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Computerized clinical decision support systems (CDSS)

Health Factors: Quality of Care
Decision Makers: Healthcare Professionals & Advocates
Evidence Rating: Scientifically Supported
Population Reach: 50-99% of WI's population
Impact on Disparities: No impact on disparities likely

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Description

Computerized clinical decision support systems (CDSS) are electronic tools that prompt provider behaviors in various areas of patient care, including medication ordering, chronic disease management, health care screening, and vaccination. CDSS can provide physicians, nurses, pharmacists, and other care providers with patient-specific prompts or warnings, treatment guidelines (e.g., order sets), automatic medication dosing calculators, or reports of overdue tests and medications as appropriate. These tools can be integrated with electronic health records (EHRs), part of a computerized physician order entry (CPOE) system, or a standalone electronic interface.

Expected Beneficial Outcomes

Improved processes of care
Increased appropriate drug prescribing
Improved health outcomes
Improved patient safety

Evidence of Effectiveness

There is strong evidence that computerized clinical decision support systems (CDSS) improve processes of care (AHRQ-Lobach 2012, Bright 2012, Roshanov 2011, Roshanov 2011a, Sahota 2011, Souza 2011, Bryan 2008), particularly when used for drug prescribing and management (Ranji 2014, Cochrane-Gillaizeau 2013, Stultz 2012, AHRQ-McKibbon 2011, Hemens 2011, Nieuwlaat 2011, Sahota 2011, Tawadrous 2011, Jamal 2009, Pearson 2009, Schedlbauer 2009, Wolfstadt 2008). Such systems have also been shown to improve patient outcomes in some circumstances (Nieuwlaat 2011, Roshanov 2011a, Sahota 2011, Souza 2011, Tawadrous 2011). Additional evidence is needed to confirm effects on patient outcomes.

CDSS can improve processes of care in primary (Bryan 2008) and acute settings (Sahota 2011), especially when systems support preventive services, prescribing therapies, and ordering of clinical studies (AHRQ-Lobach 2012, Bright 2012) and tests (Roshanov 2011a). CDSS can also improve processes for chronic disease management (Roshanov 2011) and preventive care such as screening and management of high cholesterol. In some circumstances, such systems can improve processes related to cancer screening and referrals, and mental health conditions (Souza 2011).

CDSS can improve medication management (AHRQ-McKibbon 2011) and prescribing outcomes (Pearson 2009). Combined with computerized provider order entry (CPOE), CDSS reduce medication prescribing errors (Ranji 2014, Stultz 2012, Schedlbauer 2009) and may also reduce adverse drug events (Stultz 2012, Wolfstadt 2008). Medication dosing advice via CDSS can improve some patient outcomes (Cochrane-Gillaizeau 2013, Sahota 2011) and increase physician compliance with guidelines (Tawadrous 2011, Jamal 2009, Georgiou 2007). Pharmacy-specific CDSS that address potential safety concerns are more effective than CDSS that promote compliance with evidence-based guidelines (Robertson 2010).

Frequent CDSS alerts when prescribing, especially inappropriate alerts, lead to “alert fatigue” and may cause prescribers to miss or ignore important alerts (Stultz 2012, Moxey 2010). These point of care reminders are more likely to improve clinical processes of care when providers are required to enter a response (Shojania 2010).

CDSS have been shown to improve patient outcomes in some circumstances (AHRQ-Lobach 2012, Roshanov 2011, Sahota 2011, Souza 2011, Tawadrous 2011). CDSS appear most likely to improve patient outcomes when used to help manage chronic conditions such as high cholesterol (Souza 2011) and diabetes (Nieuwlaat 2011). Such systems can improve blood glucose when implemented as part of a complex hospital-based intervention (Nirantharakumar 2011).

The cost impacts of CDSS are unclear; some studies find decreases, some increases, and some no change in the cost of care (Fillmore 2013, Hemens 2011).

Implementation

United States

Clinical decision support is required for meaningful use through the federal Medicare and Medicaid Electronic Health Records Incentive Programs (US DHHS-Meaningful use). Many commercially produced EHRs include CDSS, and organizations such as Brigham and Women’s Hospital have developed their own decision support systems.

Partners Healthcare System, an integrated system of hospitals in Massachusetts, uses CDSS to provide real-time reminders on guideline-based care recommendations for acute respiratory infections, CAD, and diabetes (AHRQ HCIE-Middleton).

Implementation Resources

US DHHS-Meaningful use - US Department of Health and Human Services (US DHHS). Achieve meaningful use. Accessed on March 3, 2017

Citations - Evidence

AHRQ-Lobach 2012 - Lobach D, Sanders G, Bright T, et al. Enabling Health Care Decisionmaking Through Clinical Decision Support and Knowledge Management. Rockville: Agency for Healthcare Research and Quality (AHRQ); 2012 Apr. (Evidence Report, No. 203). Accessed on January 25, 2016
AHRQ-McKibbon 2011 - McKibbon KA, Lokker C, Handler SM, et al. Enabling medication management through health information technology. Rockville: Agency for Healthcare Research and Quality (AHRQ); 2011. Accessed on January 25, 2016
Bright 2012 - Bright TJ, Wong A, Dhurjati R, et al. Effect of clinical decision-support systems. Annals of Internal Medicine. 2012;157(1):2-42. Accessed on January 25, 2016
Bryan 2008 - Bryan C, Boren SA. The use and effectiveness of electronic clinical decision support tools in the ambulatory/primary care setting: A systematic review of the literature. Informatics in Primary Care. 2008;16:79-91. Accessed on February 2, 2016
Cochrane-Gillaizeau 2013* - Gillaizeau F, Chan E, Trinquart L, et al. Computerized advice on drug dosage to improve prescribing practice. Cochrane Database of Systematic Reviews. 2013;(11):CD002894. Accessed on January 20, 2016
Fillmore 2013 - Fillmore CL, Bray BE, Kawamoto K. Systematic review of clinical decision support interventions with potential for inpatient cost reduction. BMC Medical Informatics and Decision Making. 2013;13(135):1-9. Accessed on January 25, 2016
Georgiou 2007* - Georgiou A, Williamson M, Westbrook JI, Ray S. The impact of computerised physician order entry systems on pathology services: A systematic review. International journal of medical informatics. 2007;76(7):514-29. Accessed on January 25, 2016
Hemens 2011 - Hemens BJ, Holbrook A, Tonkin M, et al. Computerized clinical decision support systems for drug prescribing and management: A decision-maker-researcher partnership systematic review. Implementation Science. 2011;6(89):2-17. Accessed on January 25, 2016
Jamal 2009 - Jamal A, Mckenzie K, Clark M. The impact of health information technology on the quality of medical and health care: A systematic review. Health Information Management Journal. 2009;38(3):26-37 Accessed on January 25, 2016
Moxey 2010 - Moxey A, Robertson J, Newby D, Hains I, Williamson M, Pearson S-A. Computerized clinical decision support for prescribing: Provision does not guarantee uptake. Journal of the American Medical Informatics Association (JAMIA). 2010;17:25-33. Accessed on February 2, 2016
Nieuwlaat 2011 - Nieuwlaat R, Connolly SJ, Mackay J a, et al. Computerized clinical decision support systems for therapeutic drug monitoring and dosing: A decision-maker-researcher partnership systematic review. Implementation Science. 2011;6(90):1-14. Accessed on January 25, 2016
Nirantharakumar 2011* - Nirantharakumar K, Chen YF, Marshall T, Webber J, Coleman JJ. Clinical decision support systems in the care of inpatients with diabetes in non-critical care setting: Systematic review. Diabetic Medicine. 2011;29(6):698-708. Accessed on January 25, 2016
Pearson 2009 - Pearson S-A, Moxey A, Robertson J, et al. Do computerised clinical decision support systems for prescribing change practice: A systematic review of the literature (1990-2007). BMC Health Services Research. 2009;9(154):1-14. Accessed on January 25, 2016
Ranji 2014* - Ranji SR, Rennke S, Wachter RM. Computerised provider order entry combined with clinical decision support systems to improve medication safety: A narrative review. BMJ quality & safety. 2014;23(9):773-80. Accessed on January 25, 2016
Robertson 2010 - Robertson J, Walkom E, Pearson S, Hains I. The impact of pharmacy computerised clinical decision support on prescribing, clinical and patient outcomes: A systematic review of the literature. International Journal of Pharmacy Practice. 2010;18:69-87. Accessed on January 25, 2016
Roshanov 2011 - Roshanov PS, You JJ, Dhaliwal J, et al. Can computerized clinical decision support systems improve practitioners’ diagnostic test ordering behavior: A decision-maker-researcher partnership systematic review. Implementation Science. 2011;6(88):1-12. Accessed on January 25, 2016
Roshanov 2011a - Roshanov PS, Misra S, Gerstein HC, et al. Computerized clinical decision support systems for chronic disease management: A decision-maker-researcher partnership systematic review. Implementation Science. 2011;6(92):1-16. Accessed on June 10, 2016
Sahota 2011 - Sahota N, Lloyd R, Ramakrishna A, et al. Computerized clinical decision support systems for acute care management: A decision-maker-researcher partnership systematic review of effects on process of care and patient outcomes. Implementation Science. 2011;6(91):1-14. Accessed on January 25, 2016
Schedlbauer 2009 - Schedlbauer A, Prasad V, Mulvaney C, et al. What evidence supports the use of computerized alerts and prompts to improve clinicians' prescribing behavior. Journal of the American Medical Informatics Association. 2009;16(4):531-538. Accessed on February 2, 2016
Shojania 2010 - Shojania KG, Jennings A, Mayhew A, Ramsay C, Eccles M, Grimshaw J. Effect of point-of-care computer reminders on physician behaviour: A systematic review. Canadian Medical Association Journal. 2010;182(5):1-10. Accessed on January 25, 2016
Souza 2011 - Souza NM, Sebaldt RJ, Mackay J a, et al. Computerized clinical decision support systems for primary preventive care: A decision-maker-researcher partnership systematic review of effects on process of care and patient outcomes. Implementation Science. 2011;6(1):87. Accessed on January 25, 2016
Stultz 2012 - Stultz JS, Nahata MC. Computerized clinical decision support for medication prescribing and utilization in pediatrics. Journal of the American Medical Informatics Association. 2012;19:942-53. Accessed on February 2, 2016
Tawadrous 2011* - Tawadrous D, Shariff SZ, Haynes RB, Iansavichus A V, Jain AK, Garg AX. Use of clinical decision support systems for kidney-related drug prescribing: A systematic review. American Journal of Kidney Diseases. 2011;58(6):903-914. Accessed on January 25, 2016
Wolfstadt 2008 - Wolfstadt JI, Gurwitz JH, Field TS, et al. The effect of computerized physician order entry with clinical decision support on the rates of adverse drug events: A systematic review. Journal of General Internal Medicine. 2008;23(4):451-458. Accessed on January 25, 2016

Citations - Implementation

AHRQ HCIE-Middleton - Middleton B. Real-time decision and documentation support increases adherence to recommended care for respiratory infections, diabetes, and heart disease. Rockville: AHRQ Health Care Innovations Exchange. Accessed on January 26, 2016
US DHHS-Meaningful use - US Department of Health and Human Services (US DHHS). Achieve meaningful use. Accessed on March 3, 2017

Page Last Updated

May 1, 2015

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