Electronic Decision Support System Research Articles

Cost Consequences of Implementing an Electronic Decision Support System for Ordering Laboratory Tests in Primary Care: Evidence from a Controlled Prospective Study in The Netherlands

The economic consequences of interventions to promote rational, evidence-based use of laboratory tests by physicians are not yet fully understood. We evaluated the cost consequences of a computer-based, guideline-driven decision-support system (CDSS) for ordering blood tests in primary care. We installed the CDSS in 118 practices [159 general practitioners (GPs)] throughout The Netherlands and calculated the costs of the intervention in this group. During a period of 6 months before and 6 months after installation of the CDSS, the test-ordering behavior of 87 (109 GPs) of these 118 study practices was studied and the results were compared with those of a nonhistorical control group that did not receive the CDSS. In addition the costs of laboratory requests were calculated for both groups. Total intervention costs, comprising development costs and installation costs, amounted to 79,000 euro (670 euro per practice). Whereas the introduction of the CDSS did not affect the number of order forms submitted to the laboratories, it did reduce the number of blood tests per order form. As a result, the CDSS yielded mean savings on the costs of laboratory requests of 847 euro per practice per 6 months. This study demonstrates that providing electronic decision support for ordering blood tests in primary care represents an economically promising concept. Savings on laboratory costs are achievable and not offset by disproportionally high intervention costs.

Are we measuring the right end-points? Variables that affect the impact of computerised decision support on patient outcomes: A systematic review

Previous reviews of electronic decision-support systems (EDSS) have often treated them as a single category, and factors that may modify their effectiveness of EDSS have not been examined. The objective was to summarise the evidence associating the use of computerised decision support and improved patient outcomes. PubMed/Medline and the Database of Abstracts were searched for randomised controlled trials (RCT) of EDSS from 1 January 1994 to 31 January 2006. Twenty-four RCT studies from 97 reviewed were selected, eight of them examined systems supporting decisions for patients who presented with an acute illness, and 16 studies enrolled patients with chronic conditions. Overall, 13 (54%) of the studies showed a positive result, and 11 (46%) were with no impact. Critiquing and consultative systems showed the impact in 71% and 47% of studies, respectively. All systems targeting decisions related to acute disease improved patient outcomes compared with 38% of systems focused on the management of chronic conditions (P = 0.005). Provision of EDSS improves prescribing practices and treatment outcomes of patients with acute illnesses; however, EDSS were less effective in primary care. Complex interventions as clinical EDSS may require new metrics of assessment to describe the impact on patient outcomes.

An Eclipse-based development approach to health information technology

The rapid proliferation of applications--electronic health record and clinical decision support systems among them--cannot keep up with the growing needs of healthcare delivery organisations. The absence of uniform standards and interoperability has hindered the successful deployment and acceptance of these applications. Eclipse and other open source applications have the potential to fill some of these gaps. The benefits include acceptance of open standards, enabling interoperability and scalability, prevention of vendor lock-in and lower costs. In this paper, we describe an Eclipse-based open source electronic health record application, a prototype. We contrast the Eclipse approach to other development approaches. Implementation is feasible and provides customization, although there are challenges to overcome. We envision organisations adopting open source development tools as alternatives to vendor-driven, proprietary systems.

Smoking status recording in GP electronic records: the unrealised potential

To investigate the recording of smoking status and factors associated with the recording of smoking status in general practitioner (GP) electronic medical records (EMRs) in New Zealand, and the suitability of this source as a prevalence measure. General practices affiliated with an Auckland-based primary health organisation. Patients registered with 84/107 (78.5%) eligible GPs who had used EMRs for at least a year and had PREDICT-CVD, a web-based cardiovascular disease risk assessment and management decision support program, integrated with their practice software. Audit of EMRs using data from an evaluation of PREDICT-CVD. The proportion of EMRs audited (Maori, non-Maori) with smoking status recorded and, among those with smoking status recorded, also Read-coded, and factors associated with greater recording of smoking status. Smoking status was recorded among 49.6% of Maori and 38.3% of non-Maori prior to the installation of PREDICT-CVD. Among those with smoking status recorded, smoking status was also Read-coded among 49.8% of Maori and 62.3% of non-Maori. Factors associated with greater recording of smoking status were installation of PREDICT-CVD, male sex, Maori ethnicity, cardiovascular disease and diabetes. Age was also associated with the recording of smoking status. General practitioner electronic medical records in New Zealand are currently not a suitable source of smoking prevalence data, even if manually searched, as a large proportion of records did not have smoking status recorded. Such records are an even less suitable source of smoking prevalence if data extraction by remote querying (using Read codes) is relied upon. The potential to estimate the prevalence of smoking from GP records has not yet become a reality. Installation of electronic decision support systems, such as PREDICT-CVD, could improve the recording and Read-coding of smoking status, and thereby the availability and accessibility of these data.

Multicentre study of antimicrobial resistance and antibiotic consumption among 6,780 patients with bloodstream infections

Several lines of evidence suggest there is a causal association between the use of antimicrobial agents and the prevalence of antimicrobial resistance in hospitalacquired bacterial pathogens [1, 2]. However, recently published works have indicated the magnitude of the association may be lower than that previously observed and that many other variables, such as patient factors may be responsible for the development of antimicrobial resistance [3, 4]. The specific goals of this study were (1) to estimate antimicrobial resistance rates for four epidemiologically important pathogens causing bloodstream infections (BSI), (2) to compare the antimicrobial resistance rates with the hospital’s antibiotic consumption data, and (3) to determine a possible relationship between the use of antimicrobial agents and the prevalence of drug resistance in these microorganisms. The participating hospitals were partners in the TREAT project, financed by the European Community (EC, 5th Framework, 1999) and focusing on the application of an electronic decision support system to reduce antimicrobial resistance in hospitalised patients [5] This multicentre study was conducted at Freiburg University Hospital, Freiburg, Germany; Rabin Medical Center, Tel Aviv (Petah Tiqva), Israel; Aalborg Hospital, Aalborg, Denmark; and Catholic University Hospital, Rome, Italy. Data on consumption of antibiotics (from 1998 to 2001) were supplied by the hospital pharmacies and expressed in daily defined doses (DDD) per 1,000 bed-days, as outlined by the World Health Organisation. Data on consumption of the following drugs were provided (if included in the local formulary): clindamycin, trimethoprim-sulfamethoxazole, imipenem, ampicillin, ceftazidime, cefepime, piperacillin, piperacillin-tazobactam, and gentamicin. We prospectively included, from 1998 to 2001, all consecutive non-repeat blood isolates of patients with nosocomial BSI according to the definition given by the Centers for Disease Control and Prevention (Atlanta, GA, USA). Mixed cultures were excluded. Selected isolates from patients with bacteraemia included Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae and Pseudomonas aeruginosa. Microorganisms were identified using standard methods. Trends in resistance and the possible correlation between resistance and consumption were analysed using the logit regression line. Antimicrobial consumption patterns varied widely at the four sites. The most frequently prescribed drugs (>40 DDD per 1,000 bed-days) were ampicillin and gentamicin in Denmark and Israel and ceftazidime in Germany and Italy. Eur J Clin Microbiol Infect Dis (2006) 25:815–817 DOI 10.1007/s10096-006-0211-2

Randomized Trial of a Telephone Care Management Program for Outpatients Starting Antidepressant Treatment

Randomized Trial of a Telephone Care Management Program for Outpatients Starting Antidepressant Treatment

The feasibility of implementing an electronic prescribing decision support system: a case study of an Australian public hospital

Medication errors are common in public hospitals, with the majority at the prescribing stage of the medication pathway. Electronic prescribing decision support (EPDS) is a rules-based computer system that can be used by clinicians to warn against such errors to improve patient safety and support staff workflows. Despite its apparent advantages, this technology has not been widely adopted in Australian public hospitals for inpatient prescribing. A case study using Sauer's (1993) Triangle of Dependencies Model was conducted in 2003 into the feasibility of implementing an EPDS system at an Australian public hospital in New South Wales. It was found not feasible to implement an EPDS at the hospital studied due to the legacy patient administration system, low availability of information technology on the wards, differing stakeholder views, legislation, and the Independent Pricing and Regulatory Tribunal of NSW report recommendations. A statewide standard was preferred, with an agreed specification framework identifying basic core data items and functions that an EPDS must meet which can then be used by area health services to: (i) choose a solution which best meets their contextual needs; and (ii) engage vendors to tender for building an open source (non-proprietary) system based on the specification framework.

P.2.c.034 Escitalopram versus nortriptyline in the treatment of painful physical symptoms in patients with major depression

Despite years of antidepressant drug development and patient and provider education, suboptimal medication dosing and duration of exposure resulting in incomplete remission of symptoms remains the norm in the treatment of depression. Additionally, since no one treatment is effective for all patients, optimal implementation focusing on the measurement of symptoms, side effects, and function is essential to determine effective sequential treatment approaches. There is a need for a paradigm shift in how clinical decision making is incorporated into clinical practice and for a move away from the trial-and-error approach that currently determines the “next best” treatment. This paper describes how our experience with the Texas Medication Algorithm Project (TMAP) and the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial has confirmed the need for easy-to-use clinical support systems to ensure fidelity to guidelines. To further enhance guideline fidelity, we have developed an electronic decision support system that provides critical feedback and guidance at the point of patient care. We believe that a measurement-based care (MBC) approach is essential to any decision support system, allowing physicians to individualize and adapt decisions about patient care based on symptom progress, tolerability of medication, and dose optimization. We also believe that successful integration of sequential algorithms with MBC into real-world clinics will facilitate change that will endure and improve patient outcomes. Although we use major depression to illustrate our approach, the issues addressed are applicable to other chronic psychiatric conditions including comorbid depression and substance use disorder as well as other medical illnesses.

From buzzword to business strategy: the case for information and decision support systems in e-healthcare

Although electronic healthcare can boast of a remarkable origin in modern-day e-commerce in the form of Electronic Data Interchange (EDI), its mission-critical nature in information-based strategising is yet to be realised. Restricting the scope of e-healthcare management to product advertisements and website management reflects an unfortunate trend of underutilisation of the scope of electronic decision support systems in pricing and other business strategies. This paper aims to illustrate how this trend can be corrected by transforming e-healthcare into a full-fledged business strategy for strategic positioning and corporate profitability. This argument is illustrated with the aid of a business example related to transfer pricing.

Understanding Keys to Successful Implementation of Electronic Decision Support in Rural Hospitals: Analysis of a Pilot Study for Antimicrobial Prescribing

Electronic clinical decision support systems (CDSS) have been hailed for their potential to improve clinical outcomes. Using a pretest/posttest design, an Internet-based CDSS designed to optimize antimicrobial prescribing was pilot tested for community-acquired pneumonia in 5 rural hospitals in southwestern Idaho. An antimicrobial management team was created in each hospital to address clinicians' perception of excessive time required for direct use of the CDSS. In pooled hospital data, agreement with CDSS recommendations improved to a statistically significant level. However, inspection of data at the individual hospital level demonstrated that almost all improvement occurred in a single hospital. Failure in the other hospitals appeared to be primarily a consequence of organizational and cultural barriers. These barriers are discussed to understand keys for successful future implementation of CDSS in rural hospitals, drawing on experience with cultural barriers from other industries, specifically aviation.

Electronic decision support systems at point of care: trusting the deus ex machina

Electronic decision support systems at point of care: trusting the deus ex machina

A systematic review of strategies to improve prophylaxis for venous thromboembolism in hospitals.

To assess the effectiveness of different strategies for increasing the uptake of prophylaxis for venous thromboembolism (VTE) in hospitalized patients through a systematic review of the literature. Literature databases and the Internet were searched from 1996 to May 2003. Studies of strategies to improve VTE prophylaxis practice were included. Studies where no policy or guideline was implemented or where the focus of the study was not VTE prevention were excluded. Thirty studies were included. The quality of the available evidence was average with the majority of studies being uncontrolled before and after design and thus limited by the historical nature of much of the available data. Adherence to guidelines and the provision of adequate prophylaxis were poor in studies which relied on passive dissemination of guidelines. In general, the use of multiple strategies was more effective than a single strategy used in isolation. The most effective strategies incorporated a system for reminding clinicians to assess patients for VTE risk, either electronic decision-support systems or paper-based reminders, and used audit and feedback to facilitate the iterative refinement of the intervention. There were no studies adequately powered to demonstrate a reduction in rates of VTE. Insufficient evidence was available to make useful comparisons of strategies in terms of costs and resource utilization. Passive dissemination of guidelines is unlikely to improve VTE prophylaxis practice. A number of active strategies used together, which incorporate some method for reminding clinicians to assess patients for DVT risk and assisting the selection of appropriate prophylaxis, are likely to result in the achievement of optimal outcomes.

Current requirements and emerging trends for labelling as a tool for communicating pharmacovigilance findings.

The labelling of prescription drugs is expected to ensure the safe use of medicines and effect changes in use if such changes are required by new safety information. However, withdrawal of drugs from the market and data about medication errors have demonstrated the limitations of labelling as a tool for risk management. Regulatory initiatives in many countries aim at increasing the usefulness and use of labelling by healthcare professionals and patients. These changes in regulations and guidelines, which parallel changes in the approach to premarketing risk assessment and pharmacovigilance, will result in a more relevant and extensive characterisation of a product's safety profile and better international labelling consistency. But despite improvements in the format of labelling in some countries, labelling overall continues to be bound to conventional layout and restricted in its ability to meet the heterogeneous needs of its intended audience. Technological developments such as electronic prescribing and the availability of electronic decision support systems can effectively implement compliance with labelled conditions of use and safety precautions in the prescription process. It will be one of the major challenges to make labelling easily available and suitable for use in such systems. This technology, bar coding of medicines, and preventive evaluation of labelling and packaging for clarity, readability and potential confusion can also help reduce medication errors.

Decision station: situating decision support systems

Internet facilitates access to data, information, and knowledge sources, but at the same time, it threatens to cognitively overload the decision makers. This necessitates the development of effective decision support tools to properly inform the decision process. Internet technologies require new type of decision support that provides tighter integration and higher degree of direct interaction with the problem domain. The central argument of this work is that in dynamic and highly complex electronic environments decision support systems (DSSs) should be situated in the problem domain. A generic architecture, the set of capabilities for our vision of a situated DSS is proposed, and the architecture is illustrated with a DSS for investment management.

The impact of information technology on product marketing: a case study of a multinational company in Nigeria

This study evaluated the impact of information technology (IT) on the marketing of a product of a multinational company in Nigeria by interviewing the brand manager and three marketing officers of the product. A questionnaire was also administered to 60 randomly selected literate retailers, wholesalers and consumers of the product, both in Lagos and Ibadan, to assess the impact of IT on some marketing variables. The results showed that there were savings in time and a reduction in error rate resulting from the use of electronic spreadsheets, decision support systems and computer-graphic aids. An unanticipated effect of the better understanding of sales trends and distribution planning resulted from the use of electronic spreadsheets and decision support systems, respectively. Sales were boosted as a result of optimization of activities. Labour resource savings were also achieved through the use of computer graphics. The use of e-mail increased the amount of data available for use. The impact of radio, television and telephone was also significant on some marketing variables such as product popularity, promotion/advertisement, distribution and sales. However, improper planning of jobs could lead to time-wasting with electronic spreadsheets and decision support systems.

Commentary: measuring quality and impact of the world wide web

The world wide web gives patients and professionals access to thousands of pages of clinical information, some of which are assessed by Impicciatore et al above.1 However, although the web...

Toward a National Model of an Electronic Decision Support System for Domestic Sourcing of Textiles and Apparel

This purpose of this research was to develop a model of an electronic decision support system to aid apparel product developers in sourcing domestic textile and apparel production. Database design occurred in a sequential manner based on an adaptation of a conceptual model proposed by Storey. In-depth interviews with sourcing executives from six major retailers, data collection with over 500 producers, and usability testing of two prototypes with seventeen apparel product developers from two major specialty retailers provided the functional foundation for database development. A network of researchers from universities, National Labs and [TC]2, producers, and retailers contributed to laying the infrastructure to move the model toward implementation of a national sourcing database for the textile and apparel industry.

Medication Use in the Seniors Population: Optimization of Physician Prescribing as a Means of Preventing Drug-related Illness

AbstractDrug-related illness (DRI) is a common problem in the elderly. Misuse of medications and inappropriate prescribing account for over half of all hospital admissions for DRI and both are potentially preventable. Physicians are the gatekeepers to prescription medication access and, in this role, they have the opportunity to prevent exposure to unnecessary and inappropriate medication and influence the use of medications by their elderly patients. Effective interventions to improve physician prescribing have been identified but they are costly to introduce, they require ongoing maintenance to maintain their effectiveness, they do not address the problems created by multiple prescribers or the challenges of keeping up-to-date on the growing number of new drugs that enter the market each year. Computer-based drug information networks and expert decision-making support systems are proposed as one means of providing (1) an accurate record for the prescribing physicians of drugs currently dispensed to their elderly patients, (2) a review of problems in existing and new prescriptions, and (3) an expert resource to select drug treatment. Canada is in an ideal situation to pioneer the development of these systems, but to do so, policies need to be put in place to address three problems. First, there is inadequate information available about the risks and benefits of drugs in the elderly because older sicker adults are often excluded in clinical trials of drug-effectiveness. Requirements for drug approval need to be amended so that sufficient evaluation of the risks and benefits of new drugs are carried out in the elderly. Second, computerization in the health care sector is central to the development of electronic decision-support systems in health care delivery. Future policy needs to be directed to the development of an effective infrastructure to facilitate the transition to an integrated computerized health sector. Third, the ethical and legal issues related to the access of prescription data through electronic networks need to be identified and clear guidelines for use of this new technology need to be developed.

Medication Use in the Seniors Population: Optimization of Physician Prescribing as a Means of Preventing Drug-Related Illness

Drug-related illness (DRI) is a common problem in the elderly. Misuse of medications and inappropriate prescribing account for over half of all hospital admissions for DRI and both are potentially preventable. Physicians are the gatekeepers to prescription medication access and, in this role, they have the opportunity to prevent exposure to unnecessary and inappropriate medication and influence the use of medications by their elderly patients. Effective interventions to improve physician prescribing have been identified but they are costly to introduce, they require ongoing maintenance to maintain their effectiveness, they do not address the problems created by multiple prescribers or the challenges of keeping up-to-date on the growing number of new drugs that enter the market each year. Computer-based drug information networks and expert decision-making support systems are proposed as one means of providing (1) an accurate record for the prescribing physicians of drugs currently dispensed to their elderly patients, (2) a review of problems in existing and new prescriptions, and (3) an expert resource to select drug treatment. Canada is in an ideal situation to pioneer the development of these systems, but to do so, policies need to be put in place to address three problems. First, there is inadequate information available about the risks and benefits of drugs in the elderly because older sicker adults are often excluded in clinical trials of drug-effectiveness. Requirements for drug approval need to be amended so that sufficient evaluation of the risks and benefits of new drugs are carried out in the elderly. Second, computerization in the health care sector is central to the development of electronic decision-support systems in health care delivery. Future policy needs to be directed to the development of an effective infrastructure to facilitate the transition to an integrated computerized health sector. Third, the ethical and legal issues related to the access of prescription data through electronic networks need to be identified and clear guidelines for use of this new technology need to be developed. This paper will review the problem of drug-related illness in the elderly, its consequences in terms of avoidable morbidity, and the contribution of physician prescribing to its occurrence. This will be followed by a review of interventions that have proven to be effective in improving physician prescribing as well as the barriers to adopting research into practice. Solutions to overcome these problems will then be outlined and the changes in policy needed to facilitate change will be identified.

Judgments of quality of life of individuals with severe mental disorders: Patient self-report versus provider perspectives

This study was an investigation of judgments regarding quality of life of individuals with severe mental disorders from two different perspectives: patient self-report versus provider. Judgments on several dimensions of quality of life were collected from a convenience sample of 37 schizophrenic patients and their primary clinicians by using the well-known Quality of Life Index of Spitzer et al. and the more recently developed Quality of Life Index-Mental Health. Both indexes capture judgments on a number of dimensions. Patterns of concordance for the patient-provider pairs were tested by using Cohen's kappa and Pearson correlation coefficients. The results suggest that patients' and providers' judgments are more likely to coincide on clinical aspects, such as symptoms and function, than on social aspects. Specifically, there was moderate agreement on symptoms and function, less agreement on physical health, and little to no agreement on social relations and occupational aspects of quality of life. Such differences support the notion that treatment strategies and mental health services should address a wide range of needs reflecting different aspects of quality of life perceived as important by different patients.