Hunt DL et al. 1998 "Effects of computer-based clinical decision support systems on physician performance and patient outcomes - a systematic review."

Hunt DL, Haynes RB, Hanna SE, et al. Effects of computer-based clinical decision support systems on physician performance and patient outcomes - a systematic review. JAMA 1998;280(15):1339-1346.
"Context: Many computer software developers and vendors claim that their systems can directly improve clinical decisions. As for other health care interventions, such claims should be based on careful trials that assess their effects on clinical performance and, preferably, patient outcomes.
Objective: To systematically review controlled clinical trials assessing the effects of computer-based clinical decision support systems (CDSSs) on physician performance and patient outcomes. Data Sources: We updated earlier reviews covering 1974 to 1992 by searching the MEDLINE, EMBASE, INSPEC, SCISEARCH, and the Cochrane Library bibliographic databases from 1992 to March 1998. Reference lists and conference proceedings were reviewed and evaluators of CDSSs were contacted. Study Selection: Studies were included if they involved the use of a CDSS in a clinical setting by a health care practitioner and assessed the effects of the system prospectively with a concurrent control. Data Extraction: The validity of each relevant study (scored from 0-10) was evaluated in duplicate. Data on setting, subjects, computer systems, and outcomes were abstracted and a power analysis was done on studies with negative findings. Data Synthesis: A total of 68 controlled trials met our criteria, 40 of which were published since 1992. Quality scores ranged from 2 to 10, with more recent trials rating higher (mean, 7.7) than earlier studies (mean, 6.4) (P,.001). Effects on physician performance were assessed in 65 studies and 43 found a benefit (66%). These included 9 of 15 studies on drug dosing systems, 1 of 5 studies on diagnostic aids, 14 of 19 preventive care systems, and 19 of 26 studies evaluating CDSSs for other medical care. Six of 14 studies assessing patient outcomes found a benefit. Of the remaining 8 studies, only 3 had a power of greater than 80% to detect a clinically important effect. Conclusions: Published studies of CDSSs are increasing rapidly, and their quality is improving. The CDSSs can enhance clinical performance for drug dosing, preventive care, and other aspects of medical care, but not convincingly for diagnosis. The effects of CDSSs on patient outcomes have been insufficiently studied."
To "provide a cumulative picture of the state of documentation of the effects CDSSs have on clinician performance and patient outcomes based on the strongest trials in health care settings to date."
not applicable
Type of Health IT
Decision support system
Type of Health IT Functions
"A CDSS was defined as any software designed to directly aid in clinical decision making in which characteristics of individual patients are matched to a computerized knowledge base for the purpose of generating patient-specific assessments or recommendations that are then presented to clinicians for consideration." Functions were varied but included drug dosing - particularly for intravenous drugs, patient diagnosis, and providing preventive care.
Workflow-Related Findings
Fourteen out of 16 studies examining the effect of decision support on physician performance in preventative care "found a benefit for at least one of the processes of care measured."
"The systems that provided patient-specific information about laboratory test results found improvements."
Nineteen out of 26 studies that examined the effect of CDSS on practitioner performance found a benefit. Compliance with diabetes care recommendations also improved in two out of four studies. "Compliance with recommendations for general medical problems also improved in the five studies that addressed this."
Of five studies examining the benefit of decision support in diagnosis of "pediatric patients or patients presenting with chest or abdominal pain," only one found a benefit.
Study Design
Systematic literature review
Study Participants
A search for literature in any language was conducted using the following databases: MEDLINE (1992-1998); Excerpta Medica (EMBASE); the International Information Service for the Physics and Engineering Communities (INSPEC); and the Science Citation Index (SCISEARCH). The Cochrane Library was also searched for any potentially relevant citations. Forty studies were found that met the authors' selection criteria.