RAND Corporation, 1200 South Hayes Street, Arlington, VA 22202, USA.
BMC Med Inform Decis Mak. 2012 Sep 3;12:93. doi: 10.1186/1472-6947-12-93.
The U.S. Centers for Medicare and Medicaid Services established the Electronic Health Record (EHR) Incentive Program in 2009 to stimulate the adoption of EHRs. One component of the program requires eligible providers to implement clinical decision support (CDS) interventions that can improve performance on one or more quality measures pre-selected for each specialty. Because the unique decision-making challenges and existing HIT capabilities vary widely across specialties, the development of meaningful objectives for CDS within such programs must be supported by deliberative analysis.
We developed a conceptual framework and protocol that combines evidence review with expert opinion to elicit clinically meaningful objectives for CDS directly from specialists. The framework links objectives for CDS to specialty-specific performance gaps while ensuring that a workable set of CDS opportunities are available to providers to address each performance gap. Performance gaps may include those with well-established quality measures but also priorities identified by specialists based on their clinical experience. Moreover, objectives are not constrained to performance gaps with existing CDS technologies, but rather may include those for which CDS tools might reasonably be expected to be developed in the near term, for example, by the beginning of Stage 3 of the EHR Incentive program. The protocol uses a modified Delphi expert panel process to elicit and prioritize CDS meaningful use objectives. Experts first rate the importance of performance gaps, beginning with a candidate list generated through an environmental scan and supplemented through nominations by panelists. For the highest priority performance gaps, panelists then rate the extent to which existing or future CDS interventions, characterized jointly as "CDS opportunities," might impact each performance gap and the extent to which each CDS opportunity is compatible with specialists' clinical workflows. The protocol was tested by expert panels representing four clinical specialties: oncology, orthopedic surgery, interventional cardiology, and pediatrics.
美国医疗保险和医疗补助服务中心于 2009 年设立了电子健康记录（EHR）激励计划，以刺激 EHR 的采用。该计划的一个组成部分要求合格的提供者实施临床决策支持（CDS）干预措施，这些干预措施可以提高每个专业预先选择的一个或多个质量措施的绩效。由于独特的决策挑战和现有的医疗信息技术能力在各个专业之间差异很大，因此必须通过审议分析来支持此类计划中为 CDS 制定有意义的目标。
我们开发了一个概念框架和协议，该框架结合了证据审查和专家意见，直接从专家那里引出 CDS 的临床意义目标。该框架将 CDS 的目标与特定专业的绩效差距联系起来，同时确保为提供者提供可行的 CDS 机会来解决每个绩效差距。绩效差距可能包括那些具有完善的质量措施的差距，也可能包括专家根据其临床经验确定的优先级。此外，目标不受限于具有现有 CDS 技术的绩效差距，而是可能包括在短期内可以合理预期开发 CDS 工具的目标，例如在 EHR 激励计划的第 3 阶段开始之前。该协议使用修改后的 Delphi 专家小组流程来引出和优先考虑 CDS 有意义使用的目标。专家首先对绩效差距的重要性进行评分，从通过环境扫描生成的候选列表开始，并通过小组成员的提名进行补充。对于优先级最高的绩效差距，小组成员然后对现有或未来的 CDS 干预措施（共同称为“CDS 机会”）对每个绩效差距的影响程度以及每个 CDS 机会与专家临床工作流程的兼容性程度进行评分。该协议由代表四个临床专业的专家小组进行了测试：肿瘤学、骨科、介入心脏病学和儿科。
