New Standards for Clinical Decision Support: A Survey of The State of Implementation

Objectives: To review the current state of research on designing and implementing clinical decision support (CDS) using four current interoperability standards: Fast Healthcare Interoperability Resources (FHIR); Substitutable Medical Applications and Reusable Technologies (SMART); Clinical Quality Language (CQL); and CDS Hooks. Methods: We conducted a review of original studies describing development of specific CDS tools or infrastructures using one of the four targeted standards, regardless of implementation stage. Citations published any time before the literature search was executed on October 21, 2020 were retrieved from PubMed. Two reviewers independently screened articles and abstracted data according to a protocol designed by team consensus. Results: Of 290 articles identified via PubMed search, 44 were included in this study. More than three quarters were published since 2018. Forty-three (98%) used FHIR; 22 (50%) used SMART; two (5%) used CQL; and eight (18%) used CDS Hooks. Twenty-four (55%) were in the design stage, 15 (34%) in the piloting stage, and five (11%) were deployed in a real-world setting. Only 12 (27%) of the articles reported an evaluation of the technology under development. Three of the four articles describing a deployed technology reported an evaluation. Only two evaluations with randomized study components were identified. Conclusion: The diversity of topics and approaches identified in the literature highlights the utility of these standards. The infrequency of reported evaluations, as well as the high number of studies in the design or piloting stage, indicate that these technologies are still early in their life cycles. Informaticists will require a stronger evidence base to understand the implications of using these standards in CDS design and implementation.