Mollon B et al. 2009 "Features predicting the success of computerized decision support for prescribing: a systematic review of randomized controlled trials."
Reference
Mollon B, Chong JJR, Holbrook AM, et al. Features predicting the success of computerized decision support for prescribing: a systematic review of randomized controlled trials. BMC Med Inf Decis Making 2009;9:11.
Abstract
"Background: Computerized decision support systems (CDSS) are believed to have the potential to improve the quality of health care delivery, although results from high quality studies have been mixed. We conducted a systematic review to evaluate whether certain features of prescribing decision support systems (RxCDSS) predict successful implementation, change in provider behaviour, and change in patient outcomes. Methods: A literature search of Medline, EMBASE, CINAHL and INSPEC databases (earliest entry to June 2008) was conducted to identify randomized controlled trials involving RxCDSS. Each citation was independently assessed by two reviewers for outcomes and 28 predefined system features. Statistical analysis of associations between system features and success of outcomes was planned. Results: Of 4534 citations returned by the search, 41 met the inclusion criteria. Of these, 37 reported successful system implementations, 25 reported success at changing health care provider behaviour, and 5 noted improvements in patient outcomes. A mean of 17 features per study were mentioned. The statistical analysis could not be completed due primarily to the small number of studies and lack of diversity of outcomes. Descriptive analysis did not confirm any feature to be more prevalent in successful trials relative to unsuccessful ones for implementation, provider behaviour or patient outcomes. Conclusion: While RxCDSSs have the potential to change health care provider behaviour, very few high quality studies show improvement in patient outcomes. Furthermore, the features of the RxCDSS associated with success (or failure) are poorly described, thus making it difficult for system design and implementation to improve."
Objective
"To conduct a systematic review of randomized trials, to evaluate the effectiveness of [prescribing decision support systems (RxCDSS)] using a hierarchical approach to defining success, and to determine which features of system design or implementation were associated with the success or failure of RxCDSS implementation, change in provider behaviour, and change in patient outcomes."
Type Clinic
Primary care and specialty care
Size
not applicable
Type of Health IT
Decision support system
Type of Health IT Functions
The authors reviewed prescribing clinical decision support systems (RxCDSS) that, "utilized a computer to analyze patient-specific information to advise a prescriber (primarily a physician) or pharmacist when they were writing or filling a prescription, respectively. Although the decision support itself had to be generated electronically, the support could be delivered by any means (e.g. computer terminal, fax, mail, patient record insert)." The authors only included, "systems which intervened before a drug therapy had been chosen by a physician, or had the ability to suggest alternate therapies (i.e. a drug different then that initially prescribed) to be a RxCDSS. These are the more challenging decisions for which to intervene and change. Systems whose sole purpose was to offer 'fine-tuning' advice on a pre-defined therapy - usually dose modification - were not included in this review. Systems primarily focused on diagnosis, vaccination, or nutrition, were also excluded."
Workflow-Related Findings
Features of RxCDSS included: "support of the user's task at hand (95%), provision of decision support at the time and place of decision-making (85%), provision of a recommendation rather than just an assessment (85%), automatic provision of decision support as part of clinician workflow (78%), [and] integration with charting or order entry (75%) ... However, with few exceptions, the prevalence of these features was similar between successful and unsuccessful studies when examining implementation, provider behaviour and patient outcomes."
"The features which all of the [RxCDSS affecting provider behavior] shared and which most of the unsuccessful [RxCDSS] did not, included: provision of a recommendation rather than just an assessment, justification of decision support via provision of research evidence and the system uses data standards that support integration."
Study Design
Systematic literature review
Study Participants
The review "included reports of RCTs of RxCDSS published in English." Of the 41 studies included, "37 reported successful system implementations, 25 reported success at changing health care provider behaviour, and 5 noted improvements in patient outcomes. A mean of 17 features per study were mentioned."