Advances in Clinical Decision Support Systems: Contributions from the 2022 Literature

Summary

Objective: To summarize significant research contributions published in 2022 in the field of clinical decision support (CDS) systems and select the best papers for the Decision Support section of the International Medical Informatics Association (IMIA) Yearbook 2023.

Methods: A renewed search query for identifying CDS scholarship was developed using Medical Subject Headings (MeSH) terms and related keywords. The query was executed in PubMed in January 2023. The search results were reviewed in three stages by two reviewers: title-based triaging, followed by abstract screening, and then full text review. The resulting articles were sent for external review to identity best paper candidates.

Results: A total of 1,939 articles related to CDS were retrieved. Of these, 11 articles were selected as candidates for best papers. The general themes of the final three best papers are (1) reducing documentation burden through in-line guidance for clinical notes, (2) clinician engagement for continuous improvement of CDS, and (3) mitigating healthcare-related carbon emissions using scalable and accessible CDS, respectively.

Conclusion: The field of clinical decision support remains highly active and dynamic, with innovative contributions to a range of clinical domains from primary to acute care. Interoperability issues, documentation burden, clinician acceptance, and the need for effective integration into existing healthcare workflows are among the prominent challenges and areas of interest faced by CDS implementation efforts.

Keywords

Medical informatics - clinical decision support system - implementation, expert system

1 Introduction

Clinical decision support (CDS) systems are at the forefront of the digital revolution in biomedicine. With their potential to make care safer, more efficient, and less costly they are emerging as powerful tools for clinicians in making evidence-based and informed decisions. This manuscript represents the synopsis for the Decision Support section of the 2023 International Medical Informatics Association (IMIA) Yearbook. Our synopsis supplements the review paper on the impact of CDS on health disparities and digital divide, authored by Douthit et al. [[1]]. The aim of this synopsis is to summarize significant research in the CDS domain and to select the best papers published in this field in the year 2022.

2 Methods

Following the principles outlined in the paper by Lamy et al. [[2]], the literature review process for the Yearbook's CDS synopsis is expected to be systematic and standardized including specific data sources, search strategies, and selection criteria. First, we reached out to Borbolla and Colicchio (the authors of the CDS synopsis for the 2022 IMIA Yearbook [[3]]) and discovered that the actual query used for the prior synopsis had been lost. However, salient terms were described in the 2022 CDS synopsis [[3]]. For Medical Subject Headings (MeSH), the terms “Decision Support Systems, Clinical”, “Expert systems” AND “Medical Order Entry Systems” were used. Borbolla and Colicchio also used terms such as “Clinical Decision Support”, “Medication Alert Systems”, “Computerized Provider Order Entry System” in the narrative search. Since prior queries were not available, we were forced to develop a new search strategy based on Lamy et al. recommendations [[2]] and a related systematic review by Ostropolets et al. [[4]].

We are including the actual query (see [Table 1]) to support future Yearbook contributors. Similar to prior synopsis, we searched for relevant papers in PubMed® using the newly developed search strategy. We included journal articles published in 2022 in English that had a series of keywords either in the MeSH terms or in the paper's title or abstract. For the MeSH terms, we considered, “Clinical Decision Support”, “Expert systems”, Medical Order Entry Systems”, “Decision Support Techniques”, and “Decision Support Systems, Management”. For the abstracts and title search, we used the terms, “Best Practice Alert”, “Clinical Decision Support”, “Decision Support Techniques”, “Decision Support Systems”, “Expert systems”, “Medication Alert Systems”, and “Computerized Provider Order Entry System”. The final query is shown in [Table 1].

Table 1 Search Strategy for CDS Literature Review.

We reviewed the query results in three stages: title only review, followed by abstract review, and then full text review as described below. We chose to first triage using a title only review because the query returned 5.75 times more results than in 2022 (see Results section for more details). At this stage, we were blinded to country of origin, institution, or authors. We included any articles that were selected for further review by at least one of us (CUL and VS). Following the title only review, we proceeded to screen the remaining articles using their abstracts. We individually examined the full text of all remaining articles and conducted a conference call to discuss each article that was selected by at least one of us. Through consensus, we identified the candidate best papers. The full IMIA Yearbook editorial board determined the finalists.

3 Results

The search query resulted in 1,939 unique references, which was significantly more than in 2022, where 337 references were found. After the title review, 111 references were included by either section editor (CUL and VS). While both editors agreed on 12 articles, VS had included an additional 23 articles, and CUL incorporated an additional 76 articles.

After screening the abstracts, 19 articles were identified with five selected by both editors. After full text review, 11 best paper candidates were selected in a consensus conference call ([Table 2]). Of these, three papers were published in the Journal of the American Medical Informatics Association, two each in BMC Health Services Research and Applied Clinical Informatics, and one each in BMC Medical Informatics and Decision Making, eBioMedicine, JMIR Perioperative Medicine, and Open Forum Infectious Diseases. We provide further analyses of the 11 best paper candidates using the Donabedian's structure-process-outcomes model [[5]]. After external review of best paper candidates, the IMIA Yearbook editorial committee finally selected three candidates as the best papers ([Table 3]) making the most significant contributions in the field of clinical decision support for 2022. A summary of the best papers can be found in the appendix of this synopsis.

Table 2 Best paper candidates for the Clinical Decision Support Section.

Table 3 Selection of best papers for the 2023 IMIA Yearbook of Medical Informatics for the section Decision Support. The articles are listed in alphabetical order by the first author's surname.

4 Discussion and Outlook

The eleven best paper candidates are analyzed using a range of structural, process, and outcome characteristics. Structural aspects include the type of CDS and clinical setting where the CDS was deployed or studied. Six studies included domain-specific systems such as an electronic alert to notify prescribers about inappropriate red blood cell and platelet transfusion [[6]]; a patient-specific CDS report for disease prevention and surveillance in the primary care setting [[7]]; a non-interruptive alert in anesthesia to reduce fresh gas flow when a predefined threshold was exceeded [[8]]; a real-time text message alert when antimicrobial therapy was inappropriate (i.e., an antimicrobial agent–pathogen mismatch with a positive blood culture result) [[9]]; a guideline-based CDS for maternal health [[10]]; and a microRNA-based thyroid molecular classifier test for a precision endocrinology [[11]]. Clinical settings for implementation or investigation of CDS systems included critical care, primary care, hematology and oncology, anesthesiology, pediatrics, and infectious diseases.

In terms of process characteristics, we primarily analyzed the nature of CDS evaluation (e.g., prospective vs. retrospective studies; multisite vs. single-site studies; provider-facing vs. patient-facing CDS; early-stage vs. effectiveness studies). Most studies were single-site, retrospective in nature, and focused on provider-facing CDS. Two out of the 11 best paper candidates [[7],[12]] had a patient-facing application. Lobach et al. explored the integration of a patient engagement application (for monitoring and managing COVID-19 symptoms) into the electronic health record using Health Level 7 (HL7) Fast Health Interoperability Resources (FHIR) standards, including contemporary services such as CDS Hooks [[12]]. Wu et al. conducted an implementation effectiveness trial for examining the clinical impact of patient-oriented and provider-facing CDS report for health risk assessment [[7]]. Notably, one study demonstrated the scalability and transferability of a CDS system to reduce anesthetic gas waste [[8]], innovatively linking informatics solutions to environmental impact.

Four studies [[13] [14] [15] [16]] were focused broadly on evaluating the effect of CDS on clinician-related outcomes and problems (e.g., documentation burden, alert fatigue, adherence to CDS recommendations). All of these studies were largely focused on rule-based CDS. None of the 11 selected papers had artificial intelligence and/or machine learning models as the basis for decision support. However, we predict that, in 2023, there will be a renewed and moderate attention to evaluation of expert systems for clinical decision support.

No conflict of interest has been declared by the author(s).

Acknowledgement

We are grateful to Adrien Ugon for creating a custom web-based tool for administering the peer review process. We would also like to acknowledge Kate Fultz Hollis and Lina Soualmia for leading the 2023 IMIA Yearbook of Medical Informatics as well as the reviewers for their contribution to the selection process.

• References

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Publication History

Article published online:
26 December 2023