Development and evaluation of a comprehensive clinical decision support taxonomy: comparison of front-end tools in commercial and internally developed electronic health record systems

BACKGROUND Clinical decision support (CDS) is a valuable tool for improving healthcare quality and lowering costs. However, there is no comprehensive taxonomy of types of CDS and there has been limited research on the availability of various CDS tools across current electronic health record (EHR) systems. OBJECTIVE To develop and validate a taxonomy of front-end CDS tools and to assess support for these tools in major commercial and internally developed EHRs. STUDY DESIGN AND METHODS We used a modified Delphi approach with a panel of 11 decision support experts to develop a taxonomy of 53 front-end CDS tools. Based on this taxonomy, a survey on CDS tools was sent to a purposive sample of commercial EHR vendors (n=9) and leading healthcare institutions with internally developed state-of-the-art EHRs (n=4). RESULTS Responses were received from all healthcare institutions and 7 of 9 EHR vendors (response rate: 85%). All 53 types of CDS tools identified in the taxonomy were found in at least one surveyed EHR system, but only 8 functions were present in all EHRs. Medication dosing support and order facilitators were the most commonly available classes of decision support, while expert systems (eg, diagnostic decision support, ventilator management suggestions) were the least common. CONCLUSION We developed and validated a comprehensive taxonomy of front-end CDS tools. A subsequent survey of commercial EHR vendors and leading healthcare institutions revealed a small core set of common CDS tools, but identified significant variability in the remainder of clinical decision support content.

[1]  Tejal K. Gandhi,et al.  Designing an Electronic Medication Reconciliation System , 2005, AMIA.

[2]  Melissa M. Honour,et al.  Assessment of education and computerized decision support interventions for improving transfusion practice , 2007, Transfusion.

[3]  Dave Thomas,et al.  Practice , 2004, IEEE Softw..

[4]  William DuMouchel,et al.  A meta-analysis of 16 randomized controlled trials to evaluate computer-based clinical reminder systems for preventive care in the ambulatory setting. , 1996, Journal of the American Medical Informatics Association : JAMIA.

[5]  David W Bates,et al.  Mixed results in the safety performance of computerized physician order entry. , 2010, Health affairs.

[6]  J. Black,et al.  Electronic antibiotic stewardship--reduced consumption of broad-spectrum antibiotics using a computerized antimicrobial approval system in a hospital setting. , 2008, The Journal of antimicrobial chemotherapy.

[7]  Robert J. Adams,et al.  Clinical decision support implemented with academic detailing improves prescribing of key renally cleared drugs in the hospital setting , 2010, J. Am. Medical Informatics Assoc..

[8]  David W. Bates,et al.  Viewpoint Paper: Evaluation and Certification of Computerized Provider Order Entry Systems , 2007, J. Am. Medical Informatics Assoc..

[9]  L. Schulmeister,et al.  Look-alike, sound-alike oncology medications. , 2006, Clinical journal of oncology nursing.

[10]  David W. Bates,et al.  Governance for clinical decision support: case studies and recommended practices from leading institutions , 2011, J. Am. Medical Informatics Assoc..

[11]  David L. Reich,et al.  Extraction and Mapping of Drug Names from Free Text to a Standardized Nomenclature , 2007, AMIA.

[12]  Thomas H. Payne,et al.  Review Paper: Medication-related Clinical Decision Support in Computerized Provider Order Entry Systems: A Review , 2007, J. Am. Medical Informatics Assoc..

[13]  Dean F. Sittig,et al.  Clinical evaluation of computer-based respiratory care algorithms , 1990, International journal of clinical monitoring and computing.

[14]  R M Gardner,et al.  Development of a computerized laboratory alerting system. , 1989, Computers and biomedical research, an international journal.

[15]  Hua Xu,et al.  Data from clinical notes: a perspective on the tension between structure and flexible documentation , 2011, J. Am. Medical Informatics Assoc..

[16]  Rainu Kaushal,et al.  Physicians and electronic health records: a statewide survey. , 2007, Archives of internal medicine.

[17]  Ida Sim,et al.  A taxonomic description of computer-based clinical decision support systems , 2006, J. Biomed. Informatics.

[18]  B. Jacobs,et al.  Computerized Provider Order Entry with Pager Notification Improves Efficiency in STAT Radiographic Studies and Respiratory Treatments , 2010, Thrombosis and Haemostasis.

[19]  Raymond G. Duncan,et al.  A clinical rules taxonomy for the implementation of a computerized physician order entry (CPOE) system , 2002, AMIA.

[20]  Adam Wright,et al.  An automated technique for identifying associations between medications, laboratory results and problems , 2010, J. Biomed. Informatics.

[21]  Emily S. Patterson,et al.  Exploring barriers and facilitators to the use of computerized clinical reminders. , 2005, Journal of the American Medical Informatics Association : JAMIA.

[22]  Brian Clay,et al.  Indication-Based Ordering: A New Paradigm for Glycemic Control in Hospitalized Inpatients , 2008, Journal of diabetes science and technology.

[23]  Adam Wright,et al.  A framework and model for evaluating clinical decision support architectures , 2008, J. Biomed. Informatics.

[24]  Roger B. Davis,et al.  Overrides of medication alerts in ambulatory care. , 2009, Archives of internal medicine.

[25]  Jonathan M. Teich,et al.  An information system to promote intravenous-to-oral medication conversion , 1999, AMIA.

[26]  Adam Wright,et al.  SANDS: An Architecture for Clinical Decision Support in a National Health Information Network , 2007, AMIA.

[27]  S. Wegner,et al.  Pharmacist Response to Alerts Generated From Medicaid Pharmacy Claims in a Long-term Care Setting: Results From the North Carolina Polypharmacy Initiative , 2005, Journal of managed care pharmacy : JMCP.

[28]  R. Scott Evans,et al.  Application of Information Technology: Rapid Identification of Hospitalized Patients at High Risk for MRSA Carriage , 2008, J. Am. Medical Informatics Assoc..

[29]  Blackford Middleton,et al.  Documentation-based clinical decision support to improve antibiotic prescribing for acute respiratory infections in primary care: a cluster randomised controlled trial. , 2009, Informatics in primary care.

[30]  P. Shekelle,et al.  Comparison of Quality of Care for Patients in the Veterans Health Administration and Patients in a National Sample , 2004, Annals of Internal Medicine.

[31]  R M Gardner,et al.  Computerized medication monitoring system. , 1976, American journal of hospital pharmacy.

[32]  Dean F. Sittig,et al.  Randomized clinical trial of pressure-controlled inverse ratio ventilation and extracorporeal CO2 removal for adult respiratory distress syndrome. , 1994, American journal of respiratory and critical care medicine.

[33]  Stacey C. Sawyer,et al.  Using Information Technology , 2000 .

[34]  P. Shekelle,et al.  Systematic Review: Impact of Health Information Technology on Quality, Efficiency, and Costs of Medical Care , 2006, Annals of Internal Medicine.

[35]  H. Mcdonald,et al.  Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. , 2005, JAMA.

[36]  D. Bates,et al.  Does the computerized display of charges affect inpatient ancillary test utilization? , 1997, Archives of internal medicine.

[37]  William B. Lober,et al.  Review Paper: Implementing Syndromic Surveillance: A Practical Guide Informed by the Early Experience , 2003, J. Am. Medical Informatics Assoc..

[38]  Christoph U. Lehmann,et al.  Preventing provider errors: online total parenteral nutrition calculator. , 2004, Pediatrics.

[39]  Diane L. Seger,et al.  Viewpoint Paper: Tiering Drug-Drug Interaction Alerts by Severity Increases Compliance Rates , 2009, J. Am. Medical Informatics Assoc..

[40]  Robyn Tamblyn,et al.  A randomized trial of the effectiveness of on-demand versus computer-triggered drug decision support in primary care. , 2008, Journal of the American Medical Informatics Association : JAMIA.

[41]  H L Bleich,et al.  Computer evaluation of acid-base disorders. , 1969, Transactions of the Association of American Physicians.

[42]  Alastair G. Gale,et al.  Labeling of Medicines and Patient Safety: Evaluating Methods of Reducing Drug Name Confusion , 2006, Hum. Factors.

[43]  H. E. Pople,et al.  Internist-1, an experimental computer-based diagnostic consultant for general internal medicine. , 1982, The New England journal of medicine.

[44]  Rohina Joshi,et al.  An Electronic Clinical Decision Support Tool to Assist Primary Care Providers in Cardiovascular Disease Risk Management: Development and Mixed Methods Evaluation , 2009, Journal of medical Internet research.

[45]  J. Marc Overhage,et al.  Research Paper: A Randomized Trial of "Corollary Orders" to Prevent Errors of Omission , 1997, J. Am. Medical Informatics Assoc..

[46]  Ferdinand T. Velasco,et al.  Improving Outcomes with Clinical Decision Support: An Implementer's Guide , 2012 .

[47]  Joan,et al.  Clinical Decision Support Capabilities of Commercially-available Clinical Information Systems , 2022 .

[48]  Tonya Hongsermeier,et al.  Research Paper: A Description and Functional Taxonomy of Rule-based Decision Support Content at a Large Integrated Delivery Network , 2007, J. Am. Medical Informatics Assoc..

[49]  Frederick North,et al.  Use of the Prioritization Matrix to Enhance Triage Algorithms in Clinical Decision Support Software , 2010, American journal of medical quality : the official journal of the American College of Medical Quality.

[50]  Julie M. Fiskio,et al.  Automated evidence-based critiquing of orders for abdominal radiographs: impact on utilization and appropriateness. , 1997, Journal of the American Medical Informatics Association : JAMIA.

[51]  Marc Berg,et al.  Drug safety alert generation and overriding in a large Dutch university medical centre , 2009, Pharmacoepidemiology and drug safety.

[52]  R Mohan,et al.  A comprehensive three-dimensional radiation treatment planning system. , 1988, International journal of radiation oncology, biology, physics.

[53]  T. Balcezak,et al.  Prevention of Nosocomial Catheter-Associated Urinary Tract Infections Through Computerized Feedback to Physicians and a Nurse-Directed Protocol , 2005, American journal of medical quality : the official journal of the American College of Medical Quality.

[54]  D. Blumenthal,et al.  The "meaningful use" regulation for electronic health records. , 2010, The New England journal of medicine.

[55]  C. McDonald.  Protocol-based computer reminders, the quality of care and the non-perfectability of man. , 1976, The New England journal of medicine.

[56]  Adam Wright,et al.  Ability to perform registry functions among practices with and without electronic health records. , 2008, AMIA ... Annual Symposium proceedings. AMIA Symposium.

[57]  J M Teich,et al.  An information system to improve the safety and efficiency of chemotherapy ordering. , 1996, Proceedings : a conference of the American Medical Informatics Association. AMIA Fall Symposium.

[58]  D. Bates,et al.  Guided medication dosing for inpatients with renal insufficiency. , 2001, JAMA.

[59]  L. Hayden,et al.  Ten Commandments for Effective Clinical Decision Support: Making the Practice of Evidence-based Medicine a Reality , 2011 .

[60]  H. E. Pople,et al.  Internist-I, an Experimental Computer-Based Diagnostic Consultant for General Internal Medicine , 1982 .

[61]  G. Barnett,et al.  DXplain. An evolving diagnostic decision-support system. , 1987, JAMA.

[62]  P. Ravdin,et al.  Computer program to assist in making decisions about adjuvant therapy for women with early breast cancer. , 2001, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[63]  D. Bates,et al.  Effects of computerized physician order entry on prescribing practices. , 2000, Archives of internal medicine.

[64]  Jonathan M. Teich,et al.  Grand challenges in clinical decision support , 2008, J. Biomed. Informatics.

[65]  H. Warner,et al.  Decision support in medicine: examples from the HELP system. , 1994, Computers and biomedical research, an international journal.

[66]  E. Balas,et al.  Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success , 2005, BMJ : British Medical Journal.

[67]  R M Gardner,et al.  Computer surveillance of hospital-acquired infections and antibiotic use. , 1986, JAMA.

[68]  Randolph A. Miller,et al.  The anatomy of decision support during inpatient care provider order entry (CPOE): Empirical observations from a decade of CPOE experience at Vanderbilt , 2005, J. Biomed. Informatics.