Key findings

Effectiveness and Safety

• The evidence base for the effectiveness and safety of CDSS consisted of three overviews of systematic reviews and 10 systematic reviews that were not included in the overviews.
• There is a greater volume of evidence focusing on the impact of clinical decision support systems (CDSS) on care processes, than on impact on patient outcomes.
  CDSS had a positive impact on guideline adherence, process efficiency, safe prescribing, prescriber behaviour, and appropriate test ordering.
• An overview of systematic reviews reported two potentially negative responses to CDSS: use of risky workarounds and old paper forms. One systematic review found a negative impact of CDSS on prescriber behaviour (increased errors and overrides) in 6% of primary studies.
• The impact of CDSS on patient outcomes is less clear, with effects varying between indications, outcomes, and studies. Individual studies have shown a positive effect of CDSS on mortality, diagnostic yield from medical imaging, diabetes management, and inappropriate prescribing in older adults.
  None of the systematic reviews reporting patient outcomes described a negative impact of CDSS.
• Limitations of the secondary evidence on CDSS included: a lack of meta-analyses to quantify the effects of CDSS (due to heterogeneity of included studies); the challenge of determining how much change in an outcome is attributable to the CDSS; and the potential lack of generalisability of study results to Scotland.

Implementation barriers and facilitators

• The evidence base on barriers and facilitators to implementation of CDSS consisted of 11 systematic reviews.
• The most commonly identified barriers to implementation of CDSS were user mistrust of the system, lack of efficiency due to disruption of workflow, and poor system design.
• Factors most frequently cited as facilitating CDSS implementation included: encouraging positive user expectations; designing the system for ease of use; involving stakeholders in the design process; and generating trust in the quality of recommendations produced by the system, through transparency about the underpinning evidence sources.

Costs and cost effectiveness

• The economic evidence on CDSS was limited, tended to be specific to an indication or clinical setting, and was unlikely to be generalisable to Scotland.
• One economic evaluation reported that printed decision support for reducing antibiotic prescribing in patients with acute bronchitis dominated (lower costs and fewer prescriptions) usual care and computerised decision support systems.
• Three primary studies in a systematic review on CDSS for cardiovascular disease prevention reported cost per quality adjusted life-year (QALY). Two of these studies found CDSS to be cost-effective at the US willingness-to-pay-threshold (<$50,000) but only in conjunction with additional interventions. There was uncertainty about the cost effectiveness of CDSS alone.

What were we asked to look at?

We were asked to review the evidence on the impact of knowledge-based clinical decision support systems on service delivery, patient, and clinical outcomes.

We were also asked to review the evidence on barriers and enablers for successful implementation of these systems in clinical practice.

Why is this important?

Healthcare professionals are required to make decisions relating to patient care on a daily basis. With the increasing volume of evidence available, and improvements in technology, there is an opportunity to introduce tools to aid healthcare professionals in making decisions relating to patient care. Clinical decision support systems (CDSS) are one such tool, generating evidence-based, patient-specific advice at the point-of-care.

Referred by

Scottish Government