New Standards for Clinical Decision Support: A Survey of The State of Implementation

Abstract

Summary Objectives: To review the current state of research on designing and implementing clinical decision support (CDS) using four current interoperability standards: Fast Healthcare Interoperability Resources (FHIR); Substitutable Medical Applications and Reusable Technologies (SMART); Clinical Quality Language (CQL); and CDS Hooks. Methods: We conducted a review of original studies describing development of specific CDS tools or infrastructures using one of the four targeted standards, regardless of implementation stage. Citations published any time before the literature search was executed on October 21, 2020 were retrieved from PubMed. Two reviewers independently screened articles and abstracted data according to a protocol designed by team consensus. Results: Of 290 articles identified via PubMed search, 44 were included in this study. More than three quarters were published since 2018. Forty-three (98%) used FHIR; 22 (50%) used SMART; two (5%) used CQL; and eight (18%) used CDS Hooks. Twenty-four (55%) were in the design stage, 15 (34%) in the piloting stage, and five (11%) were deployed in a real-world setting. Only 12 (27%) of the articles reported an evaluation of the technology under development. Three of the four articles describing a deployed technology reported an evaluation. Only two evaluations with randomized study components were identified. Conclusion: The diversity of topics and approaches identified in the literature highlights the utility of these standards. The infrequency of reported evaluations, as well as the high number of studies in the design or piloting stage, indicate that these technologies are still early in their life cycles. Informaticists will require a stronger evidence base to understand the implications of using these standards in CDS design and implementation.

Lessons Learned from a National Initiative Promoting Publicly Available Standards-Based Clinical Decision Support

“… 30 The few studies on the efficacy of publicly available, standards-based CDS generally focus on new products and the design or pilot stages of CDS development, rather than outcomes. 13 Yet, we found that demonstrating a return on investment (ROI) is critical to promoting CDS uptake.…”

“…10,11 See ►Table 1 for description. 12,13 Only two publicly available repositories make EHR-agnostic CDS artifacts and resources freely available. One, OpenCDS, is a collaborative community that leverages open-source tooling and services to support modular development of standards-based CDS.…”

The Impact of Clinical Decision Support on Health Disparities and the Digital Divide

“…We developed our search strategy by first using existing published strategies. To identify publications about CDS, we adopted the strategy developed by Bright et al [17], then expanded to include additional search terms identified through more recent reviews [18,19], such as "best practice advisory." We then limited the publications using the MEDLINE®/PubMed® Health Disparities and Minority Health Search Strategy [20] and search terms for digital divide.…”

Do clinical decision support systems for prescribing improve patient safety? a systematic literature review

“…Now, doctors are using CDSS more and more in many different areas, such as infection management [2], care for the elderly [3], [4], diabetes mellitus [5], chemotherapy [6], fractures [7], and cardiovascular [8]. However, the rarity of reported evaluations, as well as the high number of studies in the design or pilot phase, suggest that the use of this CDSS to support decision making is considered new and requires further study [9]. When CDSS is used correctly, it makes it possible to combine human intelligence and artificial intelligence, which are both good at doing empirical tasks [10].…”