Their Evolution   In the early days, CDS systems tended to be stand-alone systems not directly integrated into the clinical process workflow in hospitals or physician offices. This is one of the reasons why for decades they tended to be regarded as research tools and even as “toys” by many practicing physicians.   Over the past decade, CDS systems began to be integrated to varying extents into both computerized physician order entry (CPOE) and electronic prescribing systems. These two systems got a big boost in November of 1999 following release of the landmark two-year study by the Institute of Medicine concluding that perhaps as many as 98,000 patients died due to preventable errors in American hospitals annually. Kohn, LT, et. al., To Err is Human: Building a Safer Health System; Washington, D.C.; National Academy Press (2000)   Subsequent Institute of Medicine (IOM) reports in its Quality Chasm series only reinforced the notion of the importance of the integration of effective clinical decision support in the “normal” clinical workflow of physicians (including physician orders in general, and prescribing of drugs, in particular). CDS systems integrated with CPOE systems also got a big boost in the early part of the current decade when the Leapfrog Group (conceived by Fortune 100 “CEOs of the Business Roundtable”) showcased CPOE as the first (among equals) of safety leaps which they promoted among hospitals and physicians caring for their employees through value-based purchasing strategies.   Their Promise   The Roadmap for National Action on Clinical Decision Support identifies three pillars for fully realizing the promise of CDS:   Pillar 1: Best Knowledge Available When Needed This involves representing clinical knowledge and CDS interventions in standardized formats (both human and machine-interpretable), so that a variety of knowledge developers can produce this information in a way that knowledge users can readily understand, assess, and apply it.   Pillar 2: High Adoption and Effective Use This involves improving clinical adoption and usage of CDS interventions by designing CDS systems that are easy to deploy and use, and by identifying and disseminating best practices for CDS deployment by users.   Pillar 3: Continuous Improvement of Knowledge and CDS Methods This provides the ability to advance care-guiding knowledge by fully using the data available from interoperable Electronic Medical Records (EMR) to continually enhance the clinical knowledge of physicians and the overall health management of their patients.   Their Pitfalls   As discussed in the November 2007 issue of Risk Review, one of the biggest potential future methods for plaintiffs’ attorneys to demonstrate negligence will be through electronically discoverable evidence (see the March 2008 issue of Risk Review) that physicians have either ignored or even turned off the CDS systems embedded in EMRs. If the connection between the act of commission or omission for which use of the CDS system could have guided a defendant physician to a different course is sufficiently compelling, plaintiffs’ attorneys might even call such situations res ipsa loquitur (literally the thing, or act, speaks for itself as being negligent).   Conversely, physicians cannot rely on CDS systems to relieve them of liability for their actions that result in harm to patients. CDS systems are intended to augment the physician’s ability to make decisions by providing important knowledge at the point of care. They are not intended to substitute for the physician’s own clinical judgment.   Conclusion   CDS systems may decrease significantly the communication, clinical judgment and systems gaps responsible for many types of medical lawsuits.  However, they must be used and used properly. They cannot be relied upon as an absolute shield from liability.