Studies of decision aids intended primarily for patient use were excluded. Data from included studies were abstracted from full-text publications using a data abstraction form that included the study objective and design, intervention, number of subjects, study results and conclusions, location of study by country, number of study facilities (single site vs multisite), setting (inpatient vs outpatient), patient diagnosis, subject age range, CDS tool type (stand-alone, EHR-embedded) and name, study or system features, funding source, and conflict of interest declaration. (eds). J Am Med Inform Assoc. The order is not registered until the physician acknowledges that the patient either does or does not meet the criteria. Available at: Computer-based consultations in clinical therapeutics: Explanation and rule acquisition capabilities of the MYCIN system. Voeffray M, Pannatier A, Stupp R, . BCMJ standard citation style is a slight modification of the ICMJE/NLM style, as follows: For more information on the ICMJE Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work An analysis of bone metastases pathway in a large, integrated National Cancer Institute-Designated Comprehensive Cancer Center Network. Clinical decision support systems (CDSSs) have been hailed for their potential to reduce medical errors1 and increase health care quality and efficiency.2At the same time, evidence-based medicine has been widely promoted as a means of improving clinical outcomes, where evidence-based medicine refers to the practice of medicine based on the best available scientific evidence. The types of CDSS available are as broad as human ingenuity allows: from personal digital assistant applications customized by a single clinician to multihospital mainframe-based surveillance systems meant to assure care for thousands of patients. CDS tools have been incorporated across the patient care spectrum, encompassing prevention, diagnosis, and clinical monitoring. While implementing the IF-THEN-ELSE rule illustrated by the Brigham and Women’s Hospital hypokalemia/digoxin example is relatively straightforward, the programming of guidelines with their multiple, often subjective decision points tests the limits of scientific disciplines such as decision analysis and knowledge representation. A clinical decision support system is one of the key components for reaching compliance for Meaningful Use. Available at: . 2002;347:284-7. Strengths of this systematic review include the study team, comprising a research librarian, 2 practicing oncologists, and an oncology clinical pharmacist. Levit L, Balogh E, Nass S, Ganz PA, eds. Health Inf Manag 2015;44:13–22. The differences in health outcomes between Web-based and paper-based implementation of a clinical pathway for radical nephrectomy. Computerized provider order entry in pediatric oncology: design, implementation, and outcomes, Assessment of efficiency and safety of the comprehensive Chemotherapy Assistance Program for ordering oncology medications, Using an enhanced oral chemotherapy computerized provider order entry system to reduce prescribing errors and improve safety, Impact of electronic chemotherapy order forms on prescribing errors at an urban medical center: results from an interrupted time-series analysis, Computerized prescriber order entry implementation in a physician assistant-managed hematology and oncology inpatient service: effects on workflow and task switching, Impact of computerised chemotherapy prescriptions on the prevention of medication errors, Non-intercepted dose errors in prescribing anti-neoplastic treatment: a prospective, comparative cohort study, Reduction in chemotherapy order errors with computerized physician order entry, The impact of computerized prescribing on error rate in a department of Oncology/Hematology, Effect of computerisation on the quality and safety of chemotherapy prescription, How effective are clinical pathways with and without online peer-review? The ASCO Post, April 10, 2016. Hepatology 2015;62:387–396. Clinical decision support (CDS) systems include any electronic system designed to directly aid clinical decision-making by using individual patient characteristics to generate patient-specific assessments or recommendations.1,2 These systems require computable biomedical knowledge, person-specific data, and a reasoning or inferencing mechanism that combines knowledge and data to generate and present information to clinicians as care is being delivered.3 Examples of CDS tools include computerized alerts and reminders, clinical guidelines, condition-specific order sets, focused patient data reports, documentation templates, diagnostic support, and contextually relevant reference information. J Am Med Inform Assoc 2006;13:16–23. Table 2 describes individual study sample sizes, study design, number of facilities, and diagnoses, and supplemental eTable 1 summarizes the objectives and outcomes of each included study. The systems can be classified by the nature of their interaction with the clinician. Meanwhile, the reporting and methodological quality of this field were unknown. Computerized physician order entry (CPOE) is another technology that enables the presentation of tailored knowledge or information at the time of a clinical decision. A before-after study using OncoDoc, a guideline-based decision support-system on breast cancer management: impact upon physician prescribing behaviour. Clinical decision support systems for improving diagnostic accuracy and achieving precision medicine. N Engl J Med. The studies did not specify the potential challenges facilities may encounter when implementing similar systems or describe identified best practices to support successful implementation or outcomes. Methods: A systematic review of peer-reviewed studies was performed to evaluate clinically relevant outcomes related to the use of CDS tools for the diagnosis, treatment, and supportive care of patients with cancer. Robust quasi-experimental study designs, such as interrupted time series designs with a comparator group, were rare. In addition, the impact of CDS systems on patient mortality, healthcare costs, or costs associated with implementation and management was also not assessed. Consider the following example. 2004 , Dr J. Building a Safer System: A National Integrated Strategy for Improving Patient Safety in Canadian Health Care. Effect of clinical decision-support systems: a systematic review. Seven of eight relevant systematic reviews found a positive effect on provider or patient behavior. Lobach D, Sanders GD, Bright TJ, . However, many of the included studies used suboptimal study designs, and only 3 were randomized controlled trials. The group became known as the 4. Reduction in chemotherapy order errors with computerised physician order entry and clinical decision support systems. The ICMJE created the Dr Ansermino is a member of the Centre for Health Innovation and Improvement (CHIi) and a pediatric anesthesiologist at BC’s Children’s Hospital. 3. The largest category of studies included in our review comprises studies evaluating the use of CPOE systems in oncology care. Each publication that was not excluded after review of the title and abstract was then subjected to a second round of full-text review by 2 members of the study team in the same manner as before, again with adjudication of discordance by the third investigator. These studies demonstrated a positive impact on prescriber errors, safety events, and workflow.20–31 CDS tools implementing clinical pathways,32–37 CPGs,38,39 PROs,40–42 and prescriber alerts43 were also primarily associated with positive outcomes, including reduced hospital stays,35 increased guideline use and concordance,33,38,39 enhanced identification of trial-eligible patients,36 and improvements in symptom management.41 Overall, the studies suggest that clinical oncology–focused CDS systems appear to be well accepted and are associated with potentially meaningful improvements in patient care. Clinical decision support system Antibiotic Stewardship (ABS) Programs are implemented to ensure the rational use of antibiotics [ 7 ]. Questions about treatment recommendations? From: Infectious Diseases (Fourth Edition), 2017 Proc AMIA Symp 1999:221-225. Furthermore, we believe it is essential that these assessments also involve outcomes, including those associated with clinical care and costs of system implementation, when possible. We performed a systematic review of peer-reviewed, English-language studies published between January 1, 1995, and December 31, 2016, that evaluated the implementation of an electronic CDS system in the field of cancer care. J Ambul Care Manage 2008;31:201–210. Above is the information needed to cite this article in your paper or presentation. The systems used are usually referred to as clinical decision support systems or CDSS. 2. J Am Med Inform Assoc 2011;18:789–798. This blueprint can be used not only for large hospitals but also for distributed networks of care sites such as practitioners’ offices. eHealth for a Healthier Europe! The use and interpretation of quasi-experimental studies in medical informatics. Berry DL, Blumenstein BA, Halpenny B, . Effects of a computerized system to support shared decision making in symptom management of cancer patients: preliminary results. [Context Link] 15. Int J Med Inform 2013;82:504–513. Physician order entry: a mixed blessing to pharmacy? © 2019-2020 National Comprehensive Cancer Network. Washington, DC: National Academy Press, 1999. Beer J, Dobish R, Chambers C. Physician order entry: a mixed blessing to pharmacy? CDS improves healthcare process measures; however, data demonstrating their effectiveness on clinical outcomes and costs are limited.1 Accordingly, real-world uptake of CDS systems has been modest at best.4 Benefits of CDS include improved efficiency and quality of healthcare delivery and access to medical data; enhanced communication; and potential cost savings.5–14 In 2007, the American Medical Informatics Association (AMIA) sounded a call to action regarding CDS implementation that included 3 pillars for fully realizing the promise of CDS: (1) best knowledge available when needed; (2) high adoption and effective use; and (3) continuous improvement of knowledge and CDS methods.4 Furthermore, the Agency for Healthcare Research and Quality stated that the question is not whether CDS systems should be designed and implemented, but rather how to make it easy to do the right thing.15 Nevertheless, effective implementation of a CDS system is a major undertaking, considering the vast amount of clinical data and its variability, availability, and structure across facilities. Acquisition and assembly of data: Pawloski, Olson-Bullis. Vancouver Group. Accessed March 13, 2018. Clinical informatics is the application of informatics and information technology to support healthcare delivery services. Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw, Enabling health care decisionmaking through clinical decision support and knowledge management, Clinical decision support systems for improving diagnostic accuracy and achieving precision medicine, A roadmap for national action on clinical decision support, Standard practices for computerized clinical decision support in community hospitals: a national survey, The development of primary care information technology in the United Kingdom, Features of effective computerised clinical decision support systems: meta-regression of 162 randomised trials, Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success, Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review, Systematic review: impact of health information technology on quality, efficiency, and costs of medical care, A risk analysis method to evaluate the impact of a computerized provider order entry system on patient safety, Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review, Effect of clinical decision-support systems: a systematic review. CDS systems incorporated into clinical pathways have been associated with increased guideline adherence,32–37 demonstrating the benefit they can provide to clinicians, and consistent with findings of previous systematic reviews also showing a positive impact on guideline adherence.10,44 Three studies included in our analysis evaluated the use of CDS systems for PROs, and all demonstrated benefit for ≥1 outcome.40–42 These findings differ somewhat from those of a systematic review of 15 studies that assessed the effect of CDS systems on PROs, which showed a positive effect on symptoms in 3 studies (20%).45 A CDS system used with prescriber alerts demonstrated a positive impact, which is consistent with findings of a previous study.43,46, The findings are also consistent with those of a meta-analysis assessing the impact of health information technology (HIT) on cancer care from 2000 to June 2014.47 CDS systems were the most common (66%) HIT intervention identified and were implemented across several cancer types, including breast, colorectal, and prostate, for detection, diagnosis, and treatment but not for survivorship or end-of-life care. in 1978 to establish guidelines for the format of manuscripts submitted to their journals. Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Web-based clinical pathway for reducing practice variations in radical prostatectomy. In this study, we propose a three-layer knowledge base model (disease-symptom-property) to utilize more useful information in inference. With evidence supporting the effectiveness of all these systems, it is important to plan for decision support when designing and installing modern health information systems. J Am Med Inform Assoc 2012;19:980–987. BMJ Open 2012;2:2. Within the CDS systems, key factors that appear to contribute to improved outcomes include the use of real-time provider alerts and point-of-care action on prescription orders and provision of information to clinicians that CDS systems can provide.20,27,32,36,37,40–42 There appear to be resulting factors that create new challenges, such as the need to access separate systems and otherwise increase work time of prescribers or other downstream clinicians, that may reduce outcomes.21,26,34,35. Musen M, Shahar Y, Shortliffe EH. They assist with interpretation, diagnosis, and treatment. Clin Transl Oncol 2006;8:821–825. Such systems have been shown to decrease inappropriate X-ray orders by as much as 47%.[9]. in Medical Journals, visit Huertas Fernández MJ, Baena-Cañada JM, Martínez Bautista MJ, . Electronic database searches yielded 2,439 potentially eligible papers (Figure 1). Elsaid K, Truong T, Monckeberg M, . Non-intercepted dose errors in prescribing anti-neoplastic treatment: a prospective, comparative cohort study. In: Shortliffe EH, Perrault L, Wiederhold G, et al. A risk analysis method to evaluate the impact of a computerized provider order entry system on patient safety. To optimize care pathways with an intelligent decision support system aimed at facilitating diagnosis and therapeutic decisions along disease-specific pathways. Common roles for CDS include computerized physician order entry (CPOE) and electronic health record (EHR) clinical reminder systems.2. vol. Author contributions: Study concept and design: Pawloski, Brooks, Nielsen. Washington, DC: The National Academies Press; 2013. Diabetes systems might be the best example of cases where patient-specific data, such as blood glucose measurements and food intake, are used to generate customized educational modules and detailed dietary recommendations. Comput Biomed Res 1975;8:303-320. This systematic review assessed evidence supporting the use of CDS systems in cancer care delivery from studies evaluating cancer diagnosis, treatment, and supportive care. Information gleaned from computer records of these orders can also be used to guide quality improvement efforts. PubMed Abstract Full Text 17, 18 While some studies have reported improvements in documentation, 13 processes, 11, 15 or outcomes, 14 others … These types of systems are in use today.[8]. Am J Prev Med 2011;40(5 Suppl 2):S198–207. These are all crucial elements that must be assessed and understood for optimal implementation to occur. J Am Med Inform Assoc 2003;10:573–579. Impact of computerised chemotherapy prescriptions on the prevention of medication errors. These programs aim to optimize antibiotic prescriptions hence to increase guideline adherence, often leading to a reduction in overall antibiotic use [ 7 ]. Our systematic review is reported >10 years after a call to action by the AMIA regarding the use of CDS.4 The call included directives for achieving desirable levels of patient safety, care quality, patient-centeredness, and cost-effectiveness. 09-0069-EF. Medical decision support: Experience with implementing the Arden Syntax at the Columbia-Presbyterian Medical Center. The use of computers for clinical care: A case series of advanced US sites. There is a critical need for CDS systems development and well-designed studies to demonstrate improvement in patient outcomes, including impact on survival and efficiency of cancer care delivery. When the order is entered into the computer, the physician is reminded of the exact elements of the evidence-based criteria for such an order (the Ottawa Ankle Rules). Kaushal R, Shojania KG, Bates DW. A large part of any physician’s work, especially in non-procedural disciplines, involves acquiring information and then, aided by evidence and experience, making decisions for the best possible outcome. to help authors and editors create and distribute accurate, clear, easily accessible reports of biomedical studies. J Am Med Inform Assoc 2003;10:94-107. Clinical decision support (CDS) systems include any electronic system designed to directly aid clinical decision-making by using individual patient characteristics to generate patient-specific assessments or recommendations. Hsu YC, Tsui KH, Chen CL, . Rockville, MD: Agency for Healthcare Research and Quality; 2009. [1] The two most famous examples are the MYCIN and QMR systems. Garg AX, Adhikari NK, McDonald H, . [6] These applications judiciously deliver information or knowledge that can beneficially alter clinical decision making. The primary findings show that the beneficial impact differed across the cancer continuum; HIT for diagnosis and treatment was less likely to be associated with benefit compared with prevention. Do clinical decision support systems improve patient care? Meisenberg BR, Wright RR, Brady-Copertino CJ. The common thread of articles published in Decision Support Systems is their relevance to theoretical and technical issues in the support of enhanced decision making. The content of this field is kept private and will not be shown publicly. The costs of system maintenance, upgrades, or enhancements were also not described. Computer-assisted decision support in medical oncology: we need it now. In a manner consistent with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, we conducted a comprehensive review of the clinical and scientific literature.19 A trained health sciences librarian (B.A.O.B.) A more recent Canadian report[11] called for investment in information-technology infrastructures that support the standardized identification, reporting, and tracking of patient safety data. Seidman AD. It is crucial that clinicians be involved in the development and rigorous scientific evaluation of these systems. It provides continuing medical education with a focus on evidence-based medicine. This message contains, among other things, the patient’s hospital ID number and the potassium result. of Medical Journal Editors (ICMJE) recommends the following citation style, which is the now nearly universally Only the first three authors are listed, followed by "et al.". Scott GP, Shah P, Wyatt JC, . Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Clinical Decision Support Systems (CDSS) are considered essential tools of evidence-based medicine. Enhancement of clinicians’ diagnostic reasoning by computer-based consultation: A multisite study of two systems. This multicenter retrospective study sought to determine clinimetric performance of a cloud-based computerized sepsis clinical decision support system (CDS), understand the epidemiology of sepsis, and identify opportunities for quality improvement. Clinical decision support is any tool that provides clinicians, administrative staff, patients, caregivers, or other members of the care team with information that is filtered or targeted to a specific person or situation. The effectiveness of computerized clinical guidelines in the process of care: a systematic review. Edmonton: Alberta Heritage Foundation for Medical Research, 2003. In response to a Congressional directive, FDA issued a report in 2014 outlining a “risk-based” approach to the regulation of health IT generally and of clinical decision support products specifically. The Evidenc… Prevention of acute exacerbation of chronic hepatitis B infection in cancer patients receiving chemotherapy in a hepatitis B virus endemic area. The BC Medical Journal is a general medical journal published by Doctors of BC. Clinical decision support systems (CDSS—defined as any system designed to improve clinical decision-making related to diagnostic or therapeutic processes of care—were initially developed more than 40 years ago, and they have become increasingly sophisticated over time. Clinicians are confronted by increasing amounts of clinical data for each patient they treat as well as an exponentially increasing volume of relevant medical research. Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. Funding: This work was supported by a grant from the NCI (U24 CA171524; PI: L. Kushi), with no additional funding provided specifically for this work. Handbook of Medical Informatics. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement, Reduction in chemotherapy order errors with computerised physician order entry and clinical decision support systems. Our objective was to investigate the reported impact of CDS systems on clinically relevant patient outcomes. Designing good evaluative trials is difficult and the sheer variety of systems and functions makes comparison complicated. patients. Clinical Decision Support Systems: State of the Art. Background: Clinical decision support systems (CDSSs) are an integral component of today’s health information technologies. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Damiani G, Pinnarelli L, Colosimo SC, . Titles and abstracts were excluded based on mutual agreement; those not mutually determined to be included or excluded were adjudicated by the third investigator. Internist-1, an experimental computer-based diagnostic consultant for general internal medicine. 5 In the report, the agency described clinical decision support as technology that “provides healthcare providers and patients with knowledge and person-specific information, intelligently filtered or presented at … In: van Bemmel J, Musen M (eds). Of the 120 studies identified before 1995, none met the predefined inclusion criteria and therefore they were not included in this analysis. Chaudhry B, Wang J, Wu S, . Ann Intern Med 2006;144:742–752. A total of 23 studies reported improvement in key study outcomes with use of oncology CDS systems, and 12 studies assessing the systems for computerized chemotherapy order entry demonstrated reductions in prescribing error rates, medication-related safety events, and workflow interruptions. PubMed Abstract CDS is typically built into the existing order entry system and provides information to healthcare providers about scan … Published studies of CDS systems are largely associated with positive outcomes, and their findings consistent with those of studies conducted in the noncancer population. Effects of clinical decision-support systems on practitioner performance and patient outcomes: a synthesis of high-quality systematic review findings. accepted citation style for scientific papers: J Oncol Pharm Pract 2008;14:181–187. Disclosures: The authors have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. Chang PL, Li YC, Lee SH. U.S. National Library of Medicine. Clinical decision support systems use specific para… None of the studies assessed the impact of CDS systems on patient survival. National Steering Committee on Patient Safety. 9. However, with the burgeoning amount of data now available for each patient and the increasing body of medical evidence, we need tools to help us make rational decisions based on all this information. A recent review of 57 randomized controlled trials and 10 systematic reviews evaluated the effectiveness of computer-based delivery of health evidence, including CDSS. N Engl J Med 1982;307:468-476. We urge clinicians to identify opportunities for CDSS and to advocate within their health care settings for the development of systems that bring about meaningful improvement of health outcomes. Kawamoto K, Houlihan CA, Balas EA, . JAMA 1998;280:1339–1346. CPOE showed a small impact on provider behavior, with general alerts and increased pharmacist order review times. It does this by using a large database of “evoking strengths,” “importance,” and “frequencies” of findings seen in diseases within its domain. BMJ 2005;330:765. The total number of CDS systems that have been studied, had no outcome improvement, and were subject to publication bias is unknown. Computer-based clinical decision support systems and patient-reported outcomes: a systematic review. MYCIN was developed in the 1970s to help clinicians choose antibiotics for bacteremia or meningitis. Abstract: Background: One of the greatest challenges in the field of medicine is the increasing burden of chronic diseases, such as diabetes. When integrated with a computerized physician order entry (CPOE), CDSSs can guide a physician’s decisions during the process of entering medication orders or other physicians’ instructions. [4] The program takes historical and physical findings and generates a differential diagnosis. However, not all studies evaluating CDS systems have shown clinical practice improvements.48 Thus, it is imperative that systems and tools, both commercially and locally developed, be assessed for their effectiveness and impact on patient outcomes. AHRQ Publication No. Clinicians are also best placed to decide how CDSS should be implemented in local care environments. The Arden Syntax is a quasi-programming language that allows the encoding of decision rules into a computer-readable format. The EBMeDS system is the computerized clinical decision support (CCDS) system of EBPNet, a national computerized point-of-care information service in Belgium. Available at: In the first type of interaction, a clinician solicits advice from the CDSS. A broad range of information systems can now generate patient-specific advice to aid clinical decision making.