CDS Forecast (Part 1): Cloudy With a Chance of FHIR

Many studies have shown that clinical decision support (CDS) can positively impact the behavior of providers, leading to better patient care. Despite that, adoption and implementation of CDS remains limited. Much of the CDS that is implemented today is of the simplistic, off-the-shelf drug-drug interaction checking variety.

This is in large part due to the effort required to design and implement effective CDS. Whether you purchase CDS content and rules from a vendor or author them in-house, integrating them into your EHR and deploying them at your institution is not for the faint of heart. Even the simplistic medication-related rules mentioned above pose challenges with maintenance and often lag behind current best-practice guidelines, regulations, and reimbursement policies.

The Promise of Cloud-Based CDS

Can cloud-based CDS services help your organization increase its adoption of CDS? A cloud-based CDS service has several advantages:

1. All of the rules, content, logic, etc., live off-prem in the cloud.
2. Your EHR and the cloud-based CDS interface via simple APIs — your EHR sends patient data to the cloud, and the CDS sends back context-aware guidance such as required immunizations for a childhood immunizations module.
3. All of the maintenance and upkeep of rules, value sets, and reporting is performed by your cloud-based CDS vendor with little effort on your part.

The Challenges — And the New Standards Solving Them

Sounds great, right? Mostly. Even this seemingly simple implementation comes with challenges:

1. Before you start implementing, you have to make sure your EHR supports integration with cloud-based CDS services.
2. You also have to make sure your EHR can feed the API that your CDS service uses with all of the right information in the right format (CCD, SNOMED, RxNorm, LOINC, etc.).
3. Finally, you have to make sure you can insert the CDS into the appropriate workflow within your EHR and at the right trigger point.

So how do we solve those challenges? Great news: new standards are being developed to remove these exact barriers. The CDS Hooks specification is becoming central to CDS services in the cloud. CDS Hooks includes named triggers that identify workflow points at which CDS is inserted. Retrieval of patient data to feed the CDS is handled using FHIR APIs. Decision support is sent from the cloud-based CDS back to the EHR as cards containing informational text, suggestions, or links to launch apps to collect more information. The suggestions are especially helpful as they come as structured FHIR resources that can be implemented as orders or other actions. We finally have actionable CDS in a language the EHR understands.

Momentum from the EHR Vendors

At AMIA’s Annual Symposium in Washington, I was fortunate to be part of a panel, led by Dr. Blackford Middleton of Apervita, discussing this topic with three of the leading EHR vendors. All of them are already implementing support for CDS Hooks. We at Elimu will be integrating our own pharmacogenomics CDS service via CDS Hooks with those same EHR vendors at HL7’s connectathon in January.

That’s it for now. Stay tuned for part 2, where I’ll discuss what scenarios make sense for cloud-based CDS.