Best Practices For Integrating Clinical Decision Support Into Clinical Workflow

Implemented in progressive stages, the Health Information Technology for Economic and Clinical Health Act (HITECH) aimed to modernize and advance the Nation’s health care infrastructure through supporting the meaningful use (MU) of certified electronic health records (EHRs). The Stage 3 clinical decision support (CDS) objective aimed to support higher levels of outcomes-oriented coordinated care and population health management. While many healthcare providers may think solely of CDS systems as alerts or reminders, this study defined CDS more broadly as a process for enhancing health-related decisions and actions with pertinent, organized clinical knowledge and patient information to improve health and healthcare delivery.

This project determined the intensity of support that community health centers (CHCs) need to achieve the Stage 3 MU CDS objective. Additionally, it assessed strategies to more effectively integrate CDS and clinical workflows in order to improve performance on high priority health conditions. The two health priorities targeted in this study were asthma control and cardiovascular disease prevention.

The specific aims of this project were as follows:

• Determine the practice-level factors associated with successful implementation of the proposed MU Stage 3 CDS objective for two high priority health conditions—cardiovascular disease prevention and asthma management—across a national network of federally qualified health centers. 
• Determine the effects of contextual factors, such as a practice’s quality improvement infrastructure and history of innovation, on the level of support needed to achieve high rates of CDS use and integration into clinical workflow. 

Twelve practice sites were randomized to 6 months of high intensity support that included a CDS implementation toolkit with practice coaching support or low intensity support consisting of the toolkit only. The rate of asthma CDS use increased by 9.2 percent in the low intensity group and 7.3 percent in the high intensity group, but the rate of prescriptions for asthma controller medications did not significantly change for either group. For cardiovascular disease prevention, CDS use decreased by 2.3 percent in the low intensity group and increased by 4.3 percent in the high intensity group; however, the rate of statin prescriptions did not change for either group.

This study concluded that the use of a relatively low intensity, freely available CDS implementation toolkit may help CHCs to increase and improve their use of CDS over a relatively short time period. Studies of longer duration are needed to determine whether this type of support may also lead to improved clinical outcomes.