The Basics

This standard outlines the requirements for the clinical decision support tools used in the DM program.  “Clinical decision support tools” are defined as “protocols, guidelines, or algorithms that assist in the clinical decision-making process.” 

The most important element of this standard requires that your program enlist the aid of providers with appropriate expertise in the process of reviewing, no less frequently than annually, the decision support tools, updating them when appropriate. 

In addition, the tools should be up-to-date with clinical knowledge and practice and incorporate any available evidence-based practices.

Management Tips

Don’t merely rely on the tool itself as documentation; make sure you have a P&P that describes the clinical decision support tools in use for each condition within the DM program.  That P&P should describe clearly the review and approval process, including the process of selecting providers to conduct the review to assure that they have the appropriate qualifications to review the tool(s)

URAC Accreditation Tips

One of the three elements is mandatory; the other two are worth 3 points each.
Not only must you submit the applicable P&P and a copy of the decision support tool(s) themselves, but you should also provide URAC with sample minutes of meetings at which expert providers reviewed and perhaps revised decision support tools. 

The onsite reviewer will examine the tools themselves, and ask for a demonstration of their use.  In addition, the reviewer will interview both the IT and DM staff members on the tools, including questions such as:

• What clinical decision support tools do you use for [a particular condition within the program]?
• How often is that tool reviewed and/or revised?
• Who is involved in the review process?
• How do you access the tool?
• How does the tool help you provide the appropriate disease management services to the participant?