The Six Rights of Clinical Decision Support at the Dawn of the AI Era
By Steve Miller, MD
Steve Miller, MD, MBE is clinical solutions architect at FDB.
Clinical decision support (CDS) embedded in the electronic health record (EHR) has demonstrated impressive benefits for patient outcomes, particularly through medication alerts in Computerized Provider Order Entry. CDS helps prevent millions of medical errors per year. Yet the potential of CDS remains under-realized due to poor usability, misalignment with clinical and institutional goals, and its contribution to clinician burnout.
We are at the dawn of a new era in CDS, where we can realize the promise of enhanced care and financial outcomes simultaneously to the empowerment of clinicians.
Effective clinical decision support depends on meeting the Five Rights: delivering the right information, to the right person, in the right format, through the right channel, and at the right time.
Too often many CDS systems still fall short: interrupting workflows, triggering at the wrong moment, or lacking the specificity that is needed to earn clinician trust. High false-positive rates lead to reflexive overrides, eroding confidence and sometimes putting patients at risk. It’s time to evolve the framework.
I propose a sixth right: the right purpose: designing CDS with clearly defined, measurable benefits.
When interventions lack purpose or a defined return on investment, even well-built tools can fail to deliver value. As hospitals face tighter budgets and mounting pressure to improve outcomes, advances in interoperability and artificial intelligence (AI), including large language models (LLMs), offer a new path to achieving all Six Rights.
Workflow Integration: Right Person, Format, Channel, and Time
Consider a common scenario. Dr. Smith, on inpatient rounds, discusses starting spironolactone with 80-year-old Mr. Richards, who has heart failure. After researching the dose, she signs the order and is immediately interrupted by an alert flagging the drug as potentially unsafe for older adults. The decision has already been made. She is annoyed, overrides the alert, and moves on.
Now imagine a near-future alternative. An AI-powered ambient listening tool transcribes and interprets the conversation in real time. As spironolactone is mentioned, a message appears on screen with safety concerns specific to Mr. Richards in his current clinical context, a patient education prompt, alternative options, and a preselected dose. The information is timely and useful, supporting rather than disrupting shared decision-making.
Context-specific decision support could also surface during pharmacist verification, admission medication reconciliation, or through patient-facing bots. Interruptive alerts at order signature are fading. Smarter systems will deliver guidance at the right moment. They will also reduce the amount of time physicians would otherwise have to spend looking up information, such as lab values that are relevant for a specific drug.
Personalization: Right Information
Let’s revisit Mr. Richards. His heart failure has impaired his kidneys and his potassium is dangerously elevated. This places him at risk for arrhythmia if prescribed spironolactone, yet no alert fires. Dr. Smith misses this lab result, placing the patient in danger.
Now imagine a CDS module that detects elevated potassium and correlates it with spironolactone, firing only when truly relevant. Dr. Smith receives fewer alerts, but each one matters. This precision support, with both low false positives and false negatives, is achievable today using interoperable systems and standardized data.
Beyond labs, decision support can incorporate genetic tests, imaging, pathology, and patient-reported outcomes. AI can convert notes and conversations into structured insights that power a new generation of CDS that is accurate, timely, and personalized.
Return on Investment: Right Purpose
Right purpose means aligning CDS with institutional and societal goals. Tools that serve mission-critical needs, and the other five rights, drive adoption.
Back to our case. Budget cuts force the hospital to reassign pharmacists from the wards. Without human backup, prescribing errors could rise. But with AI-enhanced CDS, the computer system helps the clinical team catch errors and find opportunities to enhance care once identified by pharmacists. Rather than replacing clinicians, CDS amplifies their capabilities, delivering cost savings without compromising care.
AI could also accelerate this shift in two ways. First, AI-assisted development could speed the creation of CDS modules, enabling access to high quality and purpose-built decision support. Second, AI-powered analytics could allow hospitals to evaluate CDS performance in real time, measuring clinical and financial impact and refining systems.
A Pivotal Moment
The current moment in healthcare is one of great challenges and great possibilities. Advances in AI, data standards, and clinical messaging combine with economic pressures to fuel a necessary evolution. The future of CDS is personalized, context-aware, and results-driven. By honoring the original Five Rights, and adding a sixth of Right Purpose, we can ensure that CDS not only guides decisions, but also advances care, supports clinicians, and justifies itself in a resource-constrained world.
Comments Off on Readers Write: The Six Rights of Clinical Decision Support at the Dawn of the AI Era
I'll bite on the disagreement side. 25+ years in EHR implementation, sales, and support. First, regarding the decision effect. Sure,…