Saturday, January 2, 2010

Do Computetized Decision Support Systems Work?

How should decision support be delivered to doctors and other providers? Very simple supports, like "don't forget to do a mammogram in this 55 year-old woman," or "CT scans of the brain aren't very useful in patients without specific findings on neurologic exam" can be delivered a variety of ways - on paper or via order entry systems, or even as standing orders that require no provider input. 

But lots of medical problems are more complex. Managing chronic disease or polypharmacy or multiple diagnoses calls for multidimensional reasoning and is a notoriously difficult task for humans to master. It seems like a great opportunity for computerized decision support. One vision is that the provider interacts in real time with a computer screen that solicits inputs, provide advice, and encourages best practices. This kind of support is one of the big arguments in favor of electronic medical records. But, does it work?

This week, a new systematic review was published that examined the effectiveness of such multidimensional, real-time decision support systems in outpatient care. The results are not heartening. The authors reviewed 27 comparative studies. Less than half showed some benefits in terms of improved process measures (documentation, adherence to recommendations, etc.), but there was very little evidence that patient outcomes improved.

They conclude that
"There is little evidence at the moment for the effectiveness of an increasingly used and
commercialised instrument such as electronic multidimensional guidelines."

Why didn't they work?  It's not entirely clear, but possible reasons include bad interface design, poor integration into work flow, overwhelming volumes of feedback, hardware failures, and tedious data entry requirements. Of note, these systems generally did not involve the patient in the decision support interaction, which may be key to getting improved outcomes.

You can see all the details here:
Effectiveness of electronic guideline-based implementation systems in ambulatory care settings - a systematic review
Heselmans A, Van de Velde S, Donceel P, Aertgeerts B, Ramaekers D
Implementation Science 2009, 4:82 (30 December 2009)
[Abstract] [Provisional PDF]