The vendors in our sample represent a large cross-section of EHRs used in the United States and internationally. We believe that they are a generally representative sample of knowledge management capabilities of EHRs, with the possible exception that smaller and niche vendors are not well represented.
Based on the report by Chaudhry, as well as prevailing attitudes in the academic medical informatics community, we expected a large gap in the technical capabilities between the four "best-in-class", internally-developed systems as depicted in the scientific literature and commercial EHR vendor's products. We were pleasantly surprised to discover that all of the vendors we surveyed acknowledged and appreciated the challenges of clinical decision support, and reported that they provided knowledge management capabilities to help their customers manage their clinical knowledge. In fact, with respect to the clinical knowledge management capabilities we surveyed, there appears to be little discernable difference between the systems provided by the surveyed EHR vendors and the internally-developed systems. These results mirror our findings from two recent studies that examined the CDS capabilities of commercially-available clinical information systems [26, 27]. The vast majority of commercially-available EHR systems currently on the market in the U.S.A. today report that they provide an adequate technical infrastructure to support the required CDS and knowledge management capabilities.
Despite the strong technical capabilities provided by vendors, however, previous research has shown that simply providing healthcare organizations with CCHIT-compliant, CDS and KM feature-filled electronic health record applications will not ensure that every organization will be able to realize the process-level improvements in healthcare quality and patient safety that are possible .
First, to achieve maximum benefit, organizations will need to select, implement, and maintain the necessary hardware, networking, and operating system software. Without a robust computing infrastructure, the CDS and knowledge management features and functions will not be able to keep up with end-users demands for sub-second response time and 24 hours a day, 7 days a week availability.
Second, organizations will need to develop or purchase, implement, and maintain the clinical content required to provide the clinical decision support interventions required to help guide clinicians. Managing this content is a critical job of either the end-user, or the end-user in conjunction with the vendor, using the knowledge management tools identified in this survey. Ideally, the individuals involved have informatics training (as described below).
Third, EHR vendors will also have to develop easy to learn and use user interfaces that allow users to interact with the CDS interventions in a seamless manner, in the course of the clinical workflow. Failure to integrate the CDS interventions into the clinicians' routine workflow will undoubtedly result in less than optimal usage. Perhaps one of the main reasons that these internally-developed systems have achieved such great success with their CDS interventions is the fact that all of them have been iteratively refined over many years to more closely approximate the clinical workflow of their users. Another reason could be the sense of ownership and responsibility these developers have to make sure the CDS applications are implemented and maintained.
Fourth, to develop, implement, and maintain all of the required clinical content, new kinds of employees capable of interacting with the information technology and clinical personnel will be required. These clinical "informaticians" will be key in the successful CDS implementation and maintenance efforts. Once again, all of the internally-developed systems were designed, developed, and maintained by such a group of committed, highly-trained clinical informaticians. In addition to managing the clinical content, these informaticians also help redesign the clinicians' workflows to make optimal use of the CDS interventions. Further, clinical practice guideline authors, should take note of the clinical content needs of EMRs for CDS, and aim to deliver guidelines in an unambiguous form as near ready for implementation as possible .
Fifth, on top of all these other challenges, the organization must review and modify their clinical workflows and communication patterns  along with their internal policies and procedures to reflect newfound capabilities of CDS-enabled EHRs. Failure to make these modifications can result in significantly less then optimal usage of these systems.
Six, the organization must develop the technical and governance infrastructure required to capture, report on, and evaluate the data necessary to measure and monitor both the inner workings of the CDS as well as the effect of the interventions on clinical processes and patient outcomes . Without such careful evaluation, organizations might inadvertently negatively affect the patients' care that they are working to improve .
Finally, the local and national bodies responsible for creating and maintaining the rules and regulations that govern the operation of the healthcare facilities and their workers must be updated to take into account the new capabilities of these CDS-enabled EHR systems .
The EHR vendor data presented represents only a small sample of the 2008 CCHIT-approved, commercially available EHR systems. Second, the use of self-reported data from the vendors and the internally-developed systems may result in an overstating or an understating of the current capabilities of their systems. When possible we have spoken directly with customers who have installed and are using these systems, as well as, asking for demonstrations of the systems. To date we have not encountered any "inflation" of capabilities. Finally, even though many of these vendors reported a robust suite of CDS and knowledge management features, our experience, along with the literature , tells us that not all customers will be able to make use of this advanced CDS functionality and achieve improvements in healthcare quality, safety or reductions in cost .
Another limitation is the fact that each of the systems is different, and the survey questions may over-emphasize or under-emphasize the unique capabilities of each system. However, the survey questions needed to be general and somewhat open-ended, to allow us to capture the broad aspects of what is available. After completing this exploratory analysis, future work may involve more specific questions targeted at a limited subset of products, in order to make better comparisons.