation (PDF, 254 Kb) describes the challenges and barriers that AHRQ contractors encountered as part of their CDS demonstration project. These challenges and barriers can be successfully addressed by employing several fundamental strategies, which include utilizing standard data commutation formats, providing clinicians with appropriate training, and modifying CDS to accost clinicians' needs."  Report authors are June Eichner, G.Due south. and Maya Das, M.D., J.D. of NORC at the Academy of Chicago.

The following are excerpts from the study Introduction, Lessons Learned, and Project Teams.
I. INTRODUCTION
Overview of Clinical Decision Support
"To improve the quality of medical intendance in the United States, efforts are being fabricated to increase the practice of show-based medicine through the apply of clinical determination support (CDS) systems. CDS provides clinicians, patients, or caregivers with clinical knowledge and patient-specific information to assist them make decisions that enhance patient care. The patient's information is matched to a clinical noesis base, and patient-specific assessments or recommendations are then communicated effectively at appropriate times during patient care. Some CDS interventions include forms and templates for entering and documenting patient information, and alerts, reminders, and lodge sets for providing suggestions and other back up. Although CDS interventions can be designed to be used by clinicians, patients, and breezy caregivers, this written report focuses on the use of CDS interventions by clinicians to amend their clinical decisionmaking procedure. In addition, while CDS interventions can be both newspaper and computer based, their awarding in the following projects is limited to electronic CDS because of its greater capability for determination back up.

"The apply of CDS systems offers many potential benefits. Importantly, CDS interventions can increase adherence to show-based medical knowledge and can reduce unnecessary variation in clinical practice. The process for development and implementation of CDS systems can establish a standard knowledge structure that aligns with written evidence-based guidelines published by medical specialty societies or Federal task forces, such as the U.S. Preventive Services Chore Strength (USPSTF). CDS systems tin too assist with information management to support clinicians' decisionmaking abilities, reduce their mental workload, and improve clinical workflows.3 When well designed and implemented, CDS systems have the potential to improve health care quality, and also to increase efficiency and reduce wellness care costs.

"Despite the hope of CDS systems, numerous barriers to their development and implementation be. To date, the medical noesis base is incomplete, in function because of insufficient clinical evidence. Moreover, methodologies are still being designed to convert the knowledge base of operations into computable lawmaking, and interventions for carrying the knowledge to clinicians in a way they can easily use information technology in exercise are in the early stages of development. Low clinician demand for CDS is another barrier to broader CDS system adoption. Clinicians' lack of motivation to use CDS appears to be related to usability issues with the CDS intervention (eastward.thousand., speed, ease of use), its lack of integration into the clinical workflow, concerns about autonomy, and the legal and ethical ramifications of adhering to or overriding recommendations fabricated past the CDS system. In addition, in many cases, credence and use of CDS systems are tied to the adoption of electronic medical records (EMRs), considering EMRs can include CDS applications as part of computerized provider order entry (CPOE) and electronic prescribing (eRx) systems. This is evidenced by the results of the 2008 National Ambulatory Medical Care Survey, which show that only 38 percent of physicians used an EMR, and only 4 percent used an EMR with CDS system capabilities.

"Recent Federal and payer initiatives are providing back up for EMR and CDS adoption. For example, the Agency for Healthcare Enquiry and Quality (AHRQ) has funded CDS demonstrations. In improver, AHRQ and the U.Southward. Section of Health and Human Services Office of the National Coordinator for Wellness Information Engineering (ONC) funded the development of a Roadmap for National Activity on Clinical Decision Back up and held workshops to support CDS arrangement development and implementation. Nearly recently, the American Recovery and Reinvestment Human action of 2009 (ARRA) created financial incentives through Medicare and Medicaid for providers to "meaningfully use qualified" electronic health records (EHRs). Under the Notice for Proposed Rulemaking (NPRM) for the EHR Incentive Program published by the Centers for Medicare & Medicaid Services (CMS), the criteria for meaningful use include the implementation of v CDS rules, including the power to track compliance with those rules.

"The incorporation of evidence-based guidelines into an EMR by using CDS interventions that include quality measures may help align intendance delivery with payment incentives. Federal and private payers' current and proposed payment models offer incentives based on the quality of care provided.  CDS alerts, reminders, and standardized guild sets tin too help clinicians follow these guidelines and support the payment of clinicians based on their performance (e.m., pay-for-performance). In improver, CDS documentation tin can be used to evaluate care from a population-based perspective and to move from the measurement of care processes to the measurement of patient outcomes."

Overview of AHRQ'south Clinical Decision Support Sit-in Projects

"In 2008, AHRQ funded two demonstration projects in support of the design, development, and implementation of CDS systems. These projects aimed to:

• Incorporate CDS into EMRs that have been certified by the Certification Commission for Health Information technology (CCHIT).

• Demonstrate that CDS can operate on multiple information systems.

• Found lessons learned for CDS implementation relevant to the health it (Information technology) vendor customs.

• Assess potential benefits and drawbacks of CDS, including effects on patient satisfaction, measures of efficiency, price, and take chances.

• Evaluate methods of creating, storing, and replicating CDS across multiple clinical sites and convalescent practices."

"The projects were required to select ii or more clinical do guidelines in the public domain that had not yet been translated into a broadly available electronic CDS intervention. The called clinical practise guidelines were to accost either preventive services or management of multiple common chronic weather condition. The contractors were so to implement the CDS intervention in at least 1 wellness It product certified by CCHIT, applying American National Standards Found (ANSI) Wellness Information technology Standards Panel (HITSP) standards when available and applicable. The CDS system existence adult was to be demonstrated in ambulatory settings. In addition, the projects were required to evaluate methods for creating, storing, and replicating the CDS system beyond multiple clinical sites and EMR systems.

"The ii demonstration project contracts were awarded to Brigham and Women'southward Hospital (BWH) for its Clinical Decision Back up Consortium (CDSC) project and Yale University School of Medicine for its GuideLines Into Conclusion Support (GLIDES) project. Each project is funded for $2.5 million for a ii-twelvemonth flow, with an pick for AHRQ to continue funding the projects for up to an boosted 3 years."

Objectives of This Report
"This report briefly describes the 2 AHRQ CDS demonstrations, as well as the challenges and barriers that the contractors encountered during the initial periods of their CDS demonstration projection, how they addressed these obstacles, and the effectiveness of their strategies. The goal of this report is to share the experiences of the contractors throughout the planning, design, and implementation phases to aid others who are because funding or undertaking like efforts."

Methodology
"The information for this report is based on the contractors' monthly status reports, project proposals, evaluation plans, and other documents submitted to AHRQ project officers. In improver, discussions were held with the contractors' staff onsite and by telephone from June to September 2009. A review of the full general CDS literature was besides performed in order to provide a context for the contractors' activities."

Terminology
"The list below defines terms used throughout the written report that may have multiple definitions. These definitions are used consistently throughout the document.

• "Guidelines" refers to written statements developed by medical specialty societies, illness-focused organizations, or good panels to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.

• "Rules" refers to the abstraction of guidelines into programmable prediction statements (i.e., IF-and-So statements).

• "CDS Service" refers to a CDS functionality accessible over standard Internet protocols that is independent of the underlying EMR platform or programming language.

• "CDS intervention" refers to the diverseness of CDS applications (e.g., alerts, reminders, club sets) used to communicate knowledge to the clinician.

• "Noesis management tool" refers to resources designed to assist with the extraction, evaluation, storage, and retrieval of guidelines, frameworks, pieces of code, and other artifacts related to CDS system development (east.thousand., Documentum'due south Web Publisher, Content Management Services, the Guideline Elements Model (GEM) software tool GEMCutter, EXTRACTOR, Conference on Guideline Standardization (COGS) statement, Guideline Implementability Appraisal (GLIA)).

• SmartForm is an electronic form with electronic completion, dynamic sections, database calls, electronic submission, and other capabilities. It enables writing a multi-trouble visit note while capturing coded data and providing sophisticated decision support in the class of tailored recommendations for care.

• Dashboard is a Web-based application bachelor to clinicians that displays relevant and timely data to back up clinical decisionmaking for patient intendance, quality reporting, and population management. Dashboards may back up viewing of condition-specific data and/or functionality to take action (e.g., ordering of a lab test) from the application itself."

Organization
"The remainder of this written report is organized into iii sections. The adjacent section provides a clarification of each project and summary of the challenges and barriers faced by each of the contractors. This is followed by an assay and discussion of their experiences. The final department offers overall conclusions and recommendations for time to come work to promote CDS design and implementation."

To read descriptions of the projects and analysis and discussion, see the report pdf. This postal service skips to conclusions.

Lessons Learned
"The experience to date of these ii contractors provides lessons that are especially relevant to guideline developers, IT vendors, standards development organizations, health care provider organizations, and policymakers. The lessons specially pertinent to each group are given below."

Guideline developers:
 "Guidelines should be specific, unambiguous, and articulate.

 Guideline development committees should include individuals with programming expertise and wellness informaticians.

 Updates of the guideline recommendations are needed. Guideline developers should consider issuing statements of update when new medical testify is brought along and providing regular review and updates of guidelines. For example, the USPSTF re-reviews each topic every 5 years."

IT vendors:
 "As almost organizations utilize vendor systems with hard-coded functionality, vendors should consider ways to reduce the need for an arrangement to rebuild the CDS content when upgrading or implementing a new EMR organisation (eastward.grand., adopting a module or service-oriented approach).

 Incentives for vendor participation in CDS initiatives should be aligned with efforts, such as defining meaningful employ criteria, to encourage standards adoption."

Standards evolution organizations:
 "Implementation specifications and guides should be produced that simplify existing standards and back up consequent application of standards for messaging, interfacing, and mapping purposes.

 The development of standards and implementation specifications and guides should adjust appropriate clinical practice variations.

 When developing newer versions of standards, ways to reduce interoperability problems and data-mapping issues should be considered."

Health care provider organizations:
 "The goals of CDS development and implementation projects should align with organizational priorities to promote buy-in from both management and staff.

 The organizational working environment should foster meaningful EMR usage, including non only software and hardware needs only also the attitudinal changes needed to support adoption.

 Engaging a well-respected clinician "champion" to atomic number 82 CDS education, training, and implementation efforts will promote clinician adoption.

 Institutions wishing to use a knowledge direction procedure volition demand access to personnel with specialized cognition in clinical informatics and experience in designing new tools or using existing tools to support CDS development."

Policymakers:
 "The development of standards and clinical guidelines can promote the goals for interoperability as well every bit back up the development of the noesis base necessary for developing CDS systems.

 Incentives by funding bodies, including governmental entities, tin can promote EMR installation, implementation, and use of these systems. To reach the hope of EMR to ameliorate the quality of health care through interventions such as CDS systems, policymakers demand to continually reexamine ways to promote adoption of quality practices, including performance-based payments, incentives, and providing clinicians and patients with comparative data."

Future Work To Support CDS
"Although the contractors were able to overcome many of the challenges and barriers they faced, they were not able to overcome them all. Additional research and work are needed to accost these outstanding obstacles, equally they are of import for the advancement of the design and implementation of CDS systems. These include:"

° "Development of a stronger prove base for guidelines (single atmospheric condition, comorbidities, associated treatment options).

° Creation of more specific implementation guides and specifications to promote consequent application of standards.

° Comparison of the resources required by a provider organization to develop its own noesis management organization vs. use of a ready-made cognition management portal.

° Long-term evaluation to make up one's mind whether clinicians' employ of the EMR and CDS systems changes or stabilizes over time.

° Understanding of factors that enable EMR and CDS intervention acceptance and use by clinicians.

° Effectiveness of the diverse CDS interventions on clinician performance and clinical outcomes."

The 2 Demonstration Projection Teams

1. Clinical Conclusion Back up Consortium
"The CDSC project was awarded to Brigham and Women's Infirmary and as well includes Partners HealthCare System (Partners), an integrated wellness intendance system that includes master care and specialty clinicians, customs hospitals, two founding academic medical centers (including BWH), specialty facilities, and other wellness-related entities. For this project, BWH is collaborating with the Regenstrief Institute, the Veterans Wellness Administration (Roudebush Veterans Assistants Medical Centre), Kaiser Permanente, the University of Medicine and Dentistry of New Jersey (UMDNJ), MidValley Independent Physicians Clan (MVIPA), and EMR vendors (i.east., Siemens Medical Solutions, GE Healthcare, and NextGen). Direction of and technical expertise for this projection are provided past staff of the Partners HealthCare System's Clinical Informatics Enquiry and Development (CIRD) group."

2. GuideLines Into DEcision Support
"The GuideLines Into Decision Support (GLIDES) project is a collaboration between Yale University Schoolhouse of Medicine, Yale New Haven Health System, and the Nemours Foundation."

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