Structuring Care Recommendations for Clinical Decision Support

Historically, evidence-based clinical recommendations and performance measures have been resource intensive to implement into electronic health records (EHRs). This project developed a process for translating narrative, unstructured, evidence-based clinical recommendations and performance measures into a structured, coded format that can be implemented into health information technology (IT) systems, applications, and products. By developing such a process, the ability to integrate robust clinical decision support (CDS) rules into local health IT systems is made far easier, potentially broadening adoption of CDS and leading to improved patient care and outcomes. These structured recommendations became known as eRecommendations.

The main objectives of the project were to:

• Increase use of interventions (e.g., tests, medications, and counseling) for which evidence-based clinical recommendations indicate a clear benefit to patients. An example is routine screening for colorectal cancer in individuals between the ages of 50 and 75.
• Make it easier for clinical information system suppliers (e.g., government agencies and commercial vendors) and implementers (e.g., hospitals and physician practices) to develop and implement automated clinical reminders and related CDS tools based on widely accepted care recommendations.
• Produce and populate, with broad stakeholder input, an "eRecommendation" format for expressing clinical recommendations as structured, coded logic statements that are widely useful. This includes leveraging codes and structures used to express clinical performance measures in a computable format to help tighten the measurement and CDS components of the clinical performance improvement cycle.
• Leverage the eRecommendation format and project learning to help clinical guideline developers make their recommendations more precise and easier to translate into automated clinical reminders.

The project team developed, vetted with stakeholders, documented, and tested their formal methodology. They created structured eRecommendations for the 45 A and B recommendations from the U.S. Preventive Services Task Force and 12 rules relevant to Stage 1 Meaningful Use measures. The team created two guides to help users create and use eRecommendations. Throughout the project, the format and content of eRecommendations were vetted extensively with multiple stakeholders. Broad stakeholder feedback, which included health care provider organizations, guideline developers, EHR, and CDS suppliers, indicated wide interest in the eRecommendation work and belief that the project materials could deliver significant value.

Related projects have taken note of this project's work. The Advancing Clinical Decision Support portal project, an Office of the National Coordinator (ONC)-sponsored project, will be making eRecommendations available to the public on their portal. An additional ONC-sponsored project, the Strategic Health IT Advanced Research Projects C-2B project, will create an implementer's workbench to configuring setting specific factors related to converting eRecommendations into locally-useful CDS rules. This project interplay appears to have stimulated CDS rule development and value that is greater than the sum of the individual projects.