William A. Hyman
Professor Emeritus, Biomedical Engineering
Texas A&M University, w-hyman@tamu.edu
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Clinical Decision Support (CDS) has been part of Meaningful Use (MU) under the EHR incentive program. The current CDS requirement for hospitals is to implement five clinical decision support interventions related to four or more clinical quality measures at a relevant point in patient care for the entire EHR reporting period and to implement drug-drug and drug-allergy interaction checks. This requirement has been reflected in part in the certification standards for compliant EHRs which requires a capability for evidence-based decision support interventions based on individual patient data. In addition, EHR technology must be able to electronically identify reference information. Despite these requirements the value of CDS is for the most part unproven and the occurrence of the associated EHR alerts has been criticized as annoying and distracting. None-the-less an undated CMS CDS “Tip Sheet” asserts that “CDS has the potential to improve care and is a centerpiece of the Medicare and Medicaid EHR Incentive Programs”. Perhaps the key word here is “potential”. Similarly, it is enthusiastically stated that “When CDS is applied effectively, it increases quality of care, enhances health outcomes, helps to avoid errors and adverse events, improves efficiency, reduces costs, and boosts provider and patient satisfaction”. Here the key words are apparently “applied effectively”, ie it is good when it is good.
But now CMS is dropping the CDS requirement for hospitals as detailed in the 764-page Proposed Rule of July, 2016 and briefly stated in the associated press release. The finalization of this proposal is expected “soon”. Similarly, the CPOE requirement is also being dropped. Of course, CDS and CPOE no longer being required does not mean they cannot still be used. In a bit of what appears to me to be specious logic, one of the reasons given for dropping CDS from attestation is the very high percentage of hospitals that attested to meeting the requirement. This means that having been told that they must do it, they actually did it, or said they did it. Therefore, proof (if attestation is proof) that they are doing it is no longer required. This logic says nothing about whether they will continue to use CDS if they are no longer required to.
There are several caveats in the new rule. One is that Advanced Diagnostic Imaging Services will still have to use automated checking against Appropriate Use Criteria (AUC). Another is that EHR certification will continue to include the same CDS requirements as before. There is no mention of whether or not the user can turn off the CDS after the EHR is in use. It also remains to be seen if CDS will also be dropped under State Medicaid EHR Incentive Programs. In this regard, it is noted in the proposal that eliminating a requirement creates a new burden on the states to revise their regulations.
Speaking of burdens, I was intrigued by CMS’s estimate of how much time would be saved by a hospital not having to attest to CDS compliance. This estimate is one (1) minute. The significance of this savings can best be appreciated in the context of the more than 6 hours estimated for overall attestation. I can already imagine the great work people will do with this saved minute, or perhaps the frivolity that will ensue during this minute of leisure. On the other hand, if this number has any relationship to realty, then one might wonder why the requirement should be dropped if it only takes one minute to comply.