Toward Scalable Clinical Decision Support

In this special issue of the Open Medical Informatics Journal, four papers are presented describing various approaches to the general problem of scaling clinical decision support (CDS) – providing CDS across potentially multiple electronic medical record systems (EMR) in varying clinical practice environments, and the methods of representing, encoding, and sharing knowledge to support such services. Each describes and employs a variety of techniques to approach critical problems in this area of clinical informatics research and development: knowledge translation and specification, knowledge aggregation and dissemination, and knowledge implementation for CDS in EMRs, and other forms of health IT. These papers provide an excellent overview of current research and development activities in this area, and hold great promise for describing methods that ultimately will enable widespread adoption and use of best practices and current clinical guideline knowledge at scale. Current health policy in the US and other countries places great emphasis not only on the adoption of health information technology (HIT) in clinical practice, but also on its ability to achieve desired clinical outcomes through 'meaningful use' [1], or effective use of HIT at the point of care. With the unprecedented move to adopt HIT in clinical practice, a significant barrier to the effective use of HIT, and CDS [2] in particular, is now apparent – the non-availability of knowledge required for implementation in multiple, disparate EMR systems in a form that makes it easy for the healthcare organization to readily implement the knowledge. Absent the knowledge in such a form, each organization must implement CDS, replicating a non-trivial effort. Even when the end-user is sophisticated, and the EMR provides adequate tools for authoring and implementing clinical knowledge within the system, often the process of translating knowledge from a clinical practice guideline (CPG), arriving at consensus, and maintaining the knowledge in an appropriate current state, reflecting current best, or usual and customary, practices is beyond the capacity of most healthcare delivery systems. The adoption of CDS would likely increase with more availability of knowledge in a form that can be rapidly implemented within heterogeneous organization. However, there are two major challenges in making CDS knowledge applicable across organizations. First, each organization varies in its workflows, policies, and availability of resources, thus affecting the implementation of CDS. Second, EMR systems have significant differences in function and technology. For example, differences in data structures across EMRs make it difficult to reference patient data …