CDS Advice Delivered Via EHR

Provision of Chronic Disease Management and Preventive Care Recommendations to a Primary Care Clinician through an EHR System

(Scenario originally described in HL7 Decision Support Service (DSS) Service Functional Model (SFM) Version 1.0)

Scenario Details: Patient Jane checks into David’s clinic for her appointment. The EHR system asks DSS A to evaluate Jane using the knowledge module for chronic disease management and preventive care. Based on Jane’s age, gender, and active problems, the system recommends that Jane be evaluated using the knowledge modules that pertain to colon cancer screening, breast cancer screening, cervical cancer screening, and the management of diabetes mellitus.

The system retrieves the data required by the knowledge modules from the clinical data repository, evaluates it, and displays its recommendations to several different users.

The clinic intake nurse receives an alert in the appointment check-in module indicating that Jane needs a screening retinal exam. As a nurse practitioner trained in pharmacologically dilated fundus photography, she obtains the required screening photographs, documents the procedure in the medical record, and uploads the images for David to review.

David soon sees Jane for her appointment. At the end of the visit, he reviews the care recommendations provided by the DSS system, examines the logic and evidence behind one of the recommendations that seemed questionable, but he decides the system was indeed correct and explains all of the recommendations to Jane. Obtaining Jane’s consent, David then clicks on the “order” link next to each recommendation and places the appropriate order directly into the CPOE system.

During end-of-day processing, the Clinical Quality Manager reviews the system recommendation logs, the actions taken by clinic personnel to address them, and ensures that adequate steps to address them have been taken. She notes with satisfaction that Janes’s diabetic health maintenance requirements were resolved promptly.

Actors: Clinic Intake Nurse, Physician (David), Patient (Jane), Clinical Quality Manager

Requirements:

Requirement #	Description
1.1.1	The System shall be capable of using several external triggers to initiate the Clinical Decision Support (CDS) process. These triggers are primarily event-based and data-driven. Examples of triggers include status change of an appointment in an EHR system to ‘checked-in’, an in-patient admission or a medical device data upload event.
1.1.2	The System shall expose alerts / recommendations within a variety of clinical interfaces in workflow appropriate ways, for example in the appointment interface during check-in.
1.1.3	The System shall allow or require recipients to acknowledge alerts and to document what or how the issue was resolved (based on whether the rule author set the alert acknowledgement and resolution as optional or mandatory) for audit and process improvement monitoring.
1.1.4	The System shall optionally incorporate acknowledgement data within the patient chart or may be configured to require it.
1.1.5	The System shall have access to relevant patient medical data including diagnoses, medications, adverse events, radiology, labs, appointments, etc.
1.1.6	The System shall make metadata and narrative information regarding any executed rule visible to the user for validation and transparency.
1.1.7	The System shall enable providers to apply their digital signature to orders generated by the system and thereafter propagate them to the CPOE as live orders.
1.1.8	The System shall be capable of inferring the relevant associated knowledge modules that are applicable to a patient and of inserting them into the clinical decision support workflow.
1.1.9	The System shall be capable of evaluations initiated on a scheduled basis. Scheduled evaluations are critical to ensuring that over time individuals or known populations of patients (for example, diabetics from a disease registry) can be screened for compliance with evidence-based guidelines.
1.1.10	The System shall provide for or integrate into a Notification Service responsible of enacting CDS recommendations / tasks according to the needs or capabilities of the deploying organization. This Notification Service will be driven by the attributes and metadata defined in the Knowledge Module being executed.