Yesterday, my wife and I sat down with our kids' teachers for parent-teacher conferences and to pick up their third-quarter report cards. They did great — three B's between them, the rest A's (mind you, one of our son's B's was a borderline A!). Suffice to say, they'll be getting sundaes at our local ice cream parlor.


Sadly, it would appear that hospitals and their IT partners do not get the same stellar report cards when it comes to integrating clinical decision support into their EHRs, at least not when Zynx Health CEO Scott Weingarten is handing out the grades. Zynx has been assessing hospital EHRs and whether they incorporate support tools aimed at helping clinicians improve care and reduce costs. Studying 79 hospitals and health systems on heart failure and 72 on pneumonia, Zynx found that just 62 percent and 67 percent respectively have built those core decision support tools into their systems.

"The most important point here," Weingarten told me the other day, "is that there are significant opportunities for improvement."

Zynx is a technology vendor that offers clinical decision support tools for hospitals to bake into their EHRs, so the company certainly has an interest in understanding what's going on in the industry. Weingarten doesn't shy away from the potential business opportunities that the project may unearth, but he also points out that Zynx conducts the assessments for hospitals free of charge. He said there are actually now more than 100 hospitals — some clients, some not —partaking in the studies, which will ultimately cover 47 conditions.

The assessments, he said, are used to determine if EHRs include only those evidence-based clinical processes that are squarely aimed at reducing mortality, unnecessary readmissions and costs.

"If the right things are on the checklist or order sets, then there is a higher probability that physicians will follow through," he said. "So this is a proxy measure for what we think will happen. Over time, we will see if this translates into improved care; did the clinicians follow through."

But why aren't the decision tools being applied? Weingarten thinks that, in part, it is because hospitals spend a great deal of time and money on the go-live date for EHRs with the promise of coming back to work on clinical decision support later. What they find, he suggested, is that they don't have the energy or resources to do so.

Mark Van Kooy, M.D., director of clinical informatics at IT consultancy Aspen Advisors offers another perspective: "Many organizations appear to be implementing CDS via electronic records in a very tactical manner, focused on achieving the functionality required to meet short-term meaningful use performance requirements."

Most experts in this area will tell you that CDS is very complicated. There are a lot of things that factor into successful implementation. Linda Reed, R.N., vice president and CIO at Atlantic Health System in New Jersey, noted that physician preferences are also critical. If not done carefully, she said, decision support can lead to alert fatigue — where clinicians essentially begin to view alerts as an annoyance and start ignoring them (as a side note, the ECRI Institute named alert fatigue as its top IT hazard for 2012).

"We have had much more success building clinical decision support into smart ordering algorithms called iforms," she said. "I think all of us — vendors and providers — are getting smarter about CDS and the alerts it engenders. Accurate and important are key items as opposed to frequent and annoying."

Another factor is getting clinicians and IT staff to basically talk the same language, Marc Overhage, chief medical informatics officer at Siemens said. Taking clinical knowledge and putting it into the framework that a computer system can understand is complex work. He pointed out that some leading institutions such as Partners HealthCare in Massachusetts have formed the Clinical Decision Support Consortium which aims to help institutions cross this treacherous gap.

And lest you think that this is just a technology issue and something that can be dropped in the CIO's lap, all of the experts I connected with about this topic said that clinical decision support is becoming a major business imperative. Not only is it a huge part of meaningful use requirements, but it can also play a central role as payment policies for value-based purchasing and penalties for readmissions kick in.