Clinical decision support takes to the cloud

February 22, 2018

At HIMSS18, longtime health informaticist Blackford Middleton will show how CDS can be deployed online and via SMART on FHIR apps and shared across EHRs nationwide.



The era of value-based care demands the smart use of clinical decision support. With quality improvement now an imperative, CDS is crucial to help health systems move the needle on more effective care delivery.

Ideally, CDS tools will be readily accessible to a wide array of caregivers where and when they need them, irrespective of what electronic health record they’re using. That’s easier said than done but success stories are emerging.

Take the AHRQ-funded CDS Consortium Project, for instance.


“The CDS Consortium project demonstrated successfully that CDS from Partners Healthcare could be delivered to disparate EMRs across the country,” said Blackford Middleton, chief informatics and innovation officer at Apervita.

Other EHR platforms in the consortium work include Epic, NextGen, GE Centricity, two academic EMRs at the Regenstrief Institute, and Partners own EMR.

“Delivering well-vetted CDS via the cloud allows the average EMR user to avoid the problem of discovering the right CDS to do, and how to encode it into his or her EMR. Making knowledge artifacts for CDS shareable in this manner helps to deliver on the value proposition anticipated for EMR but not yet realized: fewer medical errors, improved compliance with guidelines, better outcomes, at a lower cost.”


It’s a complex process, said Middleton, but “with the growing availability of standards designed exactly for this purpose, it’s becoming easier to do. The 21st Century Cures Act calls for every EMR to make available an API which can be used ‘without special effort.’ This is a critical step to get data out of and back into EMRs. The next step is to standardize the knowledge representation and clinical quality language, or CQL, helps here immensely — we have already seen its impact on standardizing eCQM (electronic clinical quality measure) specifications.

CQL will help standardize the way knowledge elements for both quality measures and CDS are represented, he said. SMART on FHIR, meanwhile, “allows us to build an app that can work inside or outside of the EMR to provide extra functionality. This can be special rich data displays, interactive sessions with the clinician (or patient) to gather information not in the EMR, or problem-focused special clinical documentation tools fitting into the clinical workflow.”

Middleton added: “We strongly believe this is the way to go – it will be impossible for every EMR implementation to rediscover and implement the world’s best knowledge so it is imperative we share it across multiple EMRs in this way. We hope this leads to ‘best care everywhere.'”

At HIMSS18, Middleton and Ninad Mishra, health scientist at the U.S. Centers for Disease Control and Prevention, will show how cloud infrastructure can help.

Middleton and Mishra will describe how collaborative web-services and standards-based APIs can deliver CDS an outpatient encounter, spotlighting the current state of the technology and exploring the prospects for the future evolution of standards harmonization and vendor support.

The session will show how the Apervita platform can encode complex clinical logic and express it in various online tools and apps, explaining how it can be implemented in the cloud and securely accessed via EHRs nationwide.

Middleton and Mishra are scheduled to present, “CDS in the Cloud: Deploying a CDC Guideline for National Use,” at 1 p.m. March 8 in Venetian Murano 3304.


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