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A Technical Analysis of Clinical Decision Support Technologies in the VA's VistA EHR

The VistA EHR serves VA hospitals across the U.S. and is among the most functionally advanced electronic health records system in use today. Among its sophisticated features are a host of clinical decision support (CDS) technologies that provide alerts, reminders, order sets, intelligent clinical documentation templates, and other tools to guide patient care.

The Veterans Health Administration commissioned Sujansky & Associates to perform a comprehensive technical analysis of VistA's existing CDS capabilities with respect to knowledge representation, tooling, and standardization. The objective was to determine how the design and implementation of these capabilities facilitate or limit their practical effectiveness, and to assess what opportunities exist to improve the CDS technologies.

Relevant documents:

A Technical Review and Analysis of Clinical Decision Support Technologies
In Current Use at The Veterans Health Administration (TOC and Intro)

Sujansky & Associates' role in this project included:

  • Research of VistA's existing CDS technologies via detailed reviews of technical and user documentation, training materials, live demonstration systems, and published literature, as well as interviews with over 20 VA technical experts.

  • Characterization and classification of the various VistA CDS modalities with respect to a set of six commonly accepted functional categories: Order creation facilitators, reactive alters/reminders, documentation forms/templates, support for protocols and pathways, reference information, and relevant data presentation.

  • Analysis of each CDS modality with respect to its functionality, knowledge-representation methodology, available tooling for configuration and knowledge maintenance, and degree of standardization across VA facilities.

  • Analysis of the similarities and differences in technical features across the VistA CDS technologies.

  • Detailed documentation of our findings and recommendations in a 100-page report (see below).



At least 17 distinct CDS technologies exist within the VistA EHR, ranging from a general-purpose rules-based expert system to a customized dosing manager for a single medication.

A variety of knowledge-representation models and content-editing tools exist across the different CDS technologies within the VistA system.

The VistA EHR system includes an extensive data dictionary for the coded representation of clinical concepts needed to drive decision support.