How to handle more than one set of responses using CDS Cards

[Dr. J. Dominguez]

I am interested on implementing CDS hooks in a decision support system that handles treatment suggestions using formalised clinical guidelines. Although each of the recommendations can be specified as a cds card, the challenge is how to specify alternative treatments, as it is often depicted on clinical guidelines. For instance, given a diagnosis and a set of patient-related parameters, the CDS would suggest two equally prioritised courses of action, apply either treatment A1 along with treatment B or treatment A2 with treatment B where the clinician/patient has no initial preference. The CDS cards specification allows me to define treatment A1, A2 and B but how do we handle the grouping of treatments and the distinction among groups while following CDS cards format? Any guidance or direction to existing research would be much appreciated.

[Dennis Patterson]

Hi Dr Dominguez!

In your situation, it sounds like the CDS Service would return two Suggestions that the user could choose between, where the first Suggestion contains Actions for A1 and B, and the second Suggestions contains Actions for A2 and B.  The Card would also have the selectionBehavior set to at-most-one, meaning the user must choose between the two Suggestions.

Does that meet your use-case?

Dennis

[Dr. J. Dominguez]

Hi Dennis,

Thank you for your answer.

I am indeed following that approach. However, some of the features of the card become irrelevant when having one card with more than one suggestion (for my particular scenario). 

For instance, for my use case, the indicator field (info|warning|critical) does not convey much information if it is outside the suggestions array or even outside the actions array when denoting some interaction among treatments in one of the suggestions or even one of the actions. If there are more than one suggestion and one of the actions has some critical outcome, what would it mean to place all suggestions in the same card with the indicator set to critical? Whereas if the indicator field was more specialised, the information could be more accurate (one could decide to have an icon next to the action on the EHR to denote the criticality of it).

Another issue I have encountered for my use case is that the Suggestion is supposed to describe the label for a text in a button, for instance, whereas I find more suitable to have the label on each action so that the clinician would have more transparency when selecting 'Switch to Treatment A1' and 'Create Therapy B' instead of 'Follow Suggestion 1', where 'Switch to Treatment A1' could open a page for selecting medication and 'Create Therapy B' could lead to a link on available therapies.

These issues are not critical but I wondered whether other approaches had been considered.

Thank you again.

[Dennis Patterson]

It sounds like you see a need to have the indicator be not at the card level, but at the card.suggestion or card.suggestion.action level?  Can you give an example where suggestions/actions differ in criticality for a single card?

For the second issue, I'm curious if label placement at the action level is related to the first issue and how you are currently representing decision support in the CDS service response.  The proposal of action labels opening pages for selecting from available medications/therapies doesn't match with the specification's actions array conveying specific FHIR resources that are all part of that suggestion.  I think if there were options for treatments and therapies, those concrete actions would be in separate suggestion options.  But, some additional concrete examples may help clarify and walk through your use-case.

[Dr. J. Dominguez]

The use case is COPD and the CDS manages treatment and interaction prior to administration via formalised clinical guidelines. Here it is an example that I believe it may not worked for the indicator and labelling I commented on on my previous email:

Assume some Patient A has been diagnosed with severe COPD. Also, Patient A is a current smoker and is at high risk of Pneumonia. The COPD Gold guideline suggests 3 possible treatment paths: admin LAMA type drugs, admin LAMA + LABA combination drugs, admin LABA + ICS combination drugs. Also, there is a recommendation to suggest smoking cessation therapies to the patient and a warning that  regular treatment with ICS increases risk of Pneumonia.

The CDS device provides a response with 3 suggestions or care plans:

1. admin LAMA, suggest smoking cessation therapies

2. admin LAMA + LABA, suggest smoking cessation therapies

3. admin LABA + ICS, suggest smoking cessation therapies, warn practitioner about the risks of regular treatment with ICS on a patient susceptible to Pneumonia.

Now, these are converted into 3 care plans with goals where the CDS card action group is composed of medicationRequest and ServiceRequest resources to be done together (eg, update COPD treatment, suggest smoking cessation therapies). 

At the client end, the practitioner selects one of the care plans. That means there should be a means to create medication orders and check smoking cessation therapies by providing message boxes on the screen actionable by a simple button.

By following your initial suggestion, one card would hold 3 suggestions. However, only one of the suggestions comes with a warning. In this case, a clear solution is to have a card per suggestion instead. However, for each suggestion group, how can the CDS service preserve the format of CDS cards when specifying the actionable requests since this is defined at the suggestions level?

[Dennis Patterson]

Would it make sense to have "suggest smoking cessation therapies" be its own card?  That seems consistent guidance regardless of the other suggestions.

For option 3 where ICS has a warning, that's a different warning concept from the card indicator.  The card indicator denotes the urgency/importance of what the card conveys, not so much warnings about side affects of accepting the guidance. The note about ICS increasing risk of Pneumonia could be mentioned in the suggestion label.  Depending on the CDS Client configuration, another CDS Service could potentially warn further about risks of pneumonia if that suggestion was accepted.