Clinical/Medical Decision

Support Systems (CDSS)

1
The revolution for a better health care

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2 Unit contents

 Definition
 Types of CDSS
 Characterizing/categorizing Decision-Support Systems
 Criteria for a clinically useful DSS
 CDS Science, Policy and Products???
 policies and standards pertaining to CDS
 Benefits
 Limitations

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 3
Introduction

 Computer-based decision support systems (CDSS): are

medical information processing systems that are designed
to aid clinicians in making complex clinical based
decisions.
 CDSS provide data banks, alerts and reminders, algorithms,
analytic or pathophysiologic models, statistical pattern
recognition methods, and/or expert knowledge bases to
enhance the diagnostic, therapeutic, and prognostic-
thinking and cognitive-reasoning strategies of expert and
amateur clinicians alike.

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4 Introd…
 “Clinical Decision Support systems link health
observations with health knowledge to influence
health choices by clinicians for improved health care".
 Computer systems designed to impact clinician
decision making about individual patients at the point
in time that these decisions are made’.

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5 Introd…
 A clinical decision-support system is any
computer program designed to help health
professionals make clinical decisions.
 In a sense, any computer system that deals with
clinical data or medical knowledge is intended to
provide decision support.

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6 Decision Support Systems
 A process for incorporating guidelines, education,
expert advice and practice aids into routine clinical
practice
A more specific definitions
 Clinical decision support systems are active
knowledge systems which use two or more items of
patient data to generate case-specific advice.

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7 Main components:

 Integration in electronic patient record

 Computerised format
 Patient specific information
 Medical knowledge
 Case-specific advice

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8 DSS versus KBS

 Knowledge-based systems (KBS) are

computer programs which seek to imitate
human intelligence and expertise
 DSS emphasise SUPPORT for the
decision-making process

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9 Characterizing Decision-Support Systems

 System function
 Determining what is true about a patient (e.g.
correct diagnosis)
 Determining what to do (what test to order, to
treat or not, what therapy plan …)
 The mode for giving advice
 Passive role (physician uses the system when
advice needed)
 Active role (the system gives advice automatically
under certain conditions)

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10 Passive Systems
 The user has total control:
 Requires advice
 Analyses the advice
 Accepts/Rejects the advice
 Domain of use:
 Wide domain like internal medicine
 Examples: QMR, DXPLAIN
 Narrow domain
 Acute abdominal pain
 Analysis of ECG

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11 Active Systems
 The user has partial control
 System gives advice
 User evaluates the advice
 The user accepts/rejects the advice
 Domain of use
 Limited domain
 Drug interactions
 Laboratory results warnings
 etc
 Characteristics
 Built-in/integrated with other system (e.g. laboratory information
system, or pharmacy system)

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12 BENEFITS
 Prescribing
 Improves prescribing
 Reduces medication errors
 Preventive health
 Vaccination reminders
 Screening

 Diagnosis

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13 BENEFITS
Decision Support Systems
Support for Health Care Professionals

 Support for ordering

investigations
 Support for performing
investigations
 Support for interpretation

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14 Lab Information

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15 BENEFITS…
Decision Support Systems…
Support for Health Care Professionals…

 Support for ordering investigations

 Scheduling of Investigations
 Dynamic Scheduling of Tests
 Lab Information
 Need to work with order communication systems

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16 BENEFITS
Decision Support Systems…
Support for Health Care Professionals
 Support for performing investigations
 Advanced Instrument Interface
 Instrument Fault Diagnosis/Troubleshooting
 Quality Control
 Validation of Results

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17 Decision Support Systems…
Support for Health Care Professionals

 Support for interpretation

 Alarms and Alerts
 Graphical Presentation
 Interpretative Reporting
 Drug Alarms

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18 Computing techniques used to create DSS

 Some of Machine Learnings and Adaptive

Computing
 Inductive Tree Methods
 Artificial Neural Networks
 Expert Systems - Knowledge based Methods
 Rule based Systems

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19
Types of CDSS

There are two main types of CDSS

1. Knowledge- base
 Which applies rules to patient data using an
inference engine & displays the results to
the end user.
 The knowledge base consists of compiled
information that is in the form of if–then
rules.

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20 Types of CDSS…
 The knowledge base contains the rules and associations of compiled
data which most often take the form of IF-THEN rules.
 If this was a system for determining drug interactions, then a rule
might be that IF drug X is taken AND drug Y is taken THEN alert
user.
 Using another interface, an advanced user could edit the knowledge
base to keep it up to date with new drugs.
 The inference engine combines the rules from the knowledge base
with the patient’s data.
 The communication mechanism will allow the system to show the
results to the user as well as have input into the system

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21
Types of CDSS…

2. Non knowledge-based
 Unlike knowledge-based CDSS, some of the
non-knowledge-based CDSS use a form of
artificial intelligence called machine learning,
which allows the computer to learn from past
experiences and/or to recognize patterns in the
clinical data.
 Artificial neural networks and Genetic
algorithms are two types of non-knowledge-
based systems.
 These eliminates the need for writing rules and
for expert input. 12/15/2022
22 Types of CDSS…
 However, since systems based on machine
learning cannot explain the reasons for
their conclusions (they are so-called "black
boxes", b/c no meaningful information
about how they work can be discerned by
human inspection), most clinicians do not
use them directly for dx, for reliability and
accountability reasons.

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Application Areas
23

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24 Other forms of Categorizing CDSS

 Generating alerts and reminders

 Diagnostic assistance
 Therapy critiquing and planning
 Image recognition and interpretation

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25
Generating alerts and reminders
Pop-up alerts: Red Font Identifies Elevated Blood Pressure

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26 CDSS: UTI, Diagnosis

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27 CDSS: UTI, Risk stratification

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28 CDSS: UTI, Management

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29

CDSS: UTI, Prescribing

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30

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31

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32

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 33 Criteria for a clinically useful DSS
 Knowledge based on best evidence
 Knowledge fully covers problem
 Knowledge can be updated
 Data actively used drawn from existing
sources
 Performance validated rigorously

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34 Criteria for a clinically useful DSS (cont.)

 System improves clinical practice

 Clinician is in control
 The system is easy to use
 The decisions made are transparent

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 Acceptance /Advantage of CDSS
35
 Clinical decision support systems have been
shown to improve both patient outcomes, as
well as the cost of care.
 The reminder and alerting programs can
potentially minimize problem severity and
prevent complications.
 They can warn of early adverse drug events
that have an impact on both cost and quality
of care.
 Providing the suggestions at a time and
location where the decisions were being
made
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36 Acceptance of DSS…
 Providing actionable recommendations; and
 Computerizing the entire process (Data from
various sources – hard to managed by human)
 A successful CDSS/EHR integration will
allow the provision of best practice, high
quality care to the patient, which is the
ultimate goal of healthcare.
 Documentation of knowledge, intelligent decision
support, self learning, reasoning and explanation.

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37 Possible Disadvantages of CDSS
 A CDSS must be integrated with a healthcare
organization's clinical workflow, which is often
already complex.
 Some clinical decision support systems are
standalone products that lack interoperability with
reporting and electronic health record software
 Changing relation between patient and the physician
 Limiting professionals’ possibilities for independent
problem solving
 Legal implications - with whom does the onus of
responsibility lie?

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38 Possible Disadvantages of
CDSS…
 Biological systems are profoundly complicated
 Resistance/job fears of clinicians
 Goal is to assist clinicians, not replace them.

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39 References
 EGADSS: http://www.egadss.org
 OpenClinical: http://www.openclinical.org/dss.html
 Whyatt and Spiegelhalter (http://www.computer.privateweb.at/judith/index.html)
 OpenClinical (http://www.openclinical.org/home.html)
 de Dombal FT, Leaper DJ, Staniland JR, McCann AP, Horrocks JC. Computer-aided
diagnosis of acute abdominal pain. Br Med J. 1972 Apr 1;2(5804):9-13.
 Solventus (http://www.solventus.com/aquifer)
 WebMD (http://my.webmd.com/medical_information/check_symptoms)
 http://www.cems.uwe.ac.uk/~pcalebso/UWEDMGroup/Documents/MDSS.ppt
 http://www.healthsystem.virginia.edu/internet/familymed/information_mastery/Clin
ical_Decision_Making_in_3_Minutes_or_Less.ppt
 http://www.phoenix.tc-ieee.org/016_Clinical_Care_Support_System/Open_CIG_9_
19_sanitized.ppt

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