CDS Organizational Governance
• CDS Organizational Governance
CDS Organizational • How an organization manages its decision-making around
Governance
CDS adoption, including:
• New CDS implementation
• Review/approval of revisions to existing CDS
• Maintenance (reviewing all CDS within a set timeframe)
• Evaluation of efficacy of CDS
CDS Organizational Governance CDS Organizational Governance
• CDS organizational governance structures will vary based on • Other factors such as existing leadership structures and roles
the size and complexity of an organization may determine assignment of CDS governance
• Large academic medical centers (teaching) responsibilities
• Community hospitals (non-teaching) • No single or standard recipe for Organizational Governance
• Large or small Physician practices
CDS Organizational Governance CDS Organizational Governance
• Generally, CDS Organizational Governance structures Organizational Leadership
include: • Makeup of this group varies depending on the size of an organization
• Organizational Leadership • For large hospitals/medical centers, various leaders may be involved,
• CDS Team including - Board of Trustees, CEO, COO, CMIO/CMO, CNO, CQO
• Champions • Determine the hospital strategic goals based on hospital’s
• Key Stakeholders performance
• Clinical Decision Support Committee • Will also make high-level decisions around CDS based on
organization’s strategic goals
CDS Organizational Governance CDS Organizational Governance
CDS Team Champions
• Team responsible for developing the CDS intervention, project led by • Respected members of the constituencies who will receive the CDS
the Project Manager • Fully understand and support the CDS efforts, goals and strategies and can
• Includes: a clinical leader, an administrative or nursing leader, and a serve as ambassadors for successful use by their peers
technical expert (within organization or organization’s EHR vendor) • Liaisons between the CDS development team and end users
who can operationalize desired CDS interventions • Dedicated time for champion-related activities, including working with the
• Collaborates directly with clinical champion(s), staff, consultants, technical team and/or vendor, learning about and then communicating
and/or vendor personnel, CDS governance committees with staff about the CDS program and individual interventions before,
during and after their launch, and helping to refine interventions (in
collaboration with the technical team) after implementation
CDS Organizational Governance CDS Organizational Governance
Key Stakeholders Clinical Decision Support Committee
• CDS intervention recipients – end users who will receive and use the • Group that performs an oversight function for all CDS within the
organization, led by the CMIO, or other Physician leader
CDS (i.e., nurses, pharmacists, physicians, or other clinical disciplines
• May be responsible for reviewing and approving all CDS requests,
• Closest to the clinical workflow/direct patient interaction monitoring progress and results
• Can also include those who supply information upstream (i.e., patient • A typical CDS Committee might include: representation from primary and
weights or other data) needed for intervention success or those who specialty care; representation that includes all major stakeholder groups;
provide downstream services or supplies (i.e., mammogram testing, Resident MDs, if a teaching hospital; Mid-level providers (typically heavy
users of the system); Nursing and nursing informatics; Ancillary
or vaccines and staff to inject them) needed to carry out the departments (pharmacy, respiratory therapy, lab, etc.); Medication safety
intervention’s ultimate intent officer; Quality officer; unofficial “opinion leaders” on the medical staff or
in the practice; vocal resistors to technology and standardization of care
CDS Organizational Governance CDS Organizational Governance
Sample CDS Sample roles
Committee and
with responsibilities
interrelated for a large
Governance organization
Structures
Osheroff, J. A., Teich, J. M., Levick, D., Saldana, L., Velasco, F., & Sittig, D. F. (2012). Improving Outcomes with Clinical Decision Support (2nd Edition). CRC Press. Osheroff, J. A., Teich, J. M., Levick, D., Saldana, L., Velasco, F., & Sittig, D. F. (2012). Improving Outcomes with Clinical Decision Support (2nd Edition). CRC Press.
[Link] [Link]
Challenges of CDS*
• Potential “harm” of CDS can include:
• Alert fatigue
CDS Challenges • Users are presented with many alerts, then dismiss them all regardless of importance
• Negative impact on user skills
• Reliance/dependence on CDSS (e.g., system downtime)
• Financial challenges
• Expensive, cost/benefit may be hard to assess
• System and content maintenance challenges
• Evolving EBP may require constant updates in CDSS
• Disrupted or fragmented workflow
• May be unnatural to inject the use of CDS during some processes or provider/patient
interactions
CDS Challenges CDS Challenges
Alert Fatigue Solutions to mitigate: Negative impact on user Solutions to mitigate:
• A phenomenon where too • Prioritize critical alerts, skills • Avoid prescriptiveness in
many insignificant alerts or minimize use of disruptive • Reliance on, or excessive system design. Evaluate
CDSS recommendations are alerts for non-critical trust in the accuracy of a system impact on an
presented, and providers indications system. ongoing basis
start to dismiss them
regardless of importance.
Sutton, R. T., Pincock, D., Baumgart, D. C., Sadowski, D. C., Fedorak, R. N., & Kroeker, K. I. (2020). An overview of clinical decision support systems: benefits, risks, and Sutton, R. T., Pincock, D., Baumgart, D. C., Sadowski, D. C., Fedorak, R. N., & Kroeker, K. I. (2020). An overview of clinical decision support systems: benefits, risks, and
strategies for success. NPJ digital medicine, 3, 17. [Link] strategies for success. NPJ digital medicine, 3, 17. [Link]
CDS Challenges CDS Challenges
System and content Solutions to mitigate: User distrust of CDSS Solutions to mitigate:
maintenance challenges • (1) Knowledge Management • Users may not agree with • Reference expert
• As practice changes, there (KM) Service in place, with a the guideline provided by knowledge— include
can be difficulty keeping the focus on translation to CDSS the CDSS scientific references in
content and knowledge systems. messages where appropriate
rules that power CDSS up to • (2) System for measurement
date and analysis of CDSS
performance.
Sutton, R. T., Pincock, D., Baumgart, D. C., Sadowski, D. C., Fedorak, R. N., & Kroeker, K. I. (2020). An overview of clinical decision support systems: benefits, risks, and Sutton, R. T., Pincock, D., Baumgart, D. C., Sadowski, D. C., Fedorak, R. N., & Kroeker, K. I. (2020). An overview of clinical decision support systems: benefits, risks, and
strategies for success. NPJ digital medicine, 3, 17. [Link] strategies for success. NPJ digital medicine, 3, 17. [Link]
CDS Challenges CDS Challenges
Dependency on computer Solutions to mitigate: Inaccurate and poor-quality Solutions to mitigate:
literacy • (1) Conform to existing data / documentation • (1) Expert Knowledge of
• CDSS may require a very functionality • CDSS may aggregate data interlinked systems
high technological • (2) Adequate training made from multiple sources that • (2) IT testing/debugging
proficiency to use available at launch. are not synced properly. during development and
Users may develop manual implementation stage.
workarounds that
compromise data.
Sutton, R. T., Pincock, D., Baumgart, D. C., Sadowski, D. C., Fedorak, R. N., & Kroeker, K. I. (2020). An overview of clinical decision support systems: benefits, risks, and Sutton, R. T., Pincock, D., Baumgart, D. C., Sadowski, D. C., Fedorak, R. N., & Kroeker, K. I. (2020). An overview of clinical decision support systems: benefits, risks, and
strategies for success. NPJ digital medicine, 3, 17. [Link] strategies for success. NPJ digital medicine, 3, 17. [Link]
CDS Challenges
Disrupted / fragmented Solutions to mitigate:
workflow • (1) Usability evaluation
• CDSS can also disrupt • (2) Workflow modeling
existing workflows if they
require interaction external
to the EHR, or don’t match
the providers’ real world
information processing
sequences
Sutton, R. T., Pincock, D., Baumgart, D. C., Sadowski, D. C., Fedorak, R. N., & Kroeker, K. I. (2020). An overview of clinical decision support systems: benefits, risks, and
strategies for success. NPJ digital medicine, 3, 17. [Link]