Berlin A et al. 2006 "A taxonomic description of computer-based clinical decision support systems."

Reference

Berlin A, Sorani M, Sim I. A taxonomic description of computer-based clinical decision support systems. J Biomed Inf 2006;39(6):656-667.

Abstract

"Objective. Computer-based clinical decision support systems (CDSSs) vary greatly in design and function. Using a taxonomy that we had previously developed, we describe the characteristics of CDSSs reported in the literature. Methods. We searched PubMed and the Cochrane Library for randomized controlled trials (RCTs) published in English between 1998 and 2003 that evaluated CDSSs. We coded each CDSS using our taxonomy. Results. 58 studies met our inclusion criteria. The 74 reported CDSSs varied greatly in context of use, knowledge and data sources, nature of decision support offered, information delivery, and workflow impact. Two distinct subsets of CDSSs were seen: patient-directed systems that provided decision support for preventive care or health-related behaviors via mail or phone (38% of systems), and inpatient systems targeting clinicians with online decision support and direct online execution of the recommendations (18%). 84% of the CDSSs required extra staffing for handling CDSS-related input or output. Conclusion. Reported CDSSs are heterogeneous along many dimensions. Caution should be taken in generalizing the results of CDSS RCTs to different clinical or workflow settings."

Objective

To "describe the characteristics of CDSSs (computer-based clinical decision support systems)" reported in the literature, using a taxonomy developed by the authors.

Size

not applicable

Type of Health IT

Decision support system

Type of Health IT Functions

The authors "broadly defined a CDSS as any computer system that assists physicians or patients with clinical decision making."

Workflow-Related Findings

The authors classified "CDSSs as being moderately integrated to well integrated with clinical workflow if the CDSS did not require substantial additional work, such as a receptionist needing to enter patient demographic information into a stand-alone CDSS during the patient registration process. Thirty-one percent of the CDSSs were coded as being moderately integrated to well integrated, but we were unable to code workflow integration in another 31% of the systems because of incomplete [information]."

The authors "coded CDSSs as having workflow flexibility if the target decision maker could choose when to process the CDSSs recommendations, such as a 'View later' button for a lab test reminder. [CDSSs requiring initiation by the user] have workflow flexibility by definition. Among the 24 [CDSSs giving unsolicited recommendations to users], all of which targeted clinicians, 83% had workflow flexibility, and 80% of these systems 'pushed' their recommendations at the point of care."

"A CDSSs staffing impact is...characterized by whether a human intermediary is required to input data or to handle output (e.g., clip printout of recommendations to paper chart for target decision maker to see). In our sample, 30% of systems required a data input intermediary, and 51% required at least one output intermediary; the requirement for a data input or output intermediary could not be determined for 45% and 16% of systems, respectively.... Intermediaries were required especially for outpatient and community-based clinical settings.... Overall, only 16% of the CDSSs did not require either an input or an output intermediary, suggesting that CDSS-associated staffing burdens are common."

The authors define "a CDSS as offering 'action integration' when users are provided with single-click ability to execute a logistically simple recommendation (e.g., users can click an online order-entry form to order a recommended drug dose). Of the 40 CDSSs that made logistically simple recommendations, 40% featured action integration, especially those that delivered their recommendations via integrated EMR-CDSS sessions."

Study Design

Systematic literature review

Study Participants

The authors searched PubMed and the Cochrane Library for English-language randomized controlled trials about CDSSs published between May 1998 and December 2003. After "restrict[ing] the search to RCTs reporting on clinical outcomes (as opposed to systems-related outcomes, such as user satisfaction, and) ... exclud[ing] RCTs of systems that were directly therapeutic, systems that were strictly educational, [systems] that displayed only test results, [and] RCTs in which the effect of the CDSS intervention could not be isolated from other interventions," 58 studies were included in the systematic literature review.