CHAPTER ■ CLINICAL DECISION SUPPORT JOSEPH J ZORC, NAVEEN MUTHU Clinical decision support (CDS), broadly considered, encompasses any system, device, or document that is intended to support decision making by any individual involved in providing or receiving health care CDS has existed as long as clinical decisions have been made, and covers a wide variety of tools in the acute pediatric setting ranging from algorithms such as resuscitation guidelines or clinical pathways, devices such as measurement tapes for dose calculation, or complex smartphone applications to make diagnoses or apply clinical decision rules at the bedside More recently, CDS has become a focus within the field of clinical informatics, where it has been defined by Osheroff as content that “provides clinicians, staff, patients, or other individuals with knowledge and personspecific information, intelligently filtered or presented at appropriate times, to enhance health and health care.” Academic research and quality improvement work has often focused on CDS within the electronic health record (EHR), given its widespread recent adoption and central role within systems of clinical care However, the EHR is only one of many channels available to provide CDS PEOPLE, PROCESS, THEN TECHNOLOGY When considering an opportunity to use CDS to improve clinical care, the first step is to develop a team and identify the appropriate individuals who can best lead, inform, implement and sustain the project An adage within clinical informatics is the importance of focusing on people and process analysis before launching a proposed technology solution Much as erecting a building relies on a solid foundation, good CDS rests on an informed understanding of the individuals who will interact with the potential system, including their knowledge, attitudes, beliefs and limitations These team members can then map out the current state of the clinical process to provide a baseline for proposed interventions In parallel, understanding the goals of stakeholders and leadership will create champions and investment in resources that will be critical to CDS implementation and sustenance One of these stakeholders is the local information services team and understanding the availability of knowledge and resources within this group may provide insight into important technical constraints that affect which CDS intervention is chosen A systematic comprehensive approach to designing CDS in the acute pediatric setting has been well described in Sheehan et al., a project implementing EHR-based CDS to support a decision rule to reduce unnecessary imaging for children with head injury This project conducted a formal “sociotechnical analysis” including focus groups, workflow observation, and interviews to map out themes related to how staff interact with the EHR while providing care for these children This “gold standard” example from researchers within the Pediatric Emergency Care Applied Research Network (PECARN) provides an excellent reference for themes that are common to many acute care clinical processes However, when less resources are available, a well-led team can often an effective job in a few meetings by bringing the right team members together to map the process on a blackboard Often, producing a “fishbone diagram” identifying themes or a workflow map listing the steps in the process is an effective approach in a group meeting A “driver diagram” of key primary and secondary themes can identify key issues that may need to be addressed within or outside of technology systems CDS OPPORTUNITIES ACROSS A HEALTHCARE ENCOUNTER Determining the right approach within in a clinical process to provide CDS is another key decision Often CDS designers may fall back on familiar tools such as pop-up alerts that may be the first option to come to mind given their ubiquitous presence in EHRs However, in isolation, these popup alerts may be one of least effective methods of CDS Prior to selecting an intervention, the team should consider the full breadth of options for CDS within and outside of the EHR Osheroff and others have developed conceptual models for potential CDS opportunities across the span of a healthcare encounter, from before a patient arrives to after discharge Fortunately there are examples of each of these opportunities applied to acute pediatric care available in the literature (see Table 3.1 ) Pre-Visit Prior to a visit, information can be provided actively through referral from another provider or gathered passively from systems such as the EHR or emergency medical services (EMS) systems As an example, Dandoy describes how one pediatric ED group developed a process for oncology providers to provide recommendations in advance of an ED visit for a child referred for fever These recommendations were implemented at the time of referral using an order set The lead time provided by early ordering greatly enhanced timeliness so that antibiotics could be administered rapidly after arrival Assessment and Plan Formulation During the initial assessment phase multiple opportunities exist for CDS in the workflows of various team members For the PECARN head injury decision rule project described above, these opportunities were leveraged to gather information about risk factors through as many avenues as possible, including nursing triage and physician data entry A key theme identified in the project was the importance of delivering the CDS as early as possible, ideally prior to the provider’s evaluation of the patient, as they may have already discussed imaging with the family and made the decision by the time they used the EHR for order entry When multiple team members enter data to trigger CDS, this introduces the issue of validity and potential disagreement between those sources, and the need to update them based on additional information, which was also addressed in this project Documentation tools such as note templates that may be used by providers during history-taking can provide a useful noninterruptive and easily implemented technology method to guide data collection and provide links to CDS resources However, clinicians may often wait to document until after clinical care is delivered, limiting its timeliness TABLE 3.1 CLINICAL DECISION SUPPORT APPLIED ACROSS THE PHASES OF PEDIATRIC ACUTE CARE ... providing care for these children This “gold standard” example from researchers within the Pediatric Emergency Care Applied Research Network (PECARN) provides an excellent reference for themes... provider or gathered passively from systems such as the EHR or emergency medical services (EMS) systems As an example, Dandoy describes how one pediatric ED group developed a process for oncology providers... after discharge Fortunately there are examples of each of these opportunities applied to acute pediatric care available in the literature (see Table 3.1 ) Pre-Visit Prior to a visit, information