1.  Impact of a Computerized Clinical Decision Support System on Reducing Inappropriate Antimicrobial Use: a Randomized Controlled Trial

Author(s): McGregor JC, Weekes E, Forrest GN, et al.

Source: Journal of the American Medical Informatics Assocation (JAMIA). 2006 Jul-Aug;13(4):378-384 Epub 2006 Apr 18.

Summary: Many hospitals utilize antimicrobial management teams (AMTs) to improve patient care but function with minimal computer support. This randomized controlled trial evaluated the effectiveness and cost-effectiveness of a computerized clinical decision support (CDS) system for the management of antimicrobial utilization. The system used was developed to alert the AMT of potentially inadequate antimicrobial therapy. Outcomes assessed were hospital antimicrobial expenditures, mortality, length of hospitalization, and time spent managing antimicrobial utilization. The AMT intervened and spent approximately one hour less each day on the intervention arm. Hospital antimicrobial expenditures were a savings of $84,194 (23%), or $37.64 per patient in the intervention arm. Use of the system facilitated the management of antimicrobial utilization by allowing the AMT to intervene on more patients receiving inadequate antimicrobial therapy and to achieve substantial time and cost savings for the hospital. This is the first study that demonstrates in a patient-randomized controlled trial that computerized clinical decision support systems can improve existing antimicrobial management programs.

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2.  A Roadmap for National Action on Clinical Decision Support

Author(s): Osheroff JA, Teich JM, Middleton B, Steen EB, Wright A, Detmer DE

Source: Journal of the American Medical Informatics Assocation (JAMIA). 2007 Mar-Apr;14(2):141-145 Epub 2007 Jan 9.

Summary: Clinical decision support (CDS) provides clinicians, staff, patients, or other individuals with knowledge and person-specific information to enhance health and health care.  This document, a white paper approved by the AMIA Board of Directors, presents a roadmap for national action on clinical decision support.  The roadmap identifies three pillars for fully realizing the promise of CDS: having the best available clinical knowledge well-organized for CDS interventions; high adoption and effective use of CDS tools; and continuous improvement of knowledge and CDS methods.  Two levels of activity are presented in the roadmap: a comprehensive work plan and a critical path for CDS activities.  The comprehensive work plan outlines the full set of tasks necessary to create a robust infrastructure in which to develop CDS interventions.  The critical path tasks represent a subset of the comprehensive work plan that can be readily implemented and produce results in the short term.  The full text of this paper is published on the AMIA Web site (www.amia.org/inside/initiatives/cds).

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3.  Effects of Computerized Physician Order Entry and Clinical Decision Support Systems on Medication Safety: A Systematic Review

Author(s): Kaushal R, Shojania KG, Bates DW

Source: Archives of Internal Medicine. 2003 Jun 23;163(12):1409-1416.

Summary: Iatrogenic injuries related to medications are common, costly, and clinically significant, and the use of computerized physician order entry (CPOE) and clinical decision support systems (CDSSs) may reduce medication error rates.  Studies were included for systematic review if the design was a controlled trial (randomized or nonrandomized), or an observational study with controls and if the measured outcomes were clinical or surrogate markers.  The five CPOE studies showed improvement in: marked decrease in serious medication error rate (2); corollary orders (1); five prescribing behaviors (1); and nephrotoxic drug dose and frequency (1).  The seven studies evaluating isolated CDSSs demonstrated statistically significant improvements in antibiotic-associated medication errors or adverse drug events (3), and an improvement in theophylline-associated medication errors (1). The remaining three studies had nonsignificant results. Use of CPOE and isolated CDSSs can substantially reduce medication error rates, but most studies have not been powered to detect differences in adverse drug events and have evaluated a small number of "homegrown" systems.

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4.  Effects of Computerized Clinical Decision Support Systems on Practitioner Performance and Patient Outcomes: A Systematic Review

Author(s): Garg AX, Adhikari NK, McDonald H, Rosas-Arellano MP, Devereaux PJ, Beyene J, Sam J, Haynes RB

Source: JAMA: The Journal of the American Medical Association. 2005 Mar 9;293(10):1223-1238.

Summary: This article reviews controlled trials assessing the effects of computerized clinical decision support systems (CDSSs) and identifing study characteristics predicting benefit to patient care. We included randomized and nonrandomized controlled trials that evaluated the effect of a CDSS compared with care provided without a CDSS on practitioner performance or patient outcomes. One hundred studies met our inclusion criteria and CDSS improved practitioner performance in 62 of the 97 studies assessing this outcome. 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). In conclusion, many CDSSs improve practitioner performance; however, the effects on patient outcomes remain understudied and, when studied, inconsistent.

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5.  Improving Clinical Practice Using Clinical Decision Support Systems: A Systematic Review of Trials to Identify Features Critical to Success

Author(s): Kawamoto K, Houlihan CA, Balas EA, Lobach DF

Source: BMJ. 2005 Apr 2;330(7494):765-768 Epub 2005 Mar 14.

Summary: This systematic review of randomized controlled trials seeks to identify features of clinical decision support systems critical for improving clinical practice.  Seventy studies were assessed for statistically and clinically significant improvement in clinical practice and for the presence of 15 decision support system features whose importance had been repeatedly suggested in the literature.  Decision support systems were found to significantly improve clinical practice in 68% of trials.  Multiple logistic regression analysis identified four features as independent predictors of improved clinical practice: automatic provision of decision support as part of clinician workflow (P < 0.00001), provision of recommendations rather than just assessments (P = 0.0187), provision of decision support at the time and location of decision making (P = 0.0263), and computer-based decision support (P = 0.0294). Of 32 systems possessing all four features, 30 (94%) significantly improved clinical practice. Clinicians and other stakeholders should implement clinical decision support systems that incorporate these features whenever feasible and appropriate to improve patient care.

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6.  Expert Clinical Decision Support Systems to Enhance Antimicrobial Stewardship Programs: Insights from the Society of Infectious Diseases Pharmacists

Author(s): Pestotnik SL

Source: Pharmacotherapy. 2005 Aug;25(8):1116-1125.

Summary: Health care-associated infections (HAIs) are a leading cause of in-hospital mortality and adverse events such as antimicrobial resistance. These infections place tremendous burdens on the health care system and create situations for misuse of antimicrobial drugs. Traditionally, antimicrobial stewardship programs have relied on manual methods combined with clinical oversight and intervention to improve the management of HAIs. The advent of modern health care information technology offers the opportunity to expand the breadth and depth of these programs. Expert clinical decision support systems are the most promising of these information technology advances.  Infectious disease-specific CDS systems need to be able to adhere to organism and drug name hierarchy lexicons, system functional requirements, and automatically produce location-specific antibiograms that conform to Clinical and Laboratory Standards Institute guidelines. Infectious disease-specific CDS systems are quickly becoming an essential element in the enlarging role of clinicians, both physicians and pharmacists, who specialize in infectious diseases.

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7.  Clinical Decision Support Systems for the Practice of Evidence-based Medicine

Author(s): Sim I, Gorman P, Greenes RA, Haynes RB, Kaplan B, Lehmann H, Tang PC

Source: Journal of the American Medical Informatics Assocation (JAMIA). 2001 Nov-Dec;8(6):527-534.

Summary: The use of clinical decision support (CDS) systems to facilitate the practice of evidence-based medicine (EBM) promises to substantially improve health care quality. This paper, based on the proceedings of the Evidence and Decision Support track at the 2000 AMIA Spring Symposium, describes the research and policy challenges for capturing research and practice-based evidence in machine-interpretable repositories, and presents recommendations for adoption of CDS systems for EBM. The recommendations fall into five broad areas--capture literature-based and practice-based evidence in machine-interpretable knowledge bases; develop maintainable technical and methodological foundations for computer-based decision support; evaluate the clinical effects and costs of CDS systems and the ways they affect and are affected by professional and organizational practices; identify and disseminate best practices for work flow-sensitive implementations of CDS systems; and establish public policies that provide incentives for implementing CDS systems to improve health care quality. Although the promise of CDS system-facilitated EBM is strong, substantial work remains to be done to realize the potential benefits.

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8.  A Pragmatic Approach to Implementing Best Practices for Clinical Decision Support Systems in Computerized Provider Order Entry Systems

Author(s): Gross PA, Bates DW

Source: Journal of the American Medical Informatics Assocation (JAMIA). 2007 Jan-Feb;14(1):25-28 Epub 2006 Oct 26.

Summary: Incorporation of clinical decision support (CDS) capabilities is required to realize the greatest benefits from computerized provider order entry (CPOE) systems. Discussions at a conference on CDS in CPOE held in San Francisco, California, June 21-22, 2005 produced several papers in this issue of JAMIA. The first paper reviews CDS for electronic prescribing within CPOE systems; the second describes current controversies regarding creation, maintenance, and uses of CPOE order sets for CDS; and the third presents issues related to certification as a potential means of validating CPOE systems for widespread use.  Technical issues for CPOE included reconciling the history of drug allergies electronically, drug-based drug-drug interaction checking, drug ordering, and laboratory test monitoring.  Non-technical issues include continuous refinement of systems, taking responsibility for iterative improvements, and planning and implementation by administration.  This manuscript summarizes all of the discussions at the meeting and provides a pragmatically oriented view of how to implement CPOE with CDS.