2007 CPR Generation Criteria Update: Clinical Decision Support

Transcription

1 Industry Research Publication Date: 22 March 2007 ID Number: G CPR Generation Criteria Update: Clinical Decision Support Barry R. Hieb, M.D., Thomas J. Handler, M.D. This document provides an update of the properties and evolution of clinical decision support (CDS) through the five generations of Gartner computer-based patient record (CPR) systems. This is important to both IT professionals and clinicians because clinical decision support represents the single most important technique used to ensure patient safety. Key Findings Clinical decision support is the single most important CPR capability to assist in the avoidance of medical errors. Over time, the CDS system must be able to interact seamlessly with all other CPR components. The CDS rule engine must be coupled with an adequate notification system to ensure that critical decisions are made available to caregivers as soon as possible. Recommendations Care delivery organization (CDO) clients that will be acquiring a computer-based patient record system must carefully assess its current and planned CDS capabilities. CDOs that have an installed CPR should move aggressively to incorporate patient safety rules into its clinical decision support capabilities. CDOs should initiate efforts to develop CDS capabilities to support evidence-based processes such as those monitored by government and accrediting agencies. Reproduction and distribution of this publication in any form without prior written permission is forbidden. The information contained herein has been obtained from sources believed to be reliable. Gartner disclaims all warranties as to the accuracy, completeness or adequacy of such information. Although Gartner's research may discuss legal issues related to the information technology business, Gartner does not provide legal advice or services and its research should not be construed or used as such. Gartner shall have no liability for errors, omissions or inadequacies in the information contained herein or for interpretations thereof. The opinions expressed herein are subject to change without notice.

2 WHAT YOU NEED TO KNOW Clinical decision support represents a critical capability as CPR systems (see Note 1) become more sophisticated. It helps clinicians make complex decisions and can trigger appropriate early notification of possible untoward events. The CDS system thus is the agent where much of the medical knowledge embodied in evidence-based medicine is actually deployed during the provision of clinical care. ANALYSIS Context A major driver of the surge of investment in CDS since the Institute of Medicine's 1999 report "To Err Is Human" is the need to reduce medical errors while at the same time improving the quality and reliability of healthcare that is delivered. Clinical automation systems play an essential role in achieving these dual goals. Much of this potential is based on the incorporation of a clinical decision support capability into these complex CPR systems. At its core, a CDS has a rule engine. This engine is equipped with a variety of rules governing clinical, operational, financial and other activities. The purpose of the engine is to alert appropriate people if a rule has been violated. For example, if a physician tries to order a medication for a patient who is known to be allergic to that medicine, the rule engine should send an immediate notice to the physician. Analysis As CPR systems evolve to participate more directly at the point of care, their CDS capabilities can provide progressively increasing value. Consequently, a strong CDS capability is now essential for organizations that wish to practice state-of-the-art medicine. A CDS system will never replace the clinical judgment of a physician. However, it represents an invaluable assistant that can ensure that medically avoidable potential errors are rapidly detected and brought to the attention of those who can take appropriate corrective action. Clients that are considering the acquisition of a CPR system must carefully examine its CDS capabilities to ensure that they will provide needed functionality. Clients that already have a CPR system should continue to work actively with their CPR vendor to ensure that their CDS capabilities are being enhanced on a regular basis. This document represents an update of the CPR generation CDS requirements since they were last published in CDS Capabilities Across the CPR System Generations Gartner uses a five-generation model (see "Enterprise CPR System Generation Evaluation, 4Q05") to track the progression in capabilities of CPRs (see Note 2). The basic premise is that CPR systems will evolve through five generations, transforming from very simple systems that provide results reporting into very complex, fully integrated systems focused on the tasks directly related to promoting wellness and providing medical care for individuals across the entire healthcare continuum, within a single healthcare enterprise. A given CPR product may have some increased functionality in certain areas, but to be considered an Nth-generation product, it must at least have all the basic capabilities listed for that generation. In addition, each subsequent generation must have all the capabilities of previous generations. Using the CPR generation model, we have developed generation-specific criteria for the properties of a clinical decision support system. This document outlines those criteria. The CDS of a CPR must interact with the other core components of that system. There are 10 core CPR capabilities in the Gartner model (see Note 3). Working together, these 10 capabilities form the Publication Date: 22 March 2007/ID Number: G Page 2 of 9

3 core functionality of a modern CPR system. The CDS represents a critical safety component of the overall system. In advanced CPR systems, the CDS interacts extensively with the controlled medical vocabulary and the workflow system. Table 1 provides a comprehensive list of the CDS criteria for each of the five Gartner CPR generations. Publication Date: 22 March 2007/ID Number: G Page 3 of 9

4 Table 1. CPR Generation Clinical Decision Support Criteria Generation 1 Generation 2 CPR Generation Clinical Decision Support Criteria None. Basic rule capability for a limited set of data items (for example, drug-drug interactions and drug allergies). CDS can operate in both a real-time and a near-real-time manner and provides feedback to users at the earliest possible time (for example, an alert for a drug-drug conflict before the order is actually entered). CDS rules are based on normalized concepts represented in the CMV. CDS toolset supports both vendor and client creation and maintenance of rules. It is possible for a CDS rule to include a pointer to relevant knowledge management supporting content. Supports full Boolean logic rule expressions. The output of one rule can trigger the evaluation of a subsequent set of rules. "Proactive" alerts (for example, "Your patient on gentamicin now has worsening renal function. Do you want to lower dose?") are supported. Supports basic rule editing and management functions (for example, find all rules that deal with hip fractures). Supports at least minimal interactions with the other CPR core capabilities, especially CMV, workflow, order entry and clinical documentation. Other CPR components (for example, workflow and order entry) can trigger evaluation of CDS rules. Has a variety of notification options (for example, paging, and creating an item to be viewed by any person who reviews that patient's clinical results display). Ability to create time-based alerts. Ability to escalate alerts if the original notification is not acknowledged in a specified time period. Patient status indicators (for example, "at risk for renal failure") can be created and then used in CDS functions. Logging and auditing tracks the execution of rules and the resulting decision results. There must be an architecturally distinct CDS system rule engine. Publication Date: 22 March 2007/ID Number: G Page 4 of 9

5 CPR Generation Clinical Decision Support Criteria The rule engine must be capable of dealing with a variety of rule types, including Boolean logic, set theory and fuzzy logic algorithms. Ability to handle all decision support functions needed for clinical, operational and financial activities. CDS rules use a standardized syntax for all rules executing on the CPR rule engine. Able to fully participate in clinical care protocols, including actively monitoring all relevant data input streams. All data in rules and messages must be normalized by interaction with a CMV vocabulary server (VOSER). Supports complete rule-management capabilities for the creation, indexing, testing and maintenance of rules. Supports a full suite of alerting and notification capabilities. Ability to perform clinical simulation functions. Must provide basic integrity-checking capabilities to ensure that a given version of the institution s rule set is logically consistent. Has basic capabilities to support the import of new rules from external sources. Rules tailoring takes into account all of the patient's active diagnoses and problems, the primary practitioner caring for the patient, and all treatment protocols currently active for the patient. All decisions made by the CDS system must be logged and available for analysis to support clinical quality assurance, continuous process improvement and the development of new rules. Sufficient power to provide subsecond response times despite the existence of a large number (thousands) of rules. Existence of "wizards" and libraries to assist nontechnical staff in the design of new rules. CDS functions are fully integrated with all other CPR capabilities. Single unified management environment for all CDO decision support capabilities. Support for artificial intelligence applications when needed and appropriate. Supports customization of clinical rules based on any relevant set of clinical parameters, including information on the capabilities and limitations of the particular CDO where the patient is being treated. Publication Date: 22 March 2007/ID Number: G Page 5 of 9

6 Source: Gartner (March 2007) CPR Generation Clinical Decision Support Criteria Rules can be imported from an external authority, with the only manual step being the evaluation of the rule by whatever group is designated to approve changes in clinical practice. Robust facilities to manage the current rule set and ensure the logical integrity and consistency of the currently operating set of rules. Potential to extend clinical decision support beyond the boundaries of the institution when appropriate. Publication Date: 22 March 2007/ID Number: G Page 6 of 9

7 Key Facts Clinical decision support is the single most important CPR capability to assist in the avoidance of medical errors. Over time, the CDS system must be able to interact seamlessly with all other CPR components. The CDS rule engine must be coupled with an adequate notification system to ensure that critical decisions are made available to caregivers as soon as possible. RECOMMENDED READING "Seven Synergistic CPR Capabilities to Bolster Clinical Care" "Stop the Bleeding; Use IT to Achieve Sustained Value in Healthcare" Note 1 Defining a Computer-Based Record System Gartner defines a CPR system as containing patient-centric, electronically maintained information about an individual's health status and care, focusing on tasks and events directly related to patient care and optimized for use by clinicians. When designed and implemented correctly, it should meet all of a CDO's clinical, legal and administrative requirements for the clinical process. To avoid complications, especially as it relates to data ownership issues, Gartner restricts the scope of a CPR system to a single organization. A CPR system is composed of 10 integrated not interfaced core capabilities: clinical systems management, interoperability, clinical data repository, CMV, clinical workflow, clinical decision support, clinical documentation and data capture, clinical display (including clinician dashboards), clinical order management (including computer-based physician order entry), and knowledge management. Of course, the CPR must also be able to adequately meet the needs of care venues, as well as a wide array of clinician types. Note 2 The Five Generations of CPR Systems Generation 1: The Collector These systems provide a site-specific, encounter-based solution to accessing clinical data. Generation 2: The Documentor These are simple systems that physicians and nurses can use at the point of care to begin to document, rather than merely access, clinical data. : The Helper These systems support encounters as was as clinical episodes (that may involve more than one encounter) and can assist clinicians by providing a complete set of information on a particular patient with occasional advice triggered from a clinical decision support system. The basics of clinical decision support, workflow and knowledge management exist, but it can be difficult and resource intensive to actually implement evidence-based medicine at the point of care. These systems must be designed for use on medical-surgical floors, intensive care units, emergency departments and ambulatory settings. Publication Date: 22 March 2007/ID Number: G Page 7 of 9

8 : The Colleague These advanced systems further leverage the integration of the core components in a manner that provides substantial functionality for nurses, physicians, pharmacists and others. At this point, documentation and clinical display have been further refined to facilitate care rather than to permit documentation and review. Clinical decision support, workflow and knowledge management can more easily be used to implement EBM, are capable of discriminating between criticality of alerts and pathways, and can take into account individual clinical roles. In doing so, these CPRs take on more of a partnership role in the care of the patient. : The Mentor These are complex, sophisticated and fully integrated systems providing solutions that cover the full continuum of care and can, when appropriate, offer a different level of insights, suggestions and guidance to clinicians. The system is equipped with the tools necessary to determine the optimum treatment strategy for a patient based in part on the level of experience of the clinician, appropriate preferences of the patient, and the capabilities and restrictions of a particular institution. Physicians can consult such a system as a comprehensive and authoritative source of appropriate clinical practice guidelines, and view the system as an essential component for the delivery of state-of-the-art medicine. Note that a given CPR product may have some increased functionality in certain areas, but to be considered an Nth-generation product, it must meet all of the criteria listed for that generation. In addition, each subsequent generation must have all the capabilities of previous generations. Note 3 The 10 Gartner CPR Components Gartner includes 10 components in its model of a computer-based patient record system. They are: System management Interoperability Clinical data repository Controlled medical vocabulary Clinical decision support Workflow Clinical documentation Results display Computerized order entry Knowledge management This research is part of a set of related research pieces. See "Gartner's 2007 Criteria for the Enterprise CPR" for an overview. Publication Date: 22 March 2007/ID Number: G Page 8 of 9

9 REGIONAL HEADQUARTERS Corporate Headquarters 56 Top Gallant Road Stamford, CT U.S.A European Headquarters Tamesis The Glanty Egham Surrey, TW20 9AW UNITED KINGDOM Asia/Pacific Headquarters Gartner Australasia Pty. Ltd. Level 9, 141 Walker Street North Sydney New South Wales 2060 AUSTRALIA Japan Headquarters Gartner Japan Ltd. Aobadai Hills, 6F 7-7, Aobadai, 4-chome Meguro-ku, Tokyo JAPAN Latin America Headquarters Gartner do Brazil Av. das Nações Unidas, andar World Trade Center São Paulo SP BRAZIL Publication Date: 22 March 2007/ID Number: G Page 9 of 9