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Improving Care: Advancing Evidence into Practice through Interoperable, Patient-Centered Clinical Decision Support

The uptake of research evidence in clinical practice can be slow. Technologies such as CDS can accelerate the uptake by putting the latest evidence-based recommendations at clinicians’ fingertips, using the right formats at the right time to support them to make improved care decisions. However, healthcare systems and CDS developers often design and implement CDS in siloes, which limits dissemination of lessons learned across institutions and projects.

AHRQ has a long history of investing in research on making CDS more effective, usable, and shareable. Most recently, through funding from the Patient-Centered Outcomes Research (PCOR) Trust Fund, AHRQ has invested in a multi-component initiative (see Figure). The initiative has two ambitious goals: 1) to advance PCOR evidence into practice through CDS, and 2) to make CDS more shareable, standards-based, and publicly available.

 

Four Components of AHRQ’s PCOR CDS Initiative. 1) engaging a stakeholder community; 2) creating prototype infrastructure for sharing CDS and developing CDS; 3) advancing CDS through grant funded research; and 4) evaluating the overall initiative

 

AHRQ Invests in CDS Connect to Make CDS More Sharable, Standards-Based, and Publicly Available

CDS tools are typically developed for one organization’s EHR in a format that is not easily shared with others. Creating CDS content requires input from busy clinicians to review and choose guidelines and to specify the CDS system’s features. Then developers must build the tool according to those specifications. This approach results in each organization attempting to reinvent the wheel, leading to redundancies and the loss of precious time and resources. When new, evidence-based guidance becomes available, a fair amount of time often passes before developers can incorporate the new guidance into existing CDS tools because revisions typically require a significant amount of clinician and developer time and organizational funds. The goal of vendor-neutral interoperable CDS tools and systems is to enable organizations to share CDS so that widespread adoption occurs more efficiently.

To achieve the goal of shared, interoperable CDS, the development, revision, and dissemination processes must be standards-based. The emergence of standards, such as Health-Level 7® (HL7®)’s Clinical Quality Language (CQL) and FHIR, is rapidly advancing how healthcare organizations can share and implement interoperable CDS.

“By integrating the CDS tool, we were able to automate four USPSTF recommendations and increase preventive care using consumer-facing education in our platform.”
- Kristin Valdes, Founder and CEO, b.well Connected Health

A major focus of AHRQ’s CDS initiative is a public, web-based platform called CDS Connect. Built through a contract with the MITRE Corporation, CDS Connect makes authoring and sharing of CDS easier. CDS Connect includes an online public repository of CDS resources or “artifacts,” an authoring tool that generates standards-based CDS, and a public work group that drives the development and improvement of the platform. Importantly, CDS Connect demonstrates the platform’s functionality and tools by highlighting use cases that identify users, clinical recommendations, and technologies within a specific domain. The project then develops and disseminates CDS for that domain and makes the new tools available for re-use and adaptation to local systems.

For example, CDS Connect’s use case in 2019 focused on patient-facing CDS and preventive care. Based on USPSTF guidelines, the CDS Connect project developed CDS focused on cardiovascular disease2,3, and diabetes4,5. In partnership with b.well® Connected Health (b.well), the recommendations were delivered directly to consumers via b.well’s personalized health-management platform, which informed individuals about the potential benefits of relevant screening tests or other actions. Based on the individual’s own data in the platform and USPSTF recommendations, b.well participants were prompted, when appropriate, to speak with their doctor or schedule appointments. When participants carried out specific actions, they received rewards. As of June 2020, the CDS had been used by over 2,000 people through b.well’s platform, with many individuals completing educational activities or scheduling followup visits with their providers as a result.

Information about how this CDS was developed and deployed in b.well, including an implementation guide and interoperable logic in the form of HL-7’s CQL, is available on CDS Connect. Similar guides that include CQL are available for use cases from 2017 and 2018. These guides focused on clinician-facing CDS tools in the domains of cholesterol management and chronic pain management.

Four steps: 1) CDS Authoring, Publish clinical decision support artifacts without the CDS authoring tool. 2) CDS Connect, explore and disseminate resources for clinical decision support. 3) Health IT systems, implement CDS relevant and useful to the healthcare organization. 4) Clinical Teams, use the resources alongside existing workflows to improve quality of care.

 

Further Disseminating PCOR Findings through Applied CDS Research

In 2019, AHRQ awarded the following two grants to advance evidence into practice using CDS resources. Both will use the AHRQ CDS Connect authoring tool and health IT standards.

  • Dr. Daniel Malone at the University of Utah is investigating how to apply CDS for drug-drug interactions (DDIs) and how to incorporate the patient perspective using an interactive decision dashboard. Because DDIs are potentially harmful, sometimes even fatal, when combining medications, those risks must be considered. One particular DDI under study is the combined use of warfarin and non-steroidal anti-inflammatory drugs. Providers will use the dashboard to graphically communicate potential risks and decision options, allowing patients and providers to discuss therapy options, while taking into consideration patient preferences and goals.
  • Dr. David Dorr at the Oregon Health and Science University is studying how to address conflicting hypertension guidelines and make hypertension treatment decision-making more patient-centric. While hypertension guidelines are regularly updated, they are often not tailored to patient-specific characteristics such as severity of disease, age, race, ethnicity, other comorbid conditions, and the individual’s preferences. This research will translate hypertension guidelines into interoperable and shareable CDS tools that enable providers and patients to make patient-centered decisions.

Building a Learning Community Focused on Patient-Centered CDS

Patient engagement has always been a focus of AHRQ CDS research. From 2016-2020, RTI International led the Patient-Centered CDS Learning Network (“Learning Network”). Over the course of the grant, the Learning Network convened annual in-person meetings, created work groups, and disseminated important thought pieces and other resources to advance patient-centered CDS. In 2019, one work group focused on incorporating patient input in the design of patient-facing CDS apps (i.e., apps intended for consumers and those used as portals for patients to connect to their providers and EHR). In prior years, work groups developed a Trust Framework for sharing CDS through public platforms and a National Opioid Action Plan for leveraging patient-centered CDS to combat the opioid epidemic. The theme of the 2019 annual meeting was “Optimizing Health through Patient-Facing Clinical Decision Support.” It featured keynotes from patient activists and physician researchers working to integrate the patient perspective into the design and implementation of CDS. While the grant has ended, the resources produced are available on the Learning Network website, including reports, white papers, and other content about patient-centered CDS.

AHRQ Continues to Lead CDS Research by Scaling and Disseminating Evidence-Based, Interoperable CDS

View AHRQ CDS Connect: A Primer (3m 35s)

Alternative Audio-Described Version (4m 49s)

Learn more about the AHRQ CDS Connect project and how healthcare organizations can use standards to implement CDS.

In 2019, AHRQ’s CDS initiative continued to advance the incorporation of PCOR findings in clinical practice by convening stakeholders, building prototype tools for authoring and sharing CDS, and funding demonstrations for making CDS more interoperable. Demonstrations and publicly shareable CDS artifacts are crucial because they disseminate lessons learned and enable healthcare organizations to build on what others have accomplished.

One area of interest for AHRQ is the uptake of health IT standards such as HL7 FHIR. Adoption of FHIR continues to rise, but healthcare organizations’ integration of FHIR in EHRs continues to require significant customization. This is necessary to fill the gaps between FHIR resources required by standards-based CDS apps and the more limited set of resources commonly available through the application programming interfaces (API) of commercial EHRs. Customization reflects the nuances of local architectures, data flows, and clinical preferences, especially for CDS. Infrastructure like CDS Connect, which provides a platform for sharing implementation guides, pilot reports, and lessons learned from CDS implementation in production settings, helps healthcare organizations to learn from each other’s experiences and improve their practices.

The AHRQ Digital Healthcare Research Program will continue to invest in research to disseminate and spread interoperable CDS that help clinicians, patients, and others in care teams by delivering the right information at the right time so they can make the best care decisions.