Design, EHR Integration and Evaluation of Clinical Decision Support Workflows Driven by a Mortality Prediction Model to Promote Goal Concordant Care*

We present a clinical decision support (CDS) framework to promote goal-concordant care for cancer patients nearing end of life, enabled by a 90-day mortality prediction model. Design, workflow, and deployment for four model driven CDS tools are described alongside utilization patterns and detailed performance analysis of the first of such tools integrated into clinical practice: an alert promoting advance directive completion. The alert achieved a precision of 44.1% (95% CI: 39.6 - 48.8%) and a recall of 34% (95% CI: 30.3 - 37.4%) with 9.8% 90-day mortality prevalence over a period of 8 months. Our analysis shows that both precision and recall of the alert were significantly impacted by the underlying clinical workflows. Based on feedback, clinicians have accepted model-driven CDS as a legitimate means to prioritize patients for advance care planning interventions.