CDS and the CDS &LHS 5 Rights

The 2012 HIMSS Guidebook on Improving Outcomes with CDS defines CDS as follows:

"a process for enhancing health-related decisions and actions with pertinent, organized clinical knowledge and patient information to improve health and healthcare delivery. Information recipients can include patients, clinicians and others involved in patient care delivery; information delivered can include general clinical knowledge and guidance, intelligently processed patient data, or a mixture of both; and information delivery formats can be drawn from a rich palette of options that includes data and order entry facilitators, filtered data displays, reference information, alerts and others.

The CDS 5 Rights framework asserts that, to improve targeted healthcare decisions/outcomes with well developed & deployed CDS interventions, the interventions must provide:

              • the right information,

              • to the right people,

              • in the right intervention formats,

              • through the right channels,

              • at the right points in workflow

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The CDS 5 Rights concept and approach was first articulated by Jerome Osheroff, MD in 2006, and described formally in the 2009 book "Improving medication use and outcome with CDS: a step-by-step guide." This framework and its application are further described in the 2012 book "Improving outcomes with CDS: an implementer's guide, second edition." (More information about these guidebooks, including excerpts, can be found here.) CMS recommends this framework as a best practice approach to health IT-enabled quality improvement. A 2018 webinar describes strategies and tools for re-engineering care delivery to get the CDS 5 Rights right for improvement imperatives and transform care across targets to achieve the quadruple aim (webinar slides, recording).

Understanding and leveraging effectively these 'what, who, how, where, when' information flow dimensions is central to configuring useful CDS/QI approaches. The CDS guidebooks mentioned above devote considerable attention to how to set up CDS programs - and how to configure, vet, test, launch and evaluate CDS interventions - to get these 'CDS 5 Rights' right. The CDS/PI Collaborative covered on this website is bringing together inter-dependent stakeholders to 'get better faster - togetherSM' at improving outcomes, and is leveraging this information. A central component of this is using structured CDS/QI worksheets based on the CDS 5 Rights dimensions to document, analyze, share and improve target-focused CDS approaches.

Getting the CDS 5 Rights right requires fully leveraging available options in each of the 5 component dimensions. The CDS/QI Worksheets contain suggestions to help you broadly consider these options, and the outline below provides additional support. The 2012 CDS guidebook provides further details on options in these 5 CDS configuration dimensions. Relevant excerpts from the CDS guidebook, along with other helpful information about the CDS 5 Rights dimensions and other implementation guidance, are available in CDS/QI Resources.

EHR/HIT vendors often provide the 'format' and 'channel' dimensions for CDS interventions so their attention to optimizing their capabilities - in collaboration with their provider clients - can be particularly important in advancing target-focused CDS efforts.

Broadening the Framework: The LHS 5 Rights for Learning Health Systems1:

The CDS 5 Rights framework (which focuses primarily on clinical decisions) can be expanded to address the broader learning health system cycle, whereby evidence is synthesized into guidance that is put into action to support health and clinical decisions and actions, which generates data, that is synthesized into evidence. Ideally this produces a continually improving cycle that drives progress toward the quintuple aim.

Echoing and broadening the CDS 5 Rights framework, the LHS 5 Rights framework is an approach to supporting decisions and actions better to optimize processes and outcomes throughout the LHS cycle by getting:

  • the right information and tools/resources

  • to the right people

  • in the right formats

  • though the right channels

  • at the right times

(1first articulated by JAO, September 2019 as the "Decision/Action Support 5 Rights" framework; renamed September 2021 as the "LHS 5 Rights" framework)

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The notes below provide additional details to consider regarding the CDS 5 Rights dimensions as you configure, evaluate and improve your target-focused CDS intervention strategies.

Information Characteristics to Consider Include:

  • Evidence-based

  • Current

  • Answers questions (recognized/unrecognized)

  • Right depth/breadth/level

  • Useful for guiding action

People to Consider Include:

  • Doctors

  • Nurses

  • Pharmacists

  • Other care providers

  • Patients! (and their caregivers)

CDS Formats/Intervention Types and Channels to Consider:

The 2 Figures below are (c) HIMSS 2012; they are excerpts from "Improving outcomes with CDS: an implementer's guide. Second Edition. Osheroff, Teich, Levick et al"

Figure 5-5: Taxonomy of CDS Intervention Types

A. CDS during data-entry tasks

1. Smart Documentation Forms

2. Order Sets, Care Plans and Protocols

3. Parameter Guidance

4. Critiques and Warnings – “Immediate Alerts”

B. CDS during data-review tasks

5. Relevant Data Summaries (Single-patient)

6. Multi-patient Monitors

7. Predictive and Retrospective Analytics

C. CDS during assessment and understanding tasks

8. Filtered Reference Information and Knowledge Resources

9. Expert Workup and Management Advisors

D. CDS not triggered by a user task

10. Event-driven Alerts (Data-triggered) and Reminders (Time-triggered)

Figure 3-2: CIS applications pertinent to CDS interventions

  • Consider also patient home monitoring and support devices that are networked, such as scales, glucometers, BP cuffs, pill boxes and the like. These are particularly important for targets related to care-coordination (such as readmissions), and to chronic disease management.

Points in Workflow to Consider Include (See ACDS Workflow Taxonomy):

  • Key decision being made

    • Diagnostic approach

    • Management plan

  • Key action being taken, such as:

    • Intervention ordering

    • Data gathering and documentation

    • Medication administration/consumption

*Consider full care continuum

  • Especially w/readmissions, bundled payments, ACOs, etc.