INCORPORATING EVIDENCE:

Use of Computer-based Clinical

Decision Support Systems for
Health Professionals
 DECISION SUPPORT SYSTEMS (DSS)
-are automated tools designed to
support decision-making activities &
improve the decision-making process
& decision outcomes.
-such systems are intended to use the
enormous amounts of data that exist
in the information systems to
facilitate decision making
 CLINICAL DECISION SUPPORT
SYSTEM
-Is designed to support healthcare
providers in making decisions about the
delivery & management of patient care.
*GOAL-
-Optimization of both the efficiency &
effectiveness with w/c clinical decisions
are made & care is delivered
-CDSS requires a huge financial &
intellectual investment but also
represents the potential to reduce
care cost through improvement of
the decision process at the point of
care & to reduce the possibility of
costly error.
 NURSING DECISION SUPPORT
SYSTEM (NDSS)
-Tools that help nurses improve their
effectiveness, identify appropriate
interventions, determine areas in need of
policy & protocol development, &
support patient safety initiative & quality
improving activities.
- CDSS include knowledge-based tools that
can be fully integrated with the clinical data
embedded in the computerized patient
record to assist provider by presenting
information relevant to healthcare
problems being faced.
- It should have a powerful search function
that can access useful & reliable
information from knowledge sources
include electronic libraries, medical
dictionaries, drug formularies, expert
opinion, & patient database access.
-CDSS has the potential to transform the
healthcare delivery but it is important to
remember that the clinical user’s
experience, understanding of context &
knowledge base are not replaced but
rather, supported in the decision-making
process.
-Final decisions are always made by the
clinicians who can accept or reject the CDSS
information within the context of the
healthcare situation.
 RANDAL TOBIAS
-credited in his saying that if the advances in
power, storage capability, & cost of computers
today were compared with the mainframe of
the 60s & 70s, it would be like getting a Lexus
for 2 dollar that went 600mph & used a thimble
of gas.
-This means that the computer has virtually
unlimited capacity for processing & storage
data. The human, on the other hand, has
limited storage (memory) & processing power,
but does have judgment, experience, &
intuition.
 PURPOSES OF DSS:
1. Assist in problem solving with
semistructured problems
2. Support, not replace, the judgment of a
manager or clinician.
3. Improve the effectiveness of decision-
making process.
-highly structured problems, which can be
solved with existing facts, & unstructured
problems, w/c is highly dependent on
va,ues & beliefs, are generally not well
suited for decision support.
 HISTORY OF CDSS
1. Early systems: FOCUSE ON DIAGNOSIS
* 1972 -Earliest known CDSS is designed to
support diagnosis of acute abdominal pain
developed by de Dombal at Leed University
*1974-INTERNIST I developed at the University
of Pittsburg to support the diagnostic
process in general internal medicine by
linking diseases with symptoms.
*QUICK MEDICAL REFERENCE
-successor of Internist 1.
*1976 –MYCIN a rule-based expert system to
diagnose & recommend treatment for
certain blood infections.
*COMMES (Creighton online multiple
modular expert system) & CANDI (computer
aided nursing diagnosis & intervention)
-two early systems developed to assist
nurses with care planning & nursing
diagnosis.
2. Other CDSS uses: ADDRESS SPECIFIC
CLINICAL ISSUES
*ONCOCIN – developed for oncology protocol
management at Stanford
*CASNET – developed at Rutgers University
for treatment of Glaucoma
*ABEL – system that used to manage acid-
base & electrolyte imbalance.
*LISA – a DSS for treatment of childhood
acute lymphoblastic leukemia.
 TYPES OF DSS:
1. ADMINISTRATIVE & ORGANIZATIONAL
SYSTEM
-System that support organizational,
executive/managerial, financial 7 clinical
decisions.
-this system encompass decision processes
other than direct patient care delivery.
-in this system, decisions occur at the strategic,
tactical, population or aggregate &
operational level, not at the individual level.
2. INTEGRATED SYSTEM:
-Such systems are able to support outcomes
performance management by integrating
operational data.
*business side: budgeting, executive decision-
making, financial analysis, quality
management.
*clinical side: clinical event tracking, result
reporting, pharmaceutical ordering &
dispensing, clinical pathways, differential
diagnosis, literature research, & clinical
alerts.
 KEY CDSS FUNCTIONS:
1. ADMINISTRATIVE:
- Support for clinical coding and
documentation

2. MANAGEMENT OF CLINICAL COMPLEXITY

& DETAILS:
-keeping patients on research &
chemotherapy protocols, tracking orders,
referrals, follow-up, & preventive care.
3. COST CONTROL:
-monitoring medication orders & avoiding
duplicate or unnecessary test

4. DECISION SUPPORT:
-supporting clinical diagnostic & treatment
plan processes, use of condition-specific
guidelines, & population-based
management.
 CDSS IMPACT ON CLINICAINS &
CLINICAL DECISIONS
- Institute of medicine report (2000) identifies
human error as a major source of patient care
morbidity and mortality
-CDSS lessen the incidence of adverse drug
events, nosocomial infection,& inappropriate
use of antibiotic.
-Prevention of prescription errors is seen as one
of the most valuable & widely used functions
of CDSS.
EFFECTIVE CLINICAL DECISION
SUPPORT
depends on:
a. CDSS speed
b. anticipation of information needs
c. real-time delivery
d. Usability
e. Simplicity
f. maintenance of knowledge-based system
 BARRIERS TO THE USE OF CDSS
1. Lack of noticeable benefits
2. Insufficient cost benefits
3. Inadequate staff training
4. Lack of system support
 RESPONSIBILITY OF USER : ETHICAL
AND LEGAL ISSUES
-There seem no major adverse effect from the
use of CDSS. There still unknown legal
ramifications of not following CDSS advise.
-CDSS has been developed according to quality
and safety standards. CDSS is expected to
comply with a “duty of care” if it is to become
safely integrated into routine patient care.