Garg AX et al. 2005 "Effects of computerized clinical decision support systems on practitioner performance and patient outcomes - a systematic review."

Garg AX, Adhikari NKJ, McDonald H, et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes - a systematic review. JAMA 2005;293(10):1223-1238.
"Context: Developers of health care software have attributed improvements in patient care to these applications. As with any health care intervention, such claims require confirmation in clinical trials. Objectives: To review controlled trials assessing the effects of computerized clinical decision support systems (CDSSs) and to identify study characteristics predicting benefit. Data Sources: We updated our earlier reviews by searching the MEDLINE, EMBASE, Cochrane Library, Inspec, and ISI databases and consulting reference lists through September 2004. Authors of 64 primary studies confirmed data or provided additional information. Study Selection: We included randomized and non randomized controlled trials that evaluated the effect of a CDSS compared with care provided without a CDSS on practitioner performance or patient outcomes. Data Extraction: Teams of 2 reviewers independently abstracted data on methods, setting, CDSS and patient characteristics, and outcomes. Data Synthesis: One hundred studies met our inclusion criteria. The number and methodological quality of studies improved over time. The CDSS improved practitioner performance in 62 (64%) of the 97 studies assessing this outcome, including 4 (40%) of 10 diagnostic systems, 16 (76%) of 21 reminder systems, 23 (62%) of 37 disease management systems, and 19 (66%) of 29 drug-dosing or prescribing systems. Fifty-two trials assessed 1 or more patient outcomes, of which 7 trials (13%) reported improvements. Improved practitioner performance was associated with CDSSs that automatically prompted users compared with requiring users to activate the system (success in 73% of trials vs 47%; P=.02) and studies in which the authors also developed the CDSS software compared with studies in which the authors were not the developers (74% success vs 28%; respectively, P=.001). Conclusions: Many CDSSs improve practitioner performance. To date, the effects on patient outcomes remain understudied and, when studied, inconsistent."
"To review controlled trials assessing the effects of computerized clinical decision support systems (CDSSs) and to identify study characteristics predicting benefit.... The primary questions of this review were (1) Do CDSSs improve practice performance or patient outcomes? and (2) Which CDSS and study-level factors are associated with effective CDSSs?"
not applicable
Other Information
"The 100 trials examined more than 3,826 practitioners or practices ... caring for more than 92,895 patients ... from 1973 to 2004."
Type of Health IT
Decision support system
Type of Health IT Functions
CDSSs included in the review "had to provide patient-specific advice that was reviewed by a health care practitioner before any clinical action. Studies were excluded if the system (1) was used solely by medical students, (2) only provided summaries of patient information, (3) provided feedback on groups of patients without individual assessment, (4) only provided computer-aided instruction, or (5) was used for image analysis."
Workflow-Related Findings
"There were 29 trials of drug dosing and prescribing[, of which] single-drug dosing improved practitioner performance in 15 (62%) of 24 studies, and 2 of the 18 systems assessing patient outcomes reported an improvement. Another 5 systems used computer order entry for multidrug prescribing. Four of these systems improved practitioner performance, but none improved patient outcomes."
"There were 40 studies of CDSSs for active health conditions. These CDSSs improved practitioner performance in 23 (62%) of 37 studies evaluating this outcome. Of the 27 trials measuring patient outcomes, 5 (18%) demonstrated improvements."
Of the 10 trials evaluating diagnostic systems, "[a]ll studies measured practitioner performance, and the CDSS was beneficial in 4 studies (40%)."
" 91% the CDSS suggested new orders (vs critiquing existing orders). Expert physician opinion or clinical practice guidelines usually formed the knowledge base for the CDSS."
"The process of data entry into the CDSS was clear in 80% of trials, some of which used more than 1 method. Existing personnel most often entered data
(attending or training physician, 38%; other health care staff [eg, nurses, clerks], 29%), although many trials used ... automated data capture from an electronic medical record (30%)."
"Only 13% of trials evaluated the impact of the CDSS on clinician workflow, with more than half of these CDSSs requiring more time and effort from the user compared with paper based methods."
"Studies in which users were automatically prompted to use the system described better performance compared with studies in which users had to actively initiate the system (success in 44/60 studies [73%] vs 17/36 studies [47%]; P=.02; unadjusted OR, 2.8; 95% CI, 1.2- 6.6; OR adjusted for methodological quality, 3.0; 95% CI, 1.2-7.1).... Compared with manual initiation, automatic prompting may improve integration into practitioner workflow as well as provide better opportunities to correct inadvertent deficiencies in care."
"Barriers to implementation include failure of practitioners to use the CDSS, poor usability or integration into practitioner workflow, or practitioner nonacceptance of computer recommendations."
Of 21 studies on reminder systems for prevention, "the CDSS was beneficial [to practitioner performance] in 16 studies (76%)."
Study Design
Systematic literature review
Study Participants
One hundred trials met the author's criteria for review. They "included English-language randomized and nonrandomized trials with a contemporaneous control group that compared patient care with a CDSS to routine care without a CDSS and evaluated clinical performance (ie, a measure of process of care) or a patient outcome."