A qualitative study of the activities performed by people involved in clinical decision support: recommended practices for success.

OBJECTIVE: To describe the activities performed by people involved in clinical decision support (CDS) at leading sites. MATERIALS AND METHODS: We conducted ethnographic observations at seven diverse sites with a history of excellence in CDS using the Rapid Assessment Process and analyzed the data using a series of card sorts, informed by Linstone's Multiple Perspectives Model. RESULTS: We identified 18 activities and grouped them into four areas. Area 1: Fostering relationships across the organization, with activities (a) training and support, (b) visibility/presence on the floor, (c) liaising between people, (d) administration and leadership, (e) project management, (f) cheerleading/buy-in/sponsorship, (g) preparing for CDS implementation. Area 2: Assembling the system with activities (a) providing technical support, (b) CDS content development, (c) purchasing products from vendors (d) knowledge management, (e) system integration. Area 3: Using CDS to achieve the organization's goals with activities (a) reporting, (b) requirements-gathering/specifications, (c) monitoring CDS, (d) linking CDS to goals, (e) managing data. Area 4: Participation in external policy and standards activities (this area consists of only a single activity). We also identified a set of recommendations associated with these 18 activities. DISCUSSION: All 18 activities we identified were performed at all sites, although the way they were organized into roles differed substantially. We consider these activities critical to the success of a CDS program. CONCLUSIONS: A series of activities are performed by sites strong in CDS, and sites adopting CDS should ensure they incorporate these activities into their efforts.

The Number Needed to Remind: a Measure for Assessing CDS Effectiveness.

BACKGROUND: Clinical decision support (CDS) is associated with improvement in quality and efficiency in healthcare delivery. The appropriate way to evaluate its effectiveness remains uncertain. METHODS: We analyzed data from our electronic health record (EHR) measuring the display frequency of eight reminders for Coronary Artery disease and Type 2 Diabetes and their associated performance according to a predefined methodology. We propose two key performance indicators to measure their impact on a target population: the reminder performance (RP), and the number needed to remind (NNR), to evaluate the impact that Clinical decision support reminders have on the adherence to guideline derived CDS interventions on the entire patient population, and individual providers receiving the interventions. RESULTS: Data were available for 116,027 patients and a total of 1,982,735 reminders were displayed to a subset of 65,516 patients during the study period from January 1 to December 31, 2010. The evaluation framework assessed provider acknowledgement of the CDS intervention, and the presence of the expected performance event while accounting for patients' exposure to the CDS reminders. The total RP was 2.7% while the average NNR was 3.1 for all the reminders under study. CONCLUSIONS: The proposed framework to asses of CDS performance provides a novel approach to improve the design and evaluation of CDS interventions. The application of this methodology represents an indicator to understand the impact of CDS interventions and subsequent patient outcomes. Further research is required to evaluate the impact of these systems on the quality of care.