clinical decision support systems

Clinical Decision Support SystemsChapter 20

Objectives

What are three requirements for an excellent decision making

systems?

What are three decision support roles for computers in clinical

medicine?

What are five dimensions that characterized clinical decision support

tools?

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Clinical Decision Making

Medical Practice is medical decision making

Computer can have a direct or tangential effect on the quality of decisions

Clinical decision making is the process by which it determine who needs what and when

Three requirements for decision making

Accurate data

Pertinent knowledge

Appropriate problem solving skills

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Clinical Decision Making

A major challenge occurs when decision makers are bombarded with so

much information that they cannot process rapidly.

Decision makers must have broad knowledge of medicine and in depth

familiarity with their area of expertise

Their knowledge must also be current4

The Role of Computers in Decision Support

A clinical decision support system is any computer program designed to

help healthcare professionals to make clinical decisions

1. Tools for Information Management

• Specialized knowledge management workstations are under development in

research settings

• These workstations provide sophisticated environments for storing and

retrieving clinical knowledge5


2. Tools for focusing attention

• Clinical laboratory systems that flag abnormal values

• Provides lists of possible explanations for those abnormalities

• Program are designed to remind the user of diagnosis6


3. Tools for providing patient specific recommendation

• Provides custom tailored assessments

• Advice based on sets of patient specific data

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Historical Perspective

1. Leeds Abdominal Pain System (1972)

• University of Leeds studied the diagnostic process and developed

computer based decision aids using Bayesian Probability theory

• Leeds abdominal pain system used sensitivity, specificity and disease

prevalence data for various signs, symptoms and test results

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1. Leeds Abdominal Pain System (1972)

• The probability of seven possible explanations for acute

abdominal pain are

Appendicitis, Diverticulitis, Perforated Ulcer, Cholecystitis, Small

bowel obstruction, Pancreatitis and non specific abdominal pain.9


2. MYCIN (1976)

• MYCIN program a consultation system that de emphasized diagnosis to

concentrate on appropriate management of patients who have infections.

• MYCIN was represented as production rules each containing a “Packet” of

knowledge derived from discussions with collaborator experts.

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Example


3. HELP (1979)

• An integrated hospital information system developed at LDS Hospital in Salt Lake City

• HELP has the ability to generate alerts when abnormalities in the patient record are

noted

• HELP adds to a conventional medical record system a monitoring program and a

mechanism for storing decision logic in “HELP” sectors or Medical Logic Module (MLM)

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A structure for Characterizing Clinical Decision Support Systems

Five dimensions of characterized clinical decision support systems

1. The systems Function-What is true about a patient and What to do for the patient

2. The mode by which advice is offered-The decision support system waits for the user to come to it

3. The consultation style-The program serves as an advisor or ideas

4. Underlying decision making process-Specific flowcharts designed by clinicians

5. Factors related to human computer interaction-User’s professional routine use of computer

system

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Barriers to Decision Support Tools

Acquisition and Validation of Patient Data

Modeling of Medical Knowledge

Elicitation of Medical Knowledge

Representation of and Reasoning about Medical Knowledge

Validation of System Performance

Integration of Decision-Support Tools14

Examples

The Internist-1/ QMR project

Diagnostic program developed at the University of Pittsburg School of Medicine

Program known as Quick Medical Reference (QMR)

Contained knowledge of almost 600 diseases and of nearly 4,500 interrelated findings or disease

manifestations

On average each disease was associated with between 75 and 100 findings

The Dxplain System

Produced a ranked list of diagnoses that might explain the clinical manifestations.15

Patient Management: Guideline Based Architectures

Clinical practice guidelines standardize and provide uniform improvement in

the quality of medical care.

Guideline-Based Patient-Management Systems

Situation based rules

Skeletal plans

Protocols

Example: EON system

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EON System

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Legal and Regulatory Issues

Negligence Law

Strict liability

Validation of tools prior to release

Role of government in regulation

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