Agile Clinical Decision Support Development

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Designing effective Clinical Decision Support (CDS) tools in an Electronic Health Record (EHR) can prove challenging, due to complex real-world scenarios and newly-discovered requirements.  As such, deploying new CDS EHR tools shares much in common with new product development, where agile principles and practices consistently prove more effective than traditional project management. Typical agile principles and practices can thus prove helpful on CDS projects, including time-boxed sprints and lightweight requirements gathering with User Stories and acceptance criteria. Modeling CDS behavior removes ambiguity and promotes shared understanding of desired behavior, but risks analysis paralysis: an Agile Modeling approach can foster effective rapid-cycle CDS design and optimization. The agile practice of automated testing for test-driven design and regression testing can be applied to CDS development in EHRs using open-source tools. Ongoing monitoring of CDS behavior once released to production can identify anomalies and prompt rapid-cycle redesign to further enhance CDS effectiveness.
Using agile principles and practices, in calendar year 2015 our institution developed 58 EHR-based specialty patient registries, with 111 new CDS and data collection tools, supporting 134 clinical process and outcome clinical quality measures, and enrolling over 16,000 patients. Agile modeling proved key to joint understanding and communication during initial development–and to iteratively evolving CDS tools for optimal use in active clinical settings. The subset of UML and non-UML models found most consistently useful in designing, building, and iteratively evolving EHR-based Clinical Decision Support included User Stories, Domain Models, Use Case Diagrams, Decision Trees, Graphical User Interface Storyboards, Use Case text descriptions, and Solution Class Diagrams.