Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success
Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success
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DOI：
10.1136/bmj.38398.500764.8f
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发表时间：
2005-04-02
影响因子：
105.7
通讯作者：
Lobach, DF
中科院分区：
文献类型：
--
作者：
Kawamoto, K;Houlihan, CA;Lobach, DF
目的确定临床决策支持系统对改善临床实践的关键作用。设计随机对照试验的系统综述。资料来源：通过Medline、CINAHL和Cochrane对照试验注册检索截至2003年的文献；检索纳入研究的参考文献列表和相关综述。研究选择研究必须评估决策支持系统改善临床实践的能力。数据提取研究评估临床实践中统计和临床显著的改善以及文献中反复提到的15个决策支持系统特征的存在。结果纳入了70篇研究。决策支持系统在68%的试验中显著改善了临床实践。单变量分析显示，在五个系统特征中，具有该特征的干预措施明显比缺乏该特征的干预措施更有可能改善临床实践。多元Logistic回归分析发现四个特征是临床实践改善的独立预测因素：作为临床医生工作流程一部分的自动决策支持(P<；0.00001)，提供建议而不仅仅是评估(P=0.0187)，在决策时间和地点提供决策支持(P=0.0263)，以及基于计算机的决策支持(P=0.0294)。在拥有全部四个特征的32个系统中，30个(94%)显著改善了临床实践。此外，还发现了提供定期绩效反馈、与患者分享建议以及要求记录不遵循建议的原因的直接实验理由。结论决策支持系统的几个特征与显著改善患者护理的能力密切相关。临床医生和其他利益相关者应该实施临床决策支持系统，只要可行和适当，就应该结合这些功能。
Objective To identify features of clinical decision support systems critical for improving clinical practice.Design Systematic review of randomised controlled trials.Data sources Literature searches via Medline, CINAHL, and the Cochrane Controlled Trials Register up to 2003; and searches of reference lists of included studies and relevant reviews.Study selection Studies had to evaluate the ability of decision support systems to improve clinical practice.Data extraction Studies were assessed for statistically and clinically significant improvement in clinical practice and for the presence of 15 decision support system features whose importance had been repeatedly suggested in the literature.Results Seventy studies were included. Decision support systems significantly improved clinical practice in 68% of trials. Univariate analyses revealed that, for five of the system features, interventions possessing the feature were significantly more likely to improve clinical practice than interventions lacking the feature. Multiple logistic regression analysis identified four features as independent predictors of improved clinical practice: automatic provision of decision support as part of clinician workflow (P < 0.00001), provision of recommendations rather than just assessments (P = 0.0187), provision of decision support at the time and location of decision making (P = 0.0263), and computer based decision support (P = 0.0294). Of 32 systems possessing all four features, 30 (94%) significantly improved clinical practice. Furthermore, direct experimental justification was found for providing periodic performance feedback, sharing recommendations with patients, and requesting documentation of reasons for not following recommendations.Conclusions Several features were closely correlated with decision support systems' ability to improve patient care significantly. Clinicians and other stakeholders should implement clinical decision support systems that incorporate these features whenever feasible and appropriate.