The 5 ‘rights’ of clinical decision support

Screen pop-ups that alert, notify and suggest are a big part of clinical decision support (CDS).  But they are not the only ways to provide support.  They may not even be the best. The reason is simple. Alerts must “fire,” which means they need a trigger.

Sometimes those triggers are events that pose a threat to the welfare of the patient, put reimbursement at risk, or slow workflow.  Triggers, therefore, mean the risk has appeared.

Proactive tools put the clinician ahead of the game.  They can provide a “heads up” on something a patient needs like a test, a treatment, or a change in lifestyle. They turn clinical guidelines into condition-specific orders or recommendations for the 60-something patient who has a family history of colon cancer but no record of colonoscopy.

Armed with these facts, the physician convinces the patient – let’s say, a football coach with the personality of his high-school team’s mascot – to get a colonoscopy.  The test spots a tumor, which turns out to be cancer; for which the patient gets treatment; after which he lives to celebrate his next birthday and more. 

Here the CDS tool was built around an algorithm that mined the patient’s history. It uncovered risks, then looked for results from clinical tests that should have been performed.  When none were found, the CDS notified the physician of the specific test that should be done.  If results had been found, the CDS would have provided them to the physician.     

To be effective, CDS requires a kit comprised of several tools, each for a specific task. One might call-up a template that documents a patient’s condition.  Another might provide references helpful in the interpretation of an electronic health record (EHR).

What they all have in common is that they look for ways to make the physician more effective and more efficient – preventively, diagnostically, or therapeutically.

It’s easy to recognize a good CDS tool, using little more than the axiom “you’ll know it when you see it.” Determining ahead of time, however, whether a CDS tool will help – and figuring which tool will do the job – takes a bit more analysis.  The evaluation comes down to assessing the “five rights” of CDS:

1. The right information

2. To the right person

3. In the right intervention format

4. Through the right channel

5. At the right time in the workflow

Right information…evidence-based, derived from a set of recognized guidelines or based on a national performance measure – detailed enough for the end user to act upon, but not so detailed as to overload or cause the user to disregard it.

Right person…nurse, physician, physical therapist, significant other – whoever needs the information in order to act appropriately, excluding anyone who cannot take action.

Right way to intervene…alerts, order sets, protocols, patient monitoring systems, and info buttons – whatever is best suited to solve or address the problem or issue. 

Right channel…EHR, personal health record, computerized physician order entry, an app running on a smartphone, even a paper-based flowsheet, form or label.  Choosing the right channel depends on the person and circumstances under which the information is to be delivered. An EHR may be the best choice, when sending information to a physician in a networked office; but a smartphone app might be better suited, if the physician cannot access the network.)

Right timing…presenting information when it will do the most good.  Recognizing early in the prescription process that a patient is taking aspirin before sending the script for a blood thinner to the pharmacy is a good thing.  

Together the five rights provide a “best practice framework.” The common denominator of CDS is the improvement of patient care. Choosing the right tool is the goal.