Royal College of Surgeons in Ireland
Coláiste Ríoga na Máinleá in Éirinn
Usability and Clinical Decision Support Systems
Oxford, 29th September 2010
Derek Corrigan, Borislav D. Dimitrov, Tom Fahey
PHS / Department of General Practice
Overview
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What is a Clinical Decision Support System?
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What are the technical barriers to be considered? – “usability” issues
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What role can Clinical Predication Rules (CPRs) play in a CDSS?
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What form might a state of the art CPR based system look like?
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What are the challenges to achieving this state of the art?
PHS / Department of General Practice
Clinical Decision Support Systems
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Clinical decision support system (CDSS)
– I.T. based systems that are designed to improve clinical decision
making by suggesting possible clinical actions/interventions based
on an underlying clinical evidence base
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CDSS Types
– Diagnostic systems – diagnose appendicitis
– Reminder systems – generate patient letters
– Disease management systems – diabetes management
– Drug dosing/prescribing – insulin, warfarin
PHS / Department of General Practice
CDSS - Barriers to Implementation
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Human Issues
– As previously discussed - knowledge, attitudes, behavior
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Technical Issues
– Need to consider usability issues of CDSS and how we can
potentially use CPRs as part of them
PHS / Department of General Practice
CDSS - Usability Issues
10 Commandments for Effective CDSS –
(Bates et al 2003)
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CDSS must fit into the clinical workflow – logical sequence and steps
– Primary care diagnosis tool on laptop or PC in practice as part of consultation
– Secondary care drug administration as part of round system may need something
more mobile and compact – palm held application
– No point developing tools that can only be accessed outside of the clinical
process workflow – they are then seen as an additional overhead
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Speed is everything – users will not tolerate slow systems!
– No matter how useful an application is, it will not be used if performance is
prohibitively slow – need to prototype and user test during development
PHS / Department of General Practice
CDSS - Usability Issues (contd.)
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Deliver needs in real time – relevant information presented as needed - user
should not need to go searching for information
– In drug prescription systems, one action may imply another associated action that the
system can automatically prompt for e.g. drug interactions, corollary orders or order
sets
– Do not wait until end of the entire process to highlight issues to the user
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Physicians will resist stopping – offer alternatives and overrides
– Users will not accept blanket restrictions – result in lack of confidence and frustration
– Provide alternative suggestions justified by clinical evidence and always allow override
of recommended actions – ultimately the clinician must be trusted
PHS / Department of General Practice
CDSS - Usability Issues (contd.)
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Changing direction in a system is easier than stopping
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Can modify clinician behavior with beneficial results
Change default medication dosages based on evidence
Change default frequency of dosage based on evidence
Bates et al detail a change resulting in cost savings of $250,000 per year
Monitor impact of CDSS and usage patterns and revise
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Understand how clinicians are using your system
Track underlying usage of rules, alerts and overrides
Large levels of overrides indicate potential problem
Amend evidence base where necessary and/or provide more detailed justification
PHS / Department of General Practice
CDSS - Usability Issues (contd.)
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Simple interventions work best – CPRs rather than books of guidelines
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Simple rules may offer easiest gains e.g. Ottawa Ankle Rule
Working clinicians will not have time to review pages of guidelines – these
should be provided as supporting documentation where necessary
Usability testing – include the users!
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No point having state of the art evidence base with a bad user interface
Get user feedback through prototyping early in the design process
PHS / Department of General Practice
CDSS - Usability Issues (contd.)
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Manage your knowledge base – needs to be easily updated
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Ensure that formal evidence base review and update is done regularly based
on latest clinical evidence
Provide patient specific recommendations based on electronic patient
record (EPR)
– Ideally integrate CDSS as part of EPR
– Use individual patient data to generate individual recommendations
PHS / Department of General Practice
CDSS - Clinical Prediction Rules
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Evidence Base
– Potentially can use Clinical Prediction Rules (CPRs) as part of a
clinical guideline to drive evidence based care in a CDSS
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Issues to consider
– Level of CPR validation of potential CPRs
– Type of clinical setting where validation of CPR has been done
– Impact assessment of CPR – does it indicate a high quality CPR with
impact for patient, physician or process?
PHS / Department of General Practice
CDSS – Maintaining the Evidence Base
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Huge potential evidence base in EHRs in primary care e.g. General Practice
Research Database in UK (GPRD)
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Create clinical trials/ epidemiological studies from primary care data
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May be used to amend an existing CPR i.e. the inclusion of additional
symptoms/signs identified by data analysis as potential diagnostic cues
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May be used to create new CPR’s based on new diagnostic cue combinations
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Evidence base becomes “self-learning” and adds or improves the list of CPR’s
used as the evidence base
PHS / Department of General Practice
The TRANSFoRm Project
PHS / Department of General Practice
TRANSFoRm
Services
1 CPR Repository
Clinical Prediction
Rules Service
2 Distributed
GP EHRs
With CDSS
3 Research Study Designer
Study Criteria
Design
CP Rules
Manager
CP Classifier
5 CPR Data Mining
and Analysis
CPR Analysis &
Extraction Tool
Find Eligible Patient
4 Research Study Management
Recruit Eligible Patient
Study Data Management
PHS / Department of General Practice
CDSS - Challenges
The EPR
– Still a huge amount of work to be done just to create usable EPRs
System Interoperability – consistent representation of clinical data using
technologies
– Health Level 7 (HL7), OpenEHR – pool and share clinical data by allowing
systems to ‘talk together’
Semantic Interoperability – being able to interpret clinical concepts contained
within data in a consistent way
– Clinical Coding Terminologies such as SNOMED-CT, ICPC, ICD
PHS / Department of General Practice
In Summary
• CPRs have huge potential as a form of evidence in CDSS
• Need to consider technical usability issues as well as human
issues
• Future directions - develop the Electronic Patient Record
and incorporate research tools to generate and update the
evidence base – “self-learning”
PHS / Department of General Practice
Thank You
Discuss!
PHS / Department of General Practice