Effectiveness of a Hospital-Based Computerized Decision Support System on Clinician Recommendations and Patient Outcomes: A Randomized Clinical Trial

Abstract

Importance: Sophisticated evidence-based information resources can filter medical evidence from the literature, integrate it into electronic health records, and generate recommendations tailored to individual patients.

Objective: To assess the effectiveness of a computerized clinical decision support system (CDSS) that preappraises evidence and provides health professionals with actionable, patient-specific recommendations at the point of care.

Design, setting, and participants: Open-label, parallel-group, randomized clinical trial among internal medicine wards of a large Italian general hospital. All analyses in this randomized clinical trial followed the intent-to-treat principle. Between November 1, 2015, and December 31, 2016, patients were randomly assigned to the intervention group, in which CDSS-generated reminders were displayed to physicians, or to the control group, in which reminders were generated but not shown. Data were analyzed between February 1 and July 31, 2018.

Interventions: Evidence-Based Medicine Electronic Decision Support (EBMEDS), a commercial CDSS covering a wide array of health conditions across specialties, was integrated into the hospital electronic health records to generate patient-specific recommendations.

Main outcomes and measures: The primary outcome was the resolution rate, the rate at which medical problems identified and alerted by the CDSS were addressed by a change in practice. Secondary outcomes included the length of hospital stay and in-hospital all-cause mortality.

Results: In this randomized clinical trial, 20 563 patients were admitted to the hospital. Of these, 6480 (31.5%) were admitted to the internal medicine wards (study population) and randomized (3242 to CDSS and 3238 to control). The mean (SD) age of patients was 70.5 (17.3) years, and 54.5% were men. In total, 28 394 reminders were generated throughout the course of the trial (median, 3 reminders per patient per hospital stay; interquartile range [IQR], 1-6). These messages led to a change in practice in approximately 4 of 100 patients. The resolution rate was 38.0% (95% CI, 37.2%-38.8%) in the intervention group and 33.7% (95% CI, 32.9%-34.4%) in the control group, corresponding to an odds ratio of 1.21 (95% CI, 1.11-1.32; P < .001). The length of hospital stay did not differ between the groups, with a median time of 8 days (IQR, 5-13 days) for the intervention group and a median time of 8 days (IQR, 5-14 days) for the control group (P = .36). In-hospital all-cause mortality also did not differ between groups (odds ratio, 0.95; 95% CI, 0.77-1.17; P = .59). Alert fatigue did not differ between early and late study periods.

Conclusions and relevance: An international commercial CDSS intervention marginally influenced routine practice in a general hospital, although the change did not statistically significantly affect patient outcomes.

Trial registration: ClinicalTrials.gov identifier: NCT02577198.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Moja reported being principal investigator of the Computerized Decision Support (CODES) trial; reported having received grants from the Italian Ministry of Health and from the Lombardy region (Italy); having translated all reminders of Evidence-Based Medicine Electronic Decision Support (EBMEDS) into Italian; and occasionally having supported Medilogy Srl and Duodecim Medical Publications Ltd in raising awareness of evidence-based point-of-care summary products and disseminating their services. Dr Polo Friz reported receiving occasional fees for medical writing, lectures, and congresses from Bayer, Daiichi-Sankyo, Boehringer Ingelheim, Pfizer, Sanofi, McCann Medical Complete Srl, Health and Life, IMS Health, Clinical Forum Srl, and Medi K Srl. Mr Mangia reported being chief executive officer of Medilogy Srl. Dr Nyberg reported being a full-time employee of Duodecim Medical Publications Ltd. Dr Kunnamo reported being founder and research director of the EBMEDS clinical decision support system (CDSS), published by the Finnish Medical Society, and receiving personal fees from Duodecim Medical Publications Ltd. Dr Grimshaw reported holding a Canada Research Chair in Health Knowledge Transfer and Uptake and being a coauthor on the Cochrane systematic review of on-screen, point-of-care computer reminders. No other disclosures were reported.

Figures

Figure.. CONSORT Diagram of the Trial Timeline

Shown are hospitalized and randomized patients in the observation period. CDSS indicates clinical decision support system.