Electronic Decision Support System Research Articles

Evidence‐based management strategies for endocrine complications after pituitary adenoma surgery

AbstractThis study aims to provide a clinical reference for the management of endocrine complications in pituitary tumor patients by synthesizing recent evidence for domestic and international management strategies. Based on the PIPOST (Population, Intervention, Professional, Outcome, Setting, and Type of Evidence) framework, evidence‐based medicine targets were determined. Electronic decision support systems, guideline websites, and databases were searched to identify the best evidence on postoperative endocrine complications in pituitary tumors. The PICO (Patient, Intervention, Comparison, Outcome) principle was used to construct the search strategy, and the studies from the past 10 years (July 2013 to July 2023) were included. A total of 11 articles were included, including four guidelines, two expert consensus statements, one systematic review, one best practice article, and three randomized controlled trials. We obtained evidence on five aspects (endocrine assessment, secondary adrenal insufficiency management, water metabolism disorder management, special population management, and follow‐up management) with a total of 30 pieces of evidence. Clinical healthcare professionals should focus on the care and follow‐up of patients with postoperative complications, such as adrenal insufficiency, temporary or permanent diabetes insipidus, and hyponatremia. Future research should involve large sample sizes, long‐term follow‐ups, and multicenter studies to further clarify the protocols for fluid restriction, diet, and hormone use.

Implementation of an Electronic Clinical Decision Support System for the Early Recognition and Management of Dysglycemia in an Inpatient Mental Health Setting Using CogStack: Protocol for a Pilot Hybrid Type 3 Effectiveness-Implementation Randomized Controlled Cluster Trial.

Severe mental illnesses (SMIs), including schizophrenia, bipolar affective disorder, and major depressive disorder, are associated with an increased risk of physical health comorbidities and premature mortality from conditions including cardiovascular disease and diabetes. Digital technologies such as electronic clinical decision support systems (eCDSSs) could play a crucial role in improving the clinician-led management of conditions such as dysglycemia (deranged blood sugar levels) and associated conditions such as diabetes in people with a diagnosis of SMI in mental health settings. We have developed a real-time eCDSS using CogStack, an information retrieval and extraction platform, to automatically alert clinicians with National Health Service Trust-approved, guideline-based recommendations for dysglycemia monitoring and management in secondary mental health care. This novel system aims to improve the management of dysglycemia and associated conditions, such as diabetes, in SMI. This protocol describes a pilot study to explore the acceptability, feasibility, and evaluation of its implementation in a mental health inpatient setting. This will be a pilot hybrid type 3 effectiveness-implementation randomized controlled cluster trial in inpatient mental health wards. A ward will be the unit of recruitment, where it will be randomly allocated to receive either access to the eCDSS plus usual care or usual care alone over a 4-month period. We will measure implementation outcomes, including the feasibility and acceptability of the eCDSS to clinicians, as primary outcomes, alongside secondary outcomes relating to the process of care measures such as dysglycemia screening rates. An evaluation of other implementation outcomes relating to the eCDSS will be conducted, identifying facilitators and barriers based on established implementation science frameworks. Enrollment of wards began in April 2022, after which clinical staff were recruited to take part in surveys and interviews. The intervention period of the trial began in February 2023, and subsequent data collection was completed in August 2023. Data are currently being analyzed, and results are expected to be available in June 2024. An eCDSS can have the potential to improve clinician-led management of dysglycemia in inpatient mental health settings. If found to be feasible and acceptable, then, in combination with the results of the implementation evaluation, the system can be refined and improved to support future successful implementation. A larger and more definitive effectiveness trial should then be conducted to assess its impact on clinical outcomes and to inform scalability and application to other conditions in wider mental health care settings. ClinicalTrials.gov NCT04792268; https://clinicaltrials.gov/study/NCT04792268. DERR1-10.2196/49548.

The Effect of an Electronic Medical Record-Based Clinical Decision Support System on Adherence to Clinical Protocols in Inflammatory Bowel Disease Care: Interrupted Time Series Study.

Clinical decision support systems (CDSSs) embedded in electronic medical records (EMRs), also called electronic health records, have the potential to improve the adoption of clinical guidelines. The University of Alberta Inflammatory Bowel Disease (IBD) Group developed a CDSS for patients with IBD who might be experiencing disease flare and deployed it within a clinical information system in 2 continuous time periods. This study aims to evaluate the impact of the IBD CDSS on the adherence of health care providers (ie, physicians and nurses) to institutionally agreed clinical management protocols. A 2-period interrupted time series (ITS) design, comparing adherence to a clinical flare management protocol during outpatient visits before and after the CDSS implementation, was used. Each interruption was initiated with user training and a memo with instructions for use. A group of 7 physicians, 1 nurse practitioner, and 4 nurses were invited to use the CDSS. In total, 31,726 flare encounters were extracted from the clinical information system database, and 9217 of them were manually screened for inclusion. Each data point in the ITS analysis corresponded to 1 month of individual patient encounters, with a total of 18 months of data (9 before and 9 after interruption) for each period. The study was designed in accordance with the Statement on Reporting of Evaluation Studies in Health Informatics (STARE-HI) guidelines for health informatics evaluations. Following manual screening, 623 flare encounters were confirmed and designated for ITS analysis. The CDSS was activated in 198 of 623 encounters, most commonly in cases where the primary visit reason was a suspected IBD flare. In Implementation Period 1, before-and-after analysis demonstrates an increase in documentation of clinical scores from 3.5% to 24.1% (P<.001), with a statistically significant level change in ITS analysis (P=.03). In Implementation Period 2, the before-and-after analysis showed further increases in the ordering of acute disease flare lab tests (47.6% to 65.8%; P<.001), including the biomarker fecal calprotectin (27.9% to 37.3%; P=.03) and stool culture testing (54.6% to 66.9%; P=.005); the latter is a test used to distinguish a flare from an infectious disease. There were no significant slope or level changes in ITS analyses in Implementation Period 2. The overall provider adoption rate was moderate at approximately 25%, with greater adoption by nurse providers (used in 30.5% of flare encounters) compared to physicians (used in 6.7% of flare encounters). This is one of the first studies to investigate the implementation of a CDSS for IBD, designed with a leading EMR software (Epic Systems), providing initial evidence of an improvement over routine care. Several areas for future research were identified, notably the effect of CDSSs on outcomes and how to design a CDSS with greater utility for physicians. CDSSs for IBD should also be evaluated on a larger scale; this can be facilitated by regional and national centralized EMR systems.

Cost-effectiveness of a medication review intervention for general practitioners and their multimorbid older patients with polypharmacy

Older adults with multiple chronic conditions and polypharmacy are at an increased risk of having adverse health outcomes, affecting quality of life and generating costs. Primary care has to be effective to guarantee excellent treatment to these patients, who are among the most vulnerable. This project aimed to assess the cost-effectiveness of a tool aimed at improving general practitioners' (GPs) performance, namely a medication review intervention centered around an electronic clinical decision support system (eCDSS). We performed a pre-planned within-trial cost-effectiveness analysis of the OPTICA trial, a cluster randomized controlled trial in Swiss primary care practices aimed at optimizing medication appropriateness and reducing prescribing omissions. Trial participants were older adults aged ≥65 years with ≥3 chronic conditions and ≥5 medications. The 160 participants in the intervention group received a medication review intervention centered around an eCDSS provided by their GP and followed by shared decision-making with their GP. The 163 participants in the control group had a medication discussion in line with usual care with their GP. Patients were followed-up for 12 months. Considering the clustered structure of the data at GP practice level, we applied Generalized Structural Equation Models (GSEMs) on a multiple imputed sample to estimate intervention effects on costs and quality-adjusted life years (QALYs). The intervention strategy was dominant with cost-savings of CHF 1′857 (95 % confidence interval (CI): CHF -3′620 to −93, p-value <0.039, with CHF 1≅USD 1.11 as of November 2023) and a gain of 0.026 incremental QALYs (95 % CI: 0.013 to 0.040, p-value <0.001) per study participant. In robustness analyses, directions of effects were fully consistent, albeit some effect estimates non-significant. Subgroup analyses suggested stronger effects in men and older adults aged 65–74 years or aged ≥85 years. The medication review intervention led to cost savings and an improvement in quality of life, potentially resulting from an accumulation of multiple small positive intervention effects, such as fewer hospitalizations and nursing visits at home.

Problematic issues and development of classifications of the main parameters of quality and adherence to pharmacotherapy. Part II: physician adherence to clinical guidelines and official drug labels

The second publication is presented, devoted to the classification of the main parameters of quality and adherence to pharmacotherapy. Despite the fact that patients play a central role in the problem of medical adherence, the role of attending physicians is extremely significant both in prescribing/non-prescribing proven effective and safe therapy, and in influencing patient medical adherence. This led to the identification of a special commitment type — the physician adherence to the basic principles of rational treatment. Collection, analysis and systematization of information, as well as the related development of a classification of physician adherence/non-adherence were the aim of this review and analytical work. We searched data using keywords among Russian and English-­language sources. When compiling the classification, categories of adherence/non-adherence were identified in accordance with the implementation by physicians of the main provisions of clinical guidelines for long-term therapy for patients with non-communicable diseases (NCDs), as well as following official drug labels reflecting data on clinical pharmacology, the main side effects, drug-drug interactions. The classification of physician adherence/non-adherence to implementing the principles of rational treatment of patients with NCDs can be used in the development of electronic medical decision support systems for providing therapy with proven effectiveness and safety in specific clinical situations. In addition, on the basis of the developed classification, checklists for monitoring by healthcare specialists of the implementation of the rational treatment of patients with chronic NCDs should be created.

Deintensification of potentially inappropriate medications amongst older frail people with type 2 diabetes: Protocol for a cluster randomised controlled trial (D-MED study)

AimsAmongst elderly people with type 2 diabetes (T2D) over prescribing can result in emergency ambulance call-outs, falls and fractures and increased mortality, particularly in frail patients. Current clinical guidelines, however, remain focused on medication intensification rather than deintensification where appropriate. This study aims to evaluate the effectiveness of an electronic decision-support system and training for the deintensification of potentially inappropriate medications amongst older frail people with T2D, when compared to ‘usual’ care at 12-months. MethodsThis study is an open-label, multi-site, two-armed pragmatic cluster-randomised trial. GP practices randomised to the ‘enhanced care’ group have an electronic decision support system installed and receive training on the tool and de-intensification of diabetes medications. The system flags eligible patients for possible deintensification of diabetes medications, linking the health care professional to a clinical algorithm. The primary outcome will be the number of patients at 12-months who have had potentially inappropriate diabetes medications de-intensified. ResultsStudy recruitment commenced in June 2022. Data collection commenced in January 2023. Baseline data have been extracted from 40 practices (3145 patients). ConclusionsDigital technology, involving computer decision systems, may have the potential to reduce inappropriate medications and aid the process of de-intensification. Trial registrationInternational Standard Randomised Controlled Trial Number: ISRCTN53221378. Available at: https://www.isrctn.com/ISRCTN53221378.

P26 User experience of a clinical decision support system in the form of a mobile app in supporting antimicrobial stewardship

Abstract Background There are advancements in the use of technology in modern healthcare. Healthcare professionals use various digital platforms such as electronic medical records, e- prescriptions, websites and smartphone apps to enable prompt access to clinical information. Healthcare professionals are likely to refer to their smartphones for prompt clinical information or guidance that are easily accessible in contrast to paper guides, handbooks and desktop computers. Some studies have shown that mobile application guidelines within a smart phone app increase adherence to prescribing guidelines by clinicians. Furthermore, benefits of a smart phone app are the ability to update them more quickly than paper-based information and the ability to improve clinical decision-making within the form of an electronic clinical decision support system (CDSS). Despite the increased use of digital information there are limited studies in this area on the use of CDSS within smart phone antimicrobial apps. More evidence is needed to better understand healthcare usage of such apps in the area of antimicrobial stewardship. Microguide V1 (M1) is a smartphone antimicrobial app currently in widespread use in UK hospitals designed to provide access to local prescribing guidelines. However, M1 does not have a support tool to ‘direct’ or map prescribers to a specific treatment plan for their patients based on symptoms or suspected diagnosis. Microguide V2 (M2) is an updated version that includes an additional decision support tool that helps to identify the correct antibiotic to prescribe based on patient’s clinical symptoms. Objectives To evaluate clinician experiences with both versions of the app within Mid and South Essex University Hospitals (MSE) Trust. In MSE, the M1 is currently in use but M2 is being adopted from November 2023 onwards as part of strategies to improve antimicrobial stewardship, and to help with meeting Commissioning for Quality and Innovation (CQUIN) targets for IV to oral switching of antibiotics). Methods A mixed methods approach was devised utilizing an online survey and interviews pre- and post-introduction of M2. Questions were aligned to the COMB-B behaviour model approach influencing change. Topics covered were awareness, experience, barriers, concerns and prescribing behaviour. All prescribers within the Trust working on adult inpatient wards were eligible for participation. Results A pre-implementation survey of M2 was conducted between January and October 2023. A total of 473 people accessed the online survey, with 24 responses, but only a total of 15 participants fully completed the survey. The roles of the participants were 6 pharmacists, 3 nurses and 6 doctors. In terms of awareness of the app, 87% stated yes and 38% agreed that the app increased their awareness of antimicrobial stewardship. Two-thirds (67%) of participants used the app in supporting prescribing decisions, whilst a third had never used it. Nearly 40% of participants agreed that the app encouraged them to challenge inappropriate prescribing and almost half (46%) agreed that that they felt comfortable accessing the app at patient’s bedside. The interview analysis is still ongoing. Conclusions The results so far provide evidence that M1 is being accessed by prescribers in making clinical decisions and they find it useful. The obvious and major limitation of this study was the small number of responses, and this is partially explained by winter pressures and industrial action by nurses and doctors. This led to reduced availability of participants.

Interventions of eHealth technologies integrated with non-physician health workers for improving management of hypertension: Systematic review and meta-analysis

Hypertension is a major public health problem, accounting for 7.5 million deaths and 57 million disability-adjusted life years annually worldwide. The majority of hypertension-related deaths occur in low- and middle-income countries (LMICs). Despite the escalating prevalence of hypertension in many LMICs, only one-third of those affected are aware of their hypertension status. The rapid proliferation of eHealth technologies presents an opportunity to improve the detection and management of hypertension. Many LMICs face a critical shortage of physicians, and their services often come at a considerable cost to the health system. Non-physician health workers could be a cost-effective alternative to improve the detection and management of hypertension, particularly in LMICs. In this systematic review, we aim to synthesize and evaluate the effectiveness of interventions that integrated eHealth technologies with non-physician health workers to reduce blood pressure. A diverse range of eHealth technologies, such as mobile-based applications, telemonitoring, short text messaging and electronic decision support systems, are being used by non-physician health workers for the management of hypertension. We found that eHealth technologies integrated with non-physician health workers reduced overall mean systolic blood pressure by -4.09 mmHg (95%CI: -5.87 to -2.32) compared to usual care. Similarly, such an integrated approach also reduced diastolic blood pressure by -1.25 mmHg (-2.31 to -0.81) in the intervention group than usual care. Therefore, leveraging the use of cost-effective eHealth technologies to support task-sharing with non-physicians presents an effective strategy for enhancing blood pressure management, applicable to both high- and low-income countries.

A mixed methods evaluation of a digital antenatal quality improvement intervention in Nepal

Abstract Background Quality antenatal care plays an important role in reducing maternal and perinatal mortality. Electronic decision support systems (EDSS) aim to promote adherence to evidence-based practices. The evaluation aimed to assess the effectiveness of the intervention on improving quality of antenatal care (ANC) and understanding of implementation process and intervention effects. Methods The study was conducted in primary health care settings in Nepal. Theory of change framework was used for mixed-method evaluation. Quantitative and qualitative data were collected at multiple time points. Data were integrated using concurrent triangulation to develop explanations about the implementation process and the observed effects. Results Guided by our theory of change, we identified eleven themes that help to understand how the EDSS was used in the real context, and why the EDSS was not much effective in bringing the desired changes that was required to improve quality of ANC. EDSS appear to slightly influence ANC staff behavior, however, training ANC staff in using the EDSS did not necessarily lead to confidence in using it and ANC staff used the EDSS as recordkeeping system. We found mixed evidence on ANC staff believe that the EDSS offers benefits to their work. Inflexibility of EDSS during ANC consultation caused difficulties adapting to women's need and challenging to integrate the EDSS in ANC staffs’ workflow and daily activities. Inadequate linkage of the EDSS with existing health systems impaired the EDSS guided clinical performance. Conclusions There is some indication that the EDSS have the potential to increase the quality of care. However, the EDDS alone are not enough to bring the adequate change in ANC staff delivery of quality care. Active participation of government and grassroot level understanding of health system would be essential considering conducting further research taking in account the resources, and other factors that hinders the EDSS utilization. Key messages • Concurrent triangulation helps to understand that digital health intervention is not enough to bring intended changes in the quality-of-service delivery at health facility. • Understanding of context and ground reality is essential to improve the quality of care and enhance the performance of healthcare providers.

Impact of digital intervention on antenatal paper records: results from audit of antenatal records

Abstract Background Good recordkeeping is important in antenatal care (ANC). The mIRA study aimed to improve ANC quality through tablet-based electronic decision support systems (EDSS). Electronic data entry was implemented alongside existing paper-based ANC records, adding an additional record-keeping requirement for health care providers. This study assesses the impacts of the EDSS on paper-based ANC records. Methods The audit was conducted in 19 primary healthcare facilities in Nepal. We examined pregnant women's records before (n = 136) and after (n = 138) EDSS implementation. For eight selected indicators in the ANC card and ANC register, we estimated the percentage completeness (any value recorded) and agreement (whether values matched), comparing results before and after intervention, additionally examining EDSS records. Results Completeness of paper ANC records was high before intervention (&amp;gt;90% for all indicators, except for tetanus toxoid vaccination). There was general trend towards variables being more complete after implementation of the EDSS for both the ANC card and the ANC register. There was &amp;gt;15% improvement in completeness and in agreement of tetanus toxoid vaccination date records in ANC cards and ANC registers after the intervention. Completeness of variables in the EDSS was low, suggesting recordkeeping in ANC cards and ANC registers was prioritized. Percentage agreement increased slightly in all eight indicators after intervention. Amongst the selected eight indicators, only women's age records showed &amp;gt;90% agreement both before and after the intervention. Conclusions EDSS did not have a negative impact on paper-based ANC records. Digital records are widely being used in high-income countries and the increasing implementation of electronic health records in low-resource settings increases the demand for evidence to understand the feasibility and impacts of digital health interventions in real-world settings. Key messages • The additional recordkeeping required by the EDSS resulted in general improvements in the completeness and agreement of ANC paper records. • Large-scale EDSS implementation should consider how to integrate digital and paper-based records to decrease burden on healthcare providers, and improve the standard of records.

PO34 The Risk of Vein Thromboembolism and Prevention in the Critically Illness Facilitated with an Electronic Decision Support System

PO34 The Risk of Vein Thromboembolism and Prevention in the Critically Illness Facilitated with an Electronic Decision Support System

Optimizing Antihypertensive Management for Hypertensive Patients With Secondary Complications: A Systematic Review and Meta-Analysis in PrimaryCareSettings.

Despite significant pharmacological advancements, hypertension management remains challenging, with varying quality of primary care. Digital tools and other non-pharmacological interventions hold promise in addressing this challenge. Consequently, a thorough examination of these interventions is recommended. This meta-analysis focuses on clinician-oriented strategies aimed at improving hypertension management, to assess the most effective approaches for improving antihypertensive prescribing and blood pressure control for secondary prevention. This was done through a systematic review of randomized controlled trials published in PubMed and Embase since the beginning of 2010 that aimed to enhance antihypertensive medication prescription in primary care settings for hypertensive patients with secondary complicationswhile reporting changes in blood pressure or target achievement. We screened6305 records. Four studies met the inclusion criteria, with reported interventions including physician education and the implementation of electronic decision support systems. All studies showed that the control group had a statistically significant lower systolic blood pressure, but the effect on diastolic blood pressure was not statistically significant. The overall mean difference was 2.12 mmHg (95% CI = 0.98; 3.26, P-value = 0.0003) for systolic blood pressure in favor of the control group and 1.22 mmHg (95% CI = -0.48; 3.26, P-value = 0.16) for diastolic blood pressure, which was not statistically significant. Despite considerable efforts to control hypertension, it remains a significant obstacle to optimal cardiovascular risk reduction.This review is also limited by a scarcity of studies.

Repurposing a Digital Twin-Based Decision Support System as a Training Tool by Incorporating Learning Science Principles

The U.S. Navy has a sophisticated manpower planning process for recruiting, selecting, training, and placing thousands of enlisted Sailors into hundreds of specific jobs every year. Given the large number of “moving parts” in this manpower planning process, some inefficiencies are unavoidable. For example, there may be a non-trivial time gap between when some Sailors complete their job-specific training course and when they arrive at their duty station. During this time, their knowledge and skills will invariably decay due to lack of use. Electronic job aids, such as Interactive Electronic Technical Manuals (IETMs) and Decision Support Systems (DSS), are important to mission success because they help to reduce the need for Sailors to memorize rarely used factual details. However, IETMs and DSSs are job aids, not training tools. In this paper, we describe how we repurposed an existing digital twin-based DSS to create a ubiquitous, online training tool. We did so by leveraging the learning science principles of human performance measurement, adaptive learning with scaffolding, performance feedback, and training data analytics. We conclude with a series of best practices and lessons learned that other practitioners could follow when attempting to repurpose electronic job aids that were not originally designed for training.

Antimicrobial Stewardship Programs in Latin America and the Caribbean: A Story of Perseverance, Challenges, and Goals.

Antimicrobial resistance is one of the major global health threats. Antimicrobial stewardship (AMS) has been set as a priority within international action plans to combat this issue. The region of Latin America and the Caribbean are recognized for their high antimicrobial resistance rates; nevertheless, a low number of studies describing implemented interventions for this topic have been published. This review aims to provide an overview of the status of AMS in our region, focusing on the main progress achieved and describing the different published efforts made by countries towards the implementation of antimicrobial stewardship programs (ASP). Common areas of intervention included were (a) education approaches, (b) antimicrobial guideline implementation and monitoring, (c) diagnostic stewardship, (d) technological tools: electronic clinical decision support systems in AMS, (e) pharmacy-driven protocols and collaborative practice agreements, and (f) economic impact. The search demonstrated the varied interventions implemented in diverse healthcare settings; the results accentuate their influence on antimicrobial consumption, antimicrobial resistance, clinical outcomes, and direct economic impact. The integration of multiple strategies within each hospital was highlighted as an essential key to ASP success. Even though the literature found demonstrated clear progress, there is still a special need for strengthening leadership from the top down, defining goals based on needs, and gaining support through policy and financing in LAC.

Electronic Tendering and Organizational Performance of Parastatals in Nakuru County

E-tendering plays a key role in ensuring that the best suppliers are selected for a continuous supply of better-quality products and services. The study focused on the role of e-tendering through online registration of suppliers, virtual screening, automatic evaluation and automated supplier selection criteria- through the use of an electronic Decision Support System (e-DSS). The study adopted the null hypothesis that e- tendering had no statistically significant influence on parastatals in Nakuru County. The study population included five (5) selected state-owned organisations in Nakuru municipality with a total population of 236 employees in selected departments where a sample size of 91 employees was drawn by application of Daniel’s (1999) sample size formula. Structured questionnaires were used as the main instrument to collect data, out of which 80 respondents gave their responses, an 87.9% response rate. The regression analysis showed a 4.6% change in organisational performance was described by e-tendering. The study confirmed there was a statistical significance (p=.000) between e-tendering and organisation performance, where e-tendering, as a supplier management tool, was able to account for a positive marginal significant increase (B=.133) in organisational performance. There was a moderate positive correlation between organisational performance and e-tendering at .519. The study recommends that parastatals enhance system integration for compatibility and easy access and flow of information, leverage technology, and facilitate training and educating their suppliers on how to use the organisation’s systems and other ICT-related functions.

Clinical decision-making and the nursing process in digital health systems: An integrated systematic review.

To identify how the nursing process (assessment, planning, intervention and outcome evaluation) has been incorporated into digital health systems (electronic medical records, electronic care plans and clinical decision support systems) to gain an understanding of known benefits and challenges posed to nurses' decision-making processes. Nursing terminologies, including the International Classification for Nursing Practice (ICNP), and Nursing Minimum Data Set's (NMDS), have been developed to improve standardised language integration of components of nursing care into digital systems. However, there is limited evidence regarding whether the complete nursing process is effectively being incorporated into digital health systems. An integrative systematic review following PRISMA guidelines. A search strategy was applied to extract articles from included databases: CINAHL, MEDLINE, SCOPUS and Web of Science Core Collection. Articles were limited to English language and published January 2007-March 2022 and assessed using a pre-determined eligibility criteria. Quality assessment and a narrative synthesis were conducted. A total of 3321 articles were identified, and 27 studies included. There were (n = 10) qualitative, (n = 4) quantitative non-randomised controlled trials, (n = 3) quantitative descriptive studies and (n = 10) mixed methods. Nurse assessment and planning components were the most comprehensive phases incorporated into digital health systems, and interventions and outcome evaluation were scarcely reported. Inadequate capture of nursing work is a problem unresolved by digital health systems. This omission may be hindering nurse clinical decision-making for patient care and limiting the visibility of the nursing role in health care interventions and the associated impact on patient outcomes. Further research is needed on how digital systems can support nurses to apply the full nursing process and to further evaluate patient outcomes. Digital systems can support health-service level evaluation through capturing missed nursing care and the consequences on patients utilising nurse-sensitive-outcomes; however, this is not yet being realised.

Optimising prescribing in older adults with multimorbidity and polypharmacy in primary care (OPTICA): cluster randomised clinical trial

ObjectiveTo study the effects of a primary care medication review intervention centred around an electronic clinical decision support system (eCDSS) on appropriateness of medication and the number of prescribing omissions...

The systematic medical appraisal, referral and treatment (SMART) mental health programme: Formative research informing a cluster randomized controlled trial

BackgroundGaps exist between prevalence and treatment options for mental disorders in India. Limited awareness, poor help-seeking, scarcity of trained mental health professionals, limited mental health services and stigma are few examples of reasons contributing to treatment gap. AimsThis paper highlights findings from formative research of a primary mental healthcare model comprising of a preliminary feasibility testing of the Electronic Decision Support System (EDSS) to provide care using mobile based applications, perceptions of the community towards mental health and incorporating cultural adaptations for pre-existing anti-stigma campaign materials. MethodsA cross-sectional mixed methods approach tested the user acceptability of the electronic decision support system EDSS for accredited social health activists (ASHAs) and Primary Health Centre (PHC) doctors using tablets in two villages and two PHCs in rural Haryana (Northern India). Five focus groups and six in-depth interviews along with non-participant observations were used to ascertain community perceptions about various aspects related to mental health. Findings of the study were analyzed and interpreted against the key themes of Andersen's model. ResultsOut of a total of 553 individuals screened for common mental disorders, 51 (9.2%) were screened positive and 32 visited PHC doctors for treatment. There was limited knowledge about common mental disorders amongst community; need to train primary health workers to identify and treat mental disorders; and incorporate cultural adaptation of anti-stigma awareness materials. ConclusionsThe EDSS was found to be acceptable and feasible by primary and community health workers. The findings guided refining of the intervention prior to implementation of a large-scale cluster randomized controlled trial.

Ensuring Information Security of OLAP-Containing Distributed Electronic Systems using Blockchain Technology

The article outlines the properties of blockchain technology, according to which the content of blockchain blocks is immutable and the use of a peer-to-peer (P2P) network implies decentralized management. It describes the essence and meaning of smart-contracts and smart-views derived from them, which are involved in the process of data analysis and decision making. The article considers the papers devoted to various approaches to the problem of integration of blockchain technology and data storage. To ensure all three key aspects of information security — the integrity, availability and confidentiality of information, which is important for both government and corporate structures, the article proposes to use a private blockchain, instead of a public one. A modification of the model of an electronic decision support system containing an OLAP block, which includes a private blockchain, is developed. It is shown that this DSS model can be used as an electronic demographic DSS, which is an infrastructure for solving state problems in this area, since many of the characteristics of this model correspond to the multisectoral nature of demography.

Clinical decision support to Optimize Care of patients with Atrial Fibrillation or flutter in the Emergency department: protocol of a stepped-wedge cluster randomized pragmatic trial (O’CAFÉ trial)

BackgroundManagement of adults with atrial fibrillation (AF) or atrial flutter in the emergency department (ED) includes rate reduction, cardioversion, and stroke prevention. Different approaches to these components of care may lead to variation in frequency of hospitalization and stroke prevention actions, with significant implications for patient experience, cost of care, and risk of complications. Standardization using evidence-based recommendations could reduce variation in management, preventable hospitalizations, and stroke risk.MethodsWe describe the rationale for our ED-based AF treatment recommendations. We also describe the development of an electronic clinical decision support system (CDSS) to deliver these recommendations to emergency physicians at the point of care. We implemented the CDSS at three pilot sites to assess feasibility and solicit user feedback. We will evaluate the impact of the CDSS on hospitalization and stroke prevention actions using a stepped-wedge cluster randomized pragmatic clinical trial across 13 community EDs in Northern California.DiscussionWe hypothesize that the CDSS intervention will reduce hospitalization of adults with isolated AF or atrial flutter presenting to the ED and increase anticoagulation prescription in eligible patients at the time of ED discharge and within 30 days. If our hypotheses are confirmed, the treatment protocol and CDSS could be recommended to other EDs to improve management of adults with AF or atrial flutter.Trial registrationClinicalTrials.gov NCT05009225. Registered on 17 August 2021.