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CC BY-NC-ND 4.0 · Yearb Med Inform 2021; 30(01): 159-171
DOI: 10.1055/s-0041-1726502
Section 5: Decision Support
Survey

New Standards for Clinical Decision Support: A Survey of The State of Implementation

Peter Taber
1   Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, USA
,
Christina Radloff
2   College of Nursing, University of Utah, Salt Lake City, UT, USA
,
Guilherme Del Fiol
1   Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, USA
,
Catherine Staes
1   Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, USA
2   College of Nursing, University of Utah, Salt Lake City, UT, USA
,
Kensaku Kawamoto
1   Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, USA
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Summary

Objectives: To review the current state of research on designing and implementing clinical decision support (CDS) using four current interoperability standards: Fast Healthcare Interoperability Resources (FHIR); Substitutable Medical Applications and Reusable Technologies (SMART); Clinical Quality Language (CQL); and CDS Hooks.

Methods: We conducted a review of original studies describing development of specific CDS tools or infrastructures using one of the four targeted standards, regardless of implementation stage. Citations published any time before the literature search was executed on October 21, 2020 were retrieved from PubMed. Two reviewers independently screened articles and abstracted data according to a protocol designed by team consensus.

Results: Of 290 articles identified via PubMed search, 44 were included in this study. More than three quarters were published since 2018. Forty-three (98%) used FHIR; 22 (50%) used SMART; two (5%) used CQL; and eight (18%) used CDS Hooks. Twenty-four (55%) were in the design stage, 15 (34%) in the piloting stage, and five (11%) were deployed in a real-world setting. Only 12 (27%) of the articles reported an evaluation of the technology under development. Three of the four articles describing a deployed technology reported an evaluation. Only two evaluations with randomized study components were identified.

Conclusion: The diversity of topics and approaches identified in the literature highlights the utility of these standards. The infrequency of reported evaluations, as well as the high number of studies in the design or piloting stage, indicate that these technologies are still early in their life cycles. Informaticists will require a stronger evidence base to understand the implications of using these standards in CDS design and implementation.

Keywords

Health information interoperability - clinical decision support - FHIR - SMART - CQL - CDS hooks

Supplementary Material



Publication History

Article published online:
03 September 2021

© 2021. IMIA and Thieme. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • References

  • 1 Osheroff JA, Teich J, Levick D, Saldana L, Velasco F, Sittig D. et al. Improving outcomes with clinical decision support: an implementer's guide. HIMSS Publishing. 2012
    PubMedSearch in Google Scholar
  • 2 Greenes RA, Bates DW, Kawamoto K, Middleton B, Osheroff J, Shahar Y. Clinical decision support models and frameworks: Seeking to address research issues underlying implementation successes and failures. J Biomed Inform 2018; 78: 134-43
    CrossrefPubMedSearch in Google Scholar
  • 3 Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med 2010; 363 (06) 501-4
    CrossrefPubMedSearch in Google Scholar
  • 4 Braunstein ML. Health Care in the Age of Interoperability: The Potential and Challenges. IEEE Pulse 2018; 9 (05) 34-6
    CrossrefPubMedSearch in Google Scholar
  • 5 Braunstein ML. Healthcare in the Age of Interoperability: The Promise of Fast Healthcare Interoperability Resources. IEEE Pulse 2018; 9 (06) 24-7
    CrossrefPubMedSearch in Google Scholar
  • 6 Braunstein ML. Health Care in the Age of Interoperability Part 6: The Future of FHIR. IEEE Pulse 2019; 10 (04) 25-7
    CrossrefPubMedSearch in Google Scholar
  • 7 Strasberg HR, Rhodes B, Del Fiol G, Jenders RA, Kawamoto K. Contemporary clinical decision support standards using Health Level Seven International (HL7) Fast Healthcare Interoperability Resources (FHIR). J Am Med Inform Assoc 2020; Jun 8; ocab070
    PubMedSearch in Google Scholar
  • 8 Lehne M, Luijten S, Vom Felde Genannt Imbusch P, Thun S. The Use of FHIR in Digital Health – A Review of the Scientific Literature. Stud Health Technol Inform 2019; 267: 52-8
    PubMedSearch in Google Scholar
  • 9 Mandel JC, Kreda DA, Mandl KD, Kohane IS, Ramoni RB. SMART on FHIR: a standards-based, interoperable apps platform for electronic health records. J Am Med Inform Assoc 2016; 23 (05) 899-908
    CrossrefPubMedSearch in Google Scholar
  • 10 Mandl KD, Mandel JC, Murphy SN, Bernstam VE, Ramoni RL, Kreda DA. et al. The SMART Platform: early experience enabling substitutable applications for electronic health records. J Am Med Inform Assoc 2012; 19 (04) 597-603
    CrossrefPubMedSearch in Google Scholar
  • 11 Li M, Zhi Y, Lu X, Cai H. Extending CQL with openEHR to Express Clinical Quality Indicators. Stud Health Technol Inform 2019; 264: 1853-4
    PubMedSearch in Google Scholar
  • 12 Nguyen BP, Reese T, Decker S, Malone D, Boyce RD, Beyan O. Implementation of Clinical Decision Support Services to Detect Potential Drug-Drug Interaction Using Clinical Quality Language. Stud Health Technol Inform 2019; 264: 724-8
    PubMedSearch in Google Scholar
  • 13 HL7. Clinical Quality Language (CQL) [Internt]. 2019. [cited 2021 May 14]. Available from: https://cql.hl7.org/
    PubMed
  • 14 Dolin RH, Boxwala A, Shalaby J. A Pharmacogenomics Clinical Decision Support Service Based on FHIR and CDS Hooks. Methods Inf Med 2018; 57 (S 02) e115-e123
    Thieme ConnectPubMedSearch in Google Scholar
  • 15 Spineth M, Rappelsberger A, Adlassnig KP. Implementing CDS Hooks Communication in an Arden-Syntax-Based Clinical Decision Support Platform. Stud Health Technol Inform 2018; 255: 165-9
    PubMedSearch in Google Scholar
  • 16 Parab S, Bhalerao S. Study designs. Int J Ayurveda Res 2010; 1 (02) 128-31
    CrossrefPubMedSearch in Google Scholar
  • 17 Wright A, Sittig DF, Ash JS, Feblowith J, Meltzer S, McMullen C. et al. Development and evaluation of a comprehensive clinical decision support taxonomy: comparison of front-end tools in commercial and internally developed electronic health record systems. J Am Med Inform Assoc 2011; 18 (03) 232-42
    CrossrefPubMedSearch in Google Scholar
  • 18 Bauer J, Rohner-Rojas S, Holderried M. [Consent management and workflows for cross-sectoral patient records and teleconsultations]. Radiologe 2020; 60 (05) 430-9 German.
    CrossrefPubMedSearch in Google Scholar
  • 19 Bauer J, Rohner-Rojas S, Holderried M. [Cross-enterprise interoperability : Challenges and principles for technical implementation]. Radiologe 2020; 60 (04) 334-341 German.
    CrossrefPubMedSearch in Google Scholar
  • 20 Chen Y, Lu Y, Wang YN, Lin Z-C, Gu W, Tan L. et al. [Effect of compound qingqin liquid on the expression of toll-like receptor in the renal tissue of rats with urate nephropathy]. Zhongguo Zhong Xi Yi Jie He Za Zhi 2014; 34 (06) 722-7 Chinese.
    PubMedSearch in Google Scholar
  • 21 Djian J, Lellouch AG, Botter C, Levy J, Burgun A, Hivelin M. et al. [Clinical photography by smartphone in plastic surgery and protection of personal data: Development of a secured platform and application on 979 patients]. Ann Chir Plast Esthet 2019; 64 (01) 33-43 French.
    CrossrefPubMedSearch in Google Scholar
  • 22 Shang XZ, Ma WG, Chen Y, Lu Y, Wang Y-N, Xu Y-M. et al. [Effect of compound qingqin liquid on the expression levels of ang II and COX-2 mRNA transcription and protein expression in the renal tissue of uric acid nephropathy rats: an experimental study]. Zhongguo Zhong Xi Yi Jie He Za Zhi 2014; 34 (07) 819-25 Chinese.
    PubMedSearch in Google Scholar
  • 23 Amrollahi F, Shashikumar SP, Kathiravelu P, Sharma A, Nemati S. AIDEx - An Open-source Platform for Real-Time Forecasting Sepsis and A Case Study on Taking ML Algorithms to Production. Annu Int Conf IEEE Eng Med Biol Soc 2020; 2020: 5610-4
    PubMedSearch in Google Scholar
  • 24 Henry JR, Lynch D, Mals J, Shashikumar SP, Holder A, Sharma A. et al. A FHIR-Enabled Streaming Sepsis Prediction System for ICUs. Annu Int Conf IEEE Eng Med Biol Soc 2018; 2018: 4093-6
    PubMedSearch in Google Scholar
  • 25 Del Fiol G, Kohlmann W, Bradshaw RL, Weir CR, Flynn M, Hess R. et al. Standards-Based Clinical Decision Support Platform to Manage Patients Who Meet Guideline-Based Criteria for Genetic Evaluation of Familial Cancer. JCO Clin Cancer Inform 2020; 4: 1-9
    CrossrefPubMedSearch in Google Scholar
  • 26 Abedin Z, Hoerner R, Habboushe J, Lu Y, Kawamoto K, Warner PB. et al. Implementation of a Fast Healthcare Interoperability Resources-Based Clinical Decision Support Tool for Calculating CHA(2)DS(2)-VASc Scores. Circ Cardiovasc Qual Outcomes 2020; 13 (02) e006286
    CrossrefPubMedSearch in Google Scholar
  • 27 Curran RL, Kukhareva PV, Taft T, Weir CR, Reese TJ, Nanjo C. et al. Integrated displays to improve chronic disease management in ambulatory care: A SMART on FHIR application informed by mixed-methods user testing. J Am Med Inform Assoc 2020; 27 (08) 1225-34
    CrossrefPubMedSearch in Google Scholar
  • 28 Kawamoto K, Kukhareva P, Shakib JH, Kramer H, Rodriguez S, Warnter PB, Shields D. et al. Association of an Electronic Health Record Add-on App for Neonatal Bilirubin Management With Physician Efficiency and Care Quality. JAMA Netw Open 2019; 2 (11) e1915343
    CrossrefPubMedSearch in Google Scholar
  • 29 Alterovitz G, Heale B, Jones J, Kreda D, Lin F, Liu L. et al. FHIR Genomics: enabling standardization for precision medicine use cases. NPJ Genom Med 2020; 5: 13
    CrossrefPubMedSearch in Google Scholar
  • 30 Bergquist T, Buie RW, Li K, Brandt P. Heart on FHIR: Integrating Patient Generated Data into Clinical Care to Reduce 30 Day Heart Failure Readmissions (Extended Abstract). AMIA Annu Symp Proc 2017; 2017: 2269-73
    PubMedSearch in Google Scholar
  • 31 Bosl W, Mandel J, Jonikas M, Ramoni RB, Kohane IS, Mandl KD. Scalable decision support at the point of care: a substitutable electronic health record app for monitoring medication adherence. Interact J Med Res 2013; 2 (02) e13
    CrossrefPubMedSearch in Google Scholar
  • 32 Crump JK, Del Fiol G, Williams MS, Freimuth RR. Prototype of a Standards-Based EHR and Genetic Test Reporting Tool Coupled with HL7-Compliant Infobuttons. AMIA Jt Summits Transl Sci Proc 2018; 2017: 330-9
    PubMedSearch in Google Scholar
  • 33 de Bruin JS, Rappelsberger A, Adlassnig KP, Gawrylkowicz J. Exploring Methods of Implementing Arden Syntax for CDS Hooks. Stud Health Technol Inform 2020; 271: 191-8
    PubMedSearch in Google Scholar
  • 34 El-Sappagh S, Ali F, Hendawi A, Jang JH, Kwak KS. A mobile health monitoring-and-treatment system based on integration of the SSN sensor ontology and the HL7 FHIR standard. BMC Med Inform Decis Mak 2019; 19 (01) 97
    CrossrefPubMedSearch in Google Scholar
  • 35 Gaebel J, Cypko MA, Lemke HU. Accessing Patient Information for Probabilistic Patient Models Using Existing Standards. Stud Health Technol Inform 2016; 223: 107-112
    PubMedSearch in Google Scholar
  • 36 Glachs D, Namli T, Jung O, Strohmeier F, Ploessnig M, Rodriguez G. FHIR Driven Self-Management Support System for Diabetes. Stud Health Technol Inform 2020; 270: 1291-2
    PubMedSearch in Google Scholar
  • 37 Gordon WJ, Baronas J, Lane WJ. A FHIR Human Leukocyte Antigen (HLA) Interface for Platelet Transfusion Support. Appl Clin Inform 2017; 8 (02) 603-11
    Thieme ConnectPubMedSearch in Google Scholar
  • 38 Kamel PI, Nagy PG. Patient-Centered Radiology with FHIR: an Introduction to the Use of FHIR to Offer Radiology a Clinically Integrated Platform. J Digit Imaging 2018; 31 (03) 327-33
    CrossrefPubMedSearch in Google Scholar
  • 39 Karhade AV, Schwab JH, Del Fiol G, Kawamoto K. SMART on FHIR in spine: integrating clinical prediction models into electronic health records for precision medicine at the point of care. Spine J 2020; Jun 26;S1529 9430 (20) 30820-2
    PubMedSearch in Google Scholar
  • 40 Khalilia M, Choi M, Henderson A, Iyengar S, Braunstein M, Sun J. Clinical Predictive Modeling Development and Deployment through FHIR Web Services. AMIA Annu Symp Proc 2015; 2015: 717-26
    PubMedSearch in Google Scholar
  • 41 Kimura E, Ishihara K. Internal domain-specific language based on Arden Syntax and FHIR. Stud Health Technol Inform 2015; 216: 955
    PubMedSearch in Google Scholar
  • 42 Kogan A, Tu SW, Peleg M. Goal-driven management of interacting clinical guidelines for multimorbidity patients. AMIA Annu Symp Proc 2018; 2018: 690-9
    PubMedSearch in Google Scholar
  • 43 Schweitzer M, Huber L, Gorfer T, Hörbst A. An Approach for Dynamic Vital Parameter Monitoring - Prototype Development. Stud Health Technol Inform 2018; 251: 47-50
    PubMedSearch in Google Scholar
  • 44 Séroussi B, Guézennec G, Lamy JB. et al. Reconciliation of multiple guidelines for decision support: a case study on the multidisciplinary management of breast cancer within the DESIREE project. AMIA Annu Symp Proc 2017; 2017: 1527-36
    PubMedSearch in Google Scholar
  • 45 Sinha S, Jensen M, Mullin S, Elkin PL. Safe Opioid Prescription: A SMART on FHIR Approach to Clinical Decision Support. Online J Public Health Inform 2017; 9 (02) e193
    CrossrefPubMedSearch in Google Scholar
  • 46 Tippenhauer K, Philips M, Largiadèr CR, Sariyar M, Bürkle T. Integrating Pharmacogenetic Decision Support into a Clinical Information System. Stud Health Technol Inform 2020; 270: 618-22
    PubMedSearch in Google Scholar
  • 47 Warner JL, Prasad I, Bennett M, Arniella M, Beeghly-Fadiel A, Mandl KD. et al. SMART Cancer Navigator: A Framework for Implementing ASCO Workshop Recommendations to Enable Precision Cancer Medicine. JCO Precis Oncol. 2018 2018 po.17.00292.
    PubMedSearch in Google Scholar
  • 48 Watkins M, Eilbeck K. FHIR Lab Reports: using SMART on FHIR and CDS Hooks to increase the clinical utility of pharmacogenomic laboratory test results. AMIA Jt Summits Transl Sci Proc 2020; 2020: 683-92
    PubMedSearch in Google Scholar
  • 49 Alterovitz G, Warner J, Zhang P, Chen Y, Ullman-Cullere M, Kreda D. et al. SMART on FHIR Genomics: facilitating standardized clinico-genomic apps. J Am Med Inform Assoc 2015; 22 (06) 1173-8
    CrossrefPubMedSearch in Google Scholar
  • 50 Gesell SB, Golden SL, Limkakeng Jr AT, Carr CM, Matuskowitz. Smith LM. et al. Implementation of the HEART Pathway: Using the Consolidated Framework for Implementation Research. Crit Pathw Cardiol 2018; 17 (04) 191-200
    CrossrefPubMedSearch in Google Scholar
  • 51 Giordanengo A, Årsand E, Woldaregay AZ, Bradway M, Gottland A, Hartvigsen G. et al. Design and Prestudy Assessment of a Dashboard for Presenting Self-Collected Health Data of Patients With Diabetes to Clinicians: Iterative Approach and Qualitative Case Study. JMIR Diabetes 2019; 4 (03) e14002
    CrossrefPubMedSearch in Google Scholar
  • 52 Gruendner J, Schwachhofer T, Sippl P, Wolf N, Erpenbeck M, Gulden C. et al. KETOS: Clinical decision support and machine learning as a service – A training and deployment platform based on Docker, OMOP-CDM, and FHIR Web Services. PLoS One 2019; 14 (10) e0223010
    CrossrefPubMedSearch in Google Scholar
  • 53 Kukhareva P, Warner P, Rodriguez S, Kramer H, Weir C, Nanjo C. et al. Balancing Functionality versus Portability for SMART on FHIR Applications: Case Study for a Neonatal Bilirubin Management Application. AMIA Annu Symp Proc 2019; 2019: 562-71
    PubMedSearch in Google Scholar
  • 54 Michel J, Flores E, Mull N, Tsou AY. AHRQ Methods for Effective Health Care. In: Translation of a Cdifficile Treatment Clinical Pathway Into Machine-Readable Clinical Decision Support Artifacts Prototyped for Electronic Health Record Integration. Rockville (MD). Agency for Healthcare Research and Quality (US). 2019
    PubMedSearch in Google Scholar
  • 55 Rubin L, López NP, Gaiera A, Campos F, Luna D, de Quirós FBG. Development, Implementation and Preliminary Results of an Electronic Reminder for HIV Screening Using a Service Oriented Architecture. Stud Health Technol Inform 2019; 264: 763-7
    PubMedSearch in Google Scholar
  • 56 Schleyer TKL, Rahurkar S, Baublet AM, Kochmann M, Ning X, Martin DK. et al. Preliminary evaluation of the Chest Pain Dashboard, a FHIR-based approach for integrating health information exchange information directly into the clinical workflow. AMIA Jt Summits Transl Sci Proc 2019; 2019: 656-64
    PubMedSearch in Google Scholar
  • 57 Semenov I, Kopanitsa G. Decision Support System Based on FHIR Profiles. Stud Health Technol Inform 2018; 249: 117-21
    PubMedSearch in Google Scholar
  • 58 Warner JL, Rioth MJ, Mandl KD, Mandel JC, Kreda DA, Kohane IS. et al. SMART precision cancer medicine: a FHIR-based app to provide genomic information at the point of care. J Am Med Inform Assoc 2016; 23 (04) 701-10
    CrossrefPubMedSearch in Google Scholar
  • 59 Williams MS, Kern MS, Lerch VR, Billet J, Williams JL, Moore GJ. Implementation of a patient-facing genomic test report in the electronic health record using a web-application interface. BMC Med Inform Decis Mak 2018; 18 (01) 32
    CrossrefPubMedSearch in Google Scholar
  • 60 Bloomfield Jr RA, Polo-Wood F, Mandel JC, Mandl KD. Opening the Duke electronic health record to apps: Implementing SMART on FHIR. Int J Med Inform 2017; 99: 1-10
    CrossrefPubMedSearch in Google Scholar
  • 61 Hur S, Lee J, Kim T, Choi JS, Kang M, Chang DK. et al. An Automated Fast Healthcare Interoperability Resources-Based 12-Lead Electrocardiogram Mobile Alert System for Suspected Acute Coronary Syndrome. Yonsei Med J 2020; 61 (05) 416-22
    CrossrefPubMedSearch in Google Scholar
  • 62 Semenov I, Kopanitsa G, Denisov D, Alexandr Y, Osenev R, Andreychuk Y. Patients Decision Aid System Based on FHIR Profiles. J Med Syst 2018; 42 (09) 166
    CrossrefPubMedSearch in Google Scholar
  • 63 Semenov I, Osenev R, Gerasimov S, Kopanitsa G, Denisov D, Andreychuk Y. Experience in Developing an FHIR Medical Data Management Platform to Provide Clinical Decision Support. Int J Environ Res Public Health 2019; 17 (01) 73
    CrossrefPubMedSearch in Google Scholar