The CDS Five Rights approach outlined above speaks to setting up one or more CDS interventions to address particular performance improvement objectives. This work unfolds in the context of broader organizational programs focused on CDS. The CDS guide on which this paper is based speaks extensively to success factors in setting up these programs, as well in individual interventions.
Below is a brief overview of selected best practices for setting up a successful CDS program to address medication use, and other priority targets as well. Of note, many of these lessons for CDS resonate strongly with best practices that have been defined more broadly for HIT, such as EHR and CPOE implementation. Readers interested in exploring these synergies further might begin by examining application criteria for the HIMSS Davies Awards of Excellence, established to recognize best practices for EHR implementation and derived value (www.himss.org/davies
Establish a solid foundation for CDS efforts
CDS interventions and related activities are a means to an end, and successful programs begin with a shared understanding among key stakeholders about both the ends and (at least at a high level) the means. Solid governance structures and operating mechanisms are invaluable in building consensus around the goals of greatest mutual interest to key stakeholders (e.g., medical staff and hospital administration). They likewise play a central role in creating a shared understanding of basic concepts and approaches (e.g., the CDS five rights) and of improvement and intervention opportunities and strategies. Another key foundation component is quantifying baseline performance levels around the targets to be addressed with CDS—and producing some commitment to targeted benefits. This enables improvements to be tracked quantitatively against pre-set goals, which both justifies CDS investments to the organization, and provides a springboard for further program enhancements.
In each of these activities, it is important to engage all the pertinent stakeholders involved in the clinical and related processes, and gain their commitment to ensuring that the organizational performance improvements imperatives are realized. Successful organizations form a high-profile CDS steering committee populated with committed key leaders; for example from informatics (e.g., chief medical information officer), quality/patient safety, pharmacy, nursing, practicing physicians/thought leaders and other key functional areas. This CDS governance should be aligned with the organization’s leadership structure; for example, through formal connections with committees on EHR Oversight, Quality/Patient Safety, Medical Executive, and others.
Deploy CDS for maximum acceptance
Do CDS with users and not to them. This approach is a hallmark of the most successful CDS programs, and many CDS implementation disasters are the result of the opposite approach. When end-users are involved in developing CDS interventions that become tools that can help them achieve their important goals (or are at least aligned in some way with them), the resulting interventions will be much more likely to be used and useful.
Consider the full spectrum of potential CDS stakeholders and interventions. Observe and document relevant workflow before and after interventions to help optimize intervention acceptance and drive inevitable post-launch modifications. Prior to and surrounding intervention launch, communicate with and educate the affected users. This includes helping them understand how the CDS interventions will impact their daily activities and how they can provide feedback to implementers. Provide on-site support initially as needed to help with any immediate issues that may occur.
Devote adequate attention and resources to measurement
A well accepted adage of performance improvement is that you can’t improve what you can’t measure. Nonetheless, many CDS programs do not devote adequate attention to measuring intervention effects—both intended and unintended – and thereby miss important improvement opportunities. As noted above, a foundation for CDS efforts is establishing performance baselines and targeted improvement levels, so measurement starts well before intervention deployment. Intervention development should include formal planning for when and how intervention effects will be monitored to assess their effects. Issues to track for CDS interventions include structural measures (e.g., what interventions have we deployed?); processes measures (e.g., how are these interventions affecting decisions and workflow?); and outcome measures (e.g., to what extend are the interventions helping achieve the organization’s care quality, safety and efficacy goals?).
To the extent the goals targeted by the CDS program align with organizational priorities (such as increasing performance in core measures or decreasing “never events”), resources should be available for CDS-related process measurements as a component of the broader efforts to address those priorities. Likewise, broader organizational mechanisms for measuring and reporting outcome performance against targets can be leveraged for assessing results from the CDS component of these efforts.
Manage knowledge asset and decisions proactively
As an organization’s CDS program evolves over time, there is an increasing volume of knowledge assets—e.g. CDS interventions such as order sets, rules, referential content, etc. – as well as decisions related to those assets—e.g., why CDS targets were selected, how interventions were configured, etc. It is therefore essential to proactively manage these; for example, to ensure that the currency, consistency, evidence base and value of CDS knowledge assets remains optimized over time.
Since this type of CDS knowledge management is relatively early in its evolution, there aren’t inexpensive, robust, off-the-shelf tools to support these activities. Pioneering organizations use various online collaboration tools, web-based knowledge portals, and related mechanisms to help keep track of CDS assets and decisions related to them. In any case, a systematic, proactive approach to knowledge management will help organizations avoid a tangled, inconsistent mass of interventions, and potentially save significant time and energy as the program grows and matures.