Clinical Decision Support

The CDC’s Office of Surveillance Epidemiology and Laboratory Services (OSELS), Public Health Informatics and Technology Program Office PHITPO), Division of Informatics Practice, Policy, and Coordination (DIPPC) is currently developing the Public Health Decision Support Program to facilitate the information exchange between public health and the clinical community.

EXECUTIVE SUMMARY:
Clinical Decision Support Systems (CDSS) are applications that assist clinicians in the provision of care by providing prompts through the analysis of clinical data. These applications require patient specific clinical variables and as a result of running these variables against the decision support rules, they can provide patient specific recommendations. CDS encompasses, but is not limited to providing computerized alerts, recommendations and best practices at the point of care. The use of Clinical Decision Support (CDS) capabilities within Electronic Health Record (EHR) holds great promise for the public health. For example, decision support tools integrated with an EHR system can provide clinicians with recommendations on high priority clinical preventive services and benchmark clinical outcome for comparative analysis. Public Health Decision Support is a discipline that leverages the use of CDSS to advance population/public health goals.

As stated above, the integration of decision support into EHR systems offers significant potential to improve the health outcome and enhance quality-of-care. For example, alerts and reminders already have been implemented in EHR systems for the purposes of improving adherence to guidelines to improve screening for the immunization of high-risk persons for influenza , identifying high-risk persons for tuberculosis screening , and alerting physicians of potential prescribing errors.

In 2009, the American Recovery and Reinvestment Act (ARRA) authorized the Centers for Medicare and Medicaid Services (CMS) to provide reimbursement incentives for eligible providers who use certified EHRs in a ‘meaningful way’. Meaningful use criteria appreciates the fact that better health outcome will not solely be achieved through adoption of technology but by the exchange of relevant information at the point-of-care. The standards to achieve such functionality include criteria for decision support and interoperability.

¹ Fiks AG, Grundmeier RW, Biggs LM, Localio AR, Alessandrini EA. Impact of clinical alerts within an electronic health record on routine childhood immunization in an urban pediatric population. Pediatrics. 2007 Oct; 120(4):707-14.

² Steele AW, Eisert S, Davidson A, Sandison T, Lyons P, Garrett N, Gabow P, Ortiz E. Using computerized clinical decision support for latent tuberculosis infection screening. Am J Prev Med. 2005 Apr;28(3):281-4

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Decision Support

DIPPC is proud to announce the launch of its Decision Support Community of Practice (DsCoP). DsCoP is a forum designed to promote opportunities for networking, knowledge sharing, and personal development through its monthly meetings, online workspace, and collaborative activities. The community brings together public health practitioners from the vast fields of public health to explore the current and potential uses of decision support in public health.

DsCoP believes that it is important to develop partnerships with others currently working (or interested) in this area of work, to identify public health areas that can benefit from DSS methods and technologies; and to work together to further research in Public Health-Clinical Decision Support Program (PHCDSP).

The community is answering the following:

• How can decision support be used in public health practice?
• Where can decision support be most useful in public health practice?
• Who will PHDS impact?
• What decision support tools and/or services can improve public health practice?
   

If you would like to be a member or participant in any of the forums of DsCoP, please contact Nedra Garrett for additional information.

Clinical-Public Health Decision Support Activities at CDC:

Ninad Mishra, MD - CDC Clinical Decision Support Lead

The rapid expansion of health information technology is bringing new capabilities to the public health and clinical care domain. EHR-Public Health-CDS program at Division of Informatics Policy, Practice and Coordination (DIPPC) aims to promote methods and solutions that can leverage clinical decision support for public and population health purposes. The program primarily strives to build greater connections between the public health practitioners, clinical providers, and the health informatics community. The goal of the program is to suggest an interoperable, flexible and open architecture for decision support modules in the EMR systems that can then serve public/population health purposes and to build an interface between clinical and public health.

As stated above, the integration of decision support into EMR systems offers significant potential to improve the health outcome and enhance quality-of-care. For example, alerts and reminders have already implemented in many EMR systems to improve adherence to the guidelines for screening, for the immunization of high-risk population, and for case identification such as resistant tuberculosis. In 2009, the American Recovery and Reinvestment Act (ARRA) authorized the Centers for Medicare and Medicaid Services (CMS) to provide reimbursement incentives for eligible providers for the Meaningful Use (MU) of the EMR system. MU criteria recognize the fact that better health outcome will not solely be achieved through adoption of technology but by the exchange of relevant information at the point-of-care. The standards to achieve such functionality include criteria for decision support and interoperability.

DIPPC in conjunction Alliance of Chicago CHCs and an EMR vendor is in the process of a pilot deployment to showcase the capability to create an actionable public heath alert that can be consumed by an electronic medical record system at the point-of-care. This solution consists of three parts: 1) the public heath alert, 2) the alert knowledge repository, and 3) the anonymous profile information retrieval mechanism that interfaces with the EMR system. This solution can be repurposed for various types of alerts, guidelines, protocols and other documents that contains recommendations for screening, diagnostic evaluation, treatment, and management. This project aims to leverage opportunities created through the increase use in EMR systems in healthcare organizations by creating the ability to send actionable public health alerts that can be consumed and distributed by an EMR system. This project explores extending the existing capability to communicate with EMR systems using a standard messaging format (HITSP T 81) to deliver actionable public health alert to the provider based on a trigger. By offering a targeted method of delivery, the project aims to avoid alert fatigue and disturbance in clinical work flow. A feedback mechanism will also be included in later phases to capture the provider’s response to the alert and further improve the effectiveness of the message.

Pilot projects in collaboration with healthcare organizations are scheduled for mid 2010 to study and measure impact on the public health and clinical objectives as well as the value, accuracy, and timeliness of the information presented. The idea has been presented at PHIN and HIMSS to both public health and clinical stakeholders with positive feedback and excitement around its possibilities. Decision Support Program at CDC also aims to coordinate decision support activities within CDC by working closely with programmatic experts to provide informatics, standards and interoperability perspective to our collaborators. Some of the programmatic areas targeted for the exploration are STD/HIV, Cancer screening, Health Associated Infections (HAIs) and Diabetes.

Papers and Presentations

• A Rule-based Approach for Identifying Obesity and Its Comorbidities in Medical Discharge Summaries
  Ninad K. Mishra, MD, MS, David M. Cummo, James J. Arnzen, Jason Bonander, MA
• Characterization of Public Health Alerts and Their Suitability for Alerting in Electronic Health Record Systems
  Nedra Y. Garrett, MS; Ninad Mishra, MD, MS; Barbara Nichols, BS; Catherine J. Staes, BSN, MPH, PhD; Chuck Akin, BBA; Charles Safran, MD, MS.

Upcoming Meeting

To Be Announced

Previous Meetings

• May 2008 Meeting - Natural Language Processing in Public Health.  - Dr. Ninad Mishra.
• February 2008 – Leveraging Innovative and Emerging Technologies for Public Health Decisionmaking: How Decision Support Methodologies in Health Care Can Be Adapted to Public Health – Leslie Lenert, MD, MS, Director, NCPHI
• January 2008 – Communities of Practice and Learning Challenges in the 21^st Century. Guest Lecturer - Etienne Wenger, PhD
• December 2007 – Exploring Technologies and Methodologies for Public Health Decision Support. Guest Lecturer – Dr. Ninad Mishra
• November 2007 – Webinar: Decision Support in Public Health Practice Environment:  Opportunities & Challenges. Guest Lecturer – Dr. Sherrilynne Fuller, University of Washington
• October 2007 – Public Health Decision Support –  Guest Lecturer – Dr. Charles Safran, Harvard Medical School
  View the October Meeting.
• August 2007 – Investigating the Evidence of Decision Support in Public Health:  Exploring a Decision Support Framework
• July 2007 –  Introducing the Decision Support Community of Practice (Inaugural Meeting)