Evaluating clinical decision support rules as an intervention in clinical workflows with technology

Jane M. Brokel, University of Iowa
Tamara, J. Schwichtenberg
Douglas, S. Wakefield
Marcia, M. Ward
Michael, G. Shaw
J., M. Kramer


The implementation of electronic health records in rural settings generated new challenges beyond those seen in urban hospitals. The preparation, implementation, and sustaining of clinical decision support rules require extensive attention to standards, content design, support resources, expert knowledge, and more. A formative evaluation was used to present progress and evolution of clinical decision support rule implementation and use within clinician workflows for application in an electronic health record. The rural hospital was able to use clinical decision support rules from five urban hospitals within its system to promote safety, prevent errors, establish evidence-based practices, and support communication. This article describes tools to validate initial 54 clinical decision support rules used in a rural referral hospital and 17 used in clinics. Since 2005, the study hospital has added specific system clinical decision support rules for catheter-acquired urinary tract infection, deep venous thrombosis, heart failure, and more. The findings validate the use of clinical decision support rules across sites and ability to use existing indicators to measure outcomes. Rural hospitals can rapidly overcome the barriers to prepare and implement as well as sustain use of clinical decision support rules with a systemized approach and support structures. A model for design and validation of clinical decision support rules into workflow processes is presented. The replication and reuse of clinical decision support rule templates with data specifications that follow data models can support reapplication of the rule intervention in subsequent rural and critical access hospitals through system support resources.