Clinical Decision Support: Effectiveness in Improving Quality Processes and Clinical Outcomes and Factors That May Influence Success
This is a review by Elizabeth V. Murphy. (2014) in the Yale Journal of Biology and Medicine entitled “Clinical Decision Support: Effectiveness in Improving Quality Processes and Clinical Outcomes and Factors That May Influence Success.” 
The Health Information Technology for Economic and Clinical Health (HITECH) Act provides financial incentives to hospitals and physicians to facilitate electronic health record (EHR) “adoption” and its “meaningful use”. The clinical decision support systems (CDSS) is an important module of meaningful use. Its implementation and use are essential for improving quality processes and clinical outcomes. In this review, the author discusses the effectiveness of clinical decision support (CDS) and factors that may leverage effectiveness.
CDSS Effectiveness in Preventive Services Processes
Murphy (2014) analyzed a number of high quality studies and established the usefulness of CDS in promoting guideline-recommended preventive care. The following evidence-based preventive services that improved quality and clinical outcomes are:
Cancer prevention screening:
- 1. Colonoscopy for colon cancer.
- 2. Fecal occult blood test for gastrointestinal tract cancers.
- 3. Mammography for breast cancer.
Prevention of complications from diabetes:
- 1. Eye exam for retinopathy.
- 2. Foot exam for wounds or ulcers.
- 3. Protein in urine for nephropathy.
- 4. HbA1c to monitor glucose control.
- 1. Hypertension counselling.
- 2. Smoking cessation counselling.
- 1. Pneumococcal vaccine.
- 2. Influenza vaccine.
Clot prevention in hospitalized or trauma patients:
- 1. Heparin prophylaxis for deep venous thrombosis or pulmonary embolus.
- 2. Aspirin prophylaxis on discharge.
Although majority of the studies demonstrated efficacy of CDSS in promoting preventive care, minority of them showed insignificant outcomes such as untimely CDSS reminders, patient negotiation and disapproval for preventive services.
CDSS Effectiveness in Appropriate Care Processes
The author examined several studies that indicated physicians’ compliance with evidence-based practices/guidelines enabled by CDSS. The following are CDSS reminders, alerts, and recommendations that improved quality and clinical outcomes:
- 1. Beta-blocker prescriptions for patients with left heart failure.
- 2. Appropriate antibiotic prescription using CDSS software ‘TREAT’.
- 3. Monitoring medication levels in blood, e.g., anti-seizure drugs, certain antibiotics.
- 4. Monitoring liver and kidney function when prescribing hepatotoxic and drugs toxic to kidneys.
- 5. Ordering blood gases for changes in ventilator settings.
- 6. Monitoring prothrombin time for patients taking Coumadin.
- 7. Checking electrolytes after IV furosemide.
- 8. Ordering creatinine clearance for elderly patients and patients with renal insufficiency. Recommending appropriate dose, frequency, and medications to avoid for those with poor renal function.
- 9. Management of chronic illnesses with specially designed CDSS software. Asthma and diabetes are among the successful interventions. The quality and outcomes were demonstrated by decreased complications, number of hospitalizations, fewer emergency visits and significant cost savings.
- 10. The mobile apps with patient-based decision support enabled patients to record blood pressure, finger stick glucose, diet, and physical activity. Such data aided physicians through better clinical decisions.
Meta-Analysis in Evaluation of Effectiveness
In a 2012 AHRQ Evidence Report/Technology Assessment on clinical decision support and knowledge management, Lobach et al. performed a meta-analysis using 148 randomized controlled trials to evaluate for evidence of process or clinical outcome improvement and/or cost reduction, with clinical decision support. The results showed high effectiveness in recommended preventive care services ordered or completed and recommended treatments ordered or prescribed, moderate effectiveness in recommended clinical studies ordered or completed, and low effectiveness in the length of stay, morbidity, mortality, and adverse events.
What Features of CDSS Will Make It More Effective?
The results were aggregated from a systematic review of 70 randomized clinical trials, a meta-analysis of 91 randomized controlled trials, and a meta-regression analysis of 162 randomized controlled trials. The following are successful features (evidence)/recommendations:
- Automatic Provision of decision support as part of clinician workflow
- Provision at time and location of decision making
- Provision of a recommendation, not just an assessment
- Computer-based generation of decision support
- Integration with charting or order entry
- No need for additional clinician data entry
- Promotion of action rather than inaction
- Provision of Decision Support results to both clinician and patient
- Local user involvement in the development process
- Systems providing advice for patients in addition to practitioners
- Required practitioners to provide a reason for over-ride
- Were evaluated by their developers
Many studies have demonstrated the effectiveness of CDSS in improving quality and clinical outcomes, especially adherence to preventive care guidelines. Also, empowering both physicians and patients with clinical decision support resulted in higher compliance to CDS recommendations. However, there is insufficient data on the effectiveness of CDS on morbidity or mortality outcomes. Long-term prospective cohort studies or well-designed retrospective cohort studies are advised. In addition, practice of patient-centered care, evidence-based guidelines/recommendations, and meaningful use of CDS as mandated by HITECH Act still remain challenging. Future studies are suggested to assess the impact of financial incentives on meaningful use of CDS.
I chose this article for three reasons. Firstly, the author analyzed several high quality studies which include systematic reviews, randomized controlled trials, and meta-analyses. Secondly, the paper is a current review and focuses on highly effective features of CDSS. Finally, the author mentions Sittig’s “five rights for improving medication use and outcomes with clinical decision support -- right information, to the right person, in the right format, through the right channel, at the right point in workflow”. She questions, “Will the “right incentive” be added to the five rights?”
- Implementation Pearls from a New Guidebook on Improving Medication Use and Outcomes with Clinical Decision Support
- Predictors of Clinical Decision Support Success
- A pragmatic Approach to Implementing Best Practices for Clinical Decision Support Systems in Computerized Provider Order Entry Systems
- Outpatient Electronic Health Records and the Clinical Care and Outcomes of Patients With Diabetes Mellitus
- Elizabeth V. Murphy (2014). Clinical Decision Support: Effectiveness in Improving Quality Processes and Clinical Outcomes and Factors That May Influence Success. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4031792/ .