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.

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Arch Intern Med 2000;160:301–8 This meta‐analysis of randomized trials of physician prompts to improve screening rates found that prompts do improve the rate of performing various health maintenance interventions. A prompt is defined as anything that tells a clinician to perform a screen. The most common prompts are stickers posted to charts of patients coming in for care and computer notices generated at the time of scheduled appointment. The effects on Pap smear screening rates were significantly less than the effect of prompting for other interventions. Prompting increased an average of only 5.8% as a result of prompts at a cost of $11.75 per additional Pap smear performed. The study lumped together various interventions that differed according to timing, information provided to clinicians, and location, but the way prompt was presented did not appear to affect results significantly. Comment: Prompting clinicians using computerized reminders or notes placed on the chart is effective, but the effect is not strong, suggesting that additional efforts may be needed to improve Pap smear screening rates in health systems. (LSM)

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