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Implement five clinical decision support rules

Page history last edited by Jerry Osheroff 11 years ago

   “One CDS rule” as required by MU proposed regulations [The final rule decreased the requirement to 1 CDS rule]


Return to CDS and meaningful use home page 


  • Learn more about the final rule here: http://healthit.hhs.gov/portal/server.pt?open=512&objID=2996&mode=2 
  • A topical review of CDS within the MU regs can be found at www.himss.org/economicstimulus 


  • An AHRQ-funded project is developing structured, coded logic statements - from strongly evidence-based and widely accepted clinical recommendations - that implementers can further process and deploy as CDS rules.  Several of the logic statements provided by this project will deal with clinical recommendations corresponding to the meaningful use clinical measures noted in the tables above.  This material will be publicly available by 10/2011.

    • A more detailed description of the project can be found here 

    • A draft of the template plate that will be used to present the logic statements can be found here: eRecommendation template draft

    • Click here to provide comment on whether/how you might use this material and template in your efforts to address the '5 CDS rule' requirement     


In the coming months the CDS TF hopes to stimulate rich experience sharing and best practices around issues such as:


1.      What topics are being considered for the 1 CDS rule in your organization?

  • The following rules are either in effect or are in construction at our institution (Lehigh Valley Hospital, Don Levick):


              a)      DVT Prophylaxis: The rule invokes an order for DVT Prophylaxis when an admission order is placed. If no DVT prophlaxis order is placed, the clinician is prompted (required) to enter a reason why.

              b)      The Discharge Instruction application prompts the clinician to enter or check-off the Core Measure Indicators when the discharge diagnosis is CHF, Pneumonia or Chest Pain.

              c)      For non-urology cases, the clinician is alerted when a urinary catheter has been in place for more than 48 hours; the clinician must enter a reason for continuing the catheter

              d)      Medication – lab result based orders

    1.       Potassium supplements – if there is an elevated potassium level within 48hrs, the rule alerts the clinician at ordering, the pharmacist at verification, and the nurse at bar code scanning

    2.      Creatinine clearance is calculated and displayed when renally excreted medications are ordered.

    3.       Recent potassium level is displayed when clinician orders Digoxin; if there is no recent potassium level, the clinician is alerted of that.

    4.      Clinician is alerted when ordering Epogen if patient’s Hemoglobin is > 12

              e)      Cultural competency: the clinician is alerted when ordering blood products if the patient’s religion is Jehovah’s Witness.


  • These are some of things we have in testing or Production at Texas Health Resources that might align with the rule as written:

            a)  Upon discharging patients with diagnosis of Congestive Heart Failure, the physician is prompted  to use the CHF Discharge Order set, which drives physicians to address key measure components with hard stops. 1) ACEI or ARB on discharge or specify reason not ordered and other measures


            b)  Within admsiion order sets, physicians are prompted to order VTE prophylaxis based on risk assessment for patients>18 yrs of age and non-psychiatric patients.  If they do not order VTE prophylaxis for the patient they are prompted to provide a reason why VTE prophylaxis is not ordered.  At 24 hours, the system checks to see if VTE prophylaxis  (or a contraindication provided) is not ordered), and fires a BPA if there is not such an order.


          c)   Upon discharging patients with diagnosis of Acute MI, the physician is prompted  to use the Acute MI Discharge Order set, which drives physicians to address key measure components with hard stops. 1) Antiplatelet drugs prescribed or reason not ordered provided.


          d)   Upon discharging patients with diagnosis of Ischemic Stroke, the physician is prompted  to use the Stroke Discharge Order set, which drives physicians to address key measure components with hard stops. 1) Antiplatelet drugs prescribed or reasonn not ordered provided and other measures


          e)  For post-surgical patients, physicians are prompted to reevaluate the ongoing need for indwelling urinary catheter after 24 hours post insertion, and they must either discontinue the catheter or provide a reason not to discontinue the catheter.


  • [put your notes here]  




2.      What is the process for getting there, e.g. governance around selecting rules?

  • [put your notes here]


3.      Who’s driving the process (CMIO, CMO, IT, other)?

  • [put your notes here]


4.      What are the criteria for selecting the specific rules on which you will focus?

  • [put your notes here]


5.      How will these rules for MU integrate with other quality improvement/reporting activities already underway?

  • [put your notes here]


6.      How will your organization ensure that the rules do more good than harm, e.g. avoiding alert fatigue, etc. 

  • [put your notes here]








Comments (4)

Jerry Osheroff said

at 5:32 pm on Feb 2, 2010

Interesting to note high degree of overlap between LVH and THR rule priorities, e.g. DVT, core measures catheters. Hopefully we'll get a bunch more folks sharing, and sort through whether there really is a small set that have been top priority across many organizations. It wouldn't be surprising to find significant attention to such items, since several of these are tied to reimbursement (e.g. non-payment for hospital acquired conditions)

Joseph Ryan said

at 1:59 pm on Jul 29, 2010

I am very interested in knowing what the Eligible Professional clinical measures on which the 5 CDS rules must be focused on are. The link to table 20 only talks about the clinical measures for hospitals are, not for EPs. My focus is on the outpatient setting and I am trying to understand what a (Cliincal Decision Support System) CDSS really has to do to meet meaningful use. What is clear or what seems to be clear to me is that it is beyond the simple checks like drug to drug checking. Any thoughts?

Jerry Osheroff said

at 6:03 pm on Jul 29, 2010

Hi Joseph. The information about the NPRM no longer applies, now that the Final Rule has been published earlier this month. You can find out more about the Final Rule here: http://healthit.hhs.gov/portal/server.pt?open=512&objID=2996&mode=2. Best, Jerry

Joseph Ryan said

at 7:24 pm on Jul 29, 2010

Thanks Jerry for the response. I am still a little lost when it comes to CDSS and the final rule. It looks like in the 'final rule' there is now only 1 CDS rule instead of 5. Do you have any documentation on what this CDS requirement is for the EP side? My email is josephryan2011@u.northwestern.edu
I am trying to figure out what does a CDSS have to do to meet meaningful use more or less in terms of an EP. It still looks like it is beyond just simple drug to drug checking type of functionality.
What the final rule document says is the following:
"We purposefully used a description that would allow a provider significant leeway in determining the clinical decision support rules that are more relevant to their scope of practice and benefit their patients in the greatest way. In the proposed rule, we asked providers to relate the rules they select to clinical priorities and diagnostic test ordering". (pg 146 of Final Rule Document)
From reading this it seems like it doesn't matter what your CDSS does as long as it does something? Any clarification, documentation would be greatly appreciated. This is for a project I am working on at Northwestern Medical Informatics program (I'm a student in a clinical decision support class)

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