Acquisition and assembly of data: Pawloski, Olson-Bullis. To optimize care pathways with an intelligent decision support system aimed at facilitating diagnosis and therapeutic decisions along disease-specific pathways. A New Market Study, titled "Clinical Decision Support Systems (CDSS) Market Upcoming Trends, Growth Drivers and Challenges" has been featured on WiseGuyReports. Arch Intern Med 2003;163:1409–1416. Osheroff JA, Teich JM, Middleton B, . Scott GP, Shah P, Wyatt JC, . Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. In PubMed, the MeSH terms defined the concepts of cancer and CDS systems, medical order entry systems, or clinical pathways. HealthIT.gov website. BJU Int 2002;90:522–528. AHRQ Publication No. While electronic health records and databases help physicians manage this rising tide of information, patient-specific recommendations provided by clinical decision support systems can do even more by improving decision making and helping ensure patient safety. Common roles for CDS include computerized physician order entry (CPOE) and electronic health record (EHR) clinical reminder systems.2. Comparative studies that report outcomes of care include those of CDS systems with CPOE, clinical pathways, CPGs, PROs, and provider alerts. J Ambul Care Manage 2008;31:201–210. The NLM now lists all authors. CPOE showed a small impact on provider behavior, with general alerts and increased pharmacist order review times. Meanwhile, the reporting and methodological quality of this field were unknown. Published reports in the peer-reviewed literature were identified, and all abstracts were reviewed for eligibility. . Moher D, Liberati A, Tetzlaff J, . 14. One study evaluated prescriber alerts with CDS tools and demonstrated that hard stops for hepatitis B screening before chemotherapy treatment were associated with increased screening (99.3% vs 40.2%; PP43. HealthPartners Institute is an Affiliate Member of the HCS Research Network. in Medical Journals, visit www.icmje.org. A working definition has been proposed by Robert Hayward of the Centre for Health Evidence: "Clinical decision support systems link health observations with health … Full PubMed search parameters are available in supplemental eAppendix 1 (available with this article at JNCCN.org). In this article, the advantages, potential drawbacks, and clinical decision support system adoption barriers are discussed, followed by an in-depth review of the characteristics that make a clinical decision support system successful. We critically appraised and synthesized the published medical literature to answer the objective question, “What evidence supports the use of CDS systems for diagnosis, treatment, and supportive care in clinical oncology?” A CDS system was defined as any electronic system in which characteristics of individual patients are used to generate patient-specific assessments or recommendations that are then presented to clinicians to help with clinical decision-making.1. Methods: A systematic review of peer-reviewed studies was performed to evaluate clinically relevant outcomes related to the use of CDS tools for the diagnosis, treatment, and supportive care of patients with cancer. The clinical decision support system(CDSS) has potential to improving medication safety. Jenders RA, Hripcsak G, Sideli RV, et al. A CDSS is a promising approach to the aggregation and use of patient data to identify patients who would most benefit from interventions by pharmacy clinicians. In general, the outcomes associated with use of clinical pathway systems were compared with usual care; however, one study compared use of an electronic clinical pathway with a paper pathway.34 Most studies were framed as reporting favorable outcomes, including reduced acute care use,32,35 increased guideline concordance and reduced symptoms,33 improved identification of eligible subjects for clinical trial participation,36 and improved hemoglobin levels among patients with anemia.37 The comparison between web- and paper-based pathway systems did not show a significant difference in pathway deviations between them.34, The remaining 6 studies assessed CDS systems in CPGs (n=2),38,39 PROs (n=3),40–42 and oncology-specific prescriber alerts (n=1).43 One study evaluated CPG concordance with CDS and demonstrated a significant increase in guideline adherence (P38 Furthermore, adherence to CPGs with CDS system advice was >90% when the CDS tool included CPG recommendations.39 CDS tools for obtaining PROs and reporting the results to clinicians showed increased discussion of symptoms and quality-of-life issues (P=.03) and symptom monitoring during routine clinical care.40–42 Patients reported a high ease of use and minimal time required; however, patient satisfaction was similar between intervention and control groups. Abstract: Background: One of the greatest challenges in the field of medicine is the increasing burden of chronic diseases, such as diabetes. Blum D, Raj SX, Oberholzer R, . An important finding that is absent will downgrade the diagnosis within the differential diagnosis. The Evidenc… J Am Med Inform Assoc 2006;13:16–23. J Oncol Pract 2013;9:e103–114. The types of CDSS available are as broad as human ingenuity allows: from personal digital assistant applications customized by a single clinician to multihospital mainframe-based surveillance systems meant to assure care for thousands of patients. J Am Med Inform Assoc 2016;23:420–427. Opportunities for a better use of healthcare resources. Key features that appear to support positive outcomes include real-time information and point-of-care action. Automating complex guidelines for chronic disease: Lessons learned. Background: Clinical decision support systems (CDSSs) are an integral component of today’s health information technologies. Mark Ansermino, FFA, MMed, MSc, FRCPC, Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in The International Committee Computer-based consultations in clinical therapeutics: Explanation and rule acquisition capabilities of the MYCIN system. The review was conducted according to the PRISMA statement to ensure appropriate methods were used. U.S. National Library of Medicine. Impact of computerised chemotherapy prescriptions on the prevention of medication errors. Overview Full Text Hunt DL, Haynes RB, Hanna SE, . From: Infectious Diseases (Fourth Edition), 2017 This report provides in … The authors would also like to acknowledge Mandy Fraser, Amanda Lacy, and Lauryn Davin, who provided technical assistance during the literature review process and with manuscript preparation and submission. BMJ Open 2012;2:2. Clinical decision support systems use specific para… J Clin Oncol 2016;34:557–565. of Medical Journal Editors (ICMJE) recommends the following citation style, which is the now nearly universally A CDSS can be embedded throughout the patient safety continuum providing reminders, recommendations, and alerts to health care providers. Two investigators reviewed each title and abstract for potential inclusion. Heidelberg: Springer-Verlag, 1997:261-276. Standard practices for computerized clinical decision support in community hospitals: a national survey. [2] The clinicians would enter a series of facts about history, physical findings, and laboratory results into the system, which would then give patient-specific recommendations for antibiotic coverage. Clinical Decision Support. The types of CDSS available are as broad as human ingenuity allows: from personal digital assistant applications customized by a single clinician to multihospital mainframe-based surveillance systems meant to assure care for thousands of patients. Currently, <15 studies assessing the impact of CDS systems are underway or accruing, according to ClinicalTrials.gov.49 A recent study of CDS in patients with lung cancer showed a reduction in inappropriate granulocyte colony-stimulating factor use without an increase in febrile neutropenia rates, illustrating the positive impact these powerful tools can have on clinical oncology care.50 Further analyses of the use of these tools with appropriate study designs and analytic methods are necessary to build the case for wider implementation of CDS systems. Reducing overuse of colony-stimulating factors in patients with lung cancer receiving chemotherapy: evidence from a decision support-enabled program. BMJ 2013;346:f657. Questions about treatment recommendations? 1 The authors found no significant improvement in clinical outcomes in the subset of 30 trials that included them. 2002;347:284-7. However, one study in our analysis showed that there was an increase in pharmacist order review time without any impact on intervention rates.21 This finding underlines the potential for CDS systems to have a negative impact on care delivery, and demonstrates the importance of a thorough evaluation of these tools as a part of system implementation. Importantly, most of our findings were consistent with those of previous non–oncology-focused studies showing that CDS systems improve care process measures. However, little is known regarding the use of CDS systems in clinical oncology and their impact on patient outcomes. The promised benefits of health information technology rest in large part on the ability of these systems to use patient-specific data to provide personalized recommendations for care. PubMed Abstract Full Text Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. To date, few studies have evaluated CDS systems in oncology practice. Solid-organ transplantation in HIV-infected Disclosures: The authors have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article. Clinical oncology is a dynamic, multidimensional healthcare specialty with complex decision-making and care coordination needs and multiple handoffs between primary and specialty care providers.16 In 2013, the Institute of Medicine reported that the cancer care delivery system was in crisis due to a lack of patient-centric care, palliative care, and evidence-based decision-making.17 CDS systems have the potential to significantly improve cancer care delivery, but there are critical gaps in the availability and use of effective CDS tools.18 To better understand the current landscape of CDS systems in oncology practice, we conducted a systematic review of the literature describing real-world implementation of CDS tools for the diagnosis, treatment, and supportive care of patients with cancer. 5 , June CDS systems with all 4 features were associated with significant improvements in clinical practice. Collins CM, Elsaid KA. Promoting evidence-based management of anemia in cancer patients: concurrent and discriminant validity of RESPOND, a web-based clinical guidance system based on the EORTC guidelines for supportive care in cancer. eHealth for a Healthier Europe! There are various types of CDSS implementations, both active and passive (provider initiated). Small MD, Barrett A, Price GM. Handbook of Medical Informatics. Nonetheless, there are numerous examples of computerized guidelines in use today.[12]. Health systems were called on to optimize CDS to improve the quality of healthcare services and health in the United States. Background: Electronic health records are central to cancer care delivery. Table 2 describes individual study sample sizes, study design, number of facilities, and diagnoses, and supplemental eTable 1 summarizes the objectives and outcomes of each included study. J Am Med Inform Assoc 2003;10:573–579. Furthermore, we believe it is essential that these assessments also involve outcomes, including those associated with clinical care and costs of system implementation, when possible. Clinical Decision Support Systems: State of the Art. Available at: https://clinicaltrials.gov/ct2/home. Dr Ansermino is a member of the Centre for Health Innovation and Improvement (CHIi) and a pediatric anesthesiologist at BC’s Children’s Hospital. The content of this field is kept private and will not be shown publicly. Aziz MT, Ur-Rehman T, Qureshi S, . N Engl J Med. AHRQ Publication No. de Lusignan S, Chan T. The development of primary care information technology in the United Kingdom. performed a comprehensive search of the literature to identify studies meeting the inclusion criteria. Electronic clinical decision support (CDS) systems can potentially improve cancer care quality and safety. Available at: . When the order is entered into the computer, the physician is reminded of the exact elements of the evidence-based criteria for such an order (the Ottawa Ankle Rules). Research that identifies CDSS methods that alert health care providers to errors has become a critical element in improving patient safety. [6] These applications judiciously deliver information or knowledge that can beneficially alter clinical decision making. Seven of eight relevant systematic reviews found a positive effect on provider or patient behavior. Bouaud J, Spano JP, Lefranc JP, . Clinical decision support systems for improving diagnostic accuracy and achieving precision medicine. Making electronic prescribing alerts more effective: scenario-based experimental study in junior doctors. Within the CDS systems, key factors that appear to contribute to improved outcomes include the use of real-time provider alerts and point-of-care action on prescription orders and provision of information to clinicians that CDS systems can provide.20,27,32,36,37,40–42 There appear to be resulting factors that create new challenges, such as the need to access separate systems and otherwise increase work time of prescribers or other downstream clinicians, that may reduce outcomes.21,26,34,35. patients. Reflecting these concerns, in 2014 the Centers for Medicare and Medicaid (CMS) announced that, in order to be reimbursed by Medicare, high-cost images will have to be ordered through a Clinical Decision Support (CDS) system that meets specific Appropriate Use Criteria (AUC). Clinical decision support systems (CDSS) have been used to assist clinicians in making wise antimicrobial treatment decisions and to assist the antimicrobial stewardship program with identification of patients for potential intervention. While in experimental tests the system could be as good as a panel of clinicians, MYCIN was never widely used because of difficulties with maintenance and incorporating the system into a clinician’s workflow. Bright TJ, Wong A, Dhurjati R, . In addition, the impact of CDS systems on patient mortality, healthcare costs, or costs associated with implementation and management was also not assessed. Manuscript preparation and final approval: All authors. CPOE refers to a variety of computer-based systems for ordering medications or tests. Harris AD, McGregor JC, Perencevich EN, . The development of clinical decision support systems (CDSSs) for the diagnosis of primary headaches has long been a major research topic. to save searches and organize your favorite content. Computer-assisted decision support in medical oncology: we need it now. The message goes to a centralized computer application that manages a series of clinical rules. In the coming years, provincial and federal health ministries will invest billions of dollars in new health information systems. These systems provide physicians, caregivers and also patients with clinical knowledge needed and patient or disease specific information to help them make effective decisions that would enhance patient care and improve clinical outcomes. © 2019-2020 National Comprehensive Cancer Network. Int J Radiat Oncol Biol Phys 2012;83:1246–1251. Designing good evaluative trials is difficult and the sheer variety of systems and functions makes comparison complicated. Adeboyeje G, Agiro A, Malin J, . Stud Health Technol Inform 2001;84:420–424. A recent review of 57 randomized controlled trials and 10 systematic reviews evaluated the effectiveness of computer-based delivery of health evidence, including CDSS. Computer-Based Delivery of Health Evidence: A Systematic Review of Randomised Controlled Clinical Trials and Systematic Reviews of the Effectiveness on the Process of Care and Patient Outcomes. Available at: https://www.healthit.gov/policy-researchers-implementers/clinical-decision-support-cds. Most studies were conducted at a single facility (79%), 87% used quasi-experimental designs, and only 13% (n=3) were randomized controlled trials. While implementing the IF-THEN-ELSE rule illustrated by the Brigham and Women’s Hospital hypokalemia/digoxin example is relatively straightforward, the programming of guidelines with their multiple, often subjective decision points tests the limits of scientific disciplines such as decision analysis and knowledge representation. Meisenberg BR, Wright RR, Brady-Copertino CJ. For optimal retrieval, all terms were supplemented with relevant title and text words. A broad range of information systems can now generate patient-specific advice to aid clinical decision making. 6. Basch E, Deal AM, Kris MG, . These programs aim to optimize antibiotic prescriptions hence to increase guideline adherence, often leading to a reduction in overall antibiotic use [ 7 ]. Full-text articles were retrieved and reviewed when additional information was needed. Clinicians are also best placed to decide how CDSS should be implemented in local care environments. Seidman AD. A before-after study using OncoDoc, a guideline-based decision support-system on breast cancer management: impact upon physician prescribing behaviour. CDS tools have been incorporated across the patient care spectrum, encompassing prevention, diagnosis, and clinical monitoring. [12], How to represent complex clinical guidelines in computer applications is an area of considerable research[13] . Rockville, MD: Agency for Healthcare Research and Quality; 2009. CDS improves healthcare process measures; however, data demonstrating their effectiveness on clinical outcomes and costs are limited.1 Accordingly, real-world uptake of CDS systems has been modest at best.4 Benefits of CDS include improved efficiency and quality of healthcare delivery and access to medical data; enhanced communication; and potential cost savings.5–14 In 2007, the American Medical Informatics Association (AMIA) sounded a call to action regarding CDS implementation that included 3 pillars for fully realizing the promise of CDS: (1) best knowledge available when needed; (2) high adoption and effective use; and (3) continuous improvement of knowledge and CDS methods.4 Furthermore, the Agency for Healthcare Research and Quality stated that the question is not whether CDS systems should be designed and implemented, but rather how to make it easy to do the right thing.15 Nevertheless, effective implementation of a CDS system is a major undertaking, considering the vast amount of clinical data and its variability, availability, and structure across facilities. Lobach D, Sanders GD, Bright TJ, . Impact of electronic chemotherapy order forms on prescribing errors at an urban medical center: results from an interrupted time-series analysis. PubMed Abstract Full Text CDS systems incorporated into clinical pathways have been associated with increased guideline adherence,32–37 demonstrating the benefit they can provide to clinicians, and consistent with findings of previous systematic reviews also showing a positive impact on guideline adherence.10,44 Three studies included in our analysis evaluated the use of CDS systems for PROs, and all demonstrated benefit for ≥1 outcome.40–42 These findings differ somewhat from those of a systematic review of 15 studies that assessed the effect of CDS systems on PROs, which showed a positive effect on symptoms in 3 studies (20%).45 A CDS system used with prescriber alerts demonstrated a positive impact, which is consistent with findings of a previous study.43,46, The findings are also consistent with those of a meta-analysis assessing the impact of health information technology (HIT) on cancer care from 2000 to June 2014.47 CDS systems were the most common (66%) HIT intervention identified and were implemented across several cancer types, including breast, colorectal, and prostate, for detection, diagnosis, and treatment but not for survivorship or end-of-life care. Data from included studies were abstracted from full-text publications using a data abstraction form that included the study objective and design, intervention, number of subjects, study results and conclusions, location of study by country, number of study facilities (single site vs multisite), setting (inpatient vs outpatient), patient diagnosis, subject age range, CDS tool type (stand-alone, EHR-embedded) and name, study or system features, funding source, and conflict of interest declaration. J Am Med Inform Assoc 2007;14:141–145. Databases searched were: PubMed, Embase, Academic Search Premier, Web of Science, and Inspec. Clinical decision support (CDS) systems include any electronic system designed to directly aid clinical decision-making by using individual patient characteristics to generate patient-specific assessments or recommendations. 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