Clinical Decision Support Systems to Improve Utilization of Thromboprophylaxis: A Review of the Literature and Experience with Implementation of a Computerized Physician Order Entry Program

Abstract

Objective: A literature review was conducted of studies investigating the effectiveness of paper- and computer-based clinical decision support systems (CDSS) used with or without educational programs designed to increase the use of venous thromboembolism (VTE) prophylaxis. Methods: Medline was searched on August 9, 2010, without limits on publication year, but with restrictions to English-language articles only. The search terms used were “venous thromboembolism,” “deep vein thrombosis,” “pulmonary embolism,” “prophylaxis,” “thromboprophylaxis,” “computerized,” “computerised,” “decision support,” “alerts,” “reminder,” “paper system,” “risk assessment,” and “risk score.” All types of studies regarding the effects of CDSS on VTE prophylaxis rates were included. Studies were included if ≥ 1 post-implementation outcome was measured, such as rates of VTE, rates of prophylaxis prescribing, or guideline-adherence measures. Results: Studies evaluating paper-based CDSS used different strategies, including risk-assessment forms with prophylaxis recommendations, standard order sets, and preprinted sticker reminders on patient notes. Paper-based systems consistently improved prophylaxis rates; however, in most studies, there was still room for improvement. Furthermore, the effect of paper-based CDSS on VTE rates was not conclusively established. Studies evaluating computer-based systems used approaches including risk-assessment models integrated in the computerized physician order entry system, with or without alerts, and automatic reminders on operating schedules. Conclusion: Computerized systems are associated with substantial improvements in the prescribing of appropriate prophylaxis and reductions in VTE events, particularly in medical patients. More robust systems can be established with computer-based rather than paper-based CDSS. A drawback of computerized systems is that some hospitals may not have adequate information technology system resources.