Keywords
decision support systems - electronic health records - standards-based CDS - implementation
- facilitators and barriers
Background and Significance
Background and Significance
Clinical decision support (CDS) facilitates value-based care by increasing adherence
to evidence-based practices and supporting patient-centered decision-making.[1]
[2] CDS uses targeted clinical knowledge and patient health information, can be computerized
or not, and can provide patient-specific clinical care recommendations or evidence-based
guidance to clinicians or directly to patients.[3]
[4] Promoting CDS use is, therefore, in the public interest. Scaling use can be challenging
because health systems need both time and resources to develop or purchase, deploy,
and maintain CDS.[5]
[6] Sharing CDS resources can help avoid duplication in developing CDS[7] and improve use across health systems by lowering its cost,[8] thus improving health equity by helping make CDS available to lower-resourced health
systems.
Most health systems purchase CDS from electronic health records (EHR) developers,
which is often proprietary and may not be interoperable across different EHR systems.[9] Developing and implementing EHR-agnostic CDS requires use of standards and resources
that either allow for CDS knowledge artifact integration and execution within EHR
systems, or support CDS use as a service that exchanges patient data with the EHR.[10]
[11] See [Table 1] for description.[12]
[13]
Table 1
Clinical decision support standards
|
Standard type
|
Examples
|
|
Standard language for expressing medical knowledge in clinical decision support (CDS)
logic
|
Clinical Quality Language (CQL), Arden Syntax
|
|
Standard medical terminologies
|
Systemized Nomenclature of Medicine – Clinical Terms (SNOMED CT), Logical Observation
Identifiers Names and Codes (LOINC)
|
|
Interoperability standards to support data exchange between CDS applications and electronic
health records (EHRs)
|
Health Level Seven (HL7) Fast Healthcare Interoperability Resources (FHIR)
|
|
Standard that enables an EHR, during certain workflows, to invoke CDS services executed
outside the EHR using application programming interfaces (APIs). The CDS service may
use knowledge artifacts written in CQL or other languages. Data from the EHR is shared
with the service as FHIR resources
|
CDS Hooks
|
Only two publicly available repositories make EHR-agnostic CDS artifacts and resources
freely available. One, OpenCDS, is a collaborative community that leverages open-source
tooling and services to support modular development of standards-based CDS.[14] Another, CDS Connect, is a resource the Agency for Healthcare Research and Quality
(AHRQ) funds as part of its Patient-Centered Outcomes Research (PCOR) CDS Initiative.
CDS Connect makes standards-based CDS artifacts and metadata (e.g., implementation
guides) freely available to the public.[15]
[16] Numerous organizations have contributed artifacts to the CDS Connect Repository
that are in varying degrees of implementation readiness. Artifacts span clinical domains
that include cardiovascular disease, preventive care, chronic pain management, mental
health, and drug–drug interactions.[17] One example of a standards-based CDS artifact in CDS Connect is “Factors to Consider
in Managing Chronic Pain: A Pain Management Summary,” which provides information for
clinicians to consider when managing a patient's pain.[18]
This paper presents lessons learned about designing, developing, implementing, and
using publicly available standards-based CDS from evaluating such efforts through
the PCOR CDS Initiative and its components ([Table 2]).
Table 2
Initiative component descriptions
|
Initiative component
|
Description
|
|
Patient-Centered Clinical Decision Support (CDS) Learning Network
(2016–2020)
|
The Patient-Centered CDS Learning Network convened workgroups that produced frameworks
and other learning resources to advance evidence into practice through CDS that is
patient-centered
|
|
CDS Connect
(2016–2023)
|
CDS Connect consists of a Repository for open-source CDS, a prototype Authoring Tool
interface for creating standards-based CDS logic expressions, and other open-source
tooling to support the development of standards-based CDS
|
|
Quantifying Efficiencies Gained through Shareable CDS
(2018–2019)
|
The Quantifying Efficiencies project aimed to examine whether adoption and implementation
of shareable CDS artifacts from CDS Connect resulted in efficiencies relative to in-house
development and implementation of proprietary CDS
|
|
CDS Demonstration Projects[43]
[44]
[45]
[46]
[47]
(2019–2022)
|
Five investigator-led teams developed, tested, and implemented standards-based PC
CDS in various clinical settings. The resulting artifacts have been or will be made
available to the public through the CDS Connect Repository
|
Drawing from these lessons, we identify broader considerations for improving standards-based
CDS uptake.
Methods
The evaluation used multiple data collection methods, including: (1) key informant
interviews (KIIs), (2) a web-based survey about CDS Connect, and (3) Technical Expert
Panel (TEP) comment summaries. NORC at the University of Chicago Institutional Review
Board and the U.S. Office of Management and Budget reviewed all study procedures.
Key Informant Interviews
We interviewed 40 informants: Initiative leaders (23) and Initiative contributors,
participants, and consumers (17). Semistructured interview guides probed CDS development
experience, Initiative participation, and perspectives on shareable, standards-based
CDS. Since our study was part of the Initiative evaluation, informants' experience
developing or implementing standards-based, publicly available CDS was generally tied
to their Initiative involvement. Interview recordings were used to develop transcripts
for analysis. We developed our initial codebook from the program materials and interview
guide, which we refined using NVivo software to thematically code each transcript.[19]
Web-Based Survey
We developed the survey instrument (available from author on request) from our program
document review and preliminary KII findings, which we cognitively tested with five
informaticists. We conducted the survey from March 23 to June 7, 2021, to understand
how users engaged with CDS Connect resources and user perceptions about the resources'
value. From the 713 surveys distributed, we received 79 completes (11% response rate).
We used R statistical software to produce descriptive statistics and cross-tabs of
respondents' roles and resource use.[20] CDS Connect survey results have the potential for positive selection bias, since
respondents were known to be already at least somewhat familiar with CDS Connect.
Technical Expert Panel
A 22-member TEP provided insight into the current CDS landscape and helped synthesize
findings. Panelists were selected based on their expertise and willingness to participate
in periodic meetings related to AHRQ's PCOR CDS Initiative ([Table 3]).
Table 3
Technical Expert Panel panelist representation
|
Panelist type
|
Number of representatives
|
|
Federal agencies
|
4
|
|
Academic medical centers
|
3
|
|
Patient advocacy organizations
|
2
|
|
Health systems clinical staff and providers
|
2
|
|
Health plans and value-based purchasers
|
2
|
|
Quality standards and measure developers
|
1
|
We held two TEP meetings (in March and July 2022), at which we presented the evaluation
findings and discussed key themes and recommendations. We then reviewed the meeting
transcripts to identify lessons and other guidance relevant to the evaluation.
Analysis and Synthesis
We used triangulation to consider findings on similar topics, qualitative findings
to contextualize quantitative findings, and literature to add context for the findings.[21] Following independent data analysis for each method, four study team members compared
findings related to similar themes across data sources.[22] We then cross-referenced these findings to identify lessons learned about AHRQ's
Initiative and potential implications for the broader field. Team discussions further
refined evaluation themes and their implications for the broader field. We present
findings organized into four CDS lifecycle stages: (1) identifying and choosing evidence
to inform CDS design, (2) developing CDS, (3) implementing CDS, and (4) measuring
the impact of CDS use.[23]
Results
[Table 4] summarizes the findings from our evaluation of the PCOR CDS Initiative.
Table 4
Summary of findings on publicly available standards-based clinical decision support
|
Identifying and choosing evidence to inform clinical decision support (CDS) design
|
|
Users wanted more easy-to-understand information about the trustworthiness of the
underlying evidence/guidelines of publicly available CDS artifacts
|
|
CDS developers faced challenges related to intellectual property (IP) restrictions
around using evidence-based guidelines in free, publicly available CDS. Many used
guidelines in the public domain that federal agencies published
|
|
Developing CDS
|
|
Users/potential users of publicly available CDS suggested they would have greater
trust if the CDS was developed in collaboration with or validated by guidelines developers
or other experts in the underlying evidence base
|
|
Contributors to CDS Connect wanted to receive more information about the CDS artifacts
they contributed, including if/how the artifacts are used and any recommendations
for improvement
|
|
Implementing CDS
|
|
Informants found that most EHRs did not fully support CDS standards such as CQL, and
significant time and staff resources were needed for custom development, configuration,
and maintenance
|
|
Developers and/or users of standards-based CDS Connect artifacts emphasized the importance
of getting support from executive leadership, clinical departments, and health IT
department leadership to ensure that necessary staff and resources were available
to implement the CDS tool
|
|
Informants noted that equitable use of CDS Connect artifacts required supplying lower-resourced
settings with education materials and support, including clear implementation guides
|
|
Measuring CDS impact
|
|
Informants emphasized the importance of demonstrating improved health outcomes for
patients and a return on investment (ROI) for publicly available, standards-based
CDS from the perspective of multiple stakeholders—including health system executives,
clinician users, and health IT developers whose buy-in is critical to success
|
Identifying and Choosing Evidence to Inform Clinical Decision Support Design
In the early stages of CDS design, developers work with multiple stakeholders to prioritize
evidence-based findings for dissemination via CDS, including developing criteria and
use cases for the CDS.[23] We found that developers looking to develop publicly available, standards-based
CDS need to communicate to potential users understandable and trustworthy information
on the underlying evidence for CDS. We also found that developers looking to share
CDS publicly face challenges with the intellectual property rights related to evidence-based
guidelines.
Need for Understandable Information on Trustworthiness of Evidence Informing the Clinical
Decision Support
We found from our survey and interviews that CDS Connect Repository users wanted easily
understood information describing CDS artifacts. Users said they reviewed available
metadata—artifact goal, target population, evidence-based references, human-readable
logic, cautions, pilot findings, implementation guides—to determine CDS fitness for
use. Many found the metadata helped improve transparency and allowed for assessment
of the CDS purpose and implementation readiness, although some said not all metadata
allowed users to evaluate CDS' trustworthiness. Users sought more information on the
trustworthiness of evidence/guidelines underlying the artifacts, including identification
of clinical guideline authors, clinical professional association endorsement, or studies
demonstrating clinical effectiveness. Users also noted limited information regarding
the source of the underlying evidence base or guidelines, including when evidence
was last updated. These findings demonstrate that the ability to review metadata,
or data describing CDS artifacts, is critical for user trust and potential uptake.
Challenges of Intellectual Property Restrictions
Several interviewees reported that intellectual property licensing requirements for
some evidence-based guidelines make it challenging for developers to use them for
publicly available CDS. Many CDS development projects in the Initiative used guidelines
published by the Centers for Disease Control and Prevention (CDC) or the U.S. Preventive
Services Task Force, which alleviated some, but not all, concerns. Informants noted
that early engagement with organizations regarding intellectual property restrictions
is imperative, and whenever possible, public domain, creative commons, or open-source
licensing agreements should be utilized. Informants also suggested guideline developers
eliminate or streamline licensing restrictions to facilitate guideline adoption for
open CDS artifacts.[24]
Developing Clinical Decision Support Artifacts
After evidence or clinical guidelines have been identified for CDS, developers must
translate them into computable clinical knowledge,[23] which requires identifying key guideline elements often not specified to computable
precision.[25] The development phase also includes testing and iterative refinement of CDS, to
ensure it performs as expected and in a consistent manner.[4] When developing publicly available standards-based CDS, we found trust, once again,
to be key, as well as the need for feedback loops between users and developers of
such tools.
Trusting Knowledge Translation
In the survey, 37 out of 42 CDS Connect Repository users agreed that the Repository
was valuable for making evidence-based CDS public and advancing the development of
standards-based CDS. Yet, we found that to trust available artifacts, potential users
need to trust the knowledge translation process. Part of this process is selecting
the most appropriate codes and value sets to accurately capture criteria for which
patients, conditions, therapies, and recommended clinical actions to include or exclude.
Informants suggested that authors of standards-based CDS work in collaboration with
guideline developers, standards development organizations (e.g., Regenstrief for Logical
Observation Identifiers Names and Codes), and clinical experts, to appropriately address
gaps in existing value sets and codes[26] and validate translated CDS logic expressions to ensure accuracy and increase trust
in the translation process.
Need for Feedback Mechanisms
Several authors contributing to CDS Connect noted the importance of having a feedback
mechanism between users and developers to help them understand if and how the artifacts
are used and what improvements or updates could be made. This mechanism would also
provide an opportunity to assess artifact quality and trustworthiness through a standard
reporting process.
Implementing Clinical Decision Support
Once CDS tools are developed, they must be implemented into local systems for use.
Though repositories may make standards-based CDS publicly available, the tools still
require adaptation for use in local and often proprietary EHR environments. Implementing
CDS interventions also promotes research and knowledge-sharing on the effective use
of CDS for patients, caregivers, and other stakeholders.[23] For CDS Connect in particular, we found limited evidence that users were implementing
available CDS. Only 7 of the 42 respondents who used the CDS Connect Repository indicated
they had downloaded and adapted CDS artifacts with the intent of implementation. Among
implementation challenges were technical difficulties implementing them in EHR systems
and getting buy-in from leadership. In addition, we found making resources on implementation
available to users promotes more equitable use of available CDS, particularly in low-resourced
settings such as community health centers.
Difficulty Implementing in Electronic Health Record Systems
Sites attempting to implement CDS Connect artifacts invested significant time and
staff resources to work with EHR developers to implement and maintain standards-based
CDS. Most EHR developers do not support import or execution of Clinical Quality Language
(CQL)-based knowledge artifacts.[27] Even among EHR developers that support CDS Hooks use for enabling CQL-based CDS
as a service, CDS Hooks limits where CDS trigger points can be placed within the provider
workflow. Additionally, EHR developers do not consistently offer FHIR services to
support standards-based CDS implementation. Informants noted that two different EHR
systems can use the same FHIR service but return different EHR data elements.
Therefore, implementing standards-based artifacts requires mapping standardized data
elements to proprietary codes EHR developers use. The extent of mapping, which can
only be determined with EHR developer input, relates to the specific EHR data elements
the CDS tools must access, and whether those EHR data are accessible using FHIR resources.
Due to the high degree of CDS customization and configuration requiring EHR developer
support, implementers noted that health systems using standards-based CDS artifacts
need to account for the additional resources required to maintain and update the CDS
within specific EHR platforms.
Executive Leadership Support Critical to Implementation Success
CDS Connect artifact users noted that, before developing or implementing CDS within
a health care institution, it is important to ensure buy-in from executive leaders
who manage the staff and IT resources needed for adaptation, integration into EHR
systems, and implementation. Users recommended selecting CDS that aligns with health
system priorities. Investigators for AHRQ's Quantifying Efficiencies project found
that “shared artifacts that explicitly state how they are designed to meet specific
strategic needs (e.g., clinical priorities, regulatory mandates) may be more likely
to be selected and implemented,” and tie-in with institutional priorities helped with
receiving approvals from multiple committees.[28] To help obtain buy-in at all levels, users suggested that publicly available CDS
metadata include enough information to allow health care executives and clinical leaders
to assess alignment with organizational priorities.
Implementation Resources Necessary for Equitable Use
Publicly available, standards-based CDS hold potential for supporting more equitable
distribution of CDS resources by making evidence-based CDS freely available. Accompanying
metadata and resources (such as implementation guides) facilitate adaptation of available
CDS for local environments, build trust in its evidence-base, and maximize the potential
that the tools will be used effectively.[29] However, as noted, implementing such CDS still requires substantial investment of
time and staff. More technical assistance and support are needed to enable lower-resourced
health systems to adapt standards-based CDS in local environments.
Measuring Clinical Decision Support Impact
Measuring health care outcomes based on CDS dissemination and use is among the most
important steps of the CDS lifecycle.[23] Measuring effectiveness is important to sustain, improve, and spread CDS use, as
well as prohibit CDS-induced harm.[30] The few studies on the efficacy of publicly available, standards-based CDS generally
focus on new products and the design or pilot stages of CDS development, rather than
outcomes.[13] Yet, we found that demonstrating a return on investment (ROI) is critical to promoting
CDS uptake.
Demonstrating Return on Investment Critical for Uptake
Users and potential users of CDS artifacts desired information regarding the impact
of CDS Connect Repository artifacts on health outcomes. Informants noted that this
information would build trust and encourage broader uptake of such CDS, including
among health systems. CDS Connect includes information on the experience of implementing
a few artifacts, including detailed pilot testing reports,[31] and anecdotal reports that “sites have implemented this CDS with no reported issues.”
But these reports do not include measures that could help health systems determine
whether CDS use improved clinical processes, workflow, or patient outcomes.
Initiative stakeholders emphasized the importance of demonstrating an overall ROI.
This requires measuring and calculating the cost and resources required to develop,
implement, and maintain CDS, and the benefits and improvements resulting from its
use. Informants noted that ROI information must include multiple perspectives on success.
For a patient, success may be facilitation of an informative health care discussion;
for a clinician, success may be improved workflow efficiency; for a health system
executive, success may be population-level improvements in quality outcomes. All these
types of ROI outcomes go beyond those primarily reported by CDS researchers in the
Initiative.
Discussion
Users agreed that resources made available through the Initiative are valuable for
advancing the development of publicly available, standards-based CDS. However, several
factors may hinder uptake of these resources and related CDS. Below, we consider other
research in the field alongside our findings, to identify broader implications and
insights for promoting the advancement and adoption of publicly available, standards-based
CDS in health care.
Public Clinical Decision Support Repositories Should Include Clear Information on
the Underlying Evidence Base
Trust in their integrity and validity is important when deciding to use CDS tools.[32] Platforms that provide publicly available CDS can bolster trust by providing accessible
information that helps potential users understand and assess the evidence underlying
the tools and their fitness for use. Proposed frameworks for trust in CDS include
a rating system based on evidence assessments.[29]
[33]
Guidelines in the Public Domain Are Good Candidates for Development into Publicly
Available Clinical Decision Support
Navigating intellectual property or licensing restrictions around evidence-based guidelines
can be an arduous process. Selecting guidelines in the public domain, such as those
developed or published by federal agencies, can help avoid this.
A Collaborative Approach to Authoring Improves Trustworthiness of Publicly Available,
Standards-Based Clinical Decision Support
Even if evidence-based sources and guidelines are trusted, their translation into
CDS logic may not be—making validation of the translation process critical to avoid
misinterpretation. Other studies have noted that adopters of standards-based CDS take
steps to review CDS logic expressions prior to implementing them independently.[1]
[28] A collaborative development process that includes guideline developers, standards
development experts, patients,[34] and CDS developers can reassure patient and clinician users that CDS artifacts are
vetted. CDC's Adapting Clinical Guidelines for the Digital Age Initiative and AHRQ's
CDS Connect project have examples of a collaborative translation process that includes
input from guideline developers and clinical experts.[35] An additional potential benefit of a collaborative approach is that stewards of
CDS artifacts can work with guideline developers to ensure CDS artifacts are maintained
to align with clinical guideline updates. The CDC Initiative also informed creation
of the FHIR Clinical Guidelines Implementation Guide to support guideline developers'
and CDS developers' joint efforts to develop computable representation of narrative
clinical guidelines using FHIR.[36]
Feedback Loops Are Critical to Developing, Maintaining, Improving, and Trusting Publicly
Available, Standards-Based Clinical Decision Support Artifacts
One benefit of publicly available open-source resources for CDS, including CDS artifacts
in a repository such as CDS Connect, is that they can be iteratively improved and
refined with feedback from a community of users. This has been demonstrated through
the work of OpenCDS, which boasts over 500 members.[37] Publicly available repositories of standards-based CDS should incorporate mechanisms
by which contributing CDS authors can receive input from other CDS authors and users.
This input could inform iterative improvements for release in future artifact versions,
which could protect against inadvertent dissemination of unusable or harmful tools.
Broader Clinical Quality Language Adoption by Electronic Health Record Developers
May Ease Many Challenges Health Systems Currently Face when Implementing Standards-Based
Clinical Decision Support
Because CQL is the standard Centers for Medicare and Medicaid Services currently requires
for electronic Clinical Quality Measure specifications, EHR developers have widely
supported CQL in the quality measurement domain. Even so, most EHR vendors have not
adopted CQL as a CDS standard and still use proprietary expression languages.[27] EHR developers may not feel compelled to prioritize native support of CQL until
knowledge artifact developers create a sufficient critical mass of CQL content. Regulation
from the U.S. Office of the National Coordinator for Health Information Technology
(ONC) requires adoption of FHIR Release 4 within EHR platforms as a condition of their
certification under the Health IT Certification Program.[38] CQL is currently the only CDS standard supporting use of the FHIR as a data model,
which may spur its adoption for CDS.[39] Wider CQL adoption by EHR developers would reduce the effort required to implement
and maintain standards-based CDS, making it more accessible to lower-resourced settings.
Increasing the availability of CQL-based knowledge artifacts such as those available
in CDS Connect may support a smoother transition to CQL-based CDS within EHRs in the
future.
Successful Implementation and Use of Publicly Available, Standards-Based Clinical
Decision Support Requires “Buy-in” at Multiple Levels within a Health System
Adoption of standards that support interoperability of health care data brought with
it the promise of applications that could be “plugged into” EHR systems and then swapped
out for newer, more updated applications as needed. Users may expect standards-based
CDS to provide the same agility to install and update CDS tools in EHR systems. However,
the complex process of implementing standards-based CDS requires support from executive
leadership, health IT departments, and clinicians—making buy-in at multiple levels
within a health care system necessary for success in implementing standards-based
CDS. The effort required for full stakeholder engagement may be the same as getting
approval for developing and implementing custom-built CDS.
Lower-Resourced Settings Need Additional Support in Adapting and Implementing Publicly
Available, Standards-Based Clinical Decision Support
Implementing standards-based CDS requires health IT staff familiar with CQL who can
work with EHR developers to integrate and optimize the CDS tools, which often require
multiple iterations and testing. The developer support required may result in additional
implementation costs that put such CDS beyond the reach of lower-resourced health
settings. Additional funding to support staff time, along with detailed implementation
guides, may be necessary for publicly available, standards-based CDS to be equitably
used across health care settings.
Further Studies Are Needed on the Short-Term (Process) Outcomes, Long-Term (Clinical)
Outcomes, and Return on Investment of Adapting, Implementing, and using Publicly Available,
Standards-Based Clinical Decision Support to Bolster Use
Providing this information can help build trust[2]
[3] in CDS efficacy and help users decide whether CDS artifacts will help their health
system improve care. However, the limited information available on outcome measures
for publicly available CDS speaks to a broader issue. The paucity of CDS research
studies that measure clinical outcomes may be because sustained CDS use and long-term
patient follow-up are required to detect any significant clinical outcome impacts.[40]
ROI analyses could help justify investment in developing, implementing, using, and
maintaining publicly available, standards-based CDS. However, ROI analyses of CDS
systems and tools are rare and often rely on estimation—given the challenges of measuring
direct, indirect, and intangible costs (e.g., burnout among clinician users) and recoverable
gains from CDS implementation and use.[41] As noted, given that buy-in is often required at multiple levels of a health care
system,[5] an ROI analysis must also consider multiple perspectives in determining the appropriate
inputs to such calculations.
Conclusion
Our evaluation of AHRQ's PCOR CDS Initiative identified important lessons for developing
and implementing publicly available standards-based CDS. We found that trust, a critical
factor in uptake, can be bolstered through ensuring transparent information on underlying
evidence, collaboration with experts in the development process, and feedback loops
between users and developers to support continuous improvement. Additionally, while
adoption of CDS standards among EHR developers will make it generally easier to implement
standards-based CDS, lower-resourced health systems will need extra support to ensure
successful implementation and use. Finally, health systems desire more information
about outcomes and ROI—beyond assessments of the value and functionality of prototypes
or their potential to improve health care decision-making or health outcomes—to help
justify the cost and effort of implementing standards-based, publicly available CDS.
Our findings closely align with recommendations prepared for the ONC Office of Clinical
Quality Standards.[42] Their 2015 report highlighted barriers to CDS use, including high costs associated
with implementing, customizing, and maintaining CDS. The report also called for feedback
loops between CDS producers and users, more metadata to decrease uncertainty among
clinician users of shared CDS resources, and efforts to demonstrate value. Future
efforts to scale use of publicly available, standards-based CDS need to address persistent
issues related to trust, implementation in commercial EHR systems, and CDS ROI measurement.
Clinical Relevance Statement
Clinical Relevance Statement
CDS has the potential to lower costs, improve efficiency, and reduce patient harm
by providing timely information to clinicians, patients, and others.[2] Shareable CDS has the potential to reduce duplicative efforts of translating clinical
evidence into CDS across health care institutions. This article describes the lessons
learned about publicly available, standards-based CDS from AHRQ's PCOR CDS Initiative,
which supported implementers, clinicians, and technology vendors developing shareable,
patient-centered CDS tools.
Multiple-Choice Questions
Multiple-Choice Questions
-
What may inhibit the use of a clinical guideline for publicly available CDS?
-
Intellectual property or licensing restrictions
-
The clinical guideline is published in the public domain by a federal organization
such as the CDC
-
The clinical guideline is specified in a computable format
-
The clinical guideline aligns with health system priorities
Correct Answer: The correct answer is option a.
-
Why are feedback loops critical to publicly available, standards-based CDS?
-
They allow users to share real-world experiences with the artifact
-
They help authors update and improve the artifact
-
They can increase user trust
-
All of the above
Correct Answer: The correct answer is option d.
