Enabling Health Care Decisionmaking through the Use of Health Information Technology (North Carolina)

Project Details - Ended

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Summary:

This project conducted a systematic literature review in order to catalogue the study designs used to evaluate the clinical effectiveness of clinical decision support systems (CDSSs) and knowledge management systems (KMSs). As part of the literature review, the study team also looked at features that influence the success of CDSSs/KMSs, evidence for impact of CDSSs/KMSs on outcomes, and any identified knowledge types that can be integrated into CDSSs/KMSs. The databases searched included MEDLINE®, CINAHL®, PsycINFO®, and Web of Science®. Studies published in English between January 1976 and December 2010 were included.

The main objectives of the project were to:

  • Identify what evidence-based study designs can be used to determine the effectiveness of CDSS.
  • Identify what contextual factors and features influence the implementation and use of electronic knowledge management and CDSS.
  • Identify the impact of introducing electronic knowledge management and CDSS.
  • Identify what generalizable knowledge can be integrated into electronic knowledge management and CDSS to improve health care quality.

A total of 15,176 articles were identified, from which 148 randomized control trials (RCTs) were selected for inclusion in the review. The RCTs were 47.5 percent of the comparative studies found on CDSSs/KMSs. The literature showed that commercially available and locally developed CDSSs improved health care process measures related to preventive services, ordering clinical studies, and prescribing therapies. Fourteen CDSS/KMS features were evaluated for correlation with success of CDSSs/KMSs. Six new success features were identified: 1) integration with charting or order-entry system; 2) promotion of action rather than inaction; 3) no need for additional clinician data entry; 4) justification of decision support via research evidence; 5) local user involvement; and 6) provision of decision support results to patients as well as providers.

Three features previously identified as having correlation with success were confirmed: 1) automatic provision of decision support as part of clinician workflow; 2) provision of decision support at time and location of decisionmaking; and 3) provision of a recommendation, not just an assessment. Only 29 RCTs assessed the impact of CDSSs on clinical outcomes, 22 assessed costs, and three assessed KMSs on any outcomes. The primary source of knowledge used in CDSSs was derived from structured care protocols.

The project team concluded that there is strong evidence that CDSSs/KMSs are effective in improving health care process measures across diverse settings using both commercially and locally developed systems. The evidence base for the effectiveness of CDSSs on clinical outcomes and costs - and for KMSs on any outcomes - is minimal.

Enabling Health Care Decisionmaking through the Use of Health Information Technology - 2011

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Contract Number: 
    290-07-10066-I
  • Project Period: 
    September 2009 - February 2011
  • AHRQ Funding Amount: 
    $405,000
  • PDF Version: 
    (PDF, 182.67 KB)

Summary: Access to and utilization of knowledge, information, and clinical data via health information technology (IT) can facilitate clinical decisionmaking and communication. While the use of clinical decision support systems (CDSS) has the potential to make evidence-based practice guidelines available to clinicians at the point of care, there is uncertainty and concern about workflow disruption, usability in practice, and utility of content.

Duke University's Evidence-based Practice Center (EPC) developed a synthesis report summarizing the evidence on the use and effectiveness of CDSS across clinical settings. The report is one of three reports summarizing the state of the evidence on medication management using health IT, decision support tools, and consumer health informatics applications and their respective effect on the quality of care. The Duke EPC report focuses on facilitating health care decisionmaking with health IT. As part of the work, they convened a technical expert panel to advise them on the key questions and state of the evidence. The EPC conducted the comprehensive systematic literature search, reviewed and analyzed the existing evidence, and identified gaps in knowledge. The final report synthesizes key knowledge gaps and existing peer-reviewed research to provide critical information on developing and using electronic knowledge management, defined as any electronic system based on the distillation of primary literature used at the point-of-care to inform decision making and CDSS.

Project Objectives:

  • Identify what evidence-based study designs can be used to determine the effectiveness of CDSS. (Achieved)
  • Identify what contextual factors and features influence the implementation and use of electronic knowledge management and CDSS. (Achieved)
  • Identify the impact of introducing electronic knowledge management and CDSS. (Achieved)
  • Identify what generalizable knowledge can be integrated into electronic knowledge management and CDSS to improve health care quality. (Achieved)

2011 Activities: The focus of 2011 was dissemination of results. The final report for the project was completed at the end of March. A manuscript describing the results, Effect of Clinical Decision-Support Systems: A Systematic Review, was written and accepted in 2011 and published in the Annals of Internal Medicine in April 2012. Dr. Lobach participated in a national Web conference, Findings from the Evidence-Based Practice Centers for Health IT, hosted by the National Resource Center for Health IT at AHRQ in July, which featured the results and findings from the three EPCs.

Impact and Findings: The literature search identified 13,752 articles, from which 131 randomize control trials (RCTs) were selected for inclusion. These RCTs comprised 49 percent of the comparative studies on CDSS or electronic knowledge management. The project team determined that both commercially and locally developed CDSS deployed in many venues effectively improve process measures related to performing preventive services, ordering clinical studies, and prescribing therapies. Of the 14 CDSS features assessed in this review, the meta-analyses identified four new factors and features that correlated with the success of CDSS across all endpoints:1) integration with charting or order-entry system to support workflow; 2) promotion of action rather than inaction; 3) elimination of additional clinician data entry; and 4) local user involvement in the development process. The project team identified only 25 RCTs assessing the impact of CDSS on clinical outcomes, 20 assessing costs, and two assessing electronic knowledge management on any outcomes.

This review found strong evidence that CDSS improve process measures across diverse academic and nonacademic settings using both commercially and locally developed systems. Evidence for the effectiveness of CDSS on clinical outcomes and costs and electronic knowledge management on any outcomes is minimal, and more studies are needed in these areas.

Target Population: General

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Synthesis and Dissemination

Enabling Health Care Decisionmaking through the Use of Health Information Technology - 2010

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Contract Number: 
    290-07-10066-I
  • Project Period: 
    September 2009 – February 2011, Including No Cost Extension
  • AHRQ Funding Amount: 
    $405,000
  • PDF Version: 
    (PDF, 255.79 KB)


Target Population: Not Applicable

Summary: Access to and utilization of knowledge, information, and clinical data via health information technology (IT) can facilitate clinical decisionmaking and communication. While the use of clinical decision support systems (CDSS) has the potential to make evidence-based practice guidelines available to clinicians at the point of care, there is uncertainty and concern about workflow disruption, usability in practice, and utility of the content.

In 2009, Duke University’s Evidence-based Practice Center (EPC) was awarded a contract to develop a synthesis report summarizing the evidence on the use and effectiveness of CDSS across clinical settings. The report is part of a three-report series on the Agency for Healthcare Research and Quality’s (AHRQ’s) Health IT Portfolio’s strategic goals. The report focuses on the portfolio's goal of facilitating health care decisionmaking with health IT. As part of the work, the EPC convened a technical expert panel to conduct a comprehensive systematic literature search, review and analyze the existing evidence, and identify gaps in knowledge. The final product will be a report that synthesizes key knowledge gaps and existing peer-reviewed research to provide critical information on developing and using electronic knowledge management, defined as any electronic system based on the distillation of primary literature used at the point-of-care to inform decisionmaking, and CDSS.

Project Objectives:
  • Identity what evidence-based study designs can be used to determine the effectiveness of CDSS. (Achieved)
  • Identify what contextual factors and features influence the implementation and use of electronic knowledge management and CDSS. (Achieved)
  • Identify the impact of introducing electronic knowledge management and CDSS. (Achieved)
  • Identify what generalizable knowledge can be integrated into electronic knowledge management and CDSS to improve health care quality. (Achieved)

2010 Activities: The project team completed the literature search and the subsequent review and analysis of the existing evidence. The literature search identified 13,752 articles from which 131 randomized control trials (RCTs) were selected for inclusion. These RCTs comprised 49 percent of the comparative studies on CDSS or electronic knowledge management. The project team determined that both commercially and locally developed CDSS deployed in many venues effectively improve process measures related to performing preventive services, ordering clinical studies, and prescribing therapies. Of the 14 CDSS features assessed in this review, the meta-analyses identified several new factors and features that were correlated with the success of CDSS across all endpoints: integration with charting or order entry system to support workflow, promotion of action rather than inaction, elimination of additional clinician data entry, and local user involvement in the development process. Three previously identified successful features of CDSS were also confirmed. The project team identified only 25 RCTs assessing the impact of CDSS on clinical outcomes, 20 assessing costs, and two assessing electronic knowledge management on any outcomes. The results were synthesized in a draft repot that was submitted and posted for public review in December 2010. The final report is planned for March 2011.

Preliminary Impact and Findings: Strong evidence now shows that CDSS are effective in improving process measures across diverse academic and nonacademic settings using both commercially and locally developed systems. Evidence for the effectiveness of CDSS on clinical outcomes and costs and electronic knowledge management on any outcomes is minimal, and more studies are needed in these areas. Four features of CDSS that correlate with a successful impact of clinical decision support were newly identified, and three previously identified features were confirmed.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Synthesis and Dissemination

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