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II. Adapt to Local Workflow

Just as in real estate the key is “location, location, location,” in decision support design the key is “workflow, workflow, workflow" (Elsen RB, 1995 Primary Care). Local workflow and barrier analysis is necessary to demonstrate decision support origins (i.e., when in the course of clinical care, the decision variables are likely to have been instantiated) and insertion (i.e., when in the course of clinical care is it appropriate for the decision support to appear). Similar considerations will also dictate to whom the decision support should be addressed. It is probable that CDS implementers will need to address workflow design changes, and these will broaden the scope of the project substantially. Clinicians and other CDS end-users should be closely involved in the design and development of workflow changes.

Scoping: How Much Workflow Change To Do?

Determining how much workflow change is desirable to accompany a CDS system implementation is as much an art as a science, and requires various factors to be considered in a balanced decision:

  • How much change can an organization accommodate?
  • Is clinical leadership committed to this magnitude of change?
  • Can the change be well designed and implemented effectively?
  • Is the EMR already well integrated into the workflow?
  • Is data necessary to trigger the CDS already captured effectively?

Yale changed workflow to capture patient information directly from patients using iPad technology, to be fed into the EHR automatically, potentially diminishing the clinicians’ interviewing work.