4
AGENDA FOR CDS ADOPTION AND USE

Over the duration of the meeting series, all of the workgroups identified next steps relevant to their particular topics. Key themes related to CDS adoption and use emerged that crossed the boundaries of the specific workgroups. Through a series of discussions with the project’s steering committee, subcommittee workgroups, and meeting participants, held between the second and third meeting, a comprehensive list of actions for optimizing strategies for CDS adoption and use was identified. These priorities for action then served as the focus for the third meeting’s presentations and discussions, which in addition to considering these priorities also aimed to identify organizations that would be well situated to take lead roles in their implementation.

The organizations listed in some instances include specific examples representative of larger groups of organizations with similar characteristics, such as integrated delivery systems, academic medical centers, or specific physician or other clinical specialty societies. The lists are intended to be illustrative and name some evocative examples, not to be exhaustive or imply that only those organizations listed could take leadership roles, and not to imply that any of the specifically named example organizations have committed to carrying forward the roles for which the workgroup identified them as examples of potential leaders.

Against this backdrop of compelling opportunities emerged the common themes noted in chapter 1:

• Much like in-person peer learning (e.g., grand rounds with residents), CDS should serve as a tool to help clinicians at the front line think through options at the point of care.
• Current challenges include the various pathways for implementation of CDS within different health care organizations, lack of standards and incentives to use and improve CDS, poor data quality, and gaps in the evidence.

• One of the greatest challenges for scaling CDS adoption is its limited financial business case. It remains difficult to demonstrate the return on investment of CDS, especially against many competing priorities at the delivery system level.
• Current CDS lacks measurement practices and standards. Evaluation of current and future CDS should assess whether it measurably improves quality, health outcomes, safety, cost, and physician productivity.

Throughout the meeting series, the participants expressed an interest in focusing on these themes to identify strategies to move CDS implementation into action and help the field address longstanding challenges associated with CDS adoption and use. As Kensaku Kawamoto asked during the first meeting, “How do we help ensure that we are not here in 10 years having these same discussions?” It was this question, and the overarching drive of the meeting participants that led to efforts to identify actionable next steps and approaches to implement them.

In this respect, participants were motivated to offer their views on actionable collaborative next steps that could be initiated over the next five years. Although the summary below represents views of the authors, not the NAM, they are intended to move forward the discussion in a way that complements and enhances clinical practice, and they will require commitment by multiple stakeholders at the federal level, by the EHR and CDS vendor community, and by health delivery systems.

DEVELOP, TEST, ESTABLISH, VALIDATE, AND APPLY STANDARDS

1. Establish CDS technical standards
   • Develop coordinated activities in support of standard intervention templates, methods, artifacts, and intervention repositories.
   • Develop a standard set of each of the core CDS operational elements such as EHR trigger points, action items, and supporting data, leveraging existing work such as the 2012 NQF expert panel report and existing Health Level Seven international standards (HL7), so that CDS can be developed with confidence that these elements will be present in each EHR environment.
   • Establish repeatable conventions, such as the FHIR and APIs, to pass data and context/situational info from the EHR to the CDS and to accept recommendations from the CDS back to the EHR in the appropriate context.
   • Establish an entity of appropriate stakeholders to resolve governance issues and drive EHR vendor acceptance for support of CDS standards.

Potential leaders for such an effort include the HL7 workgroup, the CDS work group, integrated health systems, the HL7 Clinical Quality Information Workgroup, the AMIA, HIMSS, primary care practice community stakeholders, and federal agencies.

2. Engage federal leadership for CDS standards innovation and maturation
   • Have relevant federal agencies dedicate at least a critical minimum of support, reliably year over year, to foster the development and maturation of technical standards essential to achieving seamless interoperability of CDS with EHRs and other health IT used daily to support health care delivery.

Federal agencies would be the potential leaders of this activity.

3. Create a CDS technical information resource
   • List, describe, and validate existing CDS constructs, such as SMART on FHIR®, CDS Hooks, FHIR Clinical Reasoning module and industry standard APIs, and develop objective criteria on standards validation models.

Potential leaders of this effort would include the HL7 and CDS workgroups and federal agencies.

ENCOURAGE DELIVERY SYSTEM ADOPTION, USE, AND ASSESSMENT

4. Disseminate best practices
   • Convene one or more small expert groups to cultivate, plan, and direct the publication of actionable implementation guides that draw upon existing public, private, and cooperative efforts to articulate and delineate best practices in: implementation and platform integration approaches for several types of delivery systems; CDS management approaches for organizing multistakeholder CDS implementation and governance committees, and for clinicians and health systems of various sizes/resources; and usability recommendations for usable, practical, workflow-supportive CDS for various situations and objectives that are straightforward and readily adopted by designers and system configuration teams.
   • Develop education toolkits for health delivery systems implementing and using CDS.

Potential leaders for such an effort include HIMSS, medical specialty societies, AMIA, and federal agencies.

5. Create a national CDS repository
   • Develop and organize a national network of “choose and use” repositories of downloadable or service-accessible CDS interventions. The repository concept does not prescribe a single federal repository but rather a standard format that allows multiple entities to supply repositories. Providers should be able to download artifacts and use them with a minimal amount of customization. The same concept can be used to allow providers to select from a catalog of CDS services. Key considerations for a nationwide CDS repository infrastructure will include funding sources, duration, and sustainability.
   • Create CDS building blocks such as a “starter pack” of logic and operational items, value sets, and detailed clinical models that cover a meaningful portion of the high-priority CDS targets of the health care community.

EHR and CDS vendors and federal agencies are potential leaders/funders of this activity.

6. Measure CDS usage
   • At a delivery system level, measure (both pre and postimplementation) such items as number of times occurring, supporting data provided, user response, and other relevant clinical measures regardless of application and independent of application platform.
   • Over the longer term (2020 and after), the capacity to measure at the delivery system level will allow for the assessment of CDS at a national level, specifically the ability to measure CDS success by pervasiveness of adoption; assessment of override rates; the feedback of end users and patients about how and when the CDS was presented; the beneficial difference it made in overuse, underuse, and misuse of tests and treatments; and how CDS contributed to the quality outcomes that matter, such as those defined by the Institute of Medicine (now the National Academy of Medicine) definition of quality: patient-centeredness, effectiveness, safety, timeliness, efficiency, equitability¹³; and Quadruple Aim criteria.

Potential promoters of this activity would be patient safety organizations (PSOs), vendors, integrated health systems, and federal agencies.

7. Develop tools to assess CDS efficacy
   • Convene, fund, develop, and make publicly available tools and metrics for assessing CDS performance in the dimensions of quality, safety, and transparency of CDS, and for assessing ongoing performance and impact of CDS.
   • Potential leaders of this activity include integrated health systems, The National Committee for Quality Assurance (NCQA), the Institute for Healthcare Improvement (IHI), and federal agencies.

8. Publish performance evaluations
   • Publish evaluations of usability and effectiveness of vendor EHR CDS implementation with sufficient detail to facilitate purchasing decisions and postpurchase configuration and monitoring work by providers.

The AMIA, Institute for Clinical and Economic Review (ICER), IHI, Patient-Centered Outcomes Research Institute (PCORI), Institute for Safe Medication Practices (ISMP), American EHR Partners, and federal agencies are potential leaders of this activity.

9. Market CDS to stakeholders
   • Articulate a macro-level, industry-scale CDS value proposition as well as distinct value propositions on the use of CDS for different end-users such as individual practitioners and integrated health systems.
   • Develop partnerships with multiple stakeholders, including industry, federal representatives, patients and families, and professional societies, to better inform both the private and public domains of CDS value. An engaged public informed about the cost, quality, safety, and satisfaction benefits of CDS can make the case to the government of the value of CDS. Societies are positioned to review data, report back, and translate the value of CDS to public domains.

Potential leaders of this activity include HIMSS, vendors, professional societies, medical education organizations, patient advocacy organizations, and federal agencies.

10. Promote financing and measurement to accelerate CDS adoption
    • Have available from the federal government a system of strong financial incentives for the adoption and implementation of CDS, supported by information

about how specific CDS could help in improving care effectiveness, efficiency, and quality performance.

• Incorporate CDS into the Medicare Access and CHIP Reauthorization Act (MACRA) Quality Payment Program by leveraging the APMs track to drive incorporation and standardization of CDS. This action would reward participants in advanced APMs for deploying, adopting, and adhering to evidence-based best practices that facilitate standardization, reduce variation that is without value, and promote achievement of national benchmark results for quality, patient experience, and health professional engagement and alignment for better care.
• Pilot alternative approaches to health care financing in which the basis for payment is centered on documenting decisions rather than documenting observations.

Potential leaders of this activity include federal agencies, integrated health systems, and ICER.

ESTABLISH A NATIONAL CDS INFRASTRUCTURE

11. Create a legal framework for CDS
    • Convene a small, interdisciplinary group of experts in a public-private partnership to explore and address the legal concerns surrounding: adoption of CDS; creation of CDS public and private repositories/services; professional and institutional liability when using CDS; liability of authors, creators, and investigators producing CDS logic and interventions; and the FDA’s approach to CDS within its overall regulatory strategy for clinical software. Outputs of this interdisciplinary, multistakeholder group could include a framework of criteria for development and deployment of CDS resources and services which, when met, would provide clinicians assurance they could reasonably rely on those CDS resources and/or services.

Potential leaders could include AMIA, The Brookings Institution, the NAM, IHI, the Duke-Margolis Center for Health Policy, HIMSS, College of Healthcare Information Management Executives (CHIME), American Health Lawyers Association, and federal agencies.

12. Develop a multistakeholder CDS learning community to inform usability
    • Facilitate the routine engagement of end-users and key stakeholders—including providers and their staff, EHR and CDS vendors, and patients and

families—throughout the CDS design specification and implementation process.

• Develop a mechanism to collect feedback from providers and other users about efficacy, design questions, configuration tips for other users, and suggested changes to specific CDS interventions and CDS in general.
• Link patient-generated data to CDS technologies in order to generate alerts and recommendations based on the clinical and nonclinical needs of patients, including their preferences, lifestyle factors, environmental and public health issues, social determinants of health, and goals for care.

Potential leaders of this activity include HIMSS, PSOs, vendors, the Society for Medical Decision Making, the NAM, Intermountain Healthcare, Kaiser Permanente, Brigham and Women’s Hospital, other integrated health systems or academic medical centers, and federal agencies.

13. Establish an investment program for CDS research
    • Establish a national investment in a variety of research projects focused on CDS, such as multisite pragmatic cluster randomized controlled trials and implementation research—either as stand-alone projects or incorporated into other research studies conducted within real-world environments—to evaluate the optimal approaches for delivering CDS in diverse, representative clinical settings, especially:
      • the use of implemented tools within real-world environments;
      • implementation of CDS resources within various workflow and implementation models;
      • comparison and validation of various CDS implementation models; and
      • feedback on CDS use, efficacy, and usability over time to determine what is working and what is missing.

Potential leaders for this activity could include federal agencies, PCORI, IHI, the NAM, ICER, the Duke Clinical Research Institute, Duke Center for Health Informatics, the American Cancer Society, the American Heart Association, and provider societies such as the American College of Physicians and the American Academy of Family Physicians.

MOVING AHEAD

While there is important benefit to federal leadership for developing regulations, providing guidance, and funding research, advancement toward adoption

of CDS relies on engagement, leadership, and collaboration among multiple sectors and stakeholders. Industry could have a leadership role in helping to identify and test standards; knowledge from front-line users is crucial to understanding priorities, usage, workflow, and design; and professional societies are positioned to disseminate best practices and guidelines. Additionally, a convening authority for standard-setting might offer a vehicle for customer voices to motivate changes with vendors, as well as facilitate collaboration between societies, multiple vendors, and different specialties to develop building blocks for improvement.

The Steering Committee and meeting participants shared a common vision that CDS is an essential tool for health care that holds great potential for improving health delivery and outcomes. A common observation was that many participants have been engaged in trying to improve CDS for years in their own systems and throughout a number of national initiatives, and despite frustration at the pace of adoption, a number of key factors, including the emergence of new technological and policy advancements, as well as the increased willingness for collaboration across sectors, foster a health ecosystem more open to the acceleration of CDS use. Specifically, they see opportunities for:

• increased engagement of stakeholders in the design, implementation, and use of CDS;
• the incorporation of new knowledge, including patient-reported outcomes and contextual information, into CDS;
• a renewed focus on clinical decision support for health care teams;
• the creation of new multistakeholder partnerships to develop practical implementation tools and lead standardization and regulatory efforts;
• the development and deployment of CDS for public health response; and
• the strengthening of the CDS implementation evidence base.

With near-universal use of EHRs throughout hospitals and office practice settings, the time is at hand for modest investments by multistakeholder partnerships to refine technical standards, develop and create governance approaches to facilitate quality, consistency, effectiveness, and efficiency for health care teams and their patients.

By taking into account the current environment, engaging multiple stakeholders, and committing to the priorities of action identified through this work, the adoption and use of CDS may be better developed, implemented, used, and shared thus delivering on its potential to facilitate patient and clinician engagement, enhance care delivery, accelerate system-wide continuous learning, and improve health care outcomes.