Table 4.

Insights obtained from SME interviews

Insight	Source SME comments
Meaningful use dominates US health IT efforts. Widespread adoption of a CDS knowledge sharing approach will probably require tight coupling to meaningful use regulations.	SMEs consistently noted that their health IT strategies are driven by Meaningful Use regulations.
	SMEs believed that requiring vendors to support a specified knowledge sharing approach through future Meaningful Use regulations would be effective in achieving widespread adoption.
	However, many SMEs expressed concern that such a mandate would stifle innovation.
	SMEs generally preferred that additional Meaningful Use requirements for CDS focused on CDS capabilities and related clinical goals rather than on specific technical approaches.
	SMEs believed that such regulations should be accompanied by resources that facilitate the achievement of the required CDS capabilities.
Barring fiat/regulation, in order for a CDS knowledge sharing framework to be adopted, it must meet an unmet business need, and in a manner that is more cost-effective than alternative approaches	Several EHR system vendors noted they would find little value in engaging with a knowledge sharing effort focused on CDS content areas that they already supported.
	Areas of unmet CDS needs identified by these vendors consisted of areas with rapidly evolving knowledge and/or high-cost diagnostics or interventions, such as oncology.
	Some SMEs suggested that knowledge sharing efforts initially focus on relatively “CDS poor” organizations such as smaller EHR system vendors, personal health record vendors, and health information exchanges.
	SMEs noted that the CDS knowledge sharing framework must be more cost-effective than alternate approaches for fulfilling unmet CDS needs.
	Many SMEs emphasized that the approach must be relatively easy to understand and to implement by their existing workforce.
Fundamental to a business case for CDS knowledge sharing is a reimbursement model that encourages the provision of higher-quality care	SMEs noted that, barring regulation, the business case for CDS knowledge sharing depends on a reimbursement model that rewards the provision of higher-quality care and improvements patient outcomes.
	SMEs noted that given the predominant fee-for-service payment model, there is often a lack of appropriate financial incentives for implementing robust CDS capabilities.
For knowledge content vendors, a national CDS knowledge sharing framework is both an opportunity and a threat	Knowledge content vendors noted that in areas where they already had market success using proprietary approaches, a knowledge sharing framework could be a threat by reducing barriers to entry for competitors.
	However, the vendors noted interest in a national knowledge sharing framework if such a framework created access to a larger market for their products.
There are significant gaps in the required standards, and many existing standards have significant limitations	SMEs repeatedly noted the lack of common information models for CDS inputs and outputs as a barrier to CDS knowledge sharing.
	Multiple SMEs noted the need for a standard, widely adopted catalog for orderables and their results.
	SMEs noted that existing standard terminologies such as SNOMED CT, LOINC, and RxNorm were inadequate owing to the lack of needed concepts or the availability of only highly detailed concepts that were more granular than desired. For example, neither SNOMED CT nor Medcin offer full coverage of concepts required for the characterization of mild traumatic brain injury.24 As another example, RxNorm does not support the notion of drug classes, such that RxNorm must be combined with other terminologies such as NDF-RT in order to identify medications that fall under a particular drug class (eg, β blocker).25
	SMEs noted the lack of standards for documentation templates, knowledge representation, and clinical workflows.
	SMEs noted that many existing standards are too complex or cumbersome to use.
	Several SMEs noted the lack of adoption of available and appropriate standards.
	An SME noted that the typical standards development process is hindered by a “design-by-committee” approach and the limited engagement of relevant stakeholders.
	An SME noted the development of relevant standards could be accelerated significantly through direct US government sponsorship.
There is a “chicken-before-the-egg” dilemma	Multiple SMEs noted that many stakeholders are waiting for a robust, widely accepted CDS knowledge sharing framework to be established before joining and investing, whereas the development of such a framework requires early adopters.
	Multiple EHR system vendors noted that they would only allocate resources for integrating with such a framework if it provided substantial valuable content.
Important “building blocks” are missing and must be established before significant progress can be made	SMEs noted that robust standard value sets and information models are required for foundational CDS elements, such as problems, orders, results, and medications.
	Required value sets include comprehensive value sets for drug classes, problem classes, and test result classes.
	Until such building blocks are in place, SMEs noted it would not be possible to specify higher-level CDS artifacts such as order sets, documentation templates, and rules in a standard and semantically interoperable manner.
Competing approaches increase risk and hinder adoption	Several SMEs noted that the availability of multiple competing approaches to CDS knowledge sharing hinders adoption, because it is unclear which approach—if any—will end up becoming the dominant approach. Thus, while competition may foster innovation, it limits the adoption of any one of these approaches.
The US government has a critical role	SMEs noted that the US government is the only entity with the scope, resources, interests, and authority to overcome various barriers to scaling CDS.
	Specifically, one or more SMEs recommended the following actions by the US government: ▸ Spearhead the development of foundational “building blocks” for interoperable CDS, including required standards, value sets, and common order catalogs. ▸ Break the “chicken-before-the-egg” stalemate by fostering the development of a robust CDS knowledge sharing framework and accompanying content. ▸ Motivate relevant stakeholders to adopt and use designated standards and CDS knowledge sharing approaches. ▸ Modify the clinical reimbursement model to align more closely with care quality and health outcomes.
Various knowledge sharing approaches are complementary, with each having important strengths and limitations	The SMEs were asked to comment on three inter-related approaches to knowledge sharing: (1) the sharing of human readable but non-computable knowledge artifacts; (2) the sharing of structured, computable knowledge artifacts; and (3) the sharing of CDS inferencing capabilities themselves through web services.
	The SMEs saw both important benefits and challenges for each of the knowledge sharing approaches.
	Most SMEs believed that the different approaches were complementary, with their appropriateness dependent on the deployment context.
Significant work is usually required to adapt CDS knowledge resources for local use	Many SMEs noted that implementing CDS often requires significant adaptation and customization.
	Such efforts were noted to be needed at multiple levels, including terminology mapping, workflow integration, and the reconciliation of clinical content with local norms.
Medicolegal liability is a significant concern	Many SMEs expressed concern about the medicolegal liability associated with providing CDS directly, or allowing third-party CDS content to be provided through their products.
	Many SMEs were uncertain and apprehensive about the future role of the US Food and Drug Administration.
	Several SMEs suggested that the government sponsor sanctioned CDS resources accompanied by appropriate medicolegal protection for providers and vendors who use the CDS content.
Take one step at a time	Several SMEs expressed concern that efforts at establishing an operational national knowledge sharing framework may be premature, given that important prerequisites are not yet in place.
	An SME recommended using a flexible, iterative, and long-term approach so that the proposed architectures can undergo substantial operational refinement.
	An SME noted that large-scale CDS initiatives are often hindered by the mandate to accomplish strategic objectives according to a tactical timeframe.
A self-sustaining business model is needed	An SME noted that a self-sustaining business model is needed to enable CDS knowledge sharing at scale.
	Specifically, the SME noted that the business model would become difficult to scale across many knowledge producers if every knowledge producer charged each of its healthcare provider clients a modest but significant licensing fee (eg, $25 000 a year) for relatively small amounts of content. This problem could potentially be dealt with by (i) the licensing of content by the US government for nationwide use or (ii) the achievement of economies of scale, whereby per-client licensing fees could be reduced through the widespread adoption of a common CDS sharing infrastructure.
Other SME insights	Pharmaceutical companies and insurance providers are interested in influencing clinician behavior to align with their business interests, including by making sponsored CDS content available through EHR systems.
	Vendors are unlikely to initiate significant activity in this area on their own.
	The national CDS sharing framework should be open source.
	CDS supportive of common standards of care should be a baseline across EHR systems and should not be a point of competitive differentiation.
	For true knowledge sharing, an important challenge is that participants are generally much more interested in taking rather than contributing content.

CDS, clinical decision support; EHR, electronic health record; LOINC, Logical Observation Identifiers Names and Codes; NDF-RT, National Drug File-Reference Terminology; SME, subject matter expert; SNOMED CT, Systematized Nomenclature of Medicine, Clinical Terms.