Can computerised decision support systems deliver improved quality in primary care?

Abstract

Computerised decision support systems or "expert systems" are computer software systems that are designed to aid clinical decision making. Computerised decision support has been defined as provision of assessments or prompts specific to the patient and selected from a knowledge base on the basis of individual patient data.1 At its simplest this definition will include programs that suggest alternatives for treatment or diagnosis on the basis of a simple algorithm. More complex systems model the likelihood of future events and the effectiveness of proposed interventions based on individual patient data and "knowledge" of risks and the effectiveness of interventions. 2Primary care more than any other specialty is characterised by uncertainty. This is not only because it is the first point of contact and the recipient of undifferentiated problems, but also because primary care has the role of monitoring and providing optimal continuing care for many common chronic conditions. Improvement of quality by a reduction of the variation in primary care practice is a key component of UK national health policy. 3 Computerised decision support systems have potential to drive reminders, provide alerts for prescribing interactions or test results, interpret complex investigations (or electrocardiograms), predict mortality on the basis of epidemiological data, aid diagnosis, and calculate drug doses. The question examined by this review is how may computerised decision support systems contribute to improving quality in primary care?The United Kingdom has the most extensively computerised primary healthcare sector in the world and has a unique opportunity to develop and evaluate this technology. 4 As the principal purpose of computerised decision support systems is to support clinical judgment and to provide the structures underlying continuing care, it is surprising that use of computerised decision support systems is not commonplace. The principal reasons for this have been a lack of agreed national standards, a failure of systems to examine the needs of users adequately, and the profusion of different systems that do not communicate with each other.5 Recent mergers between suppliers, the development of national standards for coding and information exchange, and the latest generation of Windows based medical systems could enable the development of more sophisticated computerised decision support systems than the "electronic protocols" currently being used.3 It would seem an appropriate point to consider the scope for computerised decision support systems in supporting quality primary care.According to Buchanan and Smith 6 expert systems should • Provide a solution at the same level of performance as a human expert • Use symbolic and heuristic reasoning rather than numeric and algorithmic procedures • Store knowledge separately from inference procedures • Provide explanations of their reasoning.Shortliffe has identified barriers to the use of decision support: lack of adequate theory, failure to recognise the needs of users, la...

A hybrid knowledge-based approach to supporting the medical prescription for general practitioners: Real case in a Hong Kong medical center

“…The application of DSS in the medical domain has been mostly developed to provide physicians with advice on either diagnosis or treatment by means of artificial intelligence (AI) and Bayesian reasoning [21]. Because of the complexity of drug information, DSS demonstrates great potential in the area of medical prescription, however, only a few publications have addressed this issue.…”

Decision support system for the diagnosis of schizophrenia disorders

“…The misclassification rate was higher when schizophreniform disorder was considered as the absence of schizophrenia disorder. Schizophreniform disorder is a provisory di-The usefulness and the impact of such systems in medicine are unclear (11,27). In Psychiatry there are additional hindrances such as the lack of valid constructs of mental disorders, the subjective assessment of psychiatric symptoms, schizophrenia as a heterogeneous phenomenon, the absence of biological markers, and finally the absence of a gold standard (5,(28)(29)(30).…”

Identifying barriers to implementing a cardiovascular computerised decision support system (CDSS): a Delphi survey

“…Likewise, in the UK, which has an extensive computerised primary healthcare sector, the use of computerised decision support systems (CDSS) is not commonplace. 2 Investigating primary care physicians' use of electronic patient records in Norway, Christensen et al concluded that their full potential had not been reached and that problems of integration and functionality needed to be addressed to achieve this.…”

“…by engaging and involving patients in decision making regarding their own health care. 2,8 A range of clinical decision tools to assist providers to perform cardiovascular assessment have been developed, validated, and even adapted to hand-held computers to increase their portability. Some cardiovascular decision tools, such as those developed by the New Zealand National Prescribing Service, 9 American College of Physicians (ACP) and American College of Cardiology/American Heart Association (ACC/ AHA), are algorithmic approaches that make direct recommendations about whether to pursue cardiac testing.…”

“…Likewise, in the UK, which has an extensive computerised primary healthcare sector, the use of computerised decision support systems (CDSS) is not commonplace. 2 Investigating primary care physicians' use of electronic patient records in Norway, Christensen et al concluded that their full potential had not been reached and that problems of integration and functionality needed to be addressed to achieve this.3 Computerised decision support systems are one type of electronic interface designed to assist clinicians in decision making and risk management and to facilitate shared decision making between health professional and patient. Achieving maximum adoption and usage by primary care professionals requires a comprehensive understanding of which professionals find it attractive and why.…”