These findings have implications for four distinct constituencies: purchasers of clinical information systems, developers of clinical decision support, vendors of clinical information systems and certification bodies.

Pulling together long-term data is increasingly important in assessing environmental changes, whether regionally or globally.

PRIMARY TRACK: Guideline implementation SECONDARY TRACK: Computer-based decision support BACKGROUND (INTRODUCTION): Guidelines are often implemented as clinical decision support (CDS) in commercial electronic health record systems. However, the CDS capabilities of commercial EHR systems differ widely, and these differences have important implications for guideline developers. LEARNING OBJECTIVES (TRAINING GOALS):1. Identify clinical decision support features of electronic health record systems. 2. Understand differences in the CDS features of various commercial EHR systems. 3. Understand the implications of these differences for guideline development. METHODS: We compared the capabilities of nine commercially available clinical information systems against the 42 functional taxa from a published taxonomy of CDS capabilities. The taxonomy has four axes: 1) Triggers: events that cause a decision support rule to be invoked (e.g., ordering a laboratory test); 2) Input data: data used by a rule to make inferences (e.g., the patient's problem list); 3) Interventions: possible actions a decision support module can take (e.g., showing a guideline); 4) Offered choices: many decision support events require users of a clinical system to make a choice, e.g., choosing a safer drug. RESULTS: Overall, there was a great deal of variability among capabilities of the systems possessed. The two weakest systems evaluated were missing 18 of 42 capabilities, while the strongest system was missing only a single capability. Four of nine unique triggers (order entered, outpatient encounter opened, user request, and time) were available in all systems, seven of 14 input data elements were universally available, two of seven interventions (notify and show data entry template) were available in all systems, and only three of 12 offered choices were available in all nine systems. DISCUSSION (CONCLUSION):The clinical decision support (CDS) capabilities of these CCHIT-certified EHRs were variable, and none of the systems had every capability. Guideline authors and implementers should design guidelines with knowledge of the varying capabilities of EHRs and, preferably, guidelines should degrade gracefully in the absence of certain CDS capabilities or EHR data.

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