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Advance for Health Information Professionals • January 2017

ADVANCE FOR HEALTH INFORMATION PROFESSIONALS / CDS To support goals ranging from eliminating waste to aligning care delivery with payment incentives, provider organizations publish clinical guidelines for good reason. compliance. For large health delivery organizations, initiatives can be rolled out across the enterprise, encompassing multiple stakeholders who benefit from one development effort. Promoting Compliance Clinical decision support systems run on top of electronic medical record (EMR) systems, comparing clinician actions as they are recorded to information that can reside in various repositories— many of which are not accessible to the clinician at the point of care. This relevant clinical data can include unstructured information in EMR free text, patient monitoring systems, data recorded in the systems of labs and radiology departments and providers’ notes. When CDS analysis indicates a recorded clinical action should be reconsidered, the system presents an alert within an EMR pop-up window. In the best of these systems, alerts are relatively rare, limited to instances of highly probable concern to avoid false alarms. Clinicians remain in charge of all decisions and can choose to comply with or ignore alerts. For “hard stop” alerts, clinicians must record the reason for non-compliance. Intelligent CDS systems track post-prompt actions for each clinician, and provide reports that show compliance rates by clinician as well as trends over time. By issuing alerts at the point of care and within clinical workflow, CDS can address non-compliance issues at the point of origination. A reminder that appears when action is being initiated is far more effective than expecting clinicians to study, remember and keep current on published guidelines in material reviewed separately. 15 JANUARY 2017


Advance for Health Information Professionals • January 2017
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