1. History of Health Information Technology in the U.S.
History of Clinical Decision Support Systems
Welcome to History of Health Information Technology in the US, History of Clinical Decision Support Systems. This is lecture c, Evolution of CDS. This lecture will review how CDS systems have evolved over the years, what the implementation challenges have been, and what is likely in the future.
Lecture c – Evolution of CDS
This material Comp5_Unit7 was developed by The University of Alabama Birmingham, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 1U24OC000023

2. History of Clinical Decision Support Systems Learning Objectives
Describe various types and structures of clinical decision support (CDS) systems
Discuss the evolution of clinical decision support from expert system research
Discuss the changes in focus of clinical decision support from the 1980s to the present
Discuss the change in architecture and mode of access of clinical decision support systems from the 1980s to the present
Describe some of the early clinical decision support systems
Discuss the historical challenges in implementing CDS
The Objectives for this unit, History of Clinical Decision Support Systems are to:
Describe various types and structures of clinical decision support (CDS) systems.
Discuss the evolution of clinical decision support from expert system research.
Discuss the changes in focus of clinical decision support from the 1980s to the present.
Discuss the change in architecture and mode of access of clinical decision support systems from the 1980s to the present.
Describe some of the early clinical decision support systems.
Discuss the historical challenges in implementing CDS.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the US History of Clinical Decision Support Systems Lecture c

3. Evolution of CDS Diagnostic and reminder CDS Drug Interaction CDS
1980s to early 1990s
Drug Interaction CDS
1990s to Present
Quality Indicator CDS
2010 and beyond
We have reviewed only a few of the CDS systems that began to proliferate beginning in the late 1960s. During the 1980s clinical decision support was a major focus for informatics research and development. During that time there was a focus on diagnostic systems and reminder systems. From the late 1990s on there has been increasing interest in CDS to prevent problems when ordering medications.
In the future there is likely to be more CDS development focused on specific healthcare quality issues. These might include, for instance, reminders to monitor diabetic patients' glucose control and other indicators derived from evidence-based guidelines.
In addition to the shifts in content focus for CDS, the changes in how CDS is integrated into other systems has changed over the years.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the US History of Clinical Decision Support Systems Lecture c

4. Evolution of CDS Architecture
Stand-alone systems
Source: (Wright & Sittig, 2008)
In 2008, Adam Wright and Dean Sittig (pronounced SIT-ig) summarized some of the changes in CDS architecture over the years. By architecture they mean both how the CDS is constructed and how it is accessed, and more particularly how “sharable” the knowledge base is.
They identified four phases, although programs typical of early phases often overlapped with later ones. The first were the stand-alone systems, like the INTERNIST-1 program, that required separate data entry from the data entry into the medical record for routine clinical care. These CDS programs were not connected to any other systems and were basically run on a single computer.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the US History of Clinical Decision Support Systems Lecture c

5. Evolution of CDS Architecture
Stand-alone systems
Integrated systems
Source: (Wright & Sittig, 2008)
Second phase programs were integrated to a certain extent with other systems, usually hospital electronic health records, so that they could use the patient data included in them and all people who used the hospital system could take advantage of the integrated CDS. The Antibiotic Assistant program that is part of the HELP (pronounced help) system at LDS (pronounced L-D-S) Hospital in Utah is typical of that phase.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the US History of Clinical Decision Support Systems Lecture c

6. Evolution of CDS Architecture
Stand-alone systems
Integrated systems
Standards-based systems
Source: (Wright & Sittig, 2008)
The third phase was characterized by the development of knowledge bases with agreed upon technical standards so some of the knowledge could be shared across sites. An example of this standard was known as the Arden Syntax for describing decision rules. Arden, by the way, is not another one of our technical abbreviations, but was named after the conference center in Arden, New York where the work on developing this standard was done. Different sites with different systems could apply the knowledge if they both have systems that use the same standards.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the US History of Clinical Decision Support Systems Lecture c

7. Evolution of CDS Architecture
Stand-alone systems
Integrated systems
Standards-based systems
Service models
Source: (Wright & Sittig, 2008)
The last phase, which is really a description of what is likely in the future, is providing the CDS through the World Wide Web and having it operate behind the scenes. So that rather than an individual going to a particular Website and entering data into the CDS system, which is the way DXplain (pronounced D-explain) and some other diagnostic programs currently work, the knowledge might reside at a central place and the CDS would be programmed to access that knowledge and use it to provide decision support locally. Obviously, the local programs have to be set up to work with the Web-based system. Once this method gets more widespread and the problems are worked out for large scale use, it is likely to provide even more widespread and accessible CDS.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the US History of Clinical Decision Support Systems Lecture c

8. Historical Challenges
Funding for development
As we look into the future in using CDS it helps to look at some of the challenges that we have seen with CDS over the years so that we can avoid them in the future. One of the major impediments has been funding to sustain CDS development. Many of the older, innovative programs were developed with grant funding and once that funding ran out, they were often abandoned before being put into full use in the practice setting. While there is some evidence that CDS has the potential to save costs, that potential has not usually been enough motivation for hospitals or other larger organizations to fund the needed research and sustained development.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the US History of Clinical Decision Support Systems Lecture c

9. Historical Challenges
Funding for development
Knowledge maintenance
Knowledge maintenance is another issue that must be addressed. Medical knowledge changes rapidly and using an out-of-date CDS system can be dangerous. When QMR became commercial, the company not only had to fund experts to update the knowledge base, but they had to ship CDs with the updates to their user base. Even then they could not guarantee that users would take the time to install them to update their systems.
Most of you are familiar with software programs that offer updates. Well, even when updates are pushed to a user’s computer, there is often no guarantee that the user will install them. Certainly having the systems in a central place with Web access can make getting the most up-to-date information possible, but there are still costs in keeping that information up-to-date.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the US History of Clinical Decision Support Systems Lecture c

10. Historical Challenges
Funding for development
Knowledge maintenance
Optimal timing
Alert fatigue
Another big challenge is figuring out how to provide timely information that will be used and yet not overwhelm the user with too many alerts or reminders, inducing what has been called 'alert fatigue.' Most of you are probably familiar the little paper clip guy who pops up when you are using your word processing program. I would bet that most of you shut him off immediately. Too many alerts at the wrong times can lead to a similar reaction among clinicians. Research studies over the years have shown that when there are numerous alerts, the doctors tend to ignore them.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the US History of Clinical Decision Support Systems Lecture c

11. Historical Challenges
Funding for development
Knowledge maintenance
Optimal timing
Alert fatigue
Motivation for use
Lessons from history – 2 stories
One of the biggest problems historically for the use of the systems we have described has been the motivation for using them. QMR (pronounced Q-M-R), when it was commercially available, always had a comparatively small client base. Many physicians did not think they needed help with diagnosis.
Indeed, when Intermountain Health Care expanded beyond the LDS Hospital, all of the hospitals in its system could use the Antibiotic Assistant CDS, but many have chosen not to implement it.
However, the incentives within the 2009 HITECH Act for meaningful use of EHRs (pronounced E-H-Rs) will very likely spur development of CDS, and there are examples from history that give us hope that there will be more use in the future. I'd like to tell you two stories that give us a perspective on where we are now with CDS.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the US History of Clinical Decision Support Systems Lecture c

12. History of the Blood Pressure Cuff
Crenner CW. Introduction of the blood pressure cuff into U.S. medical practice: technology and skilled practice. Ann Intern Med Mar 15;128(6):
The first story involves the history of the blood pressure cuff as described in an article by Christopher Crenner in the Annals (pronounced ANN-uls) of Internal Medicine. In the early 1900s, before the invention of the blood pressure cuff, physicians estimated patients' blood pressure by feeling their pulses. Physicians considered this one of their unique skills. When the cuff was invented, most physicians were not interested in using it, because they either did not trust that it worked accurately, or they did not see a need for it, or they felt it would take away from their special role. Does this sound familiar?
They began to use the cuff only when influential physician leaders advocated for its use, and even then, many doctors initially felt that nobody except a physician should use it because it required the physician's unique training and expertise to properly interpret the results. Certainly, they thought, nurses could never learn to use the cuff properly!
NASA/courtesy of nasaimages.org
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the US History of Clinical Decision Support Systems Lecture c

13. History of the Blood Pressure Cuff
As we all know, today nurses are the healthcare providers who usually take our blood pressure. In fact, automation has progressed to the point that in many healthcare settings, and even in patient's homes, there are now machines that take blood pressures automatically and accurately.
With time, as CDS improves and gets easier to use, it is likely that similar resistance to CDS will not be as strong as it is today, even without the meaningful use incentives.
However, if we are going to have meaningful use of EHRs by 2014, we cannot wait 50 years for the standard of care to change. There are other precedents that may make the wait not as long. The following example is often used in discussions about the use of technology in general and CDS in particular.
NASA/courtesy of nasaimages.org
Photo by David Weiss
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the US History of Clinical Decision Support Systems Lecture c

14. A Tale of Two Tugboats
The story involves a court case known as the T.J. Hooper decision. This case involved two tugboats that were pulling barges in the 1930s when receiving radios were available, but not widely used, on boats. One boat had a radio and when storm warnings were broadcast, the tugboat pilot heard them and took his boat to a safe harbor.
The T.J. Hooper was the boat that did not yet have a radio. It missed the storm warnings and, despite the best efforts of the expert tugboat pilots, their cargo sank. They were sued by the cargo owners for negligence. The defendants argued that they had followed proper procedures to secure the cargo and that the law did not require them to have radios. Despite those seemingly reasonable arguments, they were found guilty of negligence for not having the radio, even though it was still not commonplace. Here is an excerpt from Judge Learned (pronounced learn-ned) Hand's decision.
Photo by George L. Smyth
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the US History of Clinical Decision Support Systems Lecture c

15. The T.J. Hooper Decision
[A] whole calling may have unduly lagged in the adoption of new and available devices. It never may set its own tests, however persuasive be its usages. Courts must in the end say what is required; there are precautions so imperative that even their universal disregard will not excuse their omission. But here there was no custom at all as to receiving sets; some had them, some did not; the most that can be urged is that they had not yet become general. Certainly in such a case we need not pause; when some have thought a device necessary, at least we may say that they were right, and the others too slack.
Source: (Hand, 1932)
Take a minute to read the excerpt.
What that legal decision says is that even though a system, like CDS, may not initially be the standard of care, it may still be required on moral and ethical grounds. In the words of Judge Hand in his T.J. Hooper decision, "there are precautions so imperative that even their universal disregard will not excuse their omission.“
One of the major impacts of the HITECH Act may be that it will actually change the standard of care. In regard to clinical decision support, we can hear the echoes of the Hooper decision. While our current standard of care doesn't require the use of CDS, the provisions in the HITECH Act for meaningful use of EHRs will financially reward use initially, and eventually will impose financial penalties for non-use. Based on the history of other technologies, with HITECH's incentives for meaningful use, and if the implementation challenges can be met, the future for increased use of CDS to improve care looks bright.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the US History of Clinical Decision Support Systems Lecture c

16. History of Clinical Decision Support Systems Summary
Evolution of CDS architecture
Challenges to be overcome
This concludes History of Clinical Decision Support Systems. In summary, we reviewed how CDS systems have evolved over the years, what the implementation challenges have been, and what is likely in the future.
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the US History of Clinical Decision Support Systems Lecture c

17. Credits
Some of the material in this presentation is also included in the following and is used with permission:
Berner ES, La Lande TJ. Overview of CDSS. In: Berner ES, editor. Clinical decision support systems: theory and practice. 2nd ed., New York: Springer; 2007, p
“No Audio”
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the US History of Clinical Decision Support Systems Lecture c

18. History of Clinical Decision Support Systems References – Lecture c
Berner ES, La Lande TJ. Overview of CDSS. In: Berner ES, editor. Clinical decision support systems: theory and practice. 2nd ed. New York: Springer; p
Crenner CW. Introduction of the blood pressure cuff into U.S. medical practice: technology and skilled practice. Ann Intern Med Mar 15;128(6):
Hand L. The T.J. Hooper, 60 F.2d 737, 740 (2d Cir. 1932).
Wright A, Sittig D. A four-phase model of the evolution of clinical decision support architectures. Int J Med Inform Oct;77(10):641–9.
Images
Slide 12, 13: Courtesy of NASA/nasaimages.org Available from:
Slide 13: David Weiss, Personal Collection.
Slide 14: George L. Smyth CC BY-NC-SA 2.0. Available from:
“No Audio”
Health IT Workforce Curriculum Version 3.0/Spring 2012
History of Health Information Technology in the US History of Clinical Decision Support Systems Lecture c