PAIN MEDICINE

Volume 8

bull

Number S3

bull

2007

copy American Academy of Pain Medicine 1526-237507$1500S155 S155ndashS166 doi101111j1526-4637200700278x

Blackwell Publishing IncMalden USAPMEPain Medicine1526-2375American Academy of Pain Medicine 20078S3S155S166Review Articles

Computerized Decision-Support System for PainSmith et al

Reprint requests to

Meredith Y Smith MPA PhD PurduePharma LP One Stamford Forum Stamford CT 06901USA Tel 203-588-8248 Fax 203-588-6242 E-mailmeredithsmithpharmacom

Computerized Decision-Support Systems for Chronic Pain Management in Primary Care

Meredith Y Smith MPA PhD Judith D DePue EdD MPH

dagger

and Christine Rini PhD

Mount Sinai School of Medicine New York New York

dagger

Miriam HospitalBrown Medical School Providence Rhode Island

A B S T R A C T

USA

ABSTRACT

Objective

Computerized decision-support systems (CDSSs) can offer clinical guidance as well aspromote doctorndashpatient collaboration and patient self-care As such they have great potential forimproving chronic pain management particularly in the primary care setting where physiciansoften lack sufficient pain-specific clinical expertise and communication skills The objective of thisstudy was to examine the use of CDSSs in chronic pain management and to review the evidencefor their feasibility and effectiveness

Design

A review of the available literature using search terms associated with computerized deci-sion-support and chronic pain management Major databases searched included MEDLINECINAHL PsychINFO HealthSTAR EMBASE Cochrane Library Computer and InformationSystems Abstracts and Electronics and Communications Abstracts Descriptive and evaluativestudies were included

Results

Nine studies describing eight CDSSs met study inclusion criteria With but two exceptionsCDSSs were specific to a pain-related condition(s) All were designed to assist clinicians to managepain medically Aside from pain status input specifications differed markedly Evaluative studieswere exclusively feasibility studies and varied widely in design and level of description All werenonexperimental most were methodologically weak Two primary care studies were reportedPatient and clinician acceptability ratings of CDSSs ranged from moderate to high Due to insuf-ficient data definitive conclusions concerning the impact of CDSSs on provider performance andpatient outcomes were not possible

Conclusion

Research on CDSSs in chronic pain management is limited The effects of CDSSs onprovider and patient outcomes remain understudied and their potential to improve doctorndashpatientcollaboration and self-care largely untested

Key Words

Computerized Decision-Support Systems Expert System Primary Care Chronic

Pain DoctorndashPatient Communication Disease Management for Chronic Pain

Introduction

n estimated 9 of adults in America sufferfrom chronic pain and its sequelae and over

half of these individuals seek treatment for thiscondition from a primary care physician (PCP) [1]In recognition of this fact recent American Pain

A

Society guidelines advocate that PCPs should ldquo participate in the process of screening diagnosisand long-term follow-up treatment of patientswho suffer from chronic pain [j]ust as PCPs diag-nose and maintain patients with other chronicdiseases rdquo [2] In order to accomplish this goalhowever PCPs must be equipped not only withthe necessary clinical tools and expertise but alsowith the communication and related interpersonalskills to build and sustain a strong alliance withtheir patient Collaborative management thatstrengthens and supports self-care is recognized as

S156

Smith et al

the most appropriate and cost-effective way totreat chronic pain and is moreover the approachmost often preferred by both patients and healthcare providers [2ndash6]

In reality however deficits in physiciansrsquotraining and knowledge regarding pain manage-ment coupled with time constraints during theprimary care visit frequently prevent PCPs frommeeting these dual clinical and psychosocialexpectations [57ndash15] PCPs commonly focusmore on technical aspects of care when treatingchronic pain patients and less on promotingpatient self-management behaviors [7] In addi-tion doctorndashpatient communication regardingpain is frequently inadequate [16ndash19] Conse-quently physiciansrsquo perceptions of patient painare often incongruent with patientsrsquo self-ratingstreatment goals are frequently developed withoutpatient input and patient adherence to treatmentplans is less than optimal [20ndash25]

Faced with declining reimbursement rates fromboth public and private payers physicians need analternative that enables them to reconcile the twinimperatives of providing high-quality pain carewhile maximizing efficiency in their clinicalpractice Computerized decision-support sys-tems (CDSSs) offer one potential solution tothis dilemma CDSSs are information systemsdesigned to enhance the quality of clinical decisionmaking and to minimize deviations in clinical per-formance from accepted professional standards[26] Individual patient data are entered into thesystem whereupon predetermined algorithmsguided by a resident logic library of expert-basedclinical data generate patient-specific recommen-dations [26] Data can be collected via a personalcomputer or a handheld device such as a palmpilot Typically output is available in real time foruse during the medical visit

The process involved in using a CDSS based onpersonal computer technology is illustrated as fol-lows Upon arrival at a medical appointment apatient is directed to a computer workstationequipped with a laptop stylus and printer Fol-lowing instructions on the computer screen thepatient completes an electronic questionnaire con-taining the following types of items current painstatus (eg intensity location duration) past andpresent pain treatment regimens degree of adher-ence to prescribed pain medication side effects ofcurrent medication risk factors for opioid abuseimpact of pain on respondentsrsquo quality of life(QOL) psychological status pain-related copingand self-management strategies type and degree

of social support personal goals for daily livingand (for initial visit only) demographic informa-tion The data collected are automatically storedelectronically and then run through a series ofalgorithms In the final step a report is generated(electronically in hard-copy format or both) thatcontains a synopsis of the patientrsquos pain statusrecommendations as to possible improvements inthe current pain treatment regimen key issues todiscuss with the patient (eg problems with med-ication adherence or side effects signs of depres-sion) and a list of patient-targeted suggestionsdesigned to encourage pain self-management (egrecommendations to pursue a specific exerciseregimen)

Both the type and application of CDSSs havebeen expanding rapidly in recent years To dateCDSSs have been used to diagnose a variety ofmedical conditions to enhance the provision ofpreventive care (eg cancer screening vaccina-tion) to facilitate disease management and toassist with drug prescribing [27ndash32] Evidencesuggests that CDSSs can improve health carepractitioner performance and patient outcomesparticularly in the areas of vaccinations tetanusimmunizations breast cancer screening colorectalcancer screening cardiovascular risk reductionand smoking cessation [2633ndash36]

CDSSs can be designed not only to provideclinical guidance but to capture and integratepatientsrsquo perspective on their illness and to pro-mote positive patient health-related behaviorsSometimes referred to as ldquoexpert systemsrdquo thisvariant of a CDSS is particularly promising foruse in the clinical management of chronic painfor two reasons (i) pain is a highly subjectiveexperience hence patient-reported data areessential to obtain and (ii) successful outcomesof pain management are at least equally if notmore dependent on appropriate self-care (egself-monitoring of pain adherence to prescribedmedications regular exercise weight control)than on the quality of the clinical diagnosis orrecommended therapeutic regimen [5] Based onthe data entered the expert system producestailored recommendations often derived frombehavioral change models that are specific to theneeds of the individual patient [37] Recommen-dations are directed at either the clinician or thepatient or separate output can be generated foreach party To date expert systems have beenused widely in the arena of health behavior mod-ification such as smoking cessation and weightreduction [38ndash43]

Computerized Decision-Support System for Pain

S157

The purpose of this study was to systematicallyreview the research evidence for CDSSs to addressthe following questions (i) To what extent haveCDSSs been utilized in the context of chronic painmanagement (ii) What are the characteristics ofthese systems and (iii) To what degree have theybeen evaluated and in what types of clinicalsettings

Methods

Data Sources

We conducted an automated literature searchusing the Ovid search engine With the assistanceof a research librarian we searched the followingdatabases MEDLINE (1966 to April 2006)CINAHL (1982 to April 2006) PsychINFO (1967to April 2006) HealthSTAR (1981 to April 2006)EMBASE Cochrane Library Computer andInformation Systems Abstracts Electronics andCommunications Abstracts Proust Digital Disser-tations Computer Retrieval of Informationon Scientific Projects (CRISP) LISA ERICComputer and Information Systems Abstractsand Dissertation Abstracts Key search wordsemployed included the following computer-generated decision support systems and expert sys-tems Additional terms included chronic painprimary care tailored reports personalized com-puter-based information disease management forchronic pain patient goals pain diagnosis andmanagement decision support systems neuralnetworks and fuzzy logic We also conducted amanual search to supplement the automatedsearch The manual search was not limited in timeperiod and included articles that had been refer-enced in other articles

Study Selection Criteria

Eligibility for inclusion in the final set includedany studies describing the development andorapplication of a CDSS or expert system in thecontext of chronic pain management We defineda CDSS as any electronic system designed to assistin clinical decision making regarding chronic painmanagement and in which patient-specific assess-ments and recommendations were generated foruse by a clinician andor patient [44] Consistentwith this definition we excluded any CDSSs thatexamined pain as only one component of an over-all assessment of QOL as well as any thataddressed acute pain management only We alsoexcluded studies that were written in languagesother than English

Results

The cross-database search yielded 70 publishedarticles and three federally funded research studiesdescribing ongoing investigations No additionalstudies were identified via the manual search pro-cess Full-text articles were retrieved for all titlesconsidered to be potentially relevant by theauthors Nine studies describing eight discreteCDSSs were identified as meeting our inclusioncriteria Lack of homogeneity among the final setof studies precluded a quantitative meta-analysisof the data Due to these analytic constraints weconducted a descriptive literature review only

As shown in Table 1 all eight CDSSs weredesigned to assist in the diagnosis andor manage-ment of chronic pain Two of these systems thePain Management Advisor (PMA) and the Diag-nostic Headache Diary were also designed to offereducation to the health care provider One thePMA had an interactive capability that permittedusers to query the system for explanations thera-peutic rationale and therapy guidelines Twoother systems the SymptomReport and thePAIN

ReportIt

featured adjunctive software pro-grams (SymptomConsult PAIN

ConsultN

) thatwere expressly designed as interactive educationaltools for the patient

All but two of the CDSSs were designed totarget a specific type of chronic pain or pain-related condition These included headache (2)low back (1) and cancer-related (3) Input specifi-cations also varied widely both in terms of thetype and amount of data required and in terms ofthe party responsible for data entry (ie physicianother health care provider or patient) All of theCDSSs required detailed input regarding painsymptomology Half of the systems reviewed alsoelicited data on pain medications currently usedand three requested QOL information Otherdata such as psychological status history of priortherapies (both pharmaceutical and nondrug-related therapies) patient goals for pain care andbarriers to pain management were specified asrequired inputs in only two of the CDSSsreviewed Three of the CDSSs used standard psy-chometrically validated instruments (eg McGillPain Questionnaire Medical Outcomes StudyShort Form 36 Oswestry Low Back Pain Disabil-ity Index) to collect input data

The majority of the CDSSs (5 of 8) producedoutput that was intended for clinician use(eg physician or nurse) only Three targetedboth the clinician and the patient Output varied

S158

Smith et al

Tab

le 1

Key

fea

ture

s of

clin

ical

dec

isio

n-su

ppor

t sy

stem

s (C

DS

Ss)

dev

elop

ed f

or c

hron

ic p

ain

man

agem

ent

Nam

e of

CD

SS

Pur

pose

Des

crip

tion

Sta

ge o

fD

evel

opm

ent

Har

dwar

e amp

Sof

twar

eR

equi

rem

ents

Dat

a In

put(

s)O

utpu

t(s)

Targ

et

Rec

ipie

nt(s

)of

Out

put

RH

INO

S [

45]

To a

ssis

t ph

ysic

ians

in t

he d

iagn

osis

of

chro

nic

head

ache

sor

fac

ial p

ain

Bas

ed o

n ex

pert

kno

wle

dge

of h

eada

che

and

faci

alpa

in s

peci

alis

ts U

ses

4 se

ts o

f co

nditi

onal

pr

obab

ility

-bas

ed

rule

s 1

) ex

clus

ive

rule

s (i

e

if pa

tient

has

dis

ease

D

s

he m

ust

have

sym

ptom

s S

1

S

2

S

n

) 2)

incl

usiv

e ru

les

3)

asso

ciat

e ru

les

and

4)

dise

ase

imag

e ru

les

Pro

toty

pe o

nly

no t

estin

gS

yste

m d

evel

oped

usi

ngth

e P

rolo

g-K

AB

Apr

ogra

mm

ing

lang

uage

R

uns

on p

erso

nal

com

pute

rs w

ith C

PU

808

6m

emor

y 38

2 K

byte

s

Phy

sici

an in

put

base

d on

patie

nt in

terv

iew

ndash

Pat

ient

dem

ogra

phic

sndash

Ons

et o

f he

adac

hendash

His

tory

sin

ce o

nset

ndash P

ain

char

acte

ristic

sndash

Neu

rolo

gica

l sig

nsas

soci

ated

with

pai

nndash

Sle

ep s

tatu

sndash

Per

sona

l and

fam

ilial

hist

ory

of h

eada

che

ndash Jo

lt he

adac

he (

Yes

No)

ndash S

cler

osis

of

retin

al a

rter

y

Initi

al o

utpu

t af

ter

first

set

of

scre

enin

g qu

estio

ns

ndash Li

st o

f di

seas

es n

ot r

ejec

ted

Out

put

afte

r ad

ditio

nal

ques

tion(

s)

ndash Li

st o

f po

ssib

le d

isea

ses

ndash D

iagn

ostic

con

clus

ions

ndash E

xpla

natio

n of

the

dis

ease

requ

ired

exam

inat

ions

and

sugg

este

d th

erap

yH

ospi

tal c

hart

can

be

prin

ted

from

the

inpu

t da

ta in

the

form

of

a n

atur

al la

ngua

ge

repr

esen

tatio

n

Phy

sici

ans

IVA

N [

46]

To p

rovi

dere

com

men

datio

nsfo

r co

ntro

lling

pai

nan

d pr

ovid

ing

sym

ptom

rel

ief

inca

ncer

os

teo-

and

rheu

mat

oid

arth

ritis

Cas

e-ba

sed

reas

onin

gst

rate

gy t

o re

cord

and

retr

ieve

info

rmat

ion

stor

edin

an

inte

rnal

kno

wle

dge

base

Pro

toty

pe o

nly

no t

estin

gIV

AN

sof

twar

e w

ritte

n in

LPA

Pro

log

prog

ram

min

gla

ngua

ge fo

r W

indo

ws

(ldquoW

inP

rolo

grdquo)

runs

on

PC

Win

dow

s 95

NT

Win

Pro

log

ndash P

ain

sym

ptom

che

cklis

tndash

Cur

rent

pai

n di

agno

sis

ndash C

urre

nt p

ain

trea

tmen

tre

gim

en

Com

pute

r sc

reen

dis

play

ndash

Dia

gnos

tic c

onfir

mat

ion

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escr

iptio

n of

sym

ptom

s th

atm

ay a

ppea

r la

ter

ndash Tr

eatm

ents

pro

ven

succ

essf

ulin

sim

ilar

or r

elat

ed c

ases

ndash P

ossi

ble

alte

rnat

ive

caus

esof

the

pai

n

Phy

sici

ans

and

patie

nts

The

Dia

gnos

ticH

eada

che

Dia

ry[4

7]

To e

duca

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e di

agno

stic

supp

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rimar

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rovi

ders

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der

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prov

em

anag

emen

t of

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s

Rul

e-ba

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expe

rt s

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mus

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lean

logi

c A

set

of d

iagn

ostic

rul

es u

sed

tode

term

ine

a di

agno

sis

base

dup

on t

he d

ata

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red

inpa

tient

dia

ry D

iary

dat

a ar

etr

ansf

orm

ed in

to a

dia

gnos

isfo

llow

ing

the

Inte

rnat

iona

lH

eada

che

Soc

iety

rsquoscl

assi

ficat

ion

Pro

toty

pede

velo

ped

syst

em-g

ener

ated

diag

nose

s w

ere

valid

ated

aga

inst

phys

icia

n ex

pert

-ge

nera

ted

diag

nose

s

Sta

nd-a

lone

Win

dow

s 95

prog

ram

writ

ten

in D

elph

ipr

ogra

mm

ing

lang

uage

ndash P

atie

nt d

ata

ndash H

eada

che

diar

y en

trie

sndash

Med

icat

ions

use

d to

alle

viat

e he

adac

he

ndash D

iagn

osis

of

head

ache

typ

eP

CP

s

Pai

n M

anag

emen

tA

dvis

or (

PM

A)

(Nov

aInt

ellig

ence

Inc

S

an D

iego

C

A)

[48]

To e

nhan

ce p

rimar

yca

re p

rovi

ders

rsquo(P

CP

s) m

anag

emen

tof

chr

onic

pai

n

ndash R

elie

s on

rul

e-ba

sed

algo

rithm

s de

rived

fro

mex

pert

kno

wle

dge

ofpa

in s

peci

alis

tsndash

Use

r as

ked

a se

ries

ofqu

estio

ns t

o re

fine

the

diag

nosi

s an

d de

term

ine

appr

opria

te t

hera

pyndash

Inte

ract

ive

capa

bilit

y(e

g

for

expl

anat

ions

th

erap

eutic

rat

iona

les

ther

apy

guid

elin

es)

Wor

king

ver

sion

deve

lope

d s

ome

field

tes

ting

cond

ucte

d

ndash P

entiu

m-b

ased

PC

sndash

Win

dow

s 95

ndash P

MA

writ

ten

inM

icro

Sof

t Vis

ual B

asic

v

50

ru

n as

an

expe

rtap

plic

atio

n in

Xpe

rtR

ule

ndash A

lgor

ithm

s st

ored

inM

icro

Sof

t A

cces

s da

taba

sendash

Mic

roS

oft

Hel

p U

tility

used

for

expl

anat

ions

and

quer

ies

ndash P

atie

nt d

emog

raph

ics

ndash D

iagn

osis

ndash P

ain

char

acte

ristic

sndash

Labo

rato

ry t

ests

ampim

agin

g st

udie

sndash

Cur

rent

med

icat

ions

ndash P

rior

ther

apie

sndash

Con

curr

ent

dise

ase

cond

ition

sndash

Alle

rgie

sndash

Psy

chol

ogic

al s

tatu

s

ndash A

prio

ritiz

ed li

st o

fre

com

men

datio

ns 1

) m

edic

alm

anag

emen

t (p

harm

acol

ogic

and

nonp

harm

acol

ogic

alm

anag

emen

t ph

ysic

al

psyc

hoso

cial

mod

aliti

es)

2)in

vasi

ve p

roce

dure

s 3

) re

ferr

als

PC

Ps

Computerized Decision-Support System for Pain

S159

Sym

ptom

Rep

ort

and

Sym

ptom

Con

sult

[49]

To a

ssis

t cl

inic

ians

in a

sses

sing

can

cer-

rela

ted

chro

nic

pain

and

fatig

ue

and

clar

ify p

atie

ntsrsquo

mis

belie

fs a

bout

pain

ass

essm

ent

and

man

agem

ent

Not

des

crib

edW

orki

ng v

ersi

onde

velo

ped

fiel

dte

stin

g co

nduc

ted

Mic

roS

oft W

indo

ws

959

8pe

rson

al c

ompu

ters

with

touc

h sc

reen

(P

en-T

ab)

Pat

ient

sel

f-re

port

ed in

put

ndash P

atie

nt d

emog

raph

ics

ndash 19

70 v

ersi

on o

f M

cGill

Pai

n Q

uest

ionn

aire

(M

PQ

)ndash

Bar

riers

Que

stio

nnai

re(B

Q)

ndash S

chw

artz

can

cer

fatig

uesc

ale

(SC

FS

-6)

1) H

ard

copi

es o

f ex

pert

sys

tem

repo

rt g

iven

to

patie

nt a

nd t

ocl

inic

ian

2) P

atie

nt r

ecei

ves

educ

atio

nal

mat

eria

ls o

n ho

w t

o re

port

pa

in

use

pain

med

icat

ions

sa

fely

an

d m

anag

e fa

tigue

M

ater

ials

are

cus

tom

ized

to

the

patie

ntrsquos

nee

ds a

nd

pres

ente

d in

an

inte

ract

ive

m

ultim

edia

form

at P

atie

nts

have

opt

ion

to re

ad o

r lis

ten

to

info

rmat

ion

on t

he c

ompu

ter

prin

t an

y or

all

of t

he

mat

eria

ls

or d

o bo

th

Onc

olog

ynu

rses

ot

her

clin

icia

ns

Dec

isio

n-su

ppor

tco

mpu

ter

prog

ram

for

canc

er p

ain

man

agem

ent

[50]

To im

prov

e th

eon

colo

gy n

urse

srsquode

cisi

on m

akin

gre

late

d to

can

cer

pain

man

agem

ent

amon

g cu

ltura

llydi

vers

e fe

mal

eon

colo

gy p

atie

nts

ndash S

urve

y da

ta o

n m

ultic

ultu

ral

canc

er p

ain

char

acte

ristic

sw

ere

anal

yzed

usi

ng f

uzzy

infe

renc

e lo

gic

to d

evel

op 4

mod

ules

1)

a ge

neric

know

ledg

e ba

se 2

) a

cultu

re-s

peci

fic k

now

ledg

e ba

se 3

) de

cisi

on-m

akin

g

and

4) s

elf-

adap

tatio

nndash

Dec

isio

n-m

akin

g m

odul

eco

nsis

ts o

f 2

sets

of

fuzz

yin

fere

nce

logi

c de

velo

ped

via

a ge

netic

alg

orith

m

Har

dwar

e no

t de

scrib

edndash

Ada

ptiv

e fu

zzy

logi

cso

ftwar

e us

ed t

o de

velo

pan

d ru

n th

e kn

owle

dge

base

gen

erat

ion

and

the

deci

sion

-mak

ing

and

self-

adap

tatio

n m

odul

es

Nur

se-e

nter

ed d

ata

base

don

pat

ient

inte

rvie

w

ndash P

atie

nt d

emog

raph

ics

ndash P

ain

char

acte

ristic

s

Com

pute

r sc

reen

dis

play

of

anal

gesi

c tr

eatm

ent

reco

mm

enda

tions

bas

ed o

n th

eW

orld

Hea

lth O

rgan

izat

ion

(WH

O)rsquos

ana

lges

ic la

dder

Onc

olog

ynu

rses

PAIN

Rep

or

tIt a

ndPA

IN

Con

sultN

[51

52]

To a

ssis

t cl

inic

ians

in a

sses

sing

chr

onic

pain

and

to

educ

ate

patie

nts

rega

rdin

gpa

in m

onito

ring

and

man

agem

ent

Not

des

crib

edW

orki

ng v

ersi

onde

velo

ped

fiel

dte

stin

g co

nduc

ted

Mic

roS

oft W

indo

ws

959

8pe

rson

al c

ompu

ters

with

touc

h sc

reen

(P

en-T

ab)

data

sto

red

in A

cces

s 97

data

base

Pat

ient

sel

f-re

port

ed in

put

1)

Pat

ient

dem

ogra

phic

sndash

McG

ill P

ain

Que

stio

nnai

rendash

Pai

n st

atus

ndash P

atie

nt g

oals

for

and

expe

ctat

ions

abo

ut p

ain

ndash Ty

pe a

nd e

ffect

iven

ess

of p

revi

ous

pain

trea

tmen

ts

Har

d co

pies

of

expe

rt s

yste

mre

port

giv

en t

o pa

tient

and

to

clin

icia

n o

n-sc

reen

vie

win

g of

repo

rt is

als

o po

ssib

le

Onc

olog

ynu

rses

and

othe

rcl

inic

ians

Touc

h-sc

reen

Com

pute

rA

sses

smen

t of

Chr

onic

Low

Bac

k P

ain

[53]

To c

olle

ct p

ain

sym

ptom

sta

tus

and

othe

r he

alth

info

rmat

ion

from

patie

nts

with

low

back

pai

n

Not

des

crib

edW

orki

ng v

ersi

onde

velo

ped

lim

ited

field

tes

ting

Web

-bas

ed s

yste

m u

sing

Del

l Ins

piro

n 11

00 la

ptop

with

Mic

roso

ft X

P o

pera

ting

syst

em 1

4

prime

tou

ch s

cree

n(M

agic

Tou

ch

Key

tec)

ndash P

atie

nt d

emog

raph

ics

ndash O

swes

try

Low

Bac

k P

ain

Dis

abili

ty I

ndex

(V

ersi

on 2

)ndash

Bec

k D

epre

ssio

n In

vent

ory

ndash M

OS

Sho

rt F

orm

-36

(MO

S S

F-3

6)

Not

des

crib

edP

hysi

cian

s

Nam

e of

CD

SS

Pur

pose

Des

crip

tion

Sta

ge o

fD

evel

opm

ent

Har

dwar

e amp

Sof

twar

eR

equi

rem

ents

Dat

a In

put(

s)O

utpu

t(s)

Targ

et

Rec

ipie

nt(s

)of

Out

put

S160

Smith et al

considerably in terms of content format anddelivery (eg electronic paper or both) SeveralCDSSs scored and summated patient responseson standard pain and QOL-related assessmentmeasures Based on the published descriptions atleast five of the CDSSs were designed to gener-ate output in real time at the patientrsquos medicalvisit

In terms of systems architecture all CDSSsreviewed were stand-alone personal computer-based systems None interfaced with existingelectronic medical records systems pharmacyappointment scheduling or laboratory resultsreporting Three either were Web-based or hadthe capacity to use a Web-based platform

Table 2 summarizes the types of studies con-ducted to date to evaluate chronic pain CDSSs Ofthe eight CDSSs identified five had publishedevaluation results With one exception all werefeasibility studies exclusively Studies were con-ducted in both inpatient and outpatient settingsAmong the outpatient studies two had been con-ducted with PCPs the remainder involved special-ists in tertiary care settings Study designs used forevaluating these CDSSs varied two were cross-sectional two involved immediate pre- and post-assessments of CDSS use one was longitudinal(12-month follow-up) and one was a focus groupStudy sample sizes ranged from 213 to 4 with themajority having 50 or fewer subjects

Patient acceptability of the CDSS was the sin-gle most commonly assessed variable Evaluationsof both the SymptomReport and the PAIN

Report-It

employed a common tool to assess patientacceptability Results across four pilot testsinvolving a total of 254 subjects consistentlyshowed high acceptability of these two CDSSsand 100 completion rates in terms of data input[495152] The average amount of time requiredranged from a high of 38 minutes to a low of14 minutes

Two studies addressed the issue of medicalaccuracy of the system-generated recommenda-tion Both studies examined this issue by compar-ing system-generated diagnoses andor treatmentrecommendations with those generated by physi-cian experts based on a select sample of patientcases Results showed moderate to high agreementbetween the system- and expert-generated recom-mendations [4748]

Clinician perceptions concerning ease of useand value of a CDSS for chronic pain managementwere examined in two studies Overall physiciansfound the system to be moderately easy to use and

of some clinical worth [4852] Knab and col-leagues [48] reported that the average cliniciantime spent per case on the PMA to obtain outputwas approximately 5 minutes (

plusmn

34 minutes) [48]In addition 85 of physicians adopted the PMA-generated recommendations and 25 of thestudy patients seen were referred to a pain special-ist with the average time to referral being37 months (

plusmn

06 months) [48]Analyses concerning the impact of CDSSs on

patient outcomes were limited Huang and col-leagues [51] assessed changes in pain intensity pre-and post-CDSS use in a sample of radiationoncology clinic patients Although there was adownward trend in pain levels over time resultswere not statistically significant possibly dueto the small size of the sample (N

=

15) Wilkieand colleagues [4952] reported qualitative dataregarding the impact of the SymptomReport andthe PAIN

ReportIt

on patient behavior Resultswere contradictory Of the 41 outpatients whoused the SymptomReport approximately 68stated that it had not affected their pain-relatedcommunication Some however felt that theytalked more precisely and explicitly about theirpain as a result of using it Other comments asso-ciated with use of the SymptomReport includedan increased awareness of pain symptoms andgreater compliance with pain symptom manage-ment In contrast 86 of users of the PAIN-

ReportIt

cited it as beneficial for patientndashdoctorpain-related communication and that it ldquofreedthem to describe their painrdquo

Discussion

Over the past two decades there has been a gradualbut steady growth in research on the use of CDSSsfor chronic pain management To date the numberof such systems is small but expanding Advanceshave also been evident in terms of both the quantityand quality of evaluation studies conducted Whilethe earliest versions were presented in the litera-ture as prototypes only [4546] CDSSs developedsince 2001 have all undergone some form of fieldtesting The majority of these studies howeverhave been nonexperimental in design and focusedexclusively on process measures such as patientor clinician ratings of system acceptability andusability Other salient process measures such asthe degree to which the clinician andor patientactually reviewed and utilized system output orhad confidence in its accuracy have not been con-sistently assessed Poor usability and practitioner

Computerized Decision-Support System for Pain

S161

Tab

le 2

Eva

luat

ion

of c

ompu

teri

zed

deci

sion

-sup

port

sys

tem

s (C

DS

Ss)

in c

hron

ic p

ain

man

agem

ent

Stu

dyN

ame

of C

DS

SS

ampl

eD

esig

nO

utco

mes

Ass

esse

dR

esul

ts

Nie

lsen

et a

l

[47

]D

iagn

ostic

Hea

dach

eD

iary

PC

Ps

Not

des

crib

edndash

a

gree

men

t of c

ompu

ter-

gene

rate

d vs

exp

ert

phys

icia

n di

agno

ses

ndash 10

0 a

gree

men

t of c

ompu

ter-

gene

rate

d vs

ex

pert

phy

sici

an d

iagn

oses

Kna

b et

al

[48

]P

ain

Man

agem

ent

Adv

isor

N

=

50

PC

Ps

N

=

50

chro

nic

pain

pat

ient

sLo

ngitu

dina

l w

ith 1

2-m

onth

PC

P fo

llow

-up

ndash E

ase

of u

sendash

Med

ical

app

ropr

iate

ness

of

reco

mm

enda

tions

ndash

phy

sici

ansrsquo

ado

ptin

g P

ain

Man

agem

ent

Adv

isor

tre

atm

ent

reco

mm

enda

tions

ndash

pat

ient

s re

ferr

ed t

o pa

insp

ecia

lty c

linic

Phy

sici

an a

dopt

ion

of s

yste

m-g

ener

ated

re

com

men

datio

ns 8

5 o

f ca

ses

Ave

rage

phy

sici

an t

ime

spen

t pe

r ca

se

49

min

utes

(S

D

plusmn

34)

Eas

e of

use

as

rate

d by

phy

sici

ans

42

(

plusmn

28

cm)

on s

cale

of

1ndash10

25

of

patie

nts

refe

rred

to

pain

spe

cial

ty

clin

icA

vera

ge t

ime

to p

ain

spec

ialty

ref

erra

l 3

7 m

onth

s (S

D

plusmn

06)

ndash 70

o

f no

nref

erre

d pa

tient

s st

ill r

ecei

ving

co

mpu

ter-

reco

mm

ende

d tr

eatm

ent

1 ye

ar

post

Wilk

ie e

t al

[49

]S

ympt

omR

epor

tN

=

41

outp

atie

nts

with

can

cer

Cro

ss-s

ectio

nal

tele

phon

e in

terv

iew

sndash

13-it

em p

atie

nt a

ccep

tabi

lity

scal

e as

sess

ing

ease

of

use

ofS

ympt

omR

epor

tndash

Inpu

t co

mpl

etio

n tim

endash

Qua

litat

ive

asse

ssm

ent

of d

egre

eof

com

mun

icat

ion

with

hea

lth c

are

prov

ider

s re

gard

ing

pain

and

oth

ersy

mpt

oms

ndash M

ean

time

to c

ompl

ete

Sym

ptom

Rep

ort

382

min

utes

(S

D

plusmn

202

)ndash

Mea

n tim

e to

com

plet

e S

ympt

omC

onsu

lt

209

min

utes

(S

D

plusmn

18

6)ndash

71

of

part

icip

ants

rat

ed S

ympt

omR

epor

t as

eas

y e

njoy

able

an

d in

form

ativ

endash

68

rep

orte

d th

at th

e am

ount

and

con

tent

of

the

ir pa

in-r

elat

ed c

omm

unic

atio

n w

ith

thei

r do

ctor

had

not

cha

nged

muc

hndash

Qua

litat

ive

patie

nt c

omm

ents

1)

help

ed

them

tal

k m

ore

expl

icitl

y ab

out

pain

2)

gave

the

m g

reat

er a

war

enes

s of

pai

n sy

mpt

oms

3)

incr

ease

d un

ders

tand

ing

of

and

enha

nced

com

plia

nce

rega

rdin

g sy

mpt

om m

anag

emen

t ndash

Pat

ient

com

men

ts r

e S

ympt

omC

onsu

lt 1

) co

ntai

ned

too

muc

h in

form

atio

n 2

) no

t ta

rget

ed t

o in

divi

dual

nee

ds (

3) p

rovi

ded

no n

ew in

form

atio

n

Wilk

ie e

t al

[52

]PA

IN

Rep

ortIt

N

=

213

of

who

m 1

06w

ere

canc

er in

patie

nts

10 m

etas

tatic

can

cer

outp

atie

nts

and

97

wer

e in

divi

dual

sex

perie

ncin

g ac

ute

orch

roni

c pa

in r

ecru

ited

from

non

heal

th c

are

setti

ngs

Des

crip

tive

cro

ss-

sect

iona

l stu

dy in

3se

tting

s 1

) te

rtia

ryca

re

2) r

adia

tion

onco

logy

clin

ic

3)m

obile

clin

ic

ndash 13

-item

sca

le m

easu

ring

acce

ptab

ility

of

PAIN

Rep

ortIt

(ie

tim

e to

com

plet

e e

ase

of u

se

unde

rsta

ndab

ility

of

dire

ctio

ns

ergo

nom

ic e

lem

ents

of

syst

em

and

com

plet

enes

s of

res

pons

es)

ndash 86

o

f res

pond

ents

rate

d th

e PA

IN

Rep

ortIt

as

ben

efici

al f

or p

ain

com

mun

icat

ion

ndash 10

0 p

atie

nt c

ompl

etio

n ra

te o

f PA

IN

Rep

ortIt

ndash M

ean

time

to p

atie

nt

com

plet

ion

15

8 m

inut

es (

SD

plusmn

67

)ndash

Mea

n pa

tient

acc

epta

bilit

y sc

ore

11

7 (S

D

plusmn

16

) sc

ores

ran

ged

from

6 t

o 13

80

o

f pa

tient

s ra

ted

acce

ptab

ility

as

grea

ter

than

min

imum

crit

erio

n of

10

ndash U

ser

com

men

ts 1

) so

me

mec

hani

cal

diffi

culti

es 2

) re

activ

ity t

o us

e of

sys

tem

(e

g

vom

iting

) 3)

pre

fere

nce

to r

elay

info

rmat

ion

dire

ctly

to

prov

ider

PC

P p

rimar

y ca

re p

hysi

cian

S162

Smith et al

Hua

ng e

t al

[51

]PA

IN

Rep

ortIt

and

PAIN

Con

sultN

Pilo

t st

udy

1 N

=

9pa

tient

s w

ith b

one

met

asta

sis-

rela

ted

pain

Pilo

t st

udy

2 N

=

15

patie

nts

with

can

cer

and

bone

met

asta

sis

Phy

sici

an fo

cus

grou

pN

=

4 r

adia

tion

onco

logi

sts

1) P

ilot

test

1

Fea

sibi

lity

stud

y us

ing

a te

stndashr

etes

t w

ithin

-su

bjec

t de

sign

2) P

ilot

test

2

Fea

sibi

lity

stud

y us

ing

an 1

1-da

y te

stndashr

etes

tw

ithin

-sub

ject

des

ign

3) P

hysi

cian

focu

sgr

oup

Out

com

e m

easu

res

used

for

both

pilo

t st

udie

sndash

Acc

epta

bilit

yndash

Com

plet

enes

sndash

Tim

e to

com

plet

endash

Val

idity

Phy

sici

an fo

cus

grou

pndash

Rec

eptiv

ity t

o PA

IN

Rep

ortIt

and

PAIN

Con

sultN

Pilo

t st

udy

1

ndashM

ean

time

to c

ompl

ete

PAIN

Rep

ortIt

at

pret

est

12 m

inut

es (

SD

plusmn

4)

ndashT

ime

to c

ompl

ete

PAIN

Rep

ortIt

at

post

-te

st 1

ndash7 m

inut

es p

er p

atie

ntndash

Mea

n ac

cept

abili

ty s

core

11

2 (S

D

plusmn

18

)ndash

100

com

plet

ion

rate

Pilo

t st

udy

2ndash

Mea

n tim

e to

com

plet

e PA

IN

Rep

ortIt

at

pret

est

17 m

inut

es (

SD

plusmn

6)

ndashT

ime

to c

ompl

ete

PAIN

Rep

ortIt

at p

ostte

st

14 m

inut

es (

SD

plusmn

8)

ndashM

ean

acce

ptab

ility

sco

re 1

22

(SD

plusmn

13

)ndash

100

com

plet

ion

rate

ndashPA

IN

Con

sultN

rec

omm

ende

d a

med

ian

of

4 dr

ugs

phy

sici

ans

pres

crib

ed a

med

ian

of

3 dr

ugs

post

use

ndashP

atie

nt p

ain

inte

nsity

ave

rage

4 a

t bas

elin

e an

d 2

7 at

pos

ttest

(no

t si

gnifi

cant

)

Foc

us g

roup

ndashP

hysi

cian

s sa

w v

alue

of

PAIN

Rep

ortIt

1)

incr

ease

d ef

ficie

ncy

durin

g cl

inic

vis

it 2

) su

pple

men

ted

pain

ser

vice

con

sulta

tion

3)

prov

ided

out

com

e da

tandash

PAIN

Con

sultN

was

vie

wed

as

clin

ical

ad

junc

t bu

t fo

rmat

ting

need

ed

impr

ovem

ent

Koe

stle

r et

al

[53

]To

uch-

scre

en C

ompu

ter

Ass

essm

ent

of C

hron

icLo

w B

ack

Pai

n

N

=

30

low

bac

kpa

in p

atie

nts

Cro

ss-s

ectio

nal d

esig

nin

ter

tiary

car

e cl

inic

ndashP

atie

nt-r

atin

gs o

f er

gono

mic

desi

gn d

egre

e of

tec

hnic

aldi

fficu

lties

ac

cept

abili

ty

ease

of u

se d

ata

secu

rity

ndashM

ean

time

to c

ompl

ete

the

67-it

em t

ouch

sc

reen

27

4 m

inut

es (

SD

plusmn

138

)

Stu

dyN

ame

of C

DS

SS

ampl

eD

esig

nO

utco

mes

Ass

esse

dR

esul

ts

PC

P p

rimar

y ca

re p

hysi

cian

Tab

le 2

Con

tinue

d

Computerized Decision-Support System for Pain

S163

nonacceptance of computer recommendations canserve as significant barriers to system adoption inroutine clinical practice [365455]

User preferences regarding the presentation ofcomputer output including content formatting(eg color graphics) and length have not beensolicited in most instances either Similarly thereare few published data concerning technical diffi-culties (eg type and number of system crashes ortouch-screen calibration problems) encounteredby CDSS users Both issues have important rami-fications for future system refinements [52] Addi-tionally there is a paucity of information oncontextual circumstances (eg presence of a localldquochampionrdquo of the system) or the processes usedto integrate the CDSS into the existing clinicalworkflow key considerations for successful systemimplementation Not least testing has been con-fined almost exclusively to either inpatient ortertiary care settings with only two studies con-ducted in the primary care context to date

The effects of these systems on patient out-comes remain understudied Two studies reportedqualitative data concerning CDSS impact onpatientsrsquo perceived pain-related communicationwith their physician however sample sizes weresmall and results inconsistent [4952] One studyreported system impact on patient pain intensitylevel over time but the study lacked adequate sta-tistical power to detect clinically important differ-ences [52] Other major patient outcomes such ashealth care utilization health care costs painrelief pain medication usage communication withhealth care provider about pain functional statusand QOL have not been examined One studyreported evidence that CDSS use may invokepatient reactivity (eg vomiting intensified painsymptoms) Potential adverse effects on patientsshould be measured in future investigations [52]Similarly there is need for more extensive andconsistent examination of system impact on clini-cian pain management performance

While we sought to be as comprehensive aspossible in our literature search our review wasrestricted to only English-language studies Inaddition it is possible that there are other CDSSsunder development that we failed to identify Thelimited size of the available literature as well asthe methods used in these primary studies pre-vented us from conducting a meta-analysis ofresearch findings and from reaching more defin-itive conclusions about the impact of these systemson physician performance and patient pain func-tioning and other aspects of QOL Notably in all

the studies we examined study investigators andCDSS developers were one and the same a factthat may have resulted in more positive findings[36] Lastly we did not conduct a separate evalu-ation of the clinical appropriateness of either theCDSS algorithms or treatment recommendationsnor of the underlying logic employed to generatesuch algorithms

The potential for these computer-based sys-tems to improve the quality of chronic pain man-agement in the primary care context is substantialTo manage chronic pain effectively PCPs firstneed to conduct a comprehensive patient assess-ment [56] Information on the patientrsquos pain ex-perience history of and preferences for paintreatment psychological status approach to self-management and personal goalspriorities are keyvariables to collect during assessment as they arecritical for making an accurate diagnosis and fordeveloping an appropriate treatment plan to whichthe patient will adhere [56] An expert system-typeCDSS provides a way to elicit and integrate suchpatient-specific information in a manner that isconvenient and timely for both physicians andpatients Moreover the ensuing system-generatedrecommendations are individualized to the needsand circumstances of the specific pain patient perbest clinical practices [56]

CDSSs developed for chronic pain manage-ment have as yet however to fulfill this promiseAs our review indicates systems developed thus farhave been predominantly biomedical in focus anddesigned to assist physicians and other health careproviders in the medical management of painsymptoms (including invasive procedures andreferrals) exclusively Only a few of these systemshave reached a sufficiently advanced stage ofdevelopment to warrant more rigorous testingin large-scale randomized controlled trials[264952] Such trials are imperative for under-standing system effect on provider performanceand patient outcomes

Significantly none of the systems reviewedwere integrated with existing electronic recordssystems nor did they include reminder or docu-mentation functionalities features which have allbeen shown to increase the likelihood of physicianadoption [5758] This lack of integration mayreflect the fact that widespread adoption of elec-tronic records systems by health care institutionshas been a relatively recent occurrence Potentiallythis trend coupled with pressures from majoraccrediting agencies to document the provision ofpain screening and treatment along with the

S164

Smith et al

recent publication of primary care pain manage-ment guidelines may serve to spur additionalmore rigorous research on the use of CDSSs forchronic pain management in primary care[565960] Demonstrating the clinical value ofthese systems is a critical step in convincing healthcare organizations and clinicians that the benefitsof investing in a CDSS for pain management out-weigh potential risks In particular physiciansneed to be assured that this type of system canenhance rather than erode their decision-makingabilities and that time spent learning how to usea CDSS yields measurable improvement in patienthealth and well-being

References

1 American Pain Society Chronic pain in AmericaRoadblock to relief 1999 American Pain SocietyAPS News and Announcements Available at httpwwwampainsocorgwhatsnewtoc_roadhtmtoc

2 Lande SD The problem of pain in managed careIn Lande SD Kulich RJ eds Managed Care andPain Glenview IL American Pain Society 200019

3 Turner JA Leresche L Von Korff M Ehrlich LPrimary care back pain patient characteristics visitcontent and short term outcomes Spine199823463ndash9

4 Von Korff M Gruman J Schaefer J Curry SJ Wag-ner EH Collaborative management of chronic ill-ness Ann Intern Med 1997127(12)1097ndash102

5 Von Korff M Pain management in primary care Anindividualized stepped-care approach In GatchelRJ Turk DL eds Psychosocial Factors in PainCritical Perspectives New York The GuilfordPress 1999

6 Von Korff M Katon W Bush T et al Treatmentcosts cost offset and cost-effectiveness of collabo-rative management of depression Psychosom Med199860(2)143ndash9

7 Bertakis KD Azari R Callahan EJ Patient pain Itsinfluence on primary care physicianndashpatient inter-action Fam Med 200335(2)119ndash23

8 Green CR Wheeler JRC Laporte F Marchant BGuerrero E How well is chronic pain managedWho does it well Pain Med 20023(1)56ndash62

9 Von Roenn JH Cleeland CS Gonin R HatfieldAK Pandya KJ Physician attitudes and practice incancer pain management A survey from the EasternCooperative Oncology Group Ann Intern Med1993119121ndash6

10 Cleeland CS Cleeland LM Dar R Rinehardt LCFactors influencing physician management of can-cer pain Cancer 198658796ndash800

11 Fife BL Irick N Painter JD A comparative studyof the attitudes of physicians and nurses towards themanagement of cancer pain J Pain Symptom Man-age 19938132ndash9

12 Wilson JF Brockoop GW Kryst S Steger H WittWO Medical studentsrsquo attitudes towards painbefore and after a brief course on pain Pain199250251ndash6

13 Weinstein SM Laux LF Thornby JI et al Physi-ciansrsquo attitudes towards pain and the use of opioidanalgesics Results of a survey from the Texas Can-cer Pain Initiative South Med J 200093(5)479ndash87

14 Weinstein SM Laux LF Thornby JI et al Medicalstudentsrsquo attitudes towards pain and the use of opi-oid analgesics Implications for changing medicalschool curriculum South Med J 200093(5)472ndash8

15 Whedon M Ferrell BR Professional and ethicalconsiderations in the use of high-tech pain manage-ment Oncol Nurs Forum 1991181135ndash43

16 Ward S Goldberg N Miller-Mccauley V et alPatient-related barriers to management of cancerpain Pain 199352319ndash24

17 Pargeon KL Hailey BJ Barriers to effective cancerpain management A review of the literature J PainSymptom Manage 199918358ndash68

18 Breitbart W Passik S Mcdonald MV et al Patient-related barriers to pain management in ambulatoryAIDS patients Pain 199352319ndash24

19 Gunnarsdottir S Donovan HS Serlin RC Voge CWard S Patient-related barriers to pain manage-ment The barriers questionnaire II (BQ-II) Pain200299385ndash96

20 Arora NK Interacting with cancer patients Thesignificance of physiciansrsquo communication behaviorSoc Sci Med 200357791ndash806

21 Mccaffery M Thorpe DM Differences in percep-tion of pain and the development of adversarial rela-tionships among health care providers In Hill CSFields W eds Advances in Pain Research and Ther-apy Drug Treatment of Cancer Pain in a Drug-Oriented Society Vol 11 New York Raven Press1989

22 Ong LML de Haes JCJM Hoos AM Lammes FBDoctorndashpatient communication A review of the lit-erature Soc Sci Med 199540903ndash18

23 Jones WL Rimer BK Levy MH Kinman JL Can-cer patientsrsquo knowledge beliefs and behaviorregarding pain control regimens Implications foreducation programs Patient Educ Couns19845(4)159ndash64

24 Lukoschek P Fazzari M Marantz P Patient andphysician factors predict patientsrsquo comprehensionof health information Patient Educ Couns200350201ndash10

25 Donovan JL Blake DR Patient non-complianceDeviance or reasoned decision-making Soc SciMed 199234377ndash94

26 Garg AX Adhikari NKJ Mcdonald H et al Effectsof computerized clinical decision support systemson practitioner performance and patient outcomesa systematic review JAMA 2005293(10)1223ndash38

27 Nilasena DS Lincoln MJ A computer-generatedreminder system improves physician compliance

S156

Smith et al

the most appropriate and cost-effective way totreat chronic pain and is moreover the approachmost often preferred by both patients and healthcare providers [2ndash6]

In reality however deficits in physiciansrsquotraining and knowledge regarding pain manage-ment coupled with time constraints during theprimary care visit frequently prevent PCPs frommeeting these dual clinical and psychosocialexpectations [57ndash15] PCPs commonly focusmore on technical aspects of care when treatingchronic pain patients and less on promotingpatient self-management behaviors [7] In addi-tion doctorndashpatient communication regardingpain is frequently inadequate [16ndash19] Conse-quently physiciansrsquo perceptions of patient painare often incongruent with patientsrsquo self-ratingstreatment goals are frequently developed withoutpatient input and patient adherence to treatmentplans is less than optimal [20ndash25]

Faced with declining reimbursement rates fromboth public and private payers physicians need analternative that enables them to reconcile the twinimperatives of providing high-quality pain carewhile maximizing efficiency in their clinicalpractice Computerized decision-support sys-tems (CDSSs) offer one potential solution tothis dilemma CDSSs are information systemsdesigned to enhance the quality of clinical decisionmaking and to minimize deviations in clinical per-formance from accepted professional standards[26] Individual patient data are entered into thesystem whereupon predetermined algorithmsguided by a resident logic library of expert-basedclinical data generate patient-specific recommen-dations [26] Data can be collected via a personalcomputer or a handheld device such as a palmpilot Typically output is available in real time foruse during the medical visit

The process involved in using a CDSS based onpersonal computer technology is illustrated as fol-lows Upon arrival at a medical appointment apatient is directed to a computer workstationequipped with a laptop stylus and printer Fol-lowing instructions on the computer screen thepatient completes an electronic questionnaire con-taining the following types of items current painstatus (eg intensity location duration) past andpresent pain treatment regimens degree of adher-ence to prescribed pain medication side effects ofcurrent medication risk factors for opioid abuseimpact of pain on respondentsrsquo quality of life(QOL) psychological status pain-related copingand self-management strategies type and degree

of social support personal goals for daily livingand (for initial visit only) demographic informa-tion The data collected are automatically storedelectronically and then run through a series ofalgorithms In the final step a report is generated(electronically in hard-copy format or both) thatcontains a synopsis of the patientrsquos pain statusrecommendations as to possible improvements inthe current pain treatment regimen key issues todiscuss with the patient (eg problems with med-ication adherence or side effects signs of depres-sion) and a list of patient-targeted suggestionsdesigned to encourage pain self-management (egrecommendations to pursue a specific exerciseregimen)

Both the type and application of CDSSs havebeen expanding rapidly in recent years To dateCDSSs have been used to diagnose a variety ofmedical conditions to enhance the provision ofpreventive care (eg cancer screening vaccina-tion) to facilitate disease management and toassist with drug prescribing [27ndash32] Evidencesuggests that CDSSs can improve health carepractitioner performance and patient outcomesparticularly in the areas of vaccinations tetanusimmunizations breast cancer screening colorectalcancer screening cardiovascular risk reductionand smoking cessation [2633ndash36]

CDSSs can be designed not only to provideclinical guidance but to capture and integratepatientsrsquo perspective on their illness and to pro-mote positive patient health-related behaviorsSometimes referred to as ldquoexpert systemsrdquo thisvariant of a CDSS is particularly promising foruse in the clinical management of chronic painfor two reasons (i) pain is a highly subjectiveexperience hence patient-reported data areessential to obtain and (ii) successful outcomesof pain management are at least equally if notmore dependent on appropriate self-care (egself-monitoring of pain adherence to prescribedmedications regular exercise weight control)than on the quality of the clinical diagnosis orrecommended therapeutic regimen [5] Based onthe data entered the expert system producestailored recommendations often derived frombehavioral change models that are specific to theneeds of the individual patient [37] Recommen-dations are directed at either the clinician or thepatient or separate output can be generated foreach party To date expert systems have beenused widely in the arena of health behavior mod-ification such as smoking cessation and weightreduction [38ndash43]

Computerized Decision-Support System for Pain

S157

The purpose of this study was to systematicallyreview the research evidence for CDSSs to addressthe following questions (i) To what extent haveCDSSs been utilized in the context of chronic painmanagement (ii) What are the characteristics ofthese systems and (iii) To what degree have theybeen evaluated and in what types of clinicalsettings

Methods

Data Sources

We conducted an automated literature searchusing the Ovid search engine With the assistanceof a research librarian we searched the followingdatabases MEDLINE (1966 to April 2006)CINAHL (1982 to April 2006) PsychINFO (1967to April 2006) HealthSTAR (1981 to April 2006)EMBASE Cochrane Library Computer andInformation Systems Abstracts Electronics andCommunications Abstracts Proust Digital Disser-tations Computer Retrieval of Informationon Scientific Projects (CRISP) LISA ERICComputer and Information Systems Abstractsand Dissertation Abstracts Key search wordsemployed included the following computer-generated decision support systems and expert sys-tems Additional terms included chronic painprimary care tailored reports personalized com-puter-based information disease management forchronic pain patient goals pain diagnosis andmanagement decision support systems neuralnetworks and fuzzy logic We also conducted amanual search to supplement the automatedsearch The manual search was not limited in timeperiod and included articles that had been refer-enced in other articles

Study Selection Criteria

Eligibility for inclusion in the final set includedany studies describing the development andorapplication of a CDSS or expert system in thecontext of chronic pain management We defineda CDSS as any electronic system designed to assistin clinical decision making regarding chronic painmanagement and in which patient-specific assess-ments and recommendations were generated foruse by a clinician andor patient [44] Consistentwith this definition we excluded any CDSSs thatexamined pain as only one component of an over-all assessment of QOL as well as any thataddressed acute pain management only We alsoexcluded studies that were written in languagesother than English

Results

The cross-database search yielded 70 publishedarticles and three federally funded research studiesdescribing ongoing investigations No additionalstudies were identified via the manual search pro-cess Full-text articles were retrieved for all titlesconsidered to be potentially relevant by theauthors Nine studies describing eight discreteCDSSs were identified as meeting our inclusioncriteria Lack of homogeneity among the final setof studies precluded a quantitative meta-analysisof the data Due to these analytic constraints weconducted a descriptive literature review only

As shown in Table 1 all eight CDSSs weredesigned to assist in the diagnosis andor manage-ment of chronic pain Two of these systems thePain Management Advisor (PMA) and the Diag-nostic Headache Diary were also designed to offereducation to the health care provider One thePMA had an interactive capability that permittedusers to query the system for explanations thera-peutic rationale and therapy guidelines Twoother systems the SymptomReport and thePAIN

ReportIt

featured adjunctive software pro-grams (SymptomConsult PAIN

ConsultN

) thatwere expressly designed as interactive educationaltools for the patient

All but two of the CDSSs were designed totarget a specific type of chronic pain or pain-related condition These included headache (2)low back (1) and cancer-related (3) Input specifi-cations also varied widely both in terms of thetype and amount of data required and in terms ofthe party responsible for data entry (ie physicianother health care provider or patient) All of theCDSSs required detailed input regarding painsymptomology Half of the systems reviewed alsoelicited data on pain medications currently usedand three requested QOL information Otherdata such as psychological status history of priortherapies (both pharmaceutical and nondrug-related therapies) patient goals for pain care andbarriers to pain management were specified asrequired inputs in only two of the CDSSsreviewed Three of the CDSSs used standard psy-chometrically validated instruments (eg McGillPain Questionnaire Medical Outcomes StudyShort Form 36 Oswestry Low Back Pain Disabil-ity Index) to collect input data

The majority of the CDSSs (5 of 8) producedoutput that was intended for clinician use(eg physician or nurse) only Three targetedboth the clinician and the patient Output varied

S158

Smith et al

Tab

le 1

Key

fea

ture

s of

clin

ical

dec

isio

n-su

ppor

t sy

stem

s (C

DS

Ss)

dev

elop

ed f

or c

hron

ic p

ain

man

agem

ent

Nam

e of

CD

SS

Pur

pose

Des

crip

tion

Sta

ge o

fD

evel

opm

ent

Har

dwar

e amp

Sof

twar

eR

equi

rem

ents

Dat

a In

put(

s)O

utpu

t(s)

Targ

et

Rec

ipie

nt(s

)of

Out

put

RH

INO

S [

45]

To a

ssis

t ph

ysic

ians

in t

he d

iagn

osis

of

chro

nic

head

ache

sor

fac

ial p

ain

Bas

ed o

n ex

pert

kno

wle

dge

of h

eada

che

and

faci

alpa

in s

peci

alis

ts U

ses

4 se

ts o

f co

nditi

onal

pr

obab

ility

-bas

ed

rule

s 1

) ex

clus

ive

rule

s (i

e

if pa

tient

has

dis

ease

D

s

he m

ust

have

sym

ptom

s S

1

S

2

S

n

) 2)

incl

usiv

e ru

les

3)

asso

ciat

e ru

les

and

4)

dise

ase

imag

e ru

les

Pro

toty

pe o

nly

no t

estin

gS

yste

m d

evel

oped

usi

ngth

e P

rolo

g-K

AB

Apr

ogra

mm

ing

lang

uage

R

uns

on p

erso

nal

com

pute

rs w

ith C

PU

808

6m

emor

y 38

2 K

byte

s

Phy

sici

an in

put

base

d on

patie

nt in

terv

iew

ndash

Pat

ient

dem

ogra

phic

sndash

Ons

et o

f he

adac

hendash

His

tory

sin

ce o

nset

ndash P

ain

char

acte

ristic

sndash

Neu

rolo

gica

l sig

nsas

soci

ated

with

pai

nndash

Sle

ep s

tatu

sndash

Per

sona

l and

fam

ilial

hist

ory

of h

eada

che

ndash Jo

lt he

adac

he (

Yes

No)

ndash S

cler

osis

of

retin

al a

rter

y

Initi

al o

utpu

t af

ter

first

set

of

scre

enin

g qu

estio

ns

ndash Li

st o

f di

seas

es n

ot r

ejec

ted

Out

put

afte

r ad

ditio

nal

ques

tion(

s)

ndash Li

st o

f po

ssib

le d

isea

ses

ndash D

iagn

ostic

con

clus

ions

ndash E

xpla

natio

n of

the

dis

ease

requ

ired

exam

inat

ions

and

sugg

este

d th

erap

yH

ospi

tal c

hart

can

be

prin

ted

from

the

inpu

t da

ta in

the

form

of

a n

atur

al la

ngua

ge

repr

esen

tatio

n

Phy

sici

ans

IVA

N [

46]

To p

rovi

dere

com

men

datio

nsfo

r co

ntro

lling

pai

nan

d pr

ovid

ing

sym

ptom

rel

ief

inca

ncer

os

teo-

and

rheu

mat

oid

arth

ritis

Cas

e-ba

sed

reas

onin

gst

rate

gy t

o re

cord

and

retr

ieve

info

rmat

ion

stor

edin

an

inte

rnal

kno

wle

dge

base

Pro

toty

pe o

nly

no t

estin

gIV

AN

sof

twar

e w

ritte

n in

LPA

Pro

log

prog

ram

min

gla

ngua

ge fo

r W

indo

ws

(ldquoW

inP

rolo

grdquo)

runs

on

PC

Win

dow

s 95

NT

Win

Pro

log

ndash P

ain

sym

ptom

che

cklis

tndash

Cur

rent

pai

n di

agno

sis

ndash C

urre

nt p

ain

trea

tmen

tre

gim

en

Com

pute

r sc

reen

dis

play

ndash

Dia

gnos

tic c

onfir

mat

ion

ndash D

escr

iptio

n of

sym

ptom

s th

atm

ay a

ppea

r la

ter

ndash Tr

eatm

ents

pro

ven

succ

essf

ulin

sim

ilar

or r

elat

ed c

ases

ndash P

ossi

ble

alte

rnat

ive

caus

esof

the

pai

n

Phy

sici

ans

and

patie

nts

The

Dia

gnos

ticH

eada

che

Dia

ry[4

7]

To e

duca

te a

ndpr

ovid

e di

agno

stic

supp

ort

to p

rimar

yca

re p

rovi

ders

inor

der

to im

prov

em

anag

emen

t of

head

ache

s

Rul

e-ba

sed

expe

rt s

yste

mus

ing

Boo

lean

logi

c A

set

of d

iagn

ostic

rul

es u

sed

tode

term

ine

a di

agno

sis

base

dup

on t

he d

ata

ente

red

inpa

tient

dia

ry D

iary

dat

a ar

etr

ansf

orm

ed in

to a

dia

gnos

isfo

llow

ing

the

Inte

rnat

iona

lH

eada

che

Soc

iety

rsquoscl

assi

ficat

ion

Pro

toty

pede

velo

ped

syst

em-g

ener

ated

diag

nose

s w

ere

valid

ated

aga

inst

phys

icia

n ex

pert

-ge

nera

ted

diag

nose

s

Sta

nd-a

lone

Win

dow

s 95

prog

ram

writ

ten

in D

elph

ipr

ogra

mm

ing

lang

uage

ndash P

atie

nt d

ata

ndash H

eada

che

diar

y en

trie

sndash

Med

icat

ions

use

d to

alle

viat

e he

adac

he

ndash D

iagn

osis

of

head

ache

typ

eP

CP

s

Pai

n M

anag

emen

tA

dvis

or (

PM

A)

(Nov

aInt

ellig

ence

Inc

S

an D

iego

C

A)

[48]

To e

nhan

ce p

rimar

yca

re p

rovi

ders

rsquo(P

CP

s) m

anag

emen

tof

chr

onic

pai

n

ndash R

elie

s on

rul

e-ba

sed

algo

rithm

s de

rived

fro

mex

pert

kno

wle

dge

ofpa

in s

peci

alis

tsndash

Use

r as

ked

a se

ries

ofqu

estio

ns t

o re

fine

the

diag

nosi

s an

d de

term

ine

appr

opria

te t

hera

pyndash

Inte

ract

ive

capa

bilit

y(e

g

for

expl

anat

ions

th

erap

eutic

rat

iona

les

ther

apy

guid

elin

es)

Wor

king

ver

sion

deve

lope

d s

ome

field

tes

ting

cond

ucte

d

ndash P

entiu

m-b

ased

PC

sndash

Win

dow

s 95

ndash P

MA

writ

ten

inM

icro

Sof

t Vis

ual B

asic

v

50

ru

n as

an

expe

rtap

plic

atio

n in

Xpe

rtR

ule

ndash A

lgor

ithm

s st

ored

inM

icro

Sof

t A

cces

s da

taba

sendash

Mic

roS

oft

Hel

p U

tility

used

for

expl

anat

ions

and

quer

ies

ndash P

atie

nt d

emog

raph

ics

ndash D

iagn

osis

ndash P

ain

char

acte

ristic

sndash

Labo

rato

ry t

ests

ampim

agin

g st

udie

sndash

Cur

rent

med

icat

ions

ndash P

rior

ther

apie

sndash

Con

curr

ent

dise

ase

cond

ition

sndash

Alle

rgie

sndash

Psy

chol

ogic

al s

tatu

s

ndash A

prio

ritiz

ed li

st o

fre

com

men

datio

ns 1

) m

edic

alm

anag

emen

t (p

harm

acol

ogic

and

nonp

harm

acol

ogic

alm

anag

emen

t ph

ysic

al

psyc

hoso

cial

mod

aliti

es)

2)in

vasi

ve p

roce

dure

s 3

) re

ferr

als

PC

Ps

Computerized Decision-Support System for Pain

S159

Sym

ptom

Rep

ort

and

Sym

ptom

Con

sult

[49]

To a

ssis

t cl

inic

ians

in a

sses

sing

can

cer-

rela

ted

chro

nic

pain

and

fatig

ue

and

clar

ify p

atie

ntsrsquo

mis

belie

fs a

bout

pain

ass

essm

ent

and

man

agem

ent

Not

des

crib

edW

orki

ng v

ersi

onde

velo

ped

fiel

dte

stin

g co

nduc

ted

Mic

roS

oft W

indo

ws

959

8pe

rson

al c

ompu

ters

with

touc

h sc

reen

(P

en-T

ab)

Pat

ient

sel

f-re

port

ed in

put

ndash P

atie

nt d

emog

raph

ics

ndash 19

70 v

ersi

on o

f M

cGill

Pai

n Q

uest

ionn

aire

(M

PQ

)ndash

Bar

riers

Que

stio

nnai

re(B

Q)

ndash S

chw

artz

can

cer

fatig

uesc

ale

(SC

FS

-6)

1) H

ard

copi

es o

f ex

pert

sys

tem

repo

rt g

iven

to

patie

nt a

nd t

ocl

inic

ian

2) P

atie

nt r

ecei

ves

educ

atio

nal

mat

eria

ls o

n ho

w t

o re

port

pa

in

use

pain

med

icat

ions

sa

fely

an

d m

anag

e fa

tigue

M

ater

ials

are

cus

tom

ized

to

the

patie

ntrsquos

nee

ds a

nd

pres

ente

d in

an

inte

ract

ive

m

ultim

edia

form

at P

atie

nts

have

opt

ion

to re

ad o

r lis

ten

to

info

rmat

ion

on t

he c

ompu

ter

prin

t an

y or

all

of t

he

mat

eria

ls

or d

o bo

th

Onc

olog

ynu

rses

ot

her

clin

icia

ns

Dec

isio

n-su

ppor

tco

mpu

ter

prog

ram

for

canc

er p

ain

man

agem

ent

[50]

To im

prov

e th

eon

colo

gy n

urse

srsquode

cisi

on m

akin

gre

late

d to

can

cer

pain

man

agem

ent

amon

g cu

ltura

llydi

vers

e fe

mal

eon

colo

gy p

atie

nts

ndash S

urve

y da

ta o

n m

ultic

ultu

ral

canc

er p

ain

char

acte

ristic

sw

ere

anal

yzed

usi

ng f

uzzy

infe

renc

e lo

gic

to d

evel

op 4

mod

ules

1)

a ge

neric

know

ledg

e ba

se 2

) a

cultu

re-s

peci

fic k

now

ledg

e ba

se 3

) de

cisi

on-m

akin

g

and

4) s

elf-

adap

tatio

nndash

Dec

isio

n-m

akin

g m

odul

eco

nsis

ts o

f 2

sets

of

fuzz

yin

fere

nce

logi

c de

velo

ped

via

a ge

netic

alg

orith

m

Har

dwar

e no

t de

scrib

edndash

Ada

ptiv

e fu

zzy

logi

cso

ftwar

e us

ed t

o de

velo

pan

d ru

n th

e kn

owle

dge

base

gen

erat

ion

and

the

deci

sion

-mak

ing

and

self-

adap

tatio

n m

odul

es

Nur

se-e

nter

ed d

ata

base

don

pat

ient

inte

rvie

w

ndash P

atie

nt d

emog

raph

ics

ndash P

ain

char

acte

ristic

s

Com

pute

r sc

reen

dis

play

of

anal

gesi

c tr

eatm

ent

reco

mm

enda

tions

bas

ed o

n th

eW

orld

Hea

lth O

rgan

izat

ion

(WH

O)rsquos

ana

lges

ic la

dder

Onc

olog

ynu

rses

PAIN

Rep

or

tIt a

ndPA

IN

Con

sultN

[51

52]

To a

ssis

t cl

inic

ians

in a

sses

sing

chr

onic

pain

and

to

educ

ate

patie

nts

rega

rdin

gpa

in m

onito

ring

and

man

agem

ent

Not

des

crib

edW

orki

ng v

ersi

onde

velo

ped

fiel

dte

stin

g co

nduc

ted

Mic

roS

oft W

indo

ws

959

8pe

rson

al c

ompu

ters

with

touc

h sc

reen

(P

en-T

ab)

data

sto

red

in A

cces

s 97

data

base

Pat

ient

sel

f-re

port

ed in

put

1)

Pat

ient

dem

ogra

phic

sndash

McG

ill P

ain

Que

stio

nnai

rendash

Pai

n st

atus

ndash P

atie

nt g

oals

for

and

expe

ctat

ions

abo

ut p

ain

ndash Ty

pe a

nd e

ffect

iven

ess

of p

revi

ous

pain

trea

tmen

ts

Har

d co

pies

of

expe

rt s

yste

mre

port

giv

en t

o pa

tient

and

to

clin

icia

n o

n-sc

reen

vie

win

g of

repo

rt is

als

o po

ssib

le

Onc

olog

ynu

rses

and

othe

rcl

inic

ians

Touc

h-sc

reen

Com

pute

rA

sses

smen

t of

Chr

onic

Low

Bac

k P

ain

[53]

To c

olle

ct p

ain

sym

ptom

sta

tus

and

othe

r he

alth

info

rmat

ion

from

patie

nts

with

low

back

pai

n

Not

des

crib

edW

orki

ng v

ersi

onde

velo

ped

lim

ited

field

tes

ting

Web

-bas

ed s

yste

m u

sing

Del

l Ins

piro

n 11

00 la

ptop

with

Mic

roso

ft X

P o

pera

ting

syst

em 1

4

prime

tou

ch s

cree

n(M

agic

Tou

ch

Key

tec)

ndash P

atie

nt d

emog

raph

ics

ndash O

swes

try

Low

Bac

k P

ain

Dis

abili

ty I

ndex

(V

ersi

on 2

)ndash

Bec

k D

epre

ssio

n In

vent

ory

ndash M

OS

Sho

rt F

orm

-36

(MO

S S

F-3

6)

Not

des

crib

edP

hysi

cian

s

Nam

e of

CD

SS

Pur

pose

Des

crip

tion

Sta

ge o

fD

evel

opm

ent

Har

dwar

e amp

Sof

twar

eR

equi

rem

ents

Dat

a In

put(

s)O

utpu

t(s)

Targ

et

Rec

ipie

nt(s

)of

Out

put

S160

Smith et al

considerably in terms of content format anddelivery (eg electronic paper or both) SeveralCDSSs scored and summated patient responseson standard pain and QOL-related assessmentmeasures Based on the published descriptions atleast five of the CDSSs were designed to gener-ate output in real time at the patientrsquos medicalvisit

In terms of systems architecture all CDSSsreviewed were stand-alone personal computer-based systems None interfaced with existingelectronic medical records systems pharmacyappointment scheduling or laboratory resultsreporting Three either were Web-based or hadthe capacity to use a Web-based platform

Table 2 summarizes the types of studies con-ducted to date to evaluate chronic pain CDSSs Ofthe eight CDSSs identified five had publishedevaluation results With one exception all werefeasibility studies exclusively Studies were con-ducted in both inpatient and outpatient settingsAmong the outpatient studies two had been con-ducted with PCPs the remainder involved special-ists in tertiary care settings Study designs used forevaluating these CDSSs varied two were cross-sectional two involved immediate pre- and post-assessments of CDSS use one was longitudinal(12-month follow-up) and one was a focus groupStudy sample sizes ranged from 213 to 4 with themajority having 50 or fewer subjects

Patient acceptability of the CDSS was the sin-gle most commonly assessed variable Evaluationsof both the SymptomReport and the PAIN

Report-It

employed a common tool to assess patientacceptability Results across four pilot testsinvolving a total of 254 subjects consistentlyshowed high acceptability of these two CDSSsand 100 completion rates in terms of data input[495152] The average amount of time requiredranged from a high of 38 minutes to a low of14 minutes

Two studies addressed the issue of medicalaccuracy of the system-generated recommenda-tion Both studies examined this issue by compar-ing system-generated diagnoses andor treatmentrecommendations with those generated by physi-cian experts based on a select sample of patientcases Results showed moderate to high agreementbetween the system- and expert-generated recom-mendations [4748]

Clinician perceptions concerning ease of useand value of a CDSS for chronic pain managementwere examined in two studies Overall physiciansfound the system to be moderately easy to use and

of some clinical worth [4852] Knab and col-leagues [48] reported that the average cliniciantime spent per case on the PMA to obtain outputwas approximately 5 minutes (

plusmn

34 minutes) [48]In addition 85 of physicians adopted the PMA-generated recommendations and 25 of thestudy patients seen were referred to a pain special-ist with the average time to referral being37 months (

plusmn

06 months) [48]Analyses concerning the impact of CDSSs on

patient outcomes were limited Huang and col-leagues [51] assessed changes in pain intensity pre-and post-CDSS use in a sample of radiationoncology clinic patients Although there was adownward trend in pain levels over time resultswere not statistically significant possibly dueto the small size of the sample (N

=

15) Wilkieand colleagues [4952] reported qualitative dataregarding the impact of the SymptomReport andthe PAIN

ReportIt

on patient behavior Resultswere contradictory Of the 41 outpatients whoused the SymptomReport approximately 68stated that it had not affected their pain-relatedcommunication Some however felt that theytalked more precisely and explicitly about theirpain as a result of using it Other comments asso-ciated with use of the SymptomReport includedan increased awareness of pain symptoms andgreater compliance with pain symptom manage-ment In contrast 86 of users of the PAIN-

ReportIt

cited it as beneficial for patientndashdoctorpain-related communication and that it ldquofreedthem to describe their painrdquo

Discussion

Over the past two decades there has been a gradualbut steady growth in research on the use of CDSSsfor chronic pain management To date the numberof such systems is small but expanding Advanceshave also been evident in terms of both the quantityand quality of evaluation studies conducted Whilethe earliest versions were presented in the litera-ture as prototypes only [4546] CDSSs developedsince 2001 have all undergone some form of fieldtesting The majority of these studies howeverhave been nonexperimental in design and focusedexclusively on process measures such as patientor clinician ratings of system acceptability andusability Other salient process measures such asthe degree to which the clinician andor patientactually reviewed and utilized system output orhad confidence in its accuracy have not been con-sistently assessed Poor usability and practitioner

Computerized Decision-Support System for Pain

S161

Tab

le 2

Eva

luat

ion

of c

ompu

teri

zed

deci

sion

-sup

port

sys

tem

s (C

DS

Ss)

in c

hron

ic p

ain

man

agem

ent

Stu

dyN

ame

of C

DS

SS

ampl

eD

esig

nO

utco

mes

Ass

esse

dR

esul

ts

Nie

lsen

et a

l

[47

]D

iagn

ostic

Hea

dach

eD

iary

PC

Ps

Not

des

crib

edndash

a

gree

men

t of c

ompu

ter-

gene

rate

d vs

exp

ert

phys

icia

n di

agno

ses

ndash 10

0 a

gree

men

t of c

ompu

ter-

gene

rate

d vs

ex

pert

phy

sici

an d

iagn

oses

Kna

b et

al

[48

]P

ain

Man

agem

ent

Adv

isor

N

=

50

PC

Ps

N

=

50

chro

nic

pain

pat

ient

sLo

ngitu

dina

l w

ith 1

2-m

onth

PC

P fo

llow

-up

ndash E

ase

of u

sendash

Med

ical

app

ropr

iate

ness

of

reco

mm

enda

tions

ndash

phy

sici

ansrsquo

ado

ptin

g P

ain

Man

agem

ent

Adv

isor

tre

atm

ent

reco

mm

enda

tions

ndash

pat

ient

s re

ferr

ed t

o pa

insp

ecia

lty c

linic

Phy

sici

an a

dopt

ion

of s

yste

m-g

ener

ated

re

com

men

datio

ns 8

5 o

f ca

ses

Ave

rage

phy

sici

an t

ime

spen

t pe

r ca

se

49

min

utes

(S

D

plusmn

34)

Eas

e of

use

as

rate

d by

phy

sici

ans

42

(

plusmn

28

cm)

on s

cale

of

1ndash10

25

of

patie

nts

refe

rred

to

pain

spe

cial

ty

clin

icA

vera

ge t

ime

to p

ain

spec

ialty

ref

erra

l 3

7 m

onth

s (S

D

plusmn

06)

ndash 70

o

f no

nref

erre

d pa

tient

s st

ill r

ecei

ving

co

mpu

ter-

reco

mm

ende

d tr

eatm

ent

1 ye

ar

post

Wilk

ie e

t al

[49

]S

ympt

omR

epor

tN

=

41

outp

atie

nts

with

can

cer

Cro

ss-s

ectio

nal

tele

phon

e in

terv

iew

sndash

13-it

em p

atie

nt a

ccep

tabi

lity

scal

e as

sess

ing

ease

of

use

ofS

ympt

omR

epor

tndash

Inpu

t co

mpl

etio

n tim

endash

Qua

litat

ive

asse

ssm

ent

of d

egre

eof

com

mun

icat

ion

with

hea

lth c

are

prov

ider

s re

gard

ing

pain

and

oth

ersy

mpt

oms

ndash M

ean

time

to c

ompl

ete

Sym

ptom

Rep

ort

382

min

utes

(S

D

plusmn

202

)ndash

Mea

n tim

e to

com

plet

e S

ympt

omC

onsu

lt

209

min

utes

(S

D

plusmn

18

6)ndash

71

of

part

icip

ants

rat

ed S

ympt

omR

epor

t as

eas

y e

njoy

able

an

d in

form

ativ

endash

68

rep

orte

d th

at th

e am

ount

and

con

tent

of

the

ir pa

in-r

elat

ed c

omm

unic

atio

n w

ith

thei

r do

ctor

had

not

cha

nged

muc

hndash

Qua

litat

ive

patie

nt c

omm

ents

1)

help

ed

them

tal

k m

ore

expl

icitl

y ab

out

pain

2)

gave

the

m g

reat

er a

war

enes

s of

pai

n sy

mpt

oms

3)

incr

ease

d un

ders

tand

ing

of

and

enha

nced

com

plia

nce

rega

rdin

g sy

mpt

om m

anag

emen

t ndash

Pat

ient

com

men

ts r

e S

ympt

omC

onsu

lt 1

) co

ntai

ned

too

muc

h in

form

atio

n 2

) no

t ta

rget

ed t

o in

divi

dual

nee

ds (

3) p

rovi

ded

no n

ew in

form

atio

n

Wilk

ie e

t al

[52

]PA

IN

Rep

ortIt

N

=

213

of

who

m 1

06w

ere

canc

er in

patie

nts

10 m

etas

tatic

can

cer

outp

atie

nts

and

97

wer

e in

divi

dual

sex

perie

ncin

g ac

ute

orch

roni

c pa

in r

ecru

ited

from

non

heal

th c

are

setti

ngs

Des

crip

tive

cro

ss-

sect

iona

l stu

dy in

3se

tting

s 1

) te

rtia

ryca

re

2) r

adia

tion

onco

logy

clin

ic

3)m

obile

clin

ic

ndash 13

-item

sca

le m

easu

ring

acce

ptab

ility

of

PAIN

Rep

ortIt

(ie

tim

e to

com

plet

e e

ase

of u

se

unde

rsta

ndab

ility

of

dire

ctio

ns

ergo

nom

ic e

lem

ents

of

syst

em

and

com

plet

enes

s of

res

pons

es)

ndash 86

o

f res

pond

ents

rate

d th

e PA

IN

Rep

ortIt

as

ben

efici

al f

or p

ain

com

mun

icat

ion

ndash 10

0 p

atie

nt c

ompl

etio

n ra

te o

f PA

IN

Rep

ortIt

ndash M

ean

time

to p

atie

nt

com

plet

ion

15

8 m

inut

es (

SD

plusmn

67

)ndash

Mea

n pa

tient

acc

epta

bilit

y sc

ore

11

7 (S

D

plusmn

16

) sc

ores

ran

ged

from

6 t

o 13

80

o

f pa

tient

s ra

ted

acce

ptab

ility

as

grea

ter

than

min

imum

crit

erio

n of

10

ndash U

ser

com

men

ts 1

) so

me

mec

hani

cal

diffi

culti

es 2

) re

activ

ity t

o us

e of

sys

tem

(e

g

vom

iting

) 3)

pre

fere

nce

to r

elay

info

rmat

ion

dire

ctly

to

prov

ider

PC

P p

rimar

y ca

re p

hysi

cian

S162

Smith et al

Hua

ng e

t al

[51

]PA

IN

Rep

ortIt

and

PAIN

Con

sultN

Pilo

t st

udy

1 N

=

9pa

tient

s w

ith b

one

met

asta

sis-

rela

ted

pain

Pilo

t st

udy

2 N

=

15

patie

nts

with

can

cer

and

bone

met

asta

sis

Phy

sici

an fo

cus

grou

pN

=

4 r

adia

tion

onco

logi

sts

1) P

ilot

test

1

Fea

sibi

lity

stud

y us

ing

a te

stndashr

etes

t w

ithin

-su

bjec

t de

sign

2) P

ilot

test

2

Fea

sibi

lity

stud

y us

ing

an 1

1-da

y te

stndashr

etes

tw

ithin

-sub

ject

des

ign

3) P

hysi

cian

focu

sgr

oup

Out

com

e m

easu

res

used

for

both

pilo

t st

udie

sndash

Acc

epta

bilit

yndash

Com

plet

enes

sndash

Tim

e to

com

plet

endash

Val

idity

Phy

sici

an fo

cus

grou

pndash

Rec

eptiv

ity t

o PA

IN

Rep

ortIt

and

PAIN

Con

sultN

Pilo

t st

udy

1

ndashM

ean

time

to c

ompl

ete

PAIN

Rep

ortIt

at

pret

est

12 m

inut

es (

SD

plusmn

4)

ndashT

ime

to c

ompl

ete

PAIN

Rep

ortIt

at

post

-te

st 1

ndash7 m

inut

es p

er p

atie

ntndash

Mea

n ac

cept

abili

ty s

core

11

2 (S

D

plusmn

18

)ndash

100

com

plet

ion

rate

Pilo

t st

udy

2ndash

Mea

n tim

e to

com

plet

e PA

IN

Rep

ortIt

at

pret

est

17 m

inut

es (

SD

plusmn

6)

ndashT

ime

to c

ompl

ete

PAIN

Rep

ortIt

at p

ostte

st

14 m

inut

es (

SD

plusmn

8)

ndashM

ean

acce

ptab

ility

sco

re 1

22

(SD

plusmn

13

)ndash

100

com

plet

ion

rate

ndashPA

IN

Con

sultN

rec

omm

ende

d a

med

ian

of

4 dr

ugs

phy

sici

ans

pres

crib

ed a

med

ian

of

3 dr

ugs

post

use

ndashP

atie

nt p

ain

inte

nsity

ave

rage

4 a

t bas

elin

e an

d 2

7 at

pos

ttest

(no

t si

gnifi

cant

)

Foc

us g

roup

ndashP

hysi

cian

s sa

w v

alue

of

PAIN

Rep

ortIt

1)

incr

ease

d ef

ficie

ncy

durin

g cl

inic

vis

it 2

) su

pple

men

ted

pain

ser

vice

con

sulta

tion

3)

prov

ided

out

com

e da

tandash

PAIN

Con

sultN

was

vie

wed

as

clin

ical

ad

junc

t bu

t fo

rmat

ting

need

ed

impr

ovem

ent

Koe

stle

r et

al

[53

]To

uch-

scre

en C

ompu

ter

Ass

essm

ent

of C

hron

icLo

w B

ack

Pai

n

N

=

30

low

bac

kpa

in p

atie

nts

Cro

ss-s

ectio

nal d

esig

nin

ter

tiary

car

e cl

inic

ndashP

atie

nt-r

atin

gs o

f er

gono

mic

desi

gn d

egre

e of

tec

hnic

aldi

fficu

lties

ac

cept

abili

ty

ease

of u

se d

ata

secu

rity

ndashM

ean

time

to c

ompl

ete

the

67-it

em t

ouch

sc

reen

27

4 m

inut

es (

SD

plusmn

138

)

Stu

dyN

ame

of C

DS

SS

ampl

eD

esig

nO

utco

mes

Ass

esse

dR

esul

ts

PC

P p

rimar

y ca

re p

hysi

cian

Tab

le 2

Con

tinue

d

Computerized Decision-Support System for Pain

S163

nonacceptance of computer recommendations canserve as significant barriers to system adoption inroutine clinical practice [365455]

User preferences regarding the presentation ofcomputer output including content formatting(eg color graphics) and length have not beensolicited in most instances either Similarly thereare few published data concerning technical diffi-culties (eg type and number of system crashes ortouch-screen calibration problems) encounteredby CDSS users Both issues have important rami-fications for future system refinements [52] Addi-tionally there is a paucity of information oncontextual circumstances (eg presence of a localldquochampionrdquo of the system) or the processes usedto integrate the CDSS into the existing clinicalworkflow key considerations for successful systemimplementation Not least testing has been con-fined almost exclusively to either inpatient ortertiary care settings with only two studies con-ducted in the primary care context to date

The effects of these systems on patient out-comes remain understudied Two studies reportedqualitative data concerning CDSS impact onpatientsrsquo perceived pain-related communicationwith their physician however sample sizes weresmall and results inconsistent [4952] One studyreported system impact on patient pain intensitylevel over time but the study lacked adequate sta-tistical power to detect clinically important differ-ences [52] Other major patient outcomes such ashealth care utilization health care costs painrelief pain medication usage communication withhealth care provider about pain functional statusand QOL have not been examined One studyreported evidence that CDSS use may invokepatient reactivity (eg vomiting intensified painsymptoms) Potential adverse effects on patientsshould be measured in future investigations [52]Similarly there is need for more extensive andconsistent examination of system impact on clini-cian pain management performance

While we sought to be as comprehensive aspossible in our literature search our review wasrestricted to only English-language studies Inaddition it is possible that there are other CDSSsunder development that we failed to identify Thelimited size of the available literature as well asthe methods used in these primary studies pre-vented us from conducting a meta-analysis ofresearch findings and from reaching more defin-itive conclusions about the impact of these systemson physician performance and patient pain func-tioning and other aspects of QOL Notably in all

the studies we examined study investigators andCDSS developers were one and the same a factthat may have resulted in more positive findings[36] Lastly we did not conduct a separate evalu-ation of the clinical appropriateness of either theCDSS algorithms or treatment recommendationsnor of the underlying logic employed to generatesuch algorithms

The potential for these computer-based sys-tems to improve the quality of chronic pain man-agement in the primary care context is substantialTo manage chronic pain effectively PCPs firstneed to conduct a comprehensive patient assess-ment [56] Information on the patientrsquos pain ex-perience history of and preferences for paintreatment psychological status approach to self-management and personal goalspriorities are keyvariables to collect during assessment as they arecritical for making an accurate diagnosis and fordeveloping an appropriate treatment plan to whichthe patient will adhere [56] An expert system-typeCDSS provides a way to elicit and integrate suchpatient-specific information in a manner that isconvenient and timely for both physicians andpatients Moreover the ensuing system-generatedrecommendations are individualized to the needsand circumstances of the specific pain patient perbest clinical practices [56]

CDSSs developed for chronic pain manage-ment have as yet however to fulfill this promiseAs our review indicates systems developed thus farhave been predominantly biomedical in focus anddesigned to assist physicians and other health careproviders in the medical management of painsymptoms (including invasive procedures andreferrals) exclusively Only a few of these systemshave reached a sufficiently advanced stage ofdevelopment to warrant more rigorous testingin large-scale randomized controlled trials[264952] Such trials are imperative for under-standing system effect on provider performanceand patient outcomes

Significantly none of the systems reviewedwere integrated with existing electronic recordssystems nor did they include reminder or docu-mentation functionalities features which have allbeen shown to increase the likelihood of physicianadoption [5758] This lack of integration mayreflect the fact that widespread adoption of elec-tronic records systems by health care institutionshas been a relatively recent occurrence Potentiallythis trend coupled with pressures from majoraccrediting agencies to document the provision ofpain screening and treatment along with the

S164

Smith et al

recent publication of primary care pain manage-ment guidelines may serve to spur additionalmore rigorous research on the use of CDSSs forchronic pain management in primary care[565960] Demonstrating the clinical value ofthese systems is a critical step in convincing healthcare organizations and clinicians that the benefitsof investing in a CDSS for pain management out-weigh potential risks In particular physiciansneed to be assured that this type of system canenhance rather than erode their decision-makingabilities and that time spent learning how to usea CDSS yields measurable improvement in patienthealth and well-being

References

1 American Pain Society Chronic pain in AmericaRoadblock to relief 1999 American Pain SocietyAPS News and Announcements Available at httpwwwampainsocorgwhatsnewtoc_roadhtmtoc

2 Lande SD The problem of pain in managed careIn Lande SD Kulich RJ eds Managed Care andPain Glenview IL American Pain Society 200019

3 Turner JA Leresche L Von Korff M Ehrlich LPrimary care back pain patient characteristics visitcontent and short term outcomes Spine199823463ndash9

4 Von Korff M Gruman J Schaefer J Curry SJ Wag-ner EH Collaborative management of chronic ill-ness Ann Intern Med 1997127(12)1097ndash102

5 Von Korff M Pain management in primary care Anindividualized stepped-care approach In GatchelRJ Turk DL eds Psychosocial Factors in PainCritical Perspectives New York The GuilfordPress 1999

6 Von Korff M Katon W Bush T et al Treatmentcosts cost offset and cost-effectiveness of collabo-rative management of depression Psychosom Med199860(2)143ndash9

7 Bertakis KD Azari R Callahan EJ Patient pain Itsinfluence on primary care physicianndashpatient inter-action Fam Med 200335(2)119ndash23

8 Green CR Wheeler JRC Laporte F Marchant BGuerrero E How well is chronic pain managedWho does it well Pain Med 20023(1)56ndash62

9 Von Roenn JH Cleeland CS Gonin R HatfieldAK Pandya KJ Physician attitudes and practice incancer pain management A survey from the EasternCooperative Oncology Group Ann Intern Med1993119121ndash6

10 Cleeland CS Cleeland LM Dar R Rinehardt LCFactors influencing physician management of can-cer pain Cancer 198658796ndash800

11 Fife BL Irick N Painter JD A comparative studyof the attitudes of physicians and nurses towards themanagement of cancer pain J Pain Symptom Man-age 19938132ndash9

12 Wilson JF Brockoop GW Kryst S Steger H WittWO Medical studentsrsquo attitudes towards painbefore and after a brief course on pain Pain199250251ndash6

13 Weinstein SM Laux LF Thornby JI et al Physi-ciansrsquo attitudes towards pain and the use of opioidanalgesics Results of a survey from the Texas Can-cer Pain Initiative South Med J 200093(5)479ndash87

14 Weinstein SM Laux LF Thornby JI et al Medicalstudentsrsquo attitudes towards pain and the use of opi-oid analgesics Implications for changing medicalschool curriculum South Med J 200093(5)472ndash8

15 Whedon M Ferrell BR Professional and ethicalconsiderations in the use of high-tech pain manage-ment Oncol Nurs Forum 1991181135ndash43

16 Ward S Goldberg N Miller-Mccauley V et alPatient-related barriers to management of cancerpain Pain 199352319ndash24

17 Pargeon KL Hailey BJ Barriers to effective cancerpain management A review of the literature J PainSymptom Manage 199918358ndash68

18 Breitbart W Passik S Mcdonald MV et al Patient-related barriers to pain management in ambulatoryAIDS patients Pain 199352319ndash24

19 Gunnarsdottir S Donovan HS Serlin RC Voge CWard S Patient-related barriers to pain manage-ment The barriers questionnaire II (BQ-II) Pain200299385ndash96

20 Arora NK Interacting with cancer patients Thesignificance of physiciansrsquo communication behaviorSoc Sci Med 200357791ndash806

21 Mccaffery M Thorpe DM Differences in percep-tion of pain and the development of adversarial rela-tionships among health care providers In Hill CSFields W eds Advances in Pain Research and Ther-apy Drug Treatment of Cancer Pain in a Drug-Oriented Society Vol 11 New York Raven Press1989

22 Ong LML de Haes JCJM Hoos AM Lammes FBDoctorndashpatient communication A review of the lit-erature Soc Sci Med 199540903ndash18

23 Jones WL Rimer BK Levy MH Kinman JL Can-cer patientsrsquo knowledge beliefs and behaviorregarding pain control regimens Implications foreducation programs Patient Educ Couns19845(4)159ndash64

24 Lukoschek P Fazzari M Marantz P Patient andphysician factors predict patientsrsquo comprehensionof health information Patient Educ Couns200350201ndash10

25 Donovan JL Blake DR Patient non-complianceDeviance or reasoned decision-making Soc SciMed 199234377ndash94

26 Garg AX Adhikari NKJ Mcdonald H et al Effectsof computerized clinical decision support systemson practitioner performance and patient outcomesa systematic review JAMA 2005293(10)1223ndash38

27 Nilasena DS Lincoln MJ A computer-generatedreminder system improves physician compliance

Computerized Decision-Support System for Pain

S157

The purpose of this study was to systematicallyreview the research evidence for CDSSs to addressthe following questions (i) To what extent haveCDSSs been utilized in the context of chronic painmanagement (ii) What are the characteristics ofthese systems and (iii) To what degree have theybeen evaluated and in what types of clinicalsettings

Methods

Data Sources

We conducted an automated literature searchusing the Ovid search engine With the assistanceof a research librarian we searched the followingdatabases MEDLINE (1966 to April 2006)CINAHL (1982 to April 2006) PsychINFO (1967to April 2006) HealthSTAR (1981 to April 2006)EMBASE Cochrane Library Computer andInformation Systems Abstracts Electronics andCommunications Abstracts Proust Digital Disser-tations Computer Retrieval of Informationon Scientific Projects (CRISP) LISA ERICComputer and Information Systems Abstractsand Dissertation Abstracts Key search wordsemployed included the following computer-generated decision support systems and expert sys-tems Additional terms included chronic painprimary care tailored reports personalized com-puter-based information disease management forchronic pain patient goals pain diagnosis andmanagement decision support systems neuralnetworks and fuzzy logic We also conducted amanual search to supplement the automatedsearch The manual search was not limited in timeperiod and included articles that had been refer-enced in other articles

Study Selection Criteria

Eligibility for inclusion in the final set includedany studies describing the development andorapplication of a CDSS or expert system in thecontext of chronic pain management We defineda CDSS as any electronic system designed to assistin clinical decision making regarding chronic painmanagement and in which patient-specific assess-ments and recommendations were generated foruse by a clinician andor patient [44] Consistentwith this definition we excluded any CDSSs thatexamined pain as only one component of an over-all assessment of QOL as well as any thataddressed acute pain management only We alsoexcluded studies that were written in languagesother than English

Results

The cross-database search yielded 70 publishedarticles and three federally funded research studiesdescribing ongoing investigations No additionalstudies were identified via the manual search pro-cess Full-text articles were retrieved for all titlesconsidered to be potentially relevant by theauthors Nine studies describing eight discreteCDSSs were identified as meeting our inclusioncriteria Lack of homogeneity among the final setof studies precluded a quantitative meta-analysisof the data Due to these analytic constraints weconducted a descriptive literature review only

As shown in Table 1 all eight CDSSs weredesigned to assist in the diagnosis andor manage-ment of chronic pain Two of these systems thePain Management Advisor (PMA) and the Diag-nostic Headache Diary were also designed to offereducation to the health care provider One thePMA had an interactive capability that permittedusers to query the system for explanations thera-peutic rationale and therapy guidelines Twoother systems the SymptomReport and thePAIN

ReportIt

featured adjunctive software pro-grams (SymptomConsult PAIN

ConsultN

) thatwere expressly designed as interactive educationaltools for the patient

All but two of the CDSSs were designed totarget a specific type of chronic pain or pain-related condition These included headache (2)low back (1) and cancer-related (3) Input specifi-cations also varied widely both in terms of thetype and amount of data required and in terms ofthe party responsible for data entry (ie physicianother health care provider or patient) All of theCDSSs required detailed input regarding painsymptomology Half of the systems reviewed alsoelicited data on pain medications currently usedand three requested QOL information Otherdata such as psychological status history of priortherapies (both pharmaceutical and nondrug-related therapies) patient goals for pain care andbarriers to pain management were specified asrequired inputs in only two of the CDSSsreviewed Three of the CDSSs used standard psy-chometrically validated instruments (eg McGillPain Questionnaire Medical Outcomes StudyShort Form 36 Oswestry Low Back Pain Disabil-ity Index) to collect input data

The majority of the CDSSs (5 of 8) producedoutput that was intended for clinician use(eg physician or nurse) only Three targetedboth the clinician and the patient Output varied

S158

Smith et al

Tab

le 1

Key

fea

ture

s of

clin

ical

dec

isio

n-su

ppor

t sy

stem

s (C

DS

Ss)

dev

elop

ed f

or c

hron

ic p

ain

man

agem

ent

Nam

e of

CD

SS

Pur

pose

Des

crip

tion

Sta

ge o

fD

evel

opm

ent

Har

dwar

e amp

Sof

twar

eR

equi

rem

ents

Dat

a In

put(

s)O

utpu

t(s)

Targ

et

Rec

ipie

nt(s

)of

Out

put

RH

INO

S [

45]

To a

ssis

t ph

ysic

ians

in t

he d

iagn

osis

of

chro

nic

head

ache

sor

fac

ial p

ain

Bas

ed o

n ex

pert

kno

wle

dge

of h

eada

che

and

faci

alpa

in s

peci

alis

ts U

ses

4 se

ts o

f co

nditi

onal

pr

obab

ility

-bas

ed

rule

s 1

) ex

clus

ive

rule

s (i

e

if pa

tient

has

dis

ease

D

s

he m

ust

have

sym

ptom

s S

1

S

2

S

n

) 2)

incl

usiv

e ru

les

3)

asso

ciat

e ru

les

and

4)

dise

ase

imag

e ru

les

Pro

toty

pe o

nly

no t

estin

gS

yste

m d

evel

oped

usi

ngth

e P

rolo

g-K

AB

Apr

ogra

mm

ing

lang

uage

R

uns

on p

erso

nal

com

pute

rs w

ith C

PU

808

6m

emor

y 38

2 K

byte

s

Phy

sici

an in

put

base

d on

patie

nt in

terv

iew

ndash

Pat

ient

dem

ogra

phic

sndash

Ons

et o

f he

adac

hendash

His

tory

sin

ce o

nset

ndash P

ain

char

acte

ristic

sndash

Neu

rolo

gica

l sig

nsas

soci

ated

with

pai

nndash

Sle

ep s

tatu

sndash

Per

sona

l and

fam

ilial

hist

ory

of h

eada

che

ndash Jo

lt he

adac

he (

Yes

No)

ndash S

cler

osis

of

retin

al a

rter

y

Initi

al o

utpu

t af

ter

first

set

of

scre

enin

g qu

estio

ns

ndash Li

st o

f di

seas

es n

ot r

ejec

ted

Out

put

afte

r ad

ditio

nal

ques

tion(

s)

ndash Li

st o

f po

ssib

le d

isea

ses

ndash D

iagn

ostic

con

clus

ions

ndash E

xpla

natio

n of

the

dis

ease

requ

ired

exam

inat

ions

and

sugg

este

d th

erap

yH

ospi

tal c

hart

can

be

prin

ted

from

the

inpu

t da

ta in

the

form

of

a n

atur

al la

ngua

ge

repr

esen

tatio

n

Phy

sici

ans

IVA

N [

46]

To p

rovi

dere

com

men

datio

nsfo

r co

ntro

lling

pai

nan

d pr

ovid

ing

sym

ptom

rel

ief

inca

ncer

os

teo-

and

rheu

mat

oid

arth

ritis

Cas

e-ba

sed

reas

onin

gst

rate

gy t

o re

cord

and

retr

ieve

info

rmat

ion

stor

edin

an

inte

rnal

kno

wle

dge

base

Pro

toty

pe o

nly

no t

estin

gIV

AN

sof

twar

e w

ritte

n in

LPA

Pro

log

prog

ram

min

gla

ngua

ge fo

r W

indo

ws

(ldquoW

inP

rolo

grdquo)

runs

on

PC

Win

dow

s 95

NT

Win

Pro

log

ndash P

ain

sym

ptom

che

cklis

tndash

Cur

rent

pai

n di

agno

sis

ndash C

urre

nt p

ain

trea

tmen

tre

gim

en

Com

pute

r sc

reen

dis

play

ndash

Dia

gnos

tic c

onfir

mat

ion

ndash D

escr

iptio

n of

sym

ptom

s th

atm

ay a

ppea

r la

ter

ndash Tr

eatm

ents

pro

ven

succ

essf

ulin

sim

ilar

or r

elat

ed c

ases

ndash P

ossi

ble

alte

rnat

ive

caus

esof

the

pai

n

Phy

sici

ans

and

patie

nts

The

Dia

gnos

ticH

eada

che

Dia

ry[4

7]

To e

duca

te a

ndpr

ovid

e di

agno

stic

supp

ort

to p

rimar

yca

re p

rovi

ders

inor

der

to im

prov

em

anag

emen

t of

head

ache

s

Rul

e-ba

sed

expe

rt s

yste

mus

ing

Boo

lean

logi

c A

set

of d

iagn

ostic

rul

es u

sed

tode

term

ine

a di

agno

sis

base

dup

on t

he d

ata

ente

red

inpa

tient

dia

ry D

iary

dat

a ar

etr

ansf

orm

ed in

to a

dia

gnos

isfo

llow

ing

the

Inte

rnat

iona

lH

eada

che

Soc

iety

rsquoscl

assi

ficat

ion

Pro

toty

pede

velo

ped

syst

em-g

ener

ated

diag

nose

s w

ere

valid

ated

aga

inst

phys

icia

n ex

pert

-ge

nera

ted

diag

nose

s

Sta

nd-a

lone

Win

dow

s 95

prog

ram

writ

ten

in D

elph

ipr

ogra

mm

ing

lang

uage

ndash P

atie

nt d

ata

ndash H

eada

che

diar

y en

trie

sndash

Med

icat

ions

use

d to

alle

viat

e he

adac

he

ndash D

iagn

osis

of

head

ache

typ

eP

CP

s

Pai

n M

anag

emen

tA

dvis

or (

PM

A)

(Nov

aInt

ellig

ence

Inc

S

an D

iego

C

A)

[48]

To e

nhan

ce p

rimar

yca

re p

rovi

ders

rsquo(P

CP

s) m

anag

emen

tof

chr

onic

pai

n

ndash R

elie

s on

rul

e-ba

sed

algo

rithm

s de

rived

fro

mex

pert

kno

wle

dge

ofpa

in s

peci

alis

tsndash

Use

r as

ked

a se

ries

ofqu

estio

ns t

o re

fine

the

diag

nosi

s an

d de

term

ine

appr

opria

te t

hera

pyndash

Inte

ract

ive

capa

bilit

y(e

g

for

expl

anat

ions

th

erap

eutic

rat

iona

les

ther

apy

guid

elin

es)

Wor

king

ver

sion

deve

lope

d s

ome

field

tes

ting

cond

ucte

d

ndash P

entiu

m-b

ased

PC

sndash

Win

dow

s 95

ndash P

MA

writ

ten

inM

icro

Sof

t Vis

ual B

asic

v

50

ru

n as

an

expe

rtap

plic

atio

n in

Xpe

rtR

ule

ndash A

lgor

ithm

s st

ored

inM

icro

Sof

t A

cces

s da

taba

sendash

Mic

roS

oft

Hel

p U

tility

used

for

expl

anat

ions

and

quer

ies

ndash P

atie

nt d

emog

raph

ics

ndash D

iagn

osis

ndash P

ain

char

acte

ristic

sndash

Labo

rato

ry t

ests

ampim

agin

g st

udie

sndash

Cur

rent

med

icat

ions

ndash P

rior

ther

apie

sndash

Con

curr

ent

dise

ase

cond

ition

sndash

Alle

rgie

sndash

Psy

chol

ogic

al s

tatu

s

ndash A

prio

ritiz

ed li

st o

fre

com

men

datio

ns 1

) m

edic

alm

anag

emen

t (p

harm

acol

ogic

and

nonp

harm

acol

ogic

alm

anag

emen

t ph

ysic

al

psyc

hoso

cial

mod

aliti

es)

2)in

vasi

ve p

roce

dure

s 3

) re

ferr

als

PC

Ps

Computerized Decision-Support System for Pain

S159

Sym

ptom

Rep

ort

and

Sym

ptom

Con

sult

[49]

To a

ssis

t cl

inic

ians

in a

sses

sing

can

cer-

rela

ted

chro

nic

pain

and

fatig

ue

and

clar

ify p

atie

ntsrsquo

mis

belie

fs a

bout

pain

ass

essm

ent

and

man

agem

ent

Not

des

crib

edW

orki

ng v

ersi

onde

velo

ped

fiel

dte

stin

g co

nduc

ted

Mic

roS

oft W

indo

ws

959

8pe

rson

al c

ompu

ters

with

touc

h sc

reen

(P

en-T

ab)

Pat

ient

sel

f-re

port

ed in

put

ndash P

atie

nt d

emog

raph

ics

ndash 19

70 v

ersi

on o

f M

cGill

Pai

n Q

uest

ionn

aire

(M

PQ

)ndash

Bar

riers

Que

stio

nnai

re(B

Q)

ndash S

chw

artz

can

cer

fatig

uesc

ale

(SC

FS

-6)

1) H

ard

copi

es o

f ex

pert

sys

tem

repo

rt g

iven

to

patie

nt a

nd t

ocl

inic

ian

2) P

atie

nt r

ecei

ves

educ

atio

nal

mat

eria

ls o

n ho

w t

o re

port

pa

in

use

pain

med

icat

ions

sa

fely

an

d m

anag

e fa

tigue

M

ater

ials

are

cus

tom

ized

to

the

patie

ntrsquos

nee

ds a

nd

pres

ente

d in

an

inte

ract

ive

m

ultim

edia

form

at P

atie

nts

have

opt

ion

to re

ad o

r lis

ten

to

info

rmat

ion

on t

he c

ompu

ter

prin

t an

y or

all

of t

he

mat

eria

ls

or d

o bo

th

Onc

olog

ynu

rses

ot

her

clin

icia

ns

Dec

isio

n-su

ppor

tco

mpu

ter

prog

ram

for

canc

er p

ain

man

agem

ent

[50]

To im

prov

e th

eon

colo

gy n

urse

srsquode

cisi

on m

akin

gre

late

d to

can

cer

pain

man

agem

ent

amon

g cu

ltura

llydi

vers

e fe

mal

eon

colo

gy p

atie

nts

ndash S

urve

y da

ta o

n m

ultic

ultu

ral

canc

er p

ain

char

acte

ristic

sw

ere

anal

yzed

usi

ng f

uzzy

infe

renc

e lo

gic

to d

evel

op 4

mod

ules

1)

a ge

neric

know

ledg

e ba

se 2

) a

cultu

re-s

peci

fic k

now

ledg

e ba

se 3

) de

cisi

on-m

akin

g

and

4) s

elf-

adap

tatio

nndash

Dec

isio

n-m

akin

g m

odul

eco

nsis

ts o

f 2

sets

of

fuzz

yin

fere

nce

logi

c de

velo

ped

via

a ge

netic

alg

orith

m

Har

dwar

e no

t de

scrib

edndash

Ada

ptiv

e fu

zzy

logi

cso

ftwar

e us

ed t

o de

velo

pan

d ru

n th

e kn

owle

dge

base

gen

erat

ion

and

the

deci

sion

-mak

ing

and

self-

adap

tatio

n m

odul

es

Nur

se-e

nter

ed d

ata

base

don

pat

ient

inte

rvie

w

ndash P

atie

nt d

emog

raph

ics

ndash P

ain

char

acte

ristic

s

Com

pute

r sc

reen

dis

play

of

anal

gesi

c tr

eatm

ent

reco

mm

enda

tions

bas

ed o

n th

eW

orld

Hea

lth O

rgan

izat

ion

(WH

O)rsquos

ana

lges

ic la

dder

Onc

olog

ynu

rses

PAIN

Rep

or

tIt a

ndPA

IN

Con

sultN

[51

52]

To a

ssis

t cl

inic

ians

in a

sses

sing

chr

onic

pain

and

to

educ

ate

patie

nts

rega

rdin

gpa

in m

onito

ring

and

man

agem

ent

Not

des

crib

edW

orki

ng v

ersi

onde

velo

ped

fiel

dte

stin

g co

nduc

ted

Mic

roS

oft W

indo

ws

959

8pe

rson

al c

ompu

ters

with

touc

h sc

reen

(P

en-T

ab)

data

sto

red

in A

cces

s 97

data

base

Pat

ient

sel

f-re

port

ed in

put

1)

Pat

ient

dem

ogra

phic

sndash

McG

ill P

ain

Que

stio

nnai

rendash

Pai

n st

atus

ndash P

atie

nt g

oals

for

and

expe

ctat

ions

abo

ut p

ain

ndash Ty

pe a

nd e

ffect

iven

ess

of p

revi

ous

pain

trea

tmen

ts

Har

d co

pies

of

expe

rt s

yste

mre

port

giv

en t

o pa

tient

and

to

clin

icia

n o

n-sc

reen

vie

win

g of

repo

rt is

als

o po

ssib

le

Onc

olog

ynu

rses

and

othe

rcl

inic

ians

Touc

h-sc

reen

Com

pute

rA

sses

smen

t of

Chr

onic

Low

Bac

k P

ain

[53]

To c

olle

ct p

ain

sym

ptom

sta

tus

and

othe

r he

alth

info

rmat

ion

from

patie

nts

with

low

back

pai

n

Not

des

crib

edW

orki

ng v

ersi

onde

velo

ped

lim

ited

field

tes

ting

Web

-bas

ed s

yste

m u

sing

Del

l Ins

piro

n 11

00 la

ptop

with

Mic

roso

ft X

P o

pera

ting

syst

em 1

4

prime

tou

ch s

cree

n(M

agic

Tou

ch

Key

tec)

ndash P

atie

nt d

emog

raph

ics

ndash O

swes

try

Low

Bac

k P

ain

Dis

abili

ty I

ndex

(V

ersi

on 2

)ndash

Bec

k D

epre

ssio

n In

vent

ory

ndash M

OS

Sho

rt F

orm

-36

(MO

S S

F-3

6)

Not

des

crib

edP

hysi

cian

s

Nam

e of

CD

SS

Pur

pose

Des

crip

tion

Sta

ge o

fD

evel

opm

ent

Har

dwar

e amp

Sof

twar

eR

equi

rem

ents

Dat

a In

put(

s)O

utpu

t(s)

Targ

et

Rec

ipie

nt(s

)of

Out

put

S160

Smith et al

considerably in terms of content format anddelivery (eg electronic paper or both) SeveralCDSSs scored and summated patient responseson standard pain and QOL-related assessmentmeasures Based on the published descriptions atleast five of the CDSSs were designed to gener-ate output in real time at the patientrsquos medicalvisit

In terms of systems architecture all CDSSsreviewed were stand-alone personal computer-based systems None interfaced with existingelectronic medical records systems pharmacyappointment scheduling or laboratory resultsreporting Three either were Web-based or hadthe capacity to use a Web-based platform

Table 2 summarizes the types of studies con-ducted to date to evaluate chronic pain CDSSs Ofthe eight CDSSs identified five had publishedevaluation results With one exception all werefeasibility studies exclusively Studies were con-ducted in both inpatient and outpatient settingsAmong the outpatient studies two had been con-ducted with PCPs the remainder involved special-ists in tertiary care settings Study designs used forevaluating these CDSSs varied two were cross-sectional two involved immediate pre- and post-assessments of CDSS use one was longitudinal(12-month follow-up) and one was a focus groupStudy sample sizes ranged from 213 to 4 with themajority having 50 or fewer subjects

Patient acceptability of the CDSS was the sin-gle most commonly assessed variable Evaluationsof both the SymptomReport and the PAIN

Report-It

employed a common tool to assess patientacceptability Results across four pilot testsinvolving a total of 254 subjects consistentlyshowed high acceptability of these two CDSSsand 100 completion rates in terms of data input[495152] The average amount of time requiredranged from a high of 38 minutes to a low of14 minutes

Two studies addressed the issue of medicalaccuracy of the system-generated recommenda-tion Both studies examined this issue by compar-ing system-generated diagnoses andor treatmentrecommendations with those generated by physi-cian experts based on a select sample of patientcases Results showed moderate to high agreementbetween the system- and expert-generated recom-mendations [4748]

Clinician perceptions concerning ease of useand value of a CDSS for chronic pain managementwere examined in two studies Overall physiciansfound the system to be moderately easy to use and

of some clinical worth [4852] Knab and col-leagues [48] reported that the average cliniciantime spent per case on the PMA to obtain outputwas approximately 5 minutes (

plusmn

34 minutes) [48]In addition 85 of physicians adopted the PMA-generated recommendations and 25 of thestudy patients seen were referred to a pain special-ist with the average time to referral being37 months (

plusmn

06 months) [48]Analyses concerning the impact of CDSSs on

patient outcomes were limited Huang and col-leagues [51] assessed changes in pain intensity pre-and post-CDSS use in a sample of radiationoncology clinic patients Although there was adownward trend in pain levels over time resultswere not statistically significant possibly dueto the small size of the sample (N

=

15) Wilkieand colleagues [4952] reported qualitative dataregarding the impact of the SymptomReport andthe PAIN

ReportIt

on patient behavior Resultswere contradictory Of the 41 outpatients whoused the SymptomReport approximately 68stated that it had not affected their pain-relatedcommunication Some however felt that theytalked more precisely and explicitly about theirpain as a result of using it Other comments asso-ciated with use of the SymptomReport includedan increased awareness of pain symptoms andgreater compliance with pain symptom manage-ment In contrast 86 of users of the PAIN-

ReportIt

cited it as beneficial for patientndashdoctorpain-related communication and that it ldquofreedthem to describe their painrdquo

Discussion

Over the past two decades there has been a gradualbut steady growth in research on the use of CDSSsfor chronic pain management To date the numberof such systems is small but expanding Advanceshave also been evident in terms of both the quantityand quality of evaluation studies conducted Whilethe earliest versions were presented in the litera-ture as prototypes only [4546] CDSSs developedsince 2001 have all undergone some form of fieldtesting The majority of these studies howeverhave been nonexperimental in design and focusedexclusively on process measures such as patientor clinician ratings of system acceptability andusability Other salient process measures such asthe degree to which the clinician andor patientactually reviewed and utilized system output orhad confidence in its accuracy have not been con-sistently assessed Poor usability and practitioner

Computerized Decision-Support System for Pain

S161

Tab

le 2

Eva

luat

ion

of c

ompu

teri

zed

deci

sion

-sup

port

sys

tem

s (C

DS

Ss)

in c

hron

ic p

ain

man

agem

ent

Stu

dyN

ame

of C

DS

SS

ampl

eD

esig

nO

utco

mes

Ass

esse

dR

esul

ts

Nie

lsen

et a

l

[47

]D

iagn

ostic

Hea

dach

eD

iary

PC

Ps

Not

des

crib

edndash

a

gree

men

t of c

ompu

ter-

gene

rate

d vs

exp

ert

phys

icia

n di

agno

ses

ndash 10

0 a

gree

men

t of c

ompu

ter-

gene

rate

d vs

ex

pert

phy

sici

an d

iagn

oses

Kna

b et

al

[48

]P

ain

Man

agem

ent

Adv

isor

N

=

50

PC

Ps

N

=

50

chro

nic

pain

pat

ient

sLo

ngitu

dina

l w

ith 1

2-m

onth

PC

P fo

llow

-up

ndash E

ase

of u

sendash

Med

ical

app

ropr

iate

ness

of

reco

mm

enda

tions

ndash

phy

sici

ansrsquo

ado

ptin

g P

ain

Man

agem

ent

Adv

isor

tre

atm

ent

reco

mm

enda

tions

ndash

pat

ient

s re

ferr

ed t

o pa

insp

ecia

lty c

linic

Phy

sici

an a

dopt

ion

of s

yste

m-g

ener

ated

re

com

men

datio

ns 8

5 o

f ca

ses

Ave

rage

phy

sici

an t

ime

spen

t pe

r ca

se

49

min

utes

(S

D

plusmn

34)

Eas

e of

use

as

rate

d by

phy

sici

ans

42

(

plusmn

28

cm)

on s

cale

of

1ndash10

25

of

patie

nts

refe

rred

to

pain

spe

cial

ty

clin

icA

vera

ge t

ime

to p

ain

spec

ialty

ref

erra

l 3

7 m

onth

s (S

D

plusmn

06)

ndash 70

o

f no

nref

erre

d pa

tient

s st

ill r

ecei

ving

co

mpu

ter-

reco

mm

ende

d tr

eatm

ent

1 ye

ar

post

Wilk

ie e

t al

[49

]S

ympt

omR

epor

tN

=

41

outp

atie

nts

with

can

cer

Cro

ss-s

ectio

nal

tele

phon

e in

terv

iew

sndash

13-it

em p

atie

nt a

ccep

tabi

lity

scal

e as

sess

ing

ease

of

use

ofS

ympt

omR

epor

tndash

Inpu

t co

mpl

etio

n tim

endash

Qua

litat

ive

asse

ssm

ent

of d

egre

eof

com

mun

icat

ion

with

hea

lth c

are

prov

ider

s re

gard

ing

pain

and

oth

ersy

mpt

oms

ndash M

ean

time

to c

ompl

ete

Sym

ptom

Rep

ort

382

min

utes

(S

D

plusmn

202

)ndash

Mea

n tim

e to

com

plet

e S

ympt

omC

onsu

lt

209

min

utes

(S

D

plusmn

18

6)ndash

71

of

part

icip

ants

rat

ed S

ympt

omR

epor

t as

eas

y e

njoy

able

an

d in

form

ativ

endash

68

rep

orte

d th

at th

e am

ount

and

con

tent

of

the

ir pa

in-r

elat

ed c

omm

unic

atio

n w

ith

thei

r do

ctor

had

not

cha

nged

muc

hndash

Qua

litat

ive

patie

nt c

omm

ents

1)

help

ed

them

tal

k m

ore

expl

icitl

y ab

out

pain

2)

gave

the

m g

reat

er a

war

enes

s of

pai

n sy

mpt

oms

3)

incr

ease

d un

ders

tand

ing

of

and

enha

nced

com

plia

nce

rega

rdin

g sy

mpt

om m

anag

emen

t ndash

Pat

ient

com

men

ts r

e S

ympt

omC

onsu

lt 1

) co

ntai

ned

too

muc

h in

form

atio

n 2

) no

t ta

rget

ed t

o in

divi

dual

nee

ds (

3) p

rovi

ded

no n

ew in

form

atio

n

Wilk

ie e

t al

[52

]PA

IN

Rep

ortIt

N

=

213

of

who

m 1

06w

ere

canc

er in

patie

nts

10 m

etas

tatic

can

cer

outp

atie

nts

and

97

wer

e in

divi

dual

sex

perie

ncin

g ac

ute

orch

roni

c pa

in r

ecru

ited

from

non

heal

th c

are

setti

ngs

Des

crip

tive

cro

ss-

sect

iona

l stu

dy in

3se

tting

s 1

) te

rtia

ryca

re

2) r

adia

tion

onco

logy

clin

ic

3)m

obile

clin

ic

ndash 13

-item

sca

le m

easu

ring

acce

ptab

ility

of

PAIN

Rep

ortIt

(ie

tim

e to

com

plet

e e

ase

of u

se

unde

rsta

ndab

ility

of

dire

ctio

ns

ergo

nom

ic e

lem

ents

of

syst

em

and

com

plet

enes

s of

res

pons

es)

ndash 86

o

f res

pond

ents

rate

d th

e PA

IN

Rep

ortIt

as

ben

efici

al f

or p

ain

com

mun

icat

ion

ndash 10

0 p

atie

nt c

ompl

etio

n ra

te o

f PA

IN

Rep

ortIt

ndash M

ean

time

to p

atie

nt

com

plet

ion

15

8 m

inut

es (

SD

plusmn

67

)ndash

Mea

n pa

tient

acc

epta

bilit

y sc

ore

11

7 (S

D

plusmn

16

) sc

ores

ran

ged

from

6 t

o 13

80

o

f pa

tient

s ra

ted

acce

ptab

ility

as

grea

ter

than

min

imum

crit

erio

n of

10

ndash U

ser

com

men

ts 1

) so

me

mec

hani

cal

diffi

culti

es 2

) re

activ

ity t

o us

e of

sys

tem

(e

g

vom

iting

) 3)

pre

fere

nce

to r

elay

info

rmat

ion

dire

ctly

to

prov

ider

PC

P p

rimar

y ca

re p

hysi

cian

S162

Smith et al

Hua

ng e

t al

[51

]PA

IN

Rep

ortIt

and

PAIN

Con

sultN

Pilo

t st

udy

1 N

=

9pa

tient

s w

ith b

one

met

asta

sis-

rela

ted

pain

Pilo

t st

udy

2 N

=

15

patie

nts

with

can

cer

and

bone

met

asta

sis

Phy

sici

an fo

cus

grou

pN

=

4 r

adia

tion

onco

logi

sts

1) P

ilot

test

1

Fea

sibi

lity

stud

y us

ing

a te

stndashr

etes

t w

ithin

-su

bjec

t de

sign

2) P

ilot

test

2

Fea

sibi

lity

stud

y us

ing

an 1

1-da

y te

stndashr

etes

tw

ithin

-sub

ject

des

ign

3) P

hysi

cian

focu

sgr

oup

Out

com

e m

easu

res

used

for

both

pilo

t st

udie

sndash

Acc

epta

bilit

yndash

Com

plet

enes

sndash

Tim

e to

com

plet

endash

Val

idity

Phy

sici

an fo

cus

grou

pndash

Rec

eptiv

ity t

o PA

IN

Rep

ortIt

and

PAIN

Con

sultN

Pilo

t st

udy

1

ndashM

ean

time

to c

ompl

ete

PAIN

Rep

ortIt

at

pret

est

12 m

inut

es (

SD

plusmn

4)

ndashT

ime

to c

ompl

ete

PAIN

Rep

ortIt

at

post

-te

st 1

ndash7 m

inut

es p

er p

atie

ntndash

Mea

n ac

cept

abili

ty s

core

11

2 (S

D

plusmn

18

)ndash

100

com

plet

ion

rate

Pilo

t st

udy

2ndash

Mea

n tim

e to

com

plet

e PA

IN

Rep

ortIt

at

pret

est

17 m

inut

es (

SD

plusmn

6)

ndashT

ime

to c

ompl

ete

PAIN

Rep

ortIt

at p

ostte

st

14 m

inut

es (

SD

plusmn

8)

ndashM

ean

acce

ptab

ility

sco

re 1

22

(SD

plusmn

13

)ndash

100

com

plet

ion

rate

ndashPA

IN

Con

sultN

rec

omm

ende

d a

med

ian

of

4 dr

ugs

phy

sici

ans

pres

crib

ed a

med

ian

of

3 dr

ugs

post

use

ndashP

atie

nt p

ain

inte

nsity

ave

rage

4 a

t bas

elin

e an

d 2

7 at

pos

ttest

(no

t si

gnifi

cant

)

Foc

us g

roup

ndashP

hysi

cian

s sa

w v

alue

of

PAIN

Rep

ortIt

1)

incr

ease

d ef

ficie

ncy

durin

g cl

inic

vis

it 2

) su

pple

men

ted

pain

ser

vice

con

sulta

tion

3)

prov

ided

out

com

e da

tandash

PAIN

Con

sultN

was

vie

wed

as

clin

ical

ad

junc

t bu

t fo

rmat

ting

need

ed

impr

ovem

ent

Koe

stle

r et

al

[53

]To

uch-

scre

en C

ompu

ter

Ass

essm

ent

of C

hron

icLo

w B

ack

Pai

n

N

=

30

low

bac

kpa

in p

atie

nts

Cro

ss-s

ectio

nal d

esig

nin

ter

tiary

car

e cl

inic

ndashP

atie

nt-r

atin

gs o

f er

gono

mic

desi

gn d

egre

e of

tec

hnic

aldi

fficu

lties

ac

cept

abili

ty

ease

of u

se d

ata

secu

rity

ndashM

ean

time

to c

ompl

ete

the

67-it

em t

ouch

sc

reen

27

4 m

inut

es (

SD

plusmn

138

)

Stu

dyN

ame

of C

DS

SS

ampl

eD

esig

nO

utco

mes

Ass

esse

dR

esul

ts

PC

P p

rimar

y ca

re p

hysi

cian

Tab

le 2

Con

tinue

d

Computerized Decision-Support System for Pain

S163

nonacceptance of computer recommendations canserve as significant barriers to system adoption inroutine clinical practice [365455]

User preferences regarding the presentation ofcomputer output including content formatting(eg color graphics) and length have not beensolicited in most instances either Similarly thereare few published data concerning technical diffi-culties (eg type and number of system crashes ortouch-screen calibration problems) encounteredby CDSS users Both issues have important rami-fications for future system refinements [52] Addi-tionally there is a paucity of information oncontextual circumstances (eg presence of a localldquochampionrdquo of the system) or the processes usedto integrate the CDSS into the existing clinicalworkflow key considerations for successful systemimplementation Not least testing has been con-fined almost exclusively to either inpatient ortertiary care settings with only two studies con-ducted in the primary care context to date

The effects of these systems on patient out-comes remain understudied Two studies reportedqualitative data concerning CDSS impact onpatientsrsquo perceived pain-related communicationwith their physician however sample sizes weresmall and results inconsistent [4952] One studyreported system impact on patient pain intensitylevel over time but the study lacked adequate sta-tistical power to detect clinically important differ-ences [52] Other major patient outcomes such ashealth care utilization health care costs painrelief pain medication usage communication withhealth care provider about pain functional statusand QOL have not been examined One studyreported evidence that CDSS use may invokepatient reactivity (eg vomiting intensified painsymptoms) Potential adverse effects on patientsshould be measured in future investigations [52]Similarly there is need for more extensive andconsistent examination of system impact on clini-cian pain management performance

While we sought to be as comprehensive aspossible in our literature search our review wasrestricted to only English-language studies Inaddition it is possible that there are other CDSSsunder development that we failed to identify Thelimited size of the available literature as well asthe methods used in these primary studies pre-vented us from conducting a meta-analysis ofresearch findings and from reaching more defin-itive conclusions about the impact of these systemson physician performance and patient pain func-tioning and other aspects of QOL Notably in all

the studies we examined study investigators andCDSS developers were one and the same a factthat may have resulted in more positive findings[36] Lastly we did not conduct a separate evalu-ation of the clinical appropriateness of either theCDSS algorithms or treatment recommendationsnor of the underlying logic employed to generatesuch algorithms

The potential for these computer-based sys-tems to improve the quality of chronic pain man-agement in the primary care context is substantialTo manage chronic pain effectively PCPs firstneed to conduct a comprehensive patient assess-ment [56] Information on the patientrsquos pain ex-perience history of and preferences for paintreatment psychological status approach to self-management and personal goalspriorities are keyvariables to collect during assessment as they arecritical for making an accurate diagnosis and fordeveloping an appropriate treatment plan to whichthe patient will adhere [56] An expert system-typeCDSS provides a way to elicit and integrate suchpatient-specific information in a manner that isconvenient and timely for both physicians andpatients Moreover the ensuing system-generatedrecommendations are individualized to the needsand circumstances of the specific pain patient perbest clinical practices [56]

CDSSs developed for chronic pain manage-ment have as yet however to fulfill this promiseAs our review indicates systems developed thus farhave been predominantly biomedical in focus anddesigned to assist physicians and other health careproviders in the medical management of painsymptoms (including invasive procedures andreferrals) exclusively Only a few of these systemshave reached a sufficiently advanced stage ofdevelopment to warrant more rigorous testingin large-scale randomized controlled trials[264952] Such trials are imperative for under-standing system effect on provider performanceand patient outcomes

Significantly none of the systems reviewedwere integrated with existing electronic recordssystems nor did they include reminder or docu-mentation functionalities features which have allbeen shown to increase the likelihood of physicianadoption [5758] This lack of integration mayreflect the fact that widespread adoption of elec-tronic records systems by health care institutionshas been a relatively recent occurrence Potentiallythis trend coupled with pressures from majoraccrediting agencies to document the provision ofpain screening and treatment along with the

S164

Smith et al

recent publication of primary care pain manage-ment guidelines may serve to spur additionalmore rigorous research on the use of CDSSs forchronic pain management in primary care[565960] Demonstrating the clinical value ofthese systems is a critical step in convincing healthcare organizations and clinicians that the benefitsof investing in a CDSS for pain management out-weigh potential risks In particular physiciansneed to be assured that this type of system canenhance rather than erode their decision-makingabilities and that time spent learning how to usea CDSS yields measurable improvement in patienthealth and well-being

References

1 American Pain Society Chronic pain in AmericaRoadblock to relief 1999 American Pain SocietyAPS News and Announcements Available at httpwwwampainsocorgwhatsnewtoc_roadhtmtoc

2 Lande SD The problem of pain in managed careIn Lande SD Kulich RJ eds Managed Care andPain Glenview IL American Pain Society 200019

3 Turner JA Leresche L Von Korff M Ehrlich LPrimary care back pain patient characteristics visitcontent and short term outcomes Spine199823463ndash9

4 Von Korff M Gruman J Schaefer J Curry SJ Wag-ner EH Collaborative management of chronic ill-ness Ann Intern Med 1997127(12)1097ndash102

5 Von Korff M Pain management in primary care Anindividualized stepped-care approach In GatchelRJ Turk DL eds Psychosocial Factors in PainCritical Perspectives New York The GuilfordPress 1999

6 Von Korff M Katon W Bush T et al Treatmentcosts cost offset and cost-effectiveness of collabo-rative management of depression Psychosom Med199860(2)143ndash9

7 Bertakis KD Azari R Callahan EJ Patient pain Itsinfluence on primary care physicianndashpatient inter-action Fam Med 200335(2)119ndash23

8 Green CR Wheeler JRC Laporte F Marchant BGuerrero E How well is chronic pain managedWho does it well Pain Med 20023(1)56ndash62

9 Von Roenn JH Cleeland CS Gonin R HatfieldAK Pandya KJ Physician attitudes and practice incancer pain management A survey from the EasternCooperative Oncology Group Ann Intern Med1993119121ndash6

10 Cleeland CS Cleeland LM Dar R Rinehardt LCFactors influencing physician management of can-cer pain Cancer 198658796ndash800

11 Fife BL Irick N Painter JD A comparative studyof the attitudes of physicians and nurses towards themanagement of cancer pain J Pain Symptom Man-age 19938132ndash9

12 Wilson JF Brockoop GW Kryst S Steger H WittWO Medical studentsrsquo attitudes towards painbefore and after a brief course on pain Pain199250251ndash6

13 Weinstein SM Laux LF Thornby JI et al Physi-ciansrsquo attitudes towards pain and the use of opioidanalgesics Results of a survey from the Texas Can-cer Pain Initiative South Med J 200093(5)479ndash87

14 Weinstein SM Laux LF Thornby JI et al Medicalstudentsrsquo attitudes towards pain and the use of opi-oid analgesics Implications for changing medicalschool curriculum South Med J 200093(5)472ndash8

15 Whedon M Ferrell BR Professional and ethicalconsiderations in the use of high-tech pain manage-ment Oncol Nurs Forum 1991181135ndash43

16 Ward S Goldberg N Miller-Mccauley V et alPatient-related barriers to management of cancerpain Pain 199352319ndash24

17 Pargeon KL Hailey BJ Barriers to effective cancerpain management A review of the literature J PainSymptom Manage 199918358ndash68

18 Breitbart W Passik S Mcdonald MV et al Patient-related barriers to pain management in ambulatoryAIDS patients Pain 199352319ndash24

19 Gunnarsdottir S Donovan HS Serlin RC Voge CWard S Patient-related barriers to pain manage-ment The barriers questionnaire II (BQ-II) Pain200299385ndash96

20 Arora NK Interacting with cancer patients Thesignificance of physiciansrsquo communication behaviorSoc Sci Med 200357791ndash806

21 Mccaffery M Thorpe DM Differences in percep-tion of pain and the development of adversarial rela-tionships among health care providers In Hill CSFields W eds Advances in Pain Research and Ther-apy Drug Treatment of Cancer Pain in a Drug-Oriented Society Vol 11 New York Raven Press1989

22 Ong LML de Haes JCJM Hoos AM Lammes FBDoctorndashpatient communication A review of the lit-erature Soc Sci Med 199540903ndash18

23 Jones WL Rimer BK Levy MH Kinman JL Can-cer patientsrsquo knowledge beliefs and behaviorregarding pain control regimens Implications foreducation programs Patient Educ Couns19845(4)159ndash64

24 Lukoschek P Fazzari M Marantz P Patient andphysician factors predict patientsrsquo comprehensionof health information Patient Educ Couns200350201ndash10

25 Donovan JL Blake DR Patient non-complianceDeviance or reasoned decision-making Soc SciMed 199234377ndash94

26 Garg AX Adhikari NKJ Mcdonald H et al Effectsof computerized clinical decision support systemson practitioner performance and patient outcomesa systematic review JAMA 2005293(10)1223ndash38

27 Nilasena DS Lincoln MJ A computer-generatedreminder system improves physician compliance

S158

Smith et al

Tab

le 1

Key

fea

ture

s of

clin

ical

dec

isio

n-su

ppor

t sy

stem

s (C

DS

Ss)

dev

elop

ed f

or c

hron

ic p

ain

man

agem

ent

Nam

e of

CD

SS

Pur

pose

Des

crip

tion

Sta

ge o

fD

evel

opm

ent

Har

dwar

e amp

Sof

twar

eR

equi

rem

ents

Dat

a In

put(

s)O

utpu

t(s)

Targ

et

Rec

ipie

nt(s

)of

Out

put

RH

INO

S [

45]

To a

ssis

t ph

ysic

ians

in t

he d

iagn

osis

of

chro

nic

head

ache

sor

fac

ial p

ain

Bas

ed o

n ex

pert

kno

wle

dge

of h

eada

che

and

faci

alpa

in s

peci

alis

ts U

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ts o

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ility

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) ex

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rule

s (i

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if pa

tient

has

dis

ease

D

s

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ust

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sym

ptom

s S

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usiv

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les

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les

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Pro

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R

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nal

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rs w

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y 38

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put

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terv

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ndash

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tory

sin

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nset

ndash P

ain

char

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ristic

sndash

Neu

rolo

gica

l sig

nsas

soci

ated

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nndash

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enin

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ns

ndash Li

st o

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ted

Out

put

afte

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ditio

nal

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tion(

s)

ndash Li

st o

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ssib

le d

isea

ses

ndash D

iagn

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xpla

natio

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inat

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ta in

the

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repr

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IVA

N [

46]

To p

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dere

com

men

datio

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r co

ntro

lling

pai

nan

d pr

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and

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ritis

Cas

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cord

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LPA

Pro

log

prog

ram

min

gla

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ge fo

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indo

ws

(ldquoW

inP

rolo

grdquo)

runs

on

PC

Win

dow

s 95

NT

Win

Pro

log

ndash P

ain

sym

ptom

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cklis

tndash

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rent

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n di

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ndash C

urre

nt p

ain

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Com

pute

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ndash

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tic c

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ans

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nts

The

Dia

gnos

ticH

eada

che

Dia

ry[4

7]

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duca

te a

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ovid

e di

agno

stic

supp

ort

to p

rimar

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ostic

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diag

nose

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Sta

nd-a

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dow

s 95

prog

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writ

ten

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elph

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mm

ing

lang

uage

ndash P

atie

nt d

ata

ndash H

eada

che

diar

y en

trie

sndash

Med

icat

ions

use

d to

alle

viat

e he

adac

he

ndash D

iagn

osis

of

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typ

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s

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anag

emen

tA

dvis

or (

PM

A)

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aInt

ellig

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S

an D

iego

C

A)

[48]

To e

nhan

ce p

rimar

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re p

rovi

ders

rsquo(P

CP

s) m

anag

emen

tof

chr

onic

pai

n

ndash R

elie

s on

rul

e-ba

sed

algo

rithm

s de

rived

fro

mex

pert

kno

wle

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ofpa

in s

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alis

tsndash

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r as

ked

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estio

ns t

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fine

the

diag

nosi

s an

d de

term

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te t

hera

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Inte

ract

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for

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ucte

d

ndash P

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m-b

ased

PC

sndash

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dow

s 95

ndash P

MA

writ

ten

inM

icro

Sof

t Vis

ual B

asic

v

50

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n as

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rtap

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n in

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rtR

ule

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lgor

ithm

s st

ored

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t A

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s da

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roS

oft

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p U

tility

used

for

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and

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ies

ndash P

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nt d

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raph

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ndash D

iagn

osis

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ain

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ristic

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icat

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sndash

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rgie

sndash

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chol

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tatu

s

ndash A

prio

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st o

fre

com

men

datio

ns 1

) m

edic

alm

anag

emen

t (p

harm

acol

ogic

and

nonp

harm

acol

ogic

alm

anag

emen

t ph

ysic

al

psyc

hoso

cial

mod

aliti

es)

2)in

vasi

ve p

roce

dure

s 3

) re

ferr

als

PC

Ps

Computerized Decision-Support System for Pain

S159

Sym

ptom

Rep

ort

and

Sym

ptom

Con

sult

[49]

To a

ssis

t cl

inic

ians

in a

sses

sing

can

cer-

rela

ted

chro

nic

pain

and

fatig

ue

and

clar

ify p

atie

ntsrsquo

mis

belie

fs a

bout

pain

ass

essm

ent

and

man

agem

ent

Not

des

crib

edW

orki

ng v

ersi

onde

velo

ped

fiel

dte

stin

g co

nduc

ted

Mic

roS

oft W

indo

ws

959

8pe

rson

al c

ompu

ters

with

touc

h sc

reen

(P

en-T

ab)

Pat

ient

sel

f-re

port

ed in

put

ndash P

atie

nt d

emog

raph

ics

ndash 19

70 v

ersi

on o

f M

cGill

Pai

n Q

uest

ionn

aire

(M

PQ

)ndash

Bar

riers

Que

stio

nnai

re(B

Q)

ndash S

chw

artz

can

cer

fatig

uesc

ale

(SC

FS

-6)

1) H

ard

copi

es o

f ex

pert

sys

tem

repo

rt g

iven

to

patie

nt a

nd t

ocl

inic

ian

2) P

atie

nt r

ecei

ves

educ

atio

nal

mat

eria

ls o

n ho

w t

o re

port

pa

in

use

pain

med

icat

ions

sa

fely

an

d m

anag

e fa

tigue

M

ater

ials

are

cus

tom

ized

to

the

patie

ntrsquos

nee

ds a

nd

pres

ente

d in

an

inte

ract

ive

m

ultim

edia

form

at P

atie

nts

have

opt

ion

to re

ad o

r lis

ten

to

info

rmat

ion

on t

he c

ompu

ter

prin

t an

y or

all

of t

he

mat

eria

ls

or d

o bo

th

Onc

olog

ynu

rses

ot

her

clin

icia

ns

Dec

isio

n-su

ppor

tco

mpu

ter

prog

ram

for

canc

er p

ain

man

agem

ent

[50]

To im

prov

e th

eon

colo

gy n

urse

srsquode

cisi

on m

akin

gre

late

d to

can

cer

pain

man

agem

ent

amon

g cu

ltura

llydi

vers

e fe

mal

eon

colo

gy p

atie

nts

ndash S

urve

y da

ta o

n m

ultic

ultu

ral

canc

er p

ain

char

acte

ristic

sw

ere

anal

yzed

usi

ng f

uzzy

infe

renc

e lo

gic

to d

evel

op 4

mod

ules

1)

a ge

neric

know

ledg

e ba

se 2

) a

cultu

re-s

peci

fic k

now

ledg

e ba

se 3

) de

cisi

on-m

akin

g

and

4) s

elf-

adap

tatio

nndash

Dec

isio

n-m

akin

g m

odul

eco

nsis

ts o

f 2

sets

of

fuzz

yin

fere

nce

logi

c de

velo

ped

via

a ge

netic

alg

orith

m

Har

dwar

e no

t de

scrib

edndash

Ada

ptiv

e fu

zzy

logi

cso

ftwar

e us

ed t

o de

velo

pan

d ru

n th

e kn

owle

dge

base

gen

erat

ion

and

the

deci

sion

-mak

ing

and

self-

adap

tatio

n m

odul

es

Nur

se-e

nter

ed d

ata

base

don

pat

ient

inte

rvie

w

ndash P

atie

nt d

emog

raph

ics

ndash P

ain

char

acte

ristic

s

Com

pute

r sc

reen

dis

play

of

anal

gesi

c tr

eatm

ent

reco

mm

enda

tions

bas

ed o

n th

eW

orld

Hea

lth O

rgan

izat

ion

(WH

O)rsquos

ana

lges

ic la

dder

Onc

olog

ynu

rses

PAIN

Rep

or

tIt a

ndPA

IN

Con

sultN

[51

52]

To a

ssis

t cl

inic

ians

in a

sses

sing

chr

onic

pain

and

to

educ

ate

patie

nts

rega

rdin

gpa

in m

onito

ring

and

man

agem

ent

Not

des

crib

edW

orki

ng v

ersi

onde

velo

ped

fiel

dte

stin

g co

nduc

ted

Mic

roS

oft W

indo

ws

959

8pe

rson

al c

ompu

ters

with

touc

h sc

reen

(P

en-T

ab)

data

sto

red

in A

cces

s 97

data

base

Pat

ient

sel

f-re

port

ed in

put

1)

Pat

ient

dem

ogra

phic

sndash

McG

ill P

ain

Que

stio

nnai

rendash

Pai

n st

atus

ndash P

atie

nt g

oals

for

and

expe

ctat

ions

abo

ut p

ain

ndash Ty

pe a

nd e

ffect

iven

ess

of p

revi

ous

pain

trea

tmen

ts

Har

d co

pies

of

expe

rt s

yste

mre

port

giv

en t

o pa

tient

and

to

clin

icia

n o

n-sc

reen

vie

win

g of

repo

rt is

als

o po

ssib

le

Onc

olog

ynu

rses

and

othe

rcl

inic

ians

Touc

h-sc

reen

Com

pute

rA

sses

smen

t of

Chr

onic

Low

Bac

k P

ain

[53]

To c

olle

ct p

ain

sym

ptom

sta

tus

and

othe

r he

alth

info

rmat

ion

from

patie

nts

with

low

back

pai

n

Not

des

crib

edW

orki

ng v

ersi

onde

velo

ped

lim

ited

field

tes

ting

Web

-bas

ed s

yste

m u

sing

Del

l Ins

piro

n 11

00 la

ptop

with

Mic

roso

ft X

P o

pera

ting

syst

em 1

4

prime

tou

ch s

cree

n(M

agic

Tou

ch

Key

tec)

ndash P

atie

nt d

emog

raph

ics

ndash O

swes

try

Low

Bac

k P

ain

Dis

abili

ty I

ndex

(V

ersi

on 2

)ndash

Bec

k D

epre

ssio

n In

vent

ory

ndash M

OS

Sho

rt F

orm

-36

(MO

S S

F-3

6)

Not

des

crib

edP

hysi

cian

s

Nam

e of

CD

SS

Pur

pose

Des

crip

tion

Sta

ge o

fD

evel

opm

ent

Har

dwar

e amp

Sof

twar

eR

equi

rem

ents

Dat

a In

put(

s)O

utpu

t(s)

Targ

et

Rec

ipie

nt(s

)of

Out

put

S160

Smith et al

considerably in terms of content format anddelivery (eg electronic paper or both) SeveralCDSSs scored and summated patient responseson standard pain and QOL-related assessmentmeasures Based on the published descriptions atleast five of the CDSSs were designed to gener-ate output in real time at the patientrsquos medicalvisit

In terms of systems architecture all CDSSsreviewed were stand-alone personal computer-based systems None interfaced with existingelectronic medical records systems pharmacyappointment scheduling or laboratory resultsreporting Three either were Web-based or hadthe capacity to use a Web-based platform

Table 2 summarizes the types of studies con-ducted to date to evaluate chronic pain CDSSs Ofthe eight CDSSs identified five had publishedevaluation results With one exception all werefeasibility studies exclusively Studies were con-ducted in both inpatient and outpatient settingsAmong the outpatient studies two had been con-ducted with PCPs the remainder involved special-ists in tertiary care settings Study designs used forevaluating these CDSSs varied two were cross-sectional two involved immediate pre- and post-assessments of CDSS use one was longitudinal(12-month follow-up) and one was a focus groupStudy sample sizes ranged from 213 to 4 with themajority having 50 or fewer subjects

Patient acceptability of the CDSS was the sin-gle most commonly assessed variable Evaluationsof both the SymptomReport and the PAIN

Report-It

employed a common tool to assess patientacceptability Results across four pilot testsinvolving a total of 254 subjects consistentlyshowed high acceptability of these two CDSSsand 100 completion rates in terms of data input[495152] The average amount of time requiredranged from a high of 38 minutes to a low of14 minutes

Two studies addressed the issue of medicalaccuracy of the system-generated recommenda-tion Both studies examined this issue by compar-ing system-generated diagnoses andor treatmentrecommendations with those generated by physi-cian experts based on a select sample of patientcases Results showed moderate to high agreementbetween the system- and expert-generated recom-mendations [4748]

Clinician perceptions concerning ease of useand value of a CDSS for chronic pain managementwere examined in two studies Overall physiciansfound the system to be moderately easy to use and

of some clinical worth [4852] Knab and col-leagues [48] reported that the average cliniciantime spent per case on the PMA to obtain outputwas approximately 5 minutes (

plusmn

34 minutes) [48]In addition 85 of physicians adopted the PMA-generated recommendations and 25 of thestudy patients seen were referred to a pain special-ist with the average time to referral being37 months (

plusmn

06 months) [48]Analyses concerning the impact of CDSSs on

patient outcomes were limited Huang and col-leagues [51] assessed changes in pain intensity pre-and post-CDSS use in a sample of radiationoncology clinic patients Although there was adownward trend in pain levels over time resultswere not statistically significant possibly dueto the small size of the sample (N

=

15) Wilkieand colleagues [4952] reported qualitative dataregarding the impact of the SymptomReport andthe PAIN

ReportIt

on patient behavior Resultswere contradictory Of the 41 outpatients whoused the SymptomReport approximately 68stated that it had not affected their pain-relatedcommunication Some however felt that theytalked more precisely and explicitly about theirpain as a result of using it Other comments asso-ciated with use of the SymptomReport includedan increased awareness of pain symptoms andgreater compliance with pain symptom manage-ment In contrast 86 of users of the PAIN-

ReportIt

cited it as beneficial for patientndashdoctorpain-related communication and that it ldquofreedthem to describe their painrdquo

Discussion

Over the past two decades there has been a gradualbut steady growth in research on the use of CDSSsfor chronic pain management To date the numberof such systems is small but expanding Advanceshave also been evident in terms of both the quantityand quality of evaluation studies conducted Whilethe earliest versions were presented in the litera-ture as prototypes only [4546] CDSSs developedsince 2001 have all undergone some form of fieldtesting The majority of these studies howeverhave been nonexperimental in design and focusedexclusively on process measures such as patientor clinician ratings of system acceptability andusability Other salient process measures such asthe degree to which the clinician andor patientactually reviewed and utilized system output orhad confidence in its accuracy have not been con-sistently assessed Poor usability and practitioner

Computerized Decision-Support System for Pain

S161

Tab

le 2

Eva

luat

ion

of c

ompu

teri

zed

deci

sion

-sup

port

sys

tem

s (C

DS

Ss)

in c

hron

ic p

ain

man

agem

ent

Stu

dyN

ame

of C

DS

SS

ampl

eD

esig

nO

utco

mes

Ass

esse

dR

esul

ts

Nie

lsen

et a

l

[47

]D

iagn

ostic

Hea

dach

eD

iary

PC

Ps

Not

des

crib

edndash

a

gree

men

t of c

ompu

ter-

gene

rate

d vs

exp

ert

phys

icia

n di

agno

ses

ndash 10

0 a

gree

men

t of c

ompu

ter-

gene

rate

d vs

ex

pert

phy

sici

an d

iagn

oses

Kna

b et

al

[48

]P

ain

Man

agem

ent

Adv

isor

N

=

50

PC

Ps

N

=

50

chro

nic

pain

pat

ient

sLo

ngitu

dina

l w

ith 1

2-m

onth

PC

P fo

llow

-up

ndash E

ase

of u

sendash

Med

ical

app

ropr

iate

ness

of

reco

mm

enda

tions

ndash

phy

sici

ansrsquo

ado

ptin

g P

ain

Man

agem

ent

Adv

isor

tre

atm

ent

reco

mm

enda

tions

ndash

pat

ient

s re

ferr

ed t

o pa

insp

ecia

lty c

linic

Phy

sici

an a

dopt

ion

of s

yste

m-g

ener

ated

re

com

men

datio

ns 8

5 o

f ca

ses

Ave

rage

phy

sici

an t

ime

spen

t pe

r ca

se

49

min

utes

(S

D

plusmn

34)

Eas

e of

use

as

rate

d by

phy

sici

ans

42

(

plusmn

28

cm)

on s

cale

of

1ndash10

25

of

patie

nts

refe

rred

to

pain

spe

cial

ty

clin

icA

vera

ge t

ime

to p

ain

spec

ialty

ref

erra

l 3

7 m

onth

s (S

D

plusmn

06)

ndash 70

o

f no

nref

erre

d pa

tient

s st

ill r

ecei

ving

co

mpu

ter-

reco

mm

ende

d tr

eatm

ent

1 ye

ar

post

Wilk

ie e

t al

[49

]S

ympt

omR

epor

tN

=

41

outp

atie

nts

with

can

cer

Cro

ss-s

ectio

nal

tele

phon

e in

terv

iew

sndash

13-it

em p

atie

nt a

ccep

tabi

lity

scal

e as

sess

ing

ease

of

use

ofS

ympt

omR

epor

tndash

Inpu

t co

mpl

etio

n tim

endash

Qua

litat

ive

asse

ssm

ent

of d

egre

eof

com

mun

icat

ion

with

hea

lth c

are

prov

ider

s re

gard

ing

pain

and

oth

ersy

mpt

oms

ndash M

ean

time

to c

ompl

ete

Sym

ptom

Rep

ort

382

min

utes

(S

D

plusmn

202

)ndash

Mea

n tim

e to

com

plet

e S

ympt

omC

onsu

lt

209

min

utes

(S

D

plusmn

18

6)ndash

71

of

part

icip

ants

rat

ed S

ympt

omR

epor

t as

eas

y e

njoy

able

an

d in

form

ativ

endash

68

rep

orte

d th

at th

e am

ount

and

con

tent

of

the

ir pa

in-r

elat

ed c

omm

unic

atio

n w

ith

thei

r do

ctor

had

not

cha

nged

muc

hndash

Qua

litat

ive

patie

nt c

omm

ents

1)

help

ed

them

tal

k m

ore

expl

icitl

y ab

out

pain

2)

gave

the

m g

reat

er a

war

enes

s of

pai

n sy

mpt

oms

3)

incr

ease

d un

ders

tand

ing

of

and

enha

nced

com

plia

nce

rega

rdin

g sy

mpt

om m

anag

emen

t ndash

Pat

ient

com

men

ts r

e S

ympt

omC

onsu

lt 1

) co

ntai

ned

too

muc

h in

form

atio

n 2

) no

t ta

rget

ed t

o in

divi

dual

nee

ds (

3) p

rovi

ded

no n

ew in

form

atio

n

Wilk

ie e

t al

[52

]PA

IN

Rep

ortIt

N

=

213

of

who

m 1

06w

ere

canc

er in

patie

nts

10 m

etas

tatic

can

cer

outp

atie

nts

and

97

wer

e in

divi

dual

sex

perie

ncin

g ac

ute

orch

roni

c pa

in r

ecru

ited

from

non

heal

th c

are

setti

ngs

Des

crip

tive

cro

ss-

sect

iona

l stu

dy in

3se

tting

s 1

) te

rtia

ryca

re

2) r

adia

tion

onco

logy

clin

ic

3)m

obile

clin

ic

ndash 13

-item

sca

le m

easu

ring

acce

ptab

ility

of

PAIN

Rep

ortIt

(ie

tim

e to

com

plet

e e

ase

of u

se

unde

rsta

ndab

ility

of

dire

ctio

ns

ergo

nom

ic e

lem

ents

of

syst

em

and

com

plet

enes

s of

res

pons

es)

ndash 86

o

f res

pond

ents

rate

d th

e PA

IN

Rep

ortIt

as

ben

efici

al f

or p

ain

com

mun

icat

ion

ndash 10

0 p

atie

nt c

ompl

etio

n ra

te o

f PA

IN

Rep

ortIt

ndash M

ean

time

to p

atie

nt

com

plet

ion

15

8 m

inut

es (

SD

plusmn

67

)ndash

Mea

n pa

tient

acc

epta

bilit

y sc

ore

11

7 (S

D

plusmn

16

) sc

ores

ran

ged

from

6 t

o 13

80

o

f pa

tient

s ra

ted

acce

ptab

ility

as

grea

ter

than

min

imum

crit

erio

n of

10

ndash U

ser

com

men

ts 1

) so

me

mec

hani

cal

diffi

culti

es 2

) re

activ

ity t

o us

e of

sys

tem

(e

g

vom

iting

) 3)

pre

fere

nce

to r

elay

info

rmat

ion

dire

ctly

to

prov

ider

PC

P p

rimar

y ca

re p

hysi

cian

S162

Smith et al

Hua

ng e

t al

[51

]PA

IN

Rep

ortIt

and

PAIN

Con

sultN

Pilo

t st

udy

1 N

=

9pa

tient

s w

ith b

one

met

asta

sis-

rela

ted

pain

Pilo

t st

udy

2 N

=

15

patie

nts

with

can

cer

and

bone

met

asta

sis

Phy

sici

an fo

cus

grou

pN

=

4 r

adia

tion

onco

logi

sts

1) P

ilot

test

1

Fea

sibi

lity

stud

y us

ing

a te

stndashr

etes

t w

ithin

-su

bjec

t de

sign

2) P

ilot

test

2

Fea

sibi

lity

stud

y us

ing

an 1

1-da

y te

stndashr

etes

tw

ithin

-sub

ject

des

ign

3) P

hysi

cian

focu

sgr

oup

Out

com

e m

easu

res

used

for

both

pilo

t st

udie

sndash

Acc

epta

bilit

yndash

Com

plet

enes

sndash

Tim

e to

com

plet

endash

Val

idity

Phy

sici

an fo

cus

grou

pndash

Rec

eptiv

ity t

o PA

IN

Rep

ortIt

and

PAIN

Con

sultN

Pilo

t st

udy

1

ndashM

ean

time

to c

ompl

ete

PAIN

Rep

ortIt

at

pret

est

12 m

inut

es (

SD

plusmn

4)

ndashT

ime

to c

ompl

ete

PAIN

Rep

ortIt

at

post

-te

st 1

ndash7 m

inut

es p

er p

atie

ntndash

Mea

n ac

cept

abili

ty s

core

11

2 (S

D

plusmn

18

)ndash

100

com

plet

ion

rate

Pilo

t st

udy

2ndash

Mea

n tim

e to

com

plet

e PA

IN

Rep

ortIt

at

pret

est

17 m

inut

es (

SD

plusmn

6)

ndashT

ime

to c

ompl

ete

PAIN

Rep

ortIt

at p

ostte

st

14 m

inut

es (

SD

plusmn

8)

ndashM

ean

acce

ptab

ility

sco

re 1

22

(SD

plusmn

13

)ndash

100

com

plet

ion

rate

ndashPA

IN

Con

sultN

rec

omm

ende

d a

med

ian

of

4 dr

ugs

phy

sici

ans

pres

crib

ed a

med

ian

of

3 dr

ugs

post

use

ndashP

atie

nt p

ain

inte

nsity

ave

rage

4 a

t bas

elin

e an

d 2

7 at

pos

ttest

(no

t si

gnifi

cant

)

Foc

us g

roup

ndashP

hysi

cian

s sa

w v

alue

of

PAIN

Rep

ortIt

1)

incr

ease

d ef

ficie

ncy

durin

g cl

inic

vis

it 2

) su

pple

men

ted

pain

ser

vice

con

sulta

tion

3)

prov

ided

out

com

e da

tandash

PAIN

Con

sultN

was

vie

wed

as

clin

ical

ad

junc

t bu

t fo

rmat

ting

need

ed

impr

ovem

ent

Koe

stle

r et

al

[53

]To

uch-

scre

en C

ompu

ter

Ass

essm

ent

of C

hron

icLo

w B

ack

Pai

n

N

=

30

low

bac

kpa

in p

atie

nts

Cro

ss-s

ectio

nal d

esig

nin

ter

tiary

car

e cl

inic

ndashP

atie

nt-r

atin

gs o

f er

gono

mic

desi

gn d

egre

e of

tec

hnic

aldi

fficu

lties

ac

cept

abili

ty

ease

of u

se d

ata

secu

rity

ndashM

ean

time

to c

ompl

ete

the

67-it

em t

ouch

sc

reen

27

4 m

inut

es (

SD

plusmn

138

)

Stu

dyN

ame

of C

DS

SS

ampl

eD

esig

nO

utco

mes

Ass

esse

dR

esul

ts

PC

P p

rimar

y ca

re p

hysi

cian

Tab

le 2

Con

tinue

d

Computerized Decision-Support System for Pain

S163

nonacceptance of computer recommendations canserve as significant barriers to system adoption inroutine clinical practice [365455]

User preferences regarding the presentation ofcomputer output including content formatting(eg color graphics) and length have not beensolicited in most instances either Similarly thereare few published data concerning technical diffi-culties (eg type and number of system crashes ortouch-screen calibration problems) encounteredby CDSS users Both issues have important rami-fications for future system refinements [52] Addi-tionally there is a paucity of information oncontextual circumstances (eg presence of a localldquochampionrdquo of the system) or the processes usedto integrate the CDSS into the existing clinicalworkflow key considerations for successful systemimplementation Not least testing has been con-fined almost exclusively to either inpatient ortertiary care settings with only two studies con-ducted in the primary care context to date

The effects of these systems on patient out-comes remain understudied Two studies reportedqualitative data concerning CDSS impact onpatientsrsquo perceived pain-related communicationwith their physician however sample sizes weresmall and results inconsistent [4952] One studyreported system impact on patient pain intensitylevel over time but the study lacked adequate sta-tistical power to detect clinically important differ-ences [52] Other major patient outcomes such ashealth care utilization health care costs painrelief pain medication usage communication withhealth care provider about pain functional statusand QOL have not been examined One studyreported evidence that CDSS use may invokepatient reactivity (eg vomiting intensified painsymptoms) Potential adverse effects on patientsshould be measured in future investigations [52]Similarly there is need for more extensive andconsistent examination of system impact on clini-cian pain management performance

While we sought to be as comprehensive aspossible in our literature search our review wasrestricted to only English-language studies Inaddition it is possible that there are other CDSSsunder development that we failed to identify Thelimited size of the available literature as well asthe methods used in these primary studies pre-vented us from conducting a meta-analysis ofresearch findings and from reaching more defin-itive conclusions about the impact of these systemson physician performance and patient pain func-tioning and other aspects of QOL Notably in all

the studies we examined study investigators andCDSS developers were one and the same a factthat may have resulted in more positive findings[36] Lastly we did not conduct a separate evalu-ation of the clinical appropriateness of either theCDSS algorithms or treatment recommendationsnor of the underlying logic employed to generatesuch algorithms

The potential for these computer-based sys-tems to improve the quality of chronic pain man-agement in the primary care context is substantialTo manage chronic pain effectively PCPs firstneed to conduct a comprehensive patient assess-ment [56] Information on the patientrsquos pain ex-perience history of and preferences for paintreatment psychological status approach to self-management and personal goalspriorities are keyvariables to collect during assessment as they arecritical for making an accurate diagnosis and fordeveloping an appropriate treatment plan to whichthe patient will adhere [56] An expert system-typeCDSS provides a way to elicit and integrate suchpatient-specific information in a manner that isconvenient and timely for both physicians andpatients Moreover the ensuing system-generatedrecommendations are individualized to the needsand circumstances of the specific pain patient perbest clinical practices [56]

CDSSs developed for chronic pain manage-ment have as yet however to fulfill this promiseAs our review indicates systems developed thus farhave been predominantly biomedical in focus anddesigned to assist physicians and other health careproviders in the medical management of painsymptoms (including invasive procedures andreferrals) exclusively Only a few of these systemshave reached a sufficiently advanced stage ofdevelopment to warrant more rigorous testingin large-scale randomized controlled trials[264952] Such trials are imperative for under-standing system effect on provider performanceand patient outcomes

Significantly none of the systems reviewedwere integrated with existing electronic recordssystems nor did they include reminder or docu-mentation functionalities features which have allbeen shown to increase the likelihood of physicianadoption [5758] This lack of integration mayreflect the fact that widespread adoption of elec-tronic records systems by health care institutionshas been a relatively recent occurrence Potentiallythis trend coupled with pressures from majoraccrediting agencies to document the provision ofpain screening and treatment along with the

S164

Smith et al

recent publication of primary care pain manage-ment guidelines may serve to spur additionalmore rigorous research on the use of CDSSs forchronic pain management in primary care[565960] Demonstrating the clinical value ofthese systems is a critical step in convincing healthcare organizations and clinicians that the benefitsof investing in a CDSS for pain management out-weigh potential risks In particular physiciansneed to be assured that this type of system canenhance rather than erode their decision-makingabilities and that time spent learning how to usea CDSS yields measurable improvement in patienthealth and well-being

References

1 American Pain Society Chronic pain in AmericaRoadblock to relief 1999 American Pain SocietyAPS News and Announcements Available at httpwwwampainsocorgwhatsnewtoc_roadhtmtoc

2 Lande SD The problem of pain in managed careIn Lande SD Kulich RJ eds Managed Care andPain Glenview IL American Pain Society 200019

3 Turner JA Leresche L Von Korff M Ehrlich LPrimary care back pain patient characteristics visitcontent and short term outcomes Spine199823463ndash9

4 Von Korff M Gruman J Schaefer J Curry SJ Wag-ner EH Collaborative management of chronic ill-ness Ann Intern Med 1997127(12)1097ndash102

5 Von Korff M Pain management in primary care Anindividualized stepped-care approach In GatchelRJ Turk DL eds Psychosocial Factors in PainCritical Perspectives New York The GuilfordPress 1999

6 Von Korff M Katon W Bush T et al Treatmentcosts cost offset and cost-effectiveness of collabo-rative management of depression Psychosom Med199860(2)143ndash9

7 Bertakis KD Azari R Callahan EJ Patient pain Itsinfluence on primary care physicianndashpatient inter-action Fam Med 200335(2)119ndash23

8 Green CR Wheeler JRC Laporte F Marchant BGuerrero E How well is chronic pain managedWho does it well Pain Med 20023(1)56ndash62

9 Von Roenn JH Cleeland CS Gonin R HatfieldAK Pandya KJ Physician attitudes and practice incancer pain management A survey from the EasternCooperative Oncology Group Ann Intern Med1993119121ndash6

10 Cleeland CS Cleeland LM Dar R Rinehardt LCFactors influencing physician management of can-cer pain Cancer 198658796ndash800

11 Fife BL Irick N Painter JD A comparative studyof the attitudes of physicians and nurses towards themanagement of cancer pain J Pain Symptom Man-age 19938132ndash9

12 Wilson JF Brockoop GW Kryst S Steger H WittWO Medical studentsrsquo attitudes towards painbefore and after a brief course on pain Pain199250251ndash6

13 Weinstein SM Laux LF Thornby JI et al Physi-ciansrsquo attitudes towards pain and the use of opioidanalgesics Results of a survey from the Texas Can-cer Pain Initiative South Med J 200093(5)479ndash87

14 Weinstein SM Laux LF Thornby JI et al Medicalstudentsrsquo attitudes towards pain and the use of opi-oid analgesics Implications for changing medicalschool curriculum South Med J 200093(5)472ndash8

15 Whedon M Ferrell BR Professional and ethicalconsiderations in the use of high-tech pain manage-ment Oncol Nurs Forum 1991181135ndash43

16 Ward S Goldberg N Miller-Mccauley V et alPatient-related barriers to management of cancerpain Pain 199352319ndash24

17 Pargeon KL Hailey BJ Barriers to effective cancerpain management A review of the literature J PainSymptom Manage 199918358ndash68

18 Breitbart W Passik S Mcdonald MV et al Patient-related barriers to pain management in ambulatoryAIDS patients Pain 199352319ndash24

19 Gunnarsdottir S Donovan HS Serlin RC Voge CWard S Patient-related barriers to pain manage-ment The barriers questionnaire II (BQ-II) Pain200299385ndash96

20 Arora NK Interacting with cancer patients Thesignificance of physiciansrsquo communication behaviorSoc Sci Med 200357791ndash806

21 Mccaffery M Thorpe DM Differences in percep-tion of pain and the development of adversarial rela-tionships among health care providers In Hill CSFields W eds Advances in Pain Research and Ther-apy Drug Treatment of Cancer Pain in a Drug-Oriented Society Vol 11 New York Raven Press1989

22 Ong LML de Haes JCJM Hoos AM Lammes FBDoctorndashpatient communication A review of the lit-erature Soc Sci Med 199540903ndash18

23 Jones WL Rimer BK Levy MH Kinman JL Can-cer patientsrsquo knowledge beliefs and behaviorregarding pain control regimens Implications foreducation programs Patient Educ Couns19845(4)159ndash64

24 Lukoschek P Fazzari M Marantz P Patient andphysician factors predict patientsrsquo comprehensionof health information Patient Educ Couns200350201ndash10

25 Donovan JL Blake DR Patient non-complianceDeviance or reasoned decision-making Soc SciMed 199234377ndash94

26 Garg AX Adhikari NKJ Mcdonald H et al Effectsof computerized clinical decision support systemson practitioner performance and patient outcomesa systematic review JAMA 2005293(10)1223ndash38

27 Nilasena DS Lincoln MJ A computer-generatedreminder system improves physician compliance

Computerized Decision-Support System for Pain

S159

Sym

ptom

Rep

ort

and

Sym

ptom

Con

sult

[49]

To a

ssis

t cl

inic

ians

in a

sses

sing

can

cer-

rela

ted

chro

nic

pain

and

fatig

ue

and

clar

ify p

atie

ntsrsquo

mis

belie

fs a

bout

pain

ass

essm

ent

and

man

agem

ent

Not

des

crib

edW

orki

ng v

ersi

onde

velo

ped

fiel

dte

stin

g co

nduc

ted

Mic

roS

oft W

indo

ws

959

8pe

rson

al c

ompu

ters

with

touc

h sc

reen

(P

en-T

ab)

Pat

ient

sel

f-re

port

ed in

put

ndash P

atie

nt d

emog

raph

ics

ndash 19

70 v

ersi

on o

f M

cGill

Pai

n Q

uest

ionn

aire

(M

PQ

)ndash

Bar

riers

Que

stio

nnai

re(B

Q)

ndash S

chw

artz

can

cer

fatig

uesc

ale

(SC

FS

-6)

1) H

ard

copi

es o

f ex

pert

sys

tem

repo

rt g

iven

to

patie

nt a

nd t

ocl

inic

ian

2) P

atie

nt r

ecei

ves

educ

atio

nal

mat

eria

ls o

n ho

w t

o re

port

pa

in

use

pain

med

icat

ions

sa

fely

an

d m

anag

e fa

tigue

M

ater

ials

are

cus

tom

ized

to

the

patie

ntrsquos

nee

ds a

nd

pres

ente

d in

an

inte

ract

ive

m

ultim

edia

form

at P

atie

nts

have

opt

ion

to re

ad o

r lis

ten

to

info

rmat

ion

on t

he c

ompu

ter

prin

t an

y or

all

of t

he

mat

eria

ls

or d

o bo

th

Onc

olog

ynu

rses

ot

her

clin

icia

ns

Dec

isio

n-su

ppor

tco

mpu

ter

prog

ram

for

canc

er p

ain

man

agem

ent

[50]

To im

prov

e th

eon

colo

gy n

urse

srsquode

cisi

on m

akin

gre

late

d to

can

cer

pain

man

agem

ent

amon

g cu

ltura

llydi

vers

e fe

mal

eon

colo

gy p

atie

nts

ndash S

urve

y da

ta o

n m

ultic

ultu

ral

canc

er p

ain

char

acte

ristic

sw

ere

anal

yzed

usi

ng f

uzzy

infe

renc

e lo

gic

to d

evel

op 4

mod

ules

1)

a ge

neric

know

ledg

e ba

se 2

) a

cultu

re-s

peci

fic k

now

ledg

e ba

se 3

) de

cisi

on-m

akin

g

and

4) s

elf-

adap

tatio

nndash

Dec

isio

n-m

akin

g m

odul

eco

nsis

ts o

f 2

sets

of

fuzz

yin

fere

nce

logi

c de

velo

ped

via

a ge

netic

alg

orith

m

Har

dwar

e no

t de

scrib

edndash

Ada

ptiv

e fu

zzy

logi

cso

ftwar

e us

ed t

o de

velo

pan

d ru

n th

e kn

owle

dge

base

gen

erat

ion

and

the

deci

sion

-mak

ing

and

self-

adap

tatio

n m

odul

es

Nur

se-e

nter

ed d

ata

base

don

pat

ient

inte

rvie

w

ndash P

atie

nt d

emog

raph

ics

ndash P

ain

char

acte

ristic

s

Com

pute

r sc

reen

dis

play

of

anal

gesi

c tr

eatm

ent

reco

mm

enda

tions

bas

ed o

n th

eW

orld

Hea

lth O

rgan

izat

ion

(WH

O)rsquos

ana

lges

ic la

dder

Onc

olog

ynu

rses

PAIN

Rep

or

tIt a

ndPA

IN

Con

sultN

[51

52]

To a

ssis

t cl

inic

ians

in a

sses

sing

chr

onic

pain

and

to

educ

ate

patie

nts

rega

rdin

gpa

in m

onito

ring

and

man

agem

ent

Not

des

crib

edW

orki

ng v

ersi

onde

velo

ped

fiel

dte

stin

g co

nduc

ted

Mic

roS

oft W

indo

ws

959

8pe

rson

al c

ompu

ters

with

touc

h sc

reen

(P

en-T

ab)

data

sto

red

in A

cces

s 97

data

base

Pat

ient

sel

f-re

port

ed in

put

1)

Pat

ient

dem

ogra

phic

sndash

McG

ill P

ain

Que

stio

nnai

rendash

Pai

n st

atus

ndash P

atie

nt g

oals

for

and

expe

ctat

ions

abo

ut p

ain

ndash Ty

pe a

nd e

ffect

iven

ess

of p

revi

ous

pain

trea

tmen

ts

Har

d co

pies

of

expe

rt s

yste

mre

port

giv

en t

o pa

tient

and

to

clin

icia

n o

n-sc

reen

vie

win

g of

repo

rt is

als

o po

ssib

le

Onc

olog

ynu

rses

and

othe

rcl

inic

ians

Touc

h-sc

reen

Com

pute

rA

sses

smen

t of

Chr

onic

Low

Bac

k P

ain

[53]

To c

olle

ct p

ain

sym

ptom

sta

tus

and

othe

r he

alth

info

rmat

ion

from

patie

nts

with

low

back

pai

n

Not

des

crib

edW

orki

ng v

ersi

onde

velo

ped

lim

ited

field

tes

ting

Web

-bas

ed s

yste

m u

sing

Del

l Ins

piro

n 11

00 la

ptop

with

Mic

roso

ft X

P o

pera

ting

syst

em 1

4

prime

tou

ch s

cree

n(M

agic

Tou

ch

Key

tec)

ndash P

atie

nt d

emog

raph

ics

ndash O

swes

try

Low

Bac

k P

ain

Dis

abili

ty I

ndex

(V

ersi

on 2

)ndash

Bec

k D

epre

ssio

n In

vent

ory

ndash M

OS

Sho

rt F

orm

-36

(MO

S S

F-3

6)

Not

des

crib

edP

hysi

cian

s

Nam

e of

CD

SS

Pur

pose

Des

crip

tion

Sta

ge o

fD

evel

opm

ent

Har

dwar

e amp

Sof

twar

eR

equi

rem

ents

Dat

a In

put(

s)O

utpu

t(s)

Targ

et

Rec

ipie

nt(s

)of

Out

put

S160

Smith et al

considerably in terms of content format anddelivery (eg electronic paper or both) SeveralCDSSs scored and summated patient responseson standard pain and QOL-related assessmentmeasures Based on the published descriptions atleast five of the CDSSs were designed to gener-ate output in real time at the patientrsquos medicalvisit

In terms of systems architecture all CDSSsreviewed were stand-alone personal computer-based systems None interfaced with existingelectronic medical records systems pharmacyappointment scheduling or laboratory resultsreporting Three either were Web-based or hadthe capacity to use a Web-based platform

Table 2 summarizes the types of studies con-ducted to date to evaluate chronic pain CDSSs Ofthe eight CDSSs identified five had publishedevaluation results With one exception all werefeasibility studies exclusively Studies were con-ducted in both inpatient and outpatient settingsAmong the outpatient studies two had been con-ducted with PCPs the remainder involved special-ists in tertiary care settings Study designs used forevaluating these CDSSs varied two were cross-sectional two involved immediate pre- and post-assessments of CDSS use one was longitudinal(12-month follow-up) and one was a focus groupStudy sample sizes ranged from 213 to 4 with themajority having 50 or fewer subjects

Patient acceptability of the CDSS was the sin-gle most commonly assessed variable Evaluationsof both the SymptomReport and the PAIN

Report-It

employed a common tool to assess patientacceptability Results across four pilot testsinvolving a total of 254 subjects consistentlyshowed high acceptability of these two CDSSsand 100 completion rates in terms of data input[495152] The average amount of time requiredranged from a high of 38 minutes to a low of14 minutes

Two studies addressed the issue of medicalaccuracy of the system-generated recommenda-tion Both studies examined this issue by compar-ing system-generated diagnoses andor treatmentrecommendations with those generated by physi-cian experts based on a select sample of patientcases Results showed moderate to high agreementbetween the system- and expert-generated recom-mendations [4748]

Clinician perceptions concerning ease of useand value of a CDSS for chronic pain managementwere examined in two studies Overall physiciansfound the system to be moderately easy to use and

of some clinical worth [4852] Knab and col-leagues [48] reported that the average cliniciantime spent per case on the PMA to obtain outputwas approximately 5 minutes (

plusmn

34 minutes) [48]In addition 85 of physicians adopted the PMA-generated recommendations and 25 of thestudy patients seen were referred to a pain special-ist with the average time to referral being37 months (

plusmn

06 months) [48]Analyses concerning the impact of CDSSs on

patient outcomes were limited Huang and col-leagues [51] assessed changes in pain intensity pre-and post-CDSS use in a sample of radiationoncology clinic patients Although there was adownward trend in pain levels over time resultswere not statistically significant possibly dueto the small size of the sample (N

=

15) Wilkieand colleagues [4952] reported qualitative dataregarding the impact of the SymptomReport andthe PAIN

ReportIt

on patient behavior Resultswere contradictory Of the 41 outpatients whoused the SymptomReport approximately 68stated that it had not affected their pain-relatedcommunication Some however felt that theytalked more precisely and explicitly about theirpain as a result of using it Other comments asso-ciated with use of the SymptomReport includedan increased awareness of pain symptoms andgreater compliance with pain symptom manage-ment In contrast 86 of users of the PAIN-

ReportIt

cited it as beneficial for patientndashdoctorpain-related communication and that it ldquofreedthem to describe their painrdquo

Discussion

Over the past two decades there has been a gradualbut steady growth in research on the use of CDSSsfor chronic pain management To date the numberof such systems is small but expanding Advanceshave also been evident in terms of both the quantityand quality of evaluation studies conducted Whilethe earliest versions were presented in the litera-ture as prototypes only [4546] CDSSs developedsince 2001 have all undergone some form of fieldtesting The majority of these studies howeverhave been nonexperimental in design and focusedexclusively on process measures such as patientor clinician ratings of system acceptability andusability Other salient process measures such asthe degree to which the clinician andor patientactually reviewed and utilized system output orhad confidence in its accuracy have not been con-sistently assessed Poor usability and practitioner

Computerized Decision-Support System for Pain

S161

Tab

le 2

Eva

luat

ion

of c

ompu

teri

zed

deci

sion

-sup

port

sys

tem

s (C

DS

Ss)

in c

hron

ic p

ain

man

agem

ent

Stu

dyN

ame

of C

DS

SS

ampl

eD

esig

nO

utco

mes

Ass

esse

dR

esul

ts

Nie

lsen

et a

l

[47

]D

iagn

ostic

Hea

dach

eD

iary

PC

Ps

Not

des

crib

edndash

a

gree

men

t of c

ompu

ter-

gene

rate

d vs

exp

ert

phys

icia

n di

agno

ses

ndash 10

0 a

gree

men

t of c

ompu

ter-

gene

rate

d vs

ex

pert

phy

sici

an d

iagn

oses

Kna

b et

al

[48

]P

ain

Man

agem

ent

Adv

isor

N

=

50

PC

Ps

N

=

50

chro

nic

pain

pat

ient

sLo

ngitu

dina

l w

ith 1

2-m

onth

PC

P fo

llow

-up

ndash E

ase

of u

sendash

Med

ical

app

ropr

iate

ness

of

reco

mm

enda

tions

ndash

phy

sici

ansrsquo

ado

ptin

g P

ain

Man

agem

ent

Adv

isor

tre

atm

ent

reco

mm

enda

tions

ndash

pat

ient

s re

ferr

ed t

o pa

insp

ecia

lty c

linic

Phy

sici

an a

dopt

ion

of s

yste

m-g

ener

ated

re

com

men

datio

ns 8

5 o

f ca

ses

Ave

rage

phy

sici

an t

ime

spen

t pe

r ca

se

49

min

utes

(S

D

plusmn

34)

Eas

e of

use

as

rate

d by

phy

sici

ans

42

(

plusmn

28

cm)

on s

cale

of

1ndash10

25

of

patie

nts

refe

rred

to

pain

spe

cial

ty

clin

icA

vera

ge t

ime

to p

ain

spec

ialty

ref

erra

l 3

7 m

onth

s (S

D

plusmn

06)

ndash 70

o

f no

nref

erre

d pa

tient

s st

ill r

ecei

ving

co

mpu

ter-

reco

mm

ende

d tr

eatm

ent

1 ye

ar

post

Wilk

ie e

t al

[49

]S

ympt

omR

epor

tN

=

41

outp

atie

nts

with

can

cer

Cro

ss-s

ectio

nal

tele

phon

e in

terv

iew

sndash

13-it

em p

atie

nt a

ccep

tabi

lity

scal

e as

sess

ing

ease

of

use

ofS

ympt

omR

epor

tndash

Inpu

t co

mpl

etio

n tim

endash

Qua

litat

ive

asse

ssm

ent

of d

egre

eof

com

mun

icat

ion

with

hea

lth c

are

prov

ider

s re

gard

ing

pain

and

oth

ersy

mpt

oms

ndash M

ean

time

to c

ompl

ete

Sym

ptom

Rep

ort

382

min

utes

(S

D

plusmn

202

)ndash

Mea

n tim

e to

com

plet

e S

ympt

omC

onsu

lt

209

min

utes

(S

D

plusmn

18

6)ndash

71

of

part

icip

ants

rat

ed S

ympt

omR

epor

t as

eas

y e

njoy

able

an

d in

form

ativ

endash

68

rep

orte

d th

at th

e am

ount

and

con

tent

of

the

ir pa

in-r

elat

ed c

omm

unic

atio

n w

ith

thei

r do

ctor

had

not

cha

nged

muc

hndash

Qua

litat

ive

patie

nt c

omm

ents

1)

help

ed

them

tal

k m

ore

expl

icitl

y ab

out

pain

2)

gave

the

m g

reat

er a

war

enes

s of

pai

n sy

mpt

oms

3)

incr

ease

d un

ders

tand

ing

of

and

enha

nced

com

plia

nce

rega

rdin

g sy

mpt

om m

anag

emen

t ndash

Pat

ient

com

men

ts r

e S

ympt

omC

onsu

lt 1

) co

ntai

ned

too

muc

h in

form

atio

n 2

) no

t ta

rget

ed t

o in

divi

dual

nee

ds (

3) p

rovi

ded

no n

ew in

form

atio

n

Wilk

ie e

t al

[52

]PA

IN

Rep

ortIt

N

=

213

of

who

m 1

06w

ere

canc

er in

patie

nts

10 m

etas

tatic

can

cer

outp

atie

nts

and

97

wer

e in

divi

dual

sex

perie

ncin

g ac

ute

orch

roni

c pa

in r

ecru

ited

from

non

heal

th c

are

setti

ngs

Des

crip

tive

cro

ss-

sect

iona

l stu

dy in

3se

tting

s 1

) te

rtia

ryca

re

2) r

adia

tion

onco

logy

clin

ic

3)m

obile

clin

ic

ndash 13

-item

sca

le m

easu

ring

acce

ptab

ility

of

PAIN

Rep

ortIt

(ie

tim

e to

com

plet

e e

ase

of u

se

unde

rsta

ndab

ility

of

dire

ctio

ns

ergo

nom

ic e

lem

ents

of

syst

em

and

com

plet

enes

s of

res

pons

es)

ndash 86

o

f res

pond

ents

rate

d th

e PA

IN

Rep

ortIt

as

ben

efici

al f

or p

ain

com

mun

icat

ion

ndash 10

0 p

atie

nt c

ompl

etio

n ra

te o

f PA

IN

Rep

ortIt

ndash M

ean

time

to p

atie

nt

com

plet

ion

15

8 m

inut

es (

SD

plusmn

67

)ndash

Mea

n pa

tient

acc

epta

bilit

y sc

ore

11

7 (S

D

plusmn

16

) sc

ores

ran

ged

from

6 t

o 13

80

o

f pa

tient

s ra

ted

acce

ptab

ility

as

grea

ter

than

min

imum

crit

erio

n of

10

ndash U

ser

com

men

ts 1

) so

me

mec

hani

cal

diffi

culti

es 2

) re

activ

ity t

o us

e of

sys

tem

(e

g

vom

iting

) 3)

pre

fere

nce

to r

elay

info

rmat

ion

dire

ctly

to

prov

ider

PC

P p

rimar

y ca

re p

hysi

cian

S162

Smith et al

Hua

ng e

t al

[51

]PA

IN

Rep

ortIt

and

PAIN

Con

sultN

Pilo

t st

udy

1 N

=

9pa

tient

s w

ith b

one

met

asta

sis-

rela

ted

pain

Pilo

t st

udy

2 N

=

15

patie

nts

with

can

cer

and

bone

met

asta

sis

Phy

sici

an fo

cus

grou

pN

=

4 r

adia

tion

onco

logi

sts

1) P

ilot

test

1

Fea

sibi

lity

stud

y us

ing

a te

stndashr

etes

t w

ithin

-su

bjec

t de

sign

2) P

ilot

test

2

Fea

sibi

lity

stud

y us

ing

an 1

1-da

y te

stndashr

etes

tw

ithin

-sub

ject

des

ign

3) P

hysi

cian

focu

sgr

oup

Out

com

e m

easu

res

used

for

both

pilo

t st

udie

sndash

Acc

epta

bilit

yndash

Com

plet

enes

sndash

Tim

e to

com

plet

endash

Val

idity

Phy

sici

an fo

cus

grou

pndash

Rec

eptiv

ity t

o PA

IN

Rep

ortIt

and

PAIN

Con

sultN

Pilo

t st

udy

1

ndashM

ean

time

to c

ompl

ete

PAIN

Rep

ortIt

at

pret

est

12 m

inut

es (

SD

plusmn

4)

ndashT

ime

to c

ompl

ete

PAIN

Rep

ortIt

at

post

-te

st 1

ndash7 m

inut

es p

er p

atie

ntndash

Mea

n ac

cept

abili

ty s

core

11

2 (S

D

plusmn

18

)ndash

100

com

plet

ion

rate

Pilo

t st

udy

2ndash

Mea

n tim

e to

com

plet

e PA

IN

Rep

ortIt

at

pret

est

17 m

inut

es (

SD

plusmn

6)

ndashT

ime

to c

ompl

ete

PAIN

Rep

ortIt

at p

ostte

st

14 m

inut

es (

SD

plusmn

8)

ndashM

ean

acce

ptab

ility

sco

re 1

22

(SD

plusmn

13

)ndash

100

com

plet

ion

rate

ndashPA

IN

Con

sultN

rec

omm

ende

d a

med

ian

of

4 dr

ugs

phy

sici

ans

pres

crib

ed a

med

ian

of

3 dr

ugs

post

use

ndashP

atie

nt p

ain

inte

nsity

ave

rage

4 a

t bas

elin

e an

d 2

7 at

pos

ttest

(no

t si

gnifi

cant

)

Foc

us g

roup

ndashP

hysi

cian

s sa

w v

alue

of

PAIN

Rep

ortIt

1)

incr

ease

d ef

ficie

ncy

durin

g cl

inic

vis

it 2

) su

pple

men

ted

pain

ser

vice

con

sulta

tion

3)

prov

ided

out

com

e da

tandash

PAIN

Con

sultN

was

vie

wed

as

clin

ical

ad

junc

t bu

t fo

rmat

ting

need

ed

impr

ovem

ent

Koe

stle

r et

al

[53

]To

uch-

scre

en C

ompu

ter

Ass

essm

ent

of C

hron

icLo

w B

ack

Pai

n

N

=

30

low

bac

kpa

in p

atie

nts

Cro

ss-s

ectio

nal d

esig

nin

ter

tiary

car

e cl

inic

ndashP

atie

nt-r

atin

gs o

f er

gono

mic

desi

gn d

egre

e of

tec

hnic

aldi

fficu

lties

ac

cept

abili

ty

ease

of u

se d

ata

secu

rity

ndashM

ean

time

to c

ompl

ete

the

67-it

em t

ouch

sc

reen

27

4 m

inut

es (

SD

plusmn

138

)

Stu

dyN

ame

of C

DS

SS

ampl

eD

esig

nO

utco

mes

Ass

esse

dR

esul

ts

PC

P p

rimar

y ca

re p

hysi

cian

Tab

le 2

Con

tinue

d

Computerized Decision-Support System for Pain

S163

nonacceptance of computer recommendations canserve as significant barriers to system adoption inroutine clinical practice [365455]

User preferences regarding the presentation ofcomputer output including content formatting(eg color graphics) and length have not beensolicited in most instances either Similarly thereare few published data concerning technical diffi-culties (eg type and number of system crashes ortouch-screen calibration problems) encounteredby CDSS users Both issues have important rami-fications for future system refinements [52] Addi-tionally there is a paucity of information oncontextual circumstances (eg presence of a localldquochampionrdquo of the system) or the processes usedto integrate the CDSS into the existing clinicalworkflow key considerations for successful systemimplementation Not least testing has been con-fined almost exclusively to either inpatient ortertiary care settings with only two studies con-ducted in the primary care context to date

The effects of these systems on patient out-comes remain understudied Two studies reportedqualitative data concerning CDSS impact onpatientsrsquo perceived pain-related communicationwith their physician however sample sizes weresmall and results inconsistent [4952] One studyreported system impact on patient pain intensitylevel over time but the study lacked adequate sta-tistical power to detect clinically important differ-ences [52] Other major patient outcomes such ashealth care utilization health care costs painrelief pain medication usage communication withhealth care provider about pain functional statusand QOL have not been examined One studyreported evidence that CDSS use may invokepatient reactivity (eg vomiting intensified painsymptoms) Potential adverse effects on patientsshould be measured in future investigations [52]Similarly there is need for more extensive andconsistent examination of system impact on clini-cian pain management performance

While we sought to be as comprehensive aspossible in our literature search our review wasrestricted to only English-language studies Inaddition it is possible that there are other CDSSsunder development that we failed to identify Thelimited size of the available literature as well asthe methods used in these primary studies pre-vented us from conducting a meta-analysis ofresearch findings and from reaching more defin-itive conclusions about the impact of these systemson physician performance and patient pain func-tioning and other aspects of QOL Notably in all

the studies we examined study investigators andCDSS developers were one and the same a factthat may have resulted in more positive findings[36] Lastly we did not conduct a separate evalu-ation of the clinical appropriateness of either theCDSS algorithms or treatment recommendationsnor of the underlying logic employed to generatesuch algorithms

The potential for these computer-based sys-tems to improve the quality of chronic pain man-agement in the primary care context is substantialTo manage chronic pain effectively PCPs firstneed to conduct a comprehensive patient assess-ment [56] Information on the patientrsquos pain ex-perience history of and preferences for paintreatment psychological status approach to self-management and personal goalspriorities are keyvariables to collect during assessment as they arecritical for making an accurate diagnosis and fordeveloping an appropriate treatment plan to whichthe patient will adhere [56] An expert system-typeCDSS provides a way to elicit and integrate suchpatient-specific information in a manner that isconvenient and timely for both physicians andpatients Moreover the ensuing system-generatedrecommendations are individualized to the needsand circumstances of the specific pain patient perbest clinical practices [56]

CDSSs developed for chronic pain manage-ment have as yet however to fulfill this promiseAs our review indicates systems developed thus farhave been predominantly biomedical in focus anddesigned to assist physicians and other health careproviders in the medical management of painsymptoms (including invasive procedures andreferrals) exclusively Only a few of these systemshave reached a sufficiently advanced stage ofdevelopment to warrant more rigorous testingin large-scale randomized controlled trials[264952] Such trials are imperative for under-standing system effect on provider performanceand patient outcomes

Significantly none of the systems reviewedwere integrated with existing electronic recordssystems nor did they include reminder or docu-mentation functionalities features which have allbeen shown to increase the likelihood of physicianadoption [5758] This lack of integration mayreflect the fact that widespread adoption of elec-tronic records systems by health care institutionshas been a relatively recent occurrence Potentiallythis trend coupled with pressures from majoraccrediting agencies to document the provision ofpain screening and treatment along with the

S164

Smith et al

recent publication of primary care pain manage-ment guidelines may serve to spur additionalmore rigorous research on the use of CDSSs forchronic pain management in primary care[565960] Demonstrating the clinical value ofthese systems is a critical step in convincing healthcare organizations and clinicians that the benefitsof investing in a CDSS for pain management out-weigh potential risks In particular physiciansneed to be assured that this type of system canenhance rather than erode their decision-makingabilities and that time spent learning how to usea CDSS yields measurable improvement in patienthealth and well-being

References

1 American Pain Society Chronic pain in AmericaRoadblock to relief 1999 American Pain SocietyAPS News and Announcements Available at httpwwwampainsocorgwhatsnewtoc_roadhtmtoc

2 Lande SD The problem of pain in managed careIn Lande SD Kulich RJ eds Managed Care andPain Glenview IL American Pain Society 200019

3 Turner JA Leresche L Von Korff M Ehrlich LPrimary care back pain patient characteristics visitcontent and short term outcomes Spine199823463ndash9

4 Von Korff M Gruman J Schaefer J Curry SJ Wag-ner EH Collaborative management of chronic ill-ness Ann Intern Med 1997127(12)1097ndash102

5 Von Korff M Pain management in primary care Anindividualized stepped-care approach In GatchelRJ Turk DL eds Psychosocial Factors in PainCritical Perspectives New York The GuilfordPress 1999

6 Von Korff M Katon W Bush T et al Treatmentcosts cost offset and cost-effectiveness of collabo-rative management of depression Psychosom Med199860(2)143ndash9

7 Bertakis KD Azari R Callahan EJ Patient pain Itsinfluence on primary care physicianndashpatient inter-action Fam Med 200335(2)119ndash23

8 Green CR Wheeler JRC Laporte F Marchant BGuerrero E How well is chronic pain managedWho does it well Pain Med 20023(1)56ndash62

9 Von Roenn JH Cleeland CS Gonin R HatfieldAK Pandya KJ Physician attitudes and practice incancer pain management A survey from the EasternCooperative Oncology Group Ann Intern Med1993119121ndash6

10 Cleeland CS Cleeland LM Dar R Rinehardt LCFactors influencing physician management of can-cer pain Cancer 198658796ndash800

11 Fife BL Irick N Painter JD A comparative studyof the attitudes of physicians and nurses towards themanagement of cancer pain J Pain Symptom Man-age 19938132ndash9

12 Wilson JF Brockoop GW Kryst S Steger H WittWO Medical studentsrsquo attitudes towards painbefore and after a brief course on pain Pain199250251ndash6

13 Weinstein SM Laux LF Thornby JI et al Physi-ciansrsquo attitudes towards pain and the use of opioidanalgesics Results of a survey from the Texas Can-cer Pain Initiative South Med J 200093(5)479ndash87

14 Weinstein SM Laux LF Thornby JI et al Medicalstudentsrsquo attitudes towards pain and the use of opi-oid analgesics Implications for changing medicalschool curriculum South Med J 200093(5)472ndash8

15 Whedon M Ferrell BR Professional and ethicalconsiderations in the use of high-tech pain manage-ment Oncol Nurs Forum 1991181135ndash43

16 Ward S Goldberg N Miller-Mccauley V et alPatient-related barriers to management of cancerpain Pain 199352319ndash24

17 Pargeon KL Hailey BJ Barriers to effective cancerpain management A review of the literature J PainSymptom Manage 199918358ndash68

18 Breitbart W Passik S Mcdonald MV et al Patient-related barriers to pain management in ambulatoryAIDS patients Pain 199352319ndash24

19 Gunnarsdottir S Donovan HS Serlin RC Voge CWard S Patient-related barriers to pain manage-ment The barriers questionnaire II (BQ-II) Pain200299385ndash96

20 Arora NK Interacting with cancer patients Thesignificance of physiciansrsquo communication behaviorSoc Sci Med 200357791ndash806

21 Mccaffery M Thorpe DM Differences in percep-tion of pain and the development of adversarial rela-tionships among health care providers In Hill CSFields W eds Advances in Pain Research and Ther-apy Drug Treatment of Cancer Pain in a Drug-Oriented Society Vol 11 New York Raven Press1989

22 Ong LML de Haes JCJM Hoos AM Lammes FBDoctorndashpatient communication A review of the lit-erature Soc Sci Med 199540903ndash18

23 Jones WL Rimer BK Levy MH Kinman JL Can-cer patientsrsquo knowledge beliefs and behaviorregarding pain control regimens Implications foreducation programs Patient Educ Couns19845(4)159ndash64

24 Lukoschek P Fazzari M Marantz P Patient andphysician factors predict patientsrsquo comprehensionof health information Patient Educ Couns200350201ndash10

25 Donovan JL Blake DR Patient non-complianceDeviance or reasoned decision-making Soc SciMed 199234377ndash94

26 Garg AX Adhikari NKJ Mcdonald H et al Effectsof computerized clinical decision support systemson practitioner performance and patient outcomesa systematic review JAMA 2005293(10)1223ndash38

27 Nilasena DS Lincoln MJ A computer-generatedreminder system improves physician compliance

S160

Smith et al

considerably in terms of content format anddelivery (eg electronic paper or both) SeveralCDSSs scored and summated patient responseson standard pain and QOL-related assessmentmeasures Based on the published descriptions atleast five of the CDSSs were designed to gener-ate output in real time at the patientrsquos medicalvisit

In terms of systems architecture all CDSSsreviewed were stand-alone personal computer-based systems None interfaced with existingelectronic medical records systems pharmacyappointment scheduling or laboratory resultsreporting Three either were Web-based or hadthe capacity to use a Web-based platform

Table 2 summarizes the types of studies con-ducted to date to evaluate chronic pain CDSSs Ofthe eight CDSSs identified five had publishedevaluation results With one exception all werefeasibility studies exclusively Studies were con-ducted in both inpatient and outpatient settingsAmong the outpatient studies two had been con-ducted with PCPs the remainder involved special-ists in tertiary care settings Study designs used forevaluating these CDSSs varied two were cross-sectional two involved immediate pre- and post-assessments of CDSS use one was longitudinal(12-month follow-up) and one was a focus groupStudy sample sizes ranged from 213 to 4 with themajority having 50 or fewer subjects

Patient acceptability of the CDSS was the sin-gle most commonly assessed variable Evaluationsof both the SymptomReport and the PAIN

Report-It

employed a common tool to assess patientacceptability Results across four pilot testsinvolving a total of 254 subjects consistentlyshowed high acceptability of these two CDSSsand 100 completion rates in terms of data input[495152] The average amount of time requiredranged from a high of 38 minutes to a low of14 minutes

Two studies addressed the issue of medicalaccuracy of the system-generated recommenda-tion Both studies examined this issue by compar-ing system-generated diagnoses andor treatmentrecommendations with those generated by physi-cian experts based on a select sample of patientcases Results showed moderate to high agreementbetween the system- and expert-generated recom-mendations [4748]

Clinician perceptions concerning ease of useand value of a CDSS for chronic pain managementwere examined in two studies Overall physiciansfound the system to be moderately easy to use and

of some clinical worth [4852] Knab and col-leagues [48] reported that the average cliniciantime spent per case on the PMA to obtain outputwas approximately 5 minutes (

plusmn

34 minutes) [48]In addition 85 of physicians adopted the PMA-generated recommendations and 25 of thestudy patients seen were referred to a pain special-ist with the average time to referral being37 months (

plusmn

06 months) [48]Analyses concerning the impact of CDSSs on

patient outcomes were limited Huang and col-leagues [51] assessed changes in pain intensity pre-and post-CDSS use in a sample of radiationoncology clinic patients Although there was adownward trend in pain levels over time resultswere not statistically significant possibly dueto the small size of the sample (N

=

15) Wilkieand colleagues [4952] reported qualitative dataregarding the impact of the SymptomReport andthe PAIN

ReportIt

on patient behavior Resultswere contradictory Of the 41 outpatients whoused the SymptomReport approximately 68stated that it had not affected their pain-relatedcommunication Some however felt that theytalked more precisely and explicitly about theirpain as a result of using it Other comments asso-ciated with use of the SymptomReport includedan increased awareness of pain symptoms andgreater compliance with pain symptom manage-ment In contrast 86 of users of the PAIN-

ReportIt

cited it as beneficial for patientndashdoctorpain-related communication and that it ldquofreedthem to describe their painrdquo

Discussion

Over the past two decades there has been a gradualbut steady growth in research on the use of CDSSsfor chronic pain management To date the numberof such systems is small but expanding Advanceshave also been evident in terms of both the quantityand quality of evaluation studies conducted Whilethe earliest versions were presented in the litera-ture as prototypes only [4546] CDSSs developedsince 2001 have all undergone some form of fieldtesting The majority of these studies howeverhave been nonexperimental in design and focusedexclusively on process measures such as patientor clinician ratings of system acceptability andusability Other salient process measures such asthe degree to which the clinician andor patientactually reviewed and utilized system output orhad confidence in its accuracy have not been con-sistently assessed Poor usability and practitioner

Computerized Decision-Support System for Pain

S161

Tab

le 2

Eva

luat

ion

of c

ompu

teri

zed

deci

sion

-sup

port

sys

tem

s (C

DS

Ss)

in c

hron

ic p

ain

man

agem

ent

Stu

dyN

ame

of C

DS

SS

ampl

eD

esig

nO

utco

mes

Ass

esse

dR

esul

ts

Nie

lsen

et a

l

[47

]D

iagn

ostic

Hea

dach

eD

iary

PC

Ps

Not

des

crib

edndash

a

gree

men

t of c

ompu

ter-

gene

rate

d vs

exp

ert

phys

icia

n di

agno

ses

ndash 10

0 a

gree

men

t of c

ompu

ter-

gene

rate

d vs

ex

pert

phy

sici

an d

iagn

oses

Kna

b et

al

[48

]P

ain

Man

agem

ent

Adv

isor

N

=

50

PC

Ps

N

=

50

chro

nic

pain

pat

ient

sLo

ngitu

dina

l w

ith 1

2-m

onth

PC

P fo

llow

-up

ndash E

ase

of u

sendash

Med

ical

app

ropr

iate

ness

of

reco

mm

enda

tions

ndash

phy

sici

ansrsquo

ado

ptin

g P

ain

Man

agem

ent

Adv

isor

tre

atm

ent

reco

mm

enda

tions

ndash

pat

ient

s re

ferr

ed t

o pa

insp

ecia

lty c

linic

Phy

sici

an a

dopt

ion

of s

yste

m-g

ener

ated

re

com

men

datio

ns 8

5 o

f ca

ses

Ave

rage

phy

sici

an t

ime

spen

t pe

r ca

se

49

min

utes

(S

D

plusmn

34)

Eas

e of

use

as

rate

d by

phy

sici

ans

42

(

plusmn

28

cm)

on s

cale

of

1ndash10

25

of

patie

nts

refe

rred

to

pain

spe

cial

ty

clin

icA

vera

ge t

ime

to p

ain

spec

ialty

ref

erra

l 3

7 m

onth

s (S

D

plusmn

06)

ndash 70

o

f no

nref

erre

d pa

tient

s st

ill r

ecei

ving

co

mpu

ter-

reco

mm

ende

d tr

eatm

ent

1 ye

ar

post

Wilk

ie e

t al

[49

]S

ympt

omR

epor

tN

=

41

outp

atie

nts

with

can

cer

Cro

ss-s

ectio

nal

tele

phon

e in

terv

iew

sndash

13-it

em p

atie

nt a

ccep

tabi

lity

scal

e as

sess

ing

ease

of

use

ofS

ympt

omR

epor

tndash

Inpu

t co

mpl

etio

n tim

endash

Qua

litat

ive

asse

ssm

ent

of d

egre

eof

com

mun

icat

ion

with

hea

lth c

are

prov

ider

s re

gard

ing

pain

and

oth

ersy

mpt

oms

ndash M

ean

time

to c

ompl

ete

Sym

ptom

Rep

ort

382

min

utes

(S

D

plusmn

202

)ndash

Mea

n tim

e to

com

plet

e S

ympt

omC

onsu

lt

209

min

utes

(S

D

plusmn

18

6)ndash

71

of

part

icip

ants

rat

ed S

ympt

omR

epor

t as

eas

y e

njoy

able

an

d in

form

ativ

endash

68

rep

orte

d th

at th

e am

ount

and

con

tent

of

the

ir pa

in-r

elat

ed c

omm

unic

atio

n w

ith

thei

r do

ctor

had

not

cha

nged

muc

hndash

Qua

litat

ive

patie

nt c

omm

ents

1)

help

ed

them

tal

k m

ore

expl

icitl

y ab

out

pain

2)

gave

the

m g

reat

er a

war

enes

s of

pai

n sy

mpt

oms

3)

incr

ease

d un

ders

tand

ing

of

and

enha

nced

com

plia

nce

rega

rdin

g sy

mpt

om m

anag

emen

t ndash

Pat

ient

com

men

ts r

e S

ympt

omC

onsu

lt 1

) co

ntai

ned

too

muc

h in

form

atio

n 2

) no

t ta

rget

ed t

o in

divi

dual

nee

ds (

3) p

rovi

ded

no n

ew in

form

atio

n

Wilk

ie e

t al

[52

]PA

IN

Rep

ortIt

N

=

213

of

who

m 1

06w

ere

canc

er in

patie

nts

10 m

etas

tatic

can

cer

outp

atie

nts

and

97

wer

e in

divi

dual

sex

perie

ncin

g ac

ute

orch

roni

c pa

in r

ecru

ited

from

non

heal

th c

are

setti

ngs

Des

crip

tive

cro

ss-

sect

iona

l stu

dy in

3se

tting

s 1

) te

rtia

ryca

re

2) r

adia

tion

onco

logy

clin

ic

3)m

obile

clin

ic

ndash 13

-item

sca

le m

easu

ring

acce

ptab

ility

of

PAIN

Rep

ortIt

(ie

tim

e to

com

plet

e e

ase

of u

se

unde

rsta

ndab

ility

of

dire

ctio

ns

ergo

nom

ic e

lem

ents

of

syst

em

and

com

plet

enes

s of

res

pons

es)

ndash 86

o

f res

pond

ents

rate

d th

e PA

IN

Rep

ortIt

as

ben

efici

al f

or p

ain

com

mun

icat

ion

ndash 10

0 p

atie

nt c

ompl

etio

n ra

te o

f PA

IN

Rep

ortIt

ndash M

ean

time

to p

atie

nt

com

plet

ion

15

8 m

inut

es (

SD

plusmn

67

)ndash

Mea

n pa

tient

acc

epta

bilit

y sc

ore

11

7 (S

D

plusmn

16

) sc

ores

ran

ged

from

6 t

o 13

80

o

f pa

tient

s ra

ted

acce

ptab

ility

as

grea

ter

than

min

imum

crit

erio

n of

10

ndash U

ser

com

men

ts 1

) so

me

mec

hani

cal

diffi

culti

es 2

) re

activ

ity t

o us

e of

sys

tem

(e

g

vom

iting

) 3)

pre

fere

nce

to r

elay

info

rmat

ion

dire

ctly

to

prov

ider

PC

P p

rimar

y ca

re p

hysi

cian

S162

Smith et al

Hua

ng e

t al

[51

]PA

IN

Rep

ortIt

and

PAIN

Con

sultN

Pilo

t st

udy

1 N

=

9pa

tient

s w

ith b

one

met

asta

sis-

rela

ted

pain

Pilo

t st

udy

2 N

=

15

patie

nts

with

can

cer

and

bone

met

asta

sis

Phy

sici

an fo

cus

grou

pN

=

4 r

adia

tion

onco

logi

sts

1) P

ilot

test

1

Fea

sibi

lity

stud

y us

ing

a te

stndashr

etes

t w

ithin

-su

bjec

t de

sign

2) P

ilot

test

2

Fea

sibi

lity

stud

y us

ing

an 1

1-da

y te

stndashr

etes

tw

ithin

-sub

ject

des

ign

3) P

hysi

cian

focu

sgr

oup

Out

com

e m

easu

res

used

for

both

pilo

t st

udie

sndash

Acc

epta

bilit

yndash

Com

plet

enes

sndash

Tim

e to

com

plet

endash

Val

idity

Phy

sici

an fo

cus

grou

pndash

Rec

eptiv

ity t

o PA

IN

Rep

ortIt

and

PAIN

Con

sultN

Pilo

t st

udy

1

ndashM

ean

time

to c

ompl

ete

PAIN

Rep

ortIt

at

pret

est

12 m

inut

es (

SD

plusmn

4)

ndashT

ime

to c

ompl

ete

PAIN

Rep

ortIt

at

post

-te

st 1

ndash7 m

inut

es p

er p

atie

ntndash

Mea

n ac

cept

abili

ty s

core

11

2 (S

D

plusmn

18

)ndash

100

com

plet

ion

rate

Pilo

t st

udy

2ndash

Mea

n tim

e to

com

plet

e PA

IN

Rep

ortIt

at

pret

est

17 m

inut

es (

SD

plusmn

6)

ndashT

ime

to c

ompl

ete

PAIN

Rep

ortIt

at p

ostte

st

14 m

inut

es (

SD

plusmn

8)

ndashM

ean

acce

ptab

ility

sco

re 1

22

(SD

plusmn

13

)ndash

100

com

plet

ion

rate

ndashPA

IN

Con

sultN

rec

omm

ende

d a

med

ian

of

4 dr

ugs

phy

sici

ans

pres

crib

ed a

med

ian

of

3 dr

ugs

post

use

ndashP

atie

nt p

ain

inte

nsity

ave

rage

4 a

t bas

elin

e an

d 2

7 at

pos

ttest

(no

t si

gnifi

cant

)

Foc

us g

roup

ndashP

hysi

cian

s sa

w v

alue

of

PAIN

Rep

ortIt

1)

incr

ease

d ef

ficie

ncy

durin

g cl

inic

vis

it 2

) su

pple

men

ted

pain

ser

vice

con

sulta

tion

3)

prov

ided

out

com

e da

tandash

PAIN

Con

sultN

was

vie

wed

as

clin

ical

ad

junc

t bu

t fo

rmat

ting

need

ed

impr

ovem

ent

Koe

stle

r et

al

[53

]To

uch-

scre

en C

ompu

ter

Ass

essm

ent

of C

hron

icLo

w B

ack

Pai

n

N

=

30

low

bac

kpa

in p

atie

nts

Cro

ss-s

ectio

nal d

esig

nin

ter

tiary

car

e cl

inic

ndashP

atie

nt-r

atin

gs o

f er

gono

mic

desi

gn d

egre

e of

tec

hnic

aldi

fficu

lties

ac

cept

abili

ty

ease

of u

se d

ata

secu

rity

ndashM

ean

time

to c

ompl

ete

the

67-it

em t

ouch

sc

reen

27

4 m

inut

es (

SD

plusmn

138

)

Stu

dyN

ame

of C

DS

SS

ampl

eD

esig

nO

utco

mes

Ass

esse

dR

esul

ts

PC

P p

rimar

y ca

re p

hysi

cian

Tab

le 2

Con

tinue

d

Computerized Decision-Support System for Pain

S163

nonacceptance of computer recommendations canserve as significant barriers to system adoption inroutine clinical practice [365455]

User preferences regarding the presentation ofcomputer output including content formatting(eg color graphics) and length have not beensolicited in most instances either Similarly thereare few published data concerning technical diffi-culties (eg type and number of system crashes ortouch-screen calibration problems) encounteredby CDSS users Both issues have important rami-fications for future system refinements [52] Addi-tionally there is a paucity of information oncontextual circumstances (eg presence of a localldquochampionrdquo of the system) or the processes usedto integrate the CDSS into the existing clinicalworkflow key considerations for successful systemimplementation Not least testing has been con-fined almost exclusively to either inpatient ortertiary care settings with only two studies con-ducted in the primary care context to date

The effects of these systems on patient out-comes remain understudied Two studies reportedqualitative data concerning CDSS impact onpatientsrsquo perceived pain-related communicationwith their physician however sample sizes weresmall and results inconsistent [4952] One studyreported system impact on patient pain intensitylevel over time but the study lacked adequate sta-tistical power to detect clinically important differ-ences [52] Other major patient outcomes such ashealth care utilization health care costs painrelief pain medication usage communication withhealth care provider about pain functional statusand QOL have not been examined One studyreported evidence that CDSS use may invokepatient reactivity (eg vomiting intensified painsymptoms) Potential adverse effects on patientsshould be measured in future investigations [52]Similarly there is need for more extensive andconsistent examination of system impact on clini-cian pain management performance

While we sought to be as comprehensive aspossible in our literature search our review wasrestricted to only English-language studies Inaddition it is possible that there are other CDSSsunder development that we failed to identify Thelimited size of the available literature as well asthe methods used in these primary studies pre-vented us from conducting a meta-analysis ofresearch findings and from reaching more defin-itive conclusions about the impact of these systemson physician performance and patient pain func-tioning and other aspects of QOL Notably in all

the studies we examined study investigators andCDSS developers were one and the same a factthat may have resulted in more positive findings[36] Lastly we did not conduct a separate evalu-ation of the clinical appropriateness of either theCDSS algorithms or treatment recommendationsnor of the underlying logic employed to generatesuch algorithms

The potential for these computer-based sys-tems to improve the quality of chronic pain man-agement in the primary care context is substantialTo manage chronic pain effectively PCPs firstneed to conduct a comprehensive patient assess-ment [56] Information on the patientrsquos pain ex-perience history of and preferences for paintreatment psychological status approach to self-management and personal goalspriorities are keyvariables to collect during assessment as they arecritical for making an accurate diagnosis and fordeveloping an appropriate treatment plan to whichthe patient will adhere [56] An expert system-typeCDSS provides a way to elicit and integrate suchpatient-specific information in a manner that isconvenient and timely for both physicians andpatients Moreover the ensuing system-generatedrecommendations are individualized to the needsand circumstances of the specific pain patient perbest clinical practices [56]

CDSSs developed for chronic pain manage-ment have as yet however to fulfill this promiseAs our review indicates systems developed thus farhave been predominantly biomedical in focus anddesigned to assist physicians and other health careproviders in the medical management of painsymptoms (including invasive procedures andreferrals) exclusively Only a few of these systemshave reached a sufficiently advanced stage ofdevelopment to warrant more rigorous testingin large-scale randomized controlled trials[264952] Such trials are imperative for under-standing system effect on provider performanceand patient outcomes

Significantly none of the systems reviewedwere integrated with existing electronic recordssystems nor did they include reminder or docu-mentation functionalities features which have allbeen shown to increase the likelihood of physicianadoption [5758] This lack of integration mayreflect the fact that widespread adoption of elec-tronic records systems by health care institutionshas been a relatively recent occurrence Potentiallythis trend coupled with pressures from majoraccrediting agencies to document the provision ofpain screening and treatment along with the

S164

Smith et al

recent publication of primary care pain manage-ment guidelines may serve to spur additionalmore rigorous research on the use of CDSSs forchronic pain management in primary care[565960] Demonstrating the clinical value ofthese systems is a critical step in convincing healthcare organizations and clinicians that the benefitsof investing in a CDSS for pain management out-weigh potential risks In particular physiciansneed to be assured that this type of system canenhance rather than erode their decision-makingabilities and that time spent learning how to usea CDSS yields measurable improvement in patienthealth and well-being

References

1 American Pain Society Chronic pain in AmericaRoadblock to relief 1999 American Pain SocietyAPS News and Announcements Available at httpwwwampainsocorgwhatsnewtoc_roadhtmtoc

2 Lande SD The problem of pain in managed careIn Lande SD Kulich RJ eds Managed Care andPain Glenview IL American Pain Society 200019

3 Turner JA Leresche L Von Korff M Ehrlich LPrimary care back pain patient characteristics visitcontent and short term outcomes Spine199823463ndash9

4 Von Korff M Gruman J Schaefer J Curry SJ Wag-ner EH Collaborative management of chronic ill-ness Ann Intern Med 1997127(12)1097ndash102

5 Von Korff M Pain management in primary care Anindividualized stepped-care approach In GatchelRJ Turk DL eds Psychosocial Factors in PainCritical Perspectives New York The GuilfordPress 1999

6 Von Korff M Katon W Bush T et al Treatmentcosts cost offset and cost-effectiveness of collabo-rative management of depression Psychosom Med199860(2)143ndash9

7 Bertakis KD Azari R Callahan EJ Patient pain Itsinfluence on primary care physicianndashpatient inter-action Fam Med 200335(2)119ndash23

8 Green CR Wheeler JRC Laporte F Marchant BGuerrero E How well is chronic pain managedWho does it well Pain Med 20023(1)56ndash62

9 Von Roenn JH Cleeland CS Gonin R HatfieldAK Pandya KJ Physician attitudes and practice incancer pain management A survey from the EasternCooperative Oncology Group Ann Intern Med1993119121ndash6

10 Cleeland CS Cleeland LM Dar R Rinehardt LCFactors influencing physician management of can-cer pain Cancer 198658796ndash800

11 Fife BL Irick N Painter JD A comparative studyof the attitudes of physicians and nurses towards themanagement of cancer pain J Pain Symptom Man-age 19938132ndash9

12 Wilson JF Brockoop GW Kryst S Steger H WittWO Medical studentsrsquo attitudes towards painbefore and after a brief course on pain Pain199250251ndash6

13 Weinstein SM Laux LF Thornby JI et al Physi-ciansrsquo attitudes towards pain and the use of opioidanalgesics Results of a survey from the Texas Can-cer Pain Initiative South Med J 200093(5)479ndash87

14 Weinstein SM Laux LF Thornby JI et al Medicalstudentsrsquo attitudes towards pain and the use of opi-oid analgesics Implications for changing medicalschool curriculum South Med J 200093(5)472ndash8

15 Whedon M Ferrell BR Professional and ethicalconsiderations in the use of high-tech pain manage-ment Oncol Nurs Forum 1991181135ndash43

16 Ward S Goldberg N Miller-Mccauley V et alPatient-related barriers to management of cancerpain Pain 199352319ndash24

17 Pargeon KL Hailey BJ Barriers to effective cancerpain management A review of the literature J PainSymptom Manage 199918358ndash68

18 Breitbart W Passik S Mcdonald MV et al Patient-related barriers to pain management in ambulatoryAIDS patients Pain 199352319ndash24

19 Gunnarsdottir S Donovan HS Serlin RC Voge CWard S Patient-related barriers to pain manage-ment The barriers questionnaire II (BQ-II) Pain200299385ndash96

20 Arora NK Interacting with cancer patients Thesignificance of physiciansrsquo communication behaviorSoc Sci Med 200357791ndash806

21 Mccaffery M Thorpe DM Differences in percep-tion of pain and the development of adversarial rela-tionships among health care providers In Hill CSFields W eds Advances in Pain Research and Ther-apy Drug Treatment of Cancer Pain in a Drug-Oriented Society Vol 11 New York Raven Press1989

22 Ong LML de Haes JCJM Hoos AM Lammes FBDoctorndashpatient communication A review of the lit-erature Soc Sci Med 199540903ndash18

23 Jones WL Rimer BK Levy MH Kinman JL Can-cer patientsrsquo knowledge beliefs and behaviorregarding pain control regimens Implications foreducation programs Patient Educ Couns19845(4)159ndash64

24 Lukoschek P Fazzari M Marantz P Patient andphysician factors predict patientsrsquo comprehensionof health information Patient Educ Couns200350201ndash10

25 Donovan JL Blake DR Patient non-complianceDeviance or reasoned decision-making Soc SciMed 199234377ndash94

26 Garg AX Adhikari NKJ Mcdonald H et al Effectsof computerized clinical decision support systemson practitioner performance and patient outcomesa systematic review JAMA 2005293(10)1223ndash38

27 Nilasena DS Lincoln MJ A computer-generatedreminder system improves physician compliance

Computerized Decision-Support System for Pain

S161

Tab

le 2

Eva

luat

ion

of c

ompu

teri

zed

deci

sion

-sup

port

sys

tem

s (C

DS

Ss)

in c

hron

ic p

ain

man

agem

ent

Stu

dyN

ame

of C

DS

SS

ampl

eD

esig

nO

utco

mes

Ass

esse

dR

esul

ts

Nie

lsen

et a

l

[47

]D

iagn

ostic

Hea

dach

eD

iary

PC

Ps

Not

des

crib

edndash

a

gree

men

t of c

ompu

ter-

gene

rate

d vs

exp

ert

phys

icia

n di

agno

ses

ndash 10

0 a

gree

men

t of c

ompu

ter-

gene

rate

d vs

ex

pert

phy

sici

an d

iagn

oses

Kna

b et

al

[48

]P

ain

Man

agem

ent

Adv

isor

N

=

50

PC

Ps

N

=

50

chro

nic

pain

pat

ient

sLo

ngitu

dina

l w

ith 1

2-m

onth

PC

P fo

llow

-up

ndash E

ase

of u

sendash

Med

ical

app

ropr

iate

ness

of

reco

mm

enda

tions

ndash

phy

sici

ansrsquo

ado

ptin

g P

ain

Man

agem

ent

Adv

isor

tre

atm

ent

reco

mm

enda

tions

ndash

pat

ient

s re

ferr

ed t

o pa

insp

ecia

lty c

linic

Phy

sici

an a

dopt

ion

of s

yste

m-g

ener

ated

re

com

men

datio

ns 8

5 o

f ca

ses

Ave

rage

phy

sici

an t

ime

spen

t pe

r ca

se

49

min

utes

(S

D

plusmn

34)

Eas

e of

use

as

rate

d by

phy

sici

ans

42

(

plusmn

28

cm)

on s

cale

of

1ndash10

25

of

patie

nts

refe

rred

to

pain

spe

cial

ty

clin

icA

vera

ge t

ime

to p

ain

spec

ialty

ref

erra

l 3

7 m

onth

s (S

D

plusmn

06)

ndash 70

o

f no

nref

erre

d pa

tient

s st

ill r

ecei

ving

co

mpu

ter-

reco

mm

ende

d tr

eatm

ent

1 ye

ar

post

Wilk

ie e

t al

[49

]S

ympt

omR

epor

tN

=

41

outp

atie

nts

with

can

cer

Cro

ss-s

ectio

nal

tele

phon

e in

terv

iew

sndash

13-it

em p

atie

nt a

ccep

tabi

lity

scal

e as

sess

ing

ease

of

use

ofS

ympt

omR

epor

tndash

Inpu

t co

mpl

etio

n tim

endash

Qua

litat

ive

asse

ssm

ent

of d

egre

eof

com

mun

icat

ion

with

hea

lth c

are

prov

ider

s re

gard

ing

pain

and

oth

ersy

mpt

oms

ndash M

ean

time

to c

ompl

ete

Sym

ptom

Rep

ort

382

min

utes

(S

D

plusmn

202

)ndash

Mea

n tim

e to

com

plet

e S

ympt

omC

onsu

lt

209

min

utes

(S

D

plusmn

18

6)ndash

71

of

part

icip

ants

rat

ed S

ympt

omR

epor

t as

eas

y e

njoy

able

an

d in

form

ativ

endash

68

rep

orte

d th

at th

e am

ount

and

con

tent

of

the

ir pa

in-r

elat

ed c

omm

unic

atio

n w

ith

thei

r do

ctor

had

not

cha

nged

muc

hndash

Qua

litat

ive

patie

nt c

omm

ents

1)

help

ed

them

tal

k m

ore

expl

icitl

y ab

out

pain

2)

gave

the

m g

reat

er a

war

enes

s of

pai

n sy

mpt

oms

3)

incr

ease

d un

ders

tand

ing

of

and

enha

nced

com

plia

nce

rega

rdin

g sy

mpt

om m

anag

emen

t ndash

Pat

ient

com

men

ts r

e S

ympt

omC

onsu

lt 1

) co

ntai

ned

too

muc

h in

form

atio

n 2

) no

t ta

rget

ed t

o in

divi

dual

nee

ds (

3) p

rovi

ded

no n

ew in

form

atio

n

Wilk

ie e

t al

[52

]PA

IN

Rep

ortIt

N

=

213

of

who

m 1

06w

ere

canc

er in

patie

nts

10 m

etas

tatic

can

cer

outp

atie

nts

and

97

wer

e in

divi

dual

sex

perie

ncin

g ac

ute

orch

roni

c pa

in r

ecru

ited

from

non

heal

th c

are

setti

ngs

Des

crip

tive

cro

ss-

sect

iona

l stu

dy in

3se

tting

s 1

) te

rtia

ryca

re

2) r

adia

tion

onco

logy

clin

ic

3)m

obile

clin

ic

ndash 13

-item

sca

le m

easu

ring

acce

ptab

ility

of

PAIN

Rep

ortIt

(ie

tim

e to

com

plet

e e

ase

of u

se

unde

rsta

ndab

ility

of

dire

ctio

ns

ergo

nom

ic e

lem

ents

of

syst

em

and

com

plet

enes

s of

res

pons

es)

ndash 86

o

f res

pond

ents

rate

d th

e PA

IN

Rep

ortIt

as

ben

efici

al f

or p

ain

com

mun

icat

ion

ndash 10

0 p

atie

nt c

ompl

etio

n ra

te o

f PA

IN

Rep

ortIt

ndash M

ean

time

to p

atie

nt

com

plet

ion

15

8 m

inut

es (

SD

plusmn

67

)ndash

Mea

n pa

tient

acc

epta

bilit

y sc

ore

11

7 (S

D

plusmn

16

) sc

ores

ran

ged

from

6 t

o 13

80

o

f pa

tient

s ra

ted

acce

ptab

ility

as

grea

ter

than

min

imum

crit

erio

n of

10

ndash U

ser

com

men

ts 1

) so

me

mec

hani

cal

diffi

culti

es 2

) re

activ

ity t

o us

e of

sys

tem

(e

g

vom

iting

) 3)

pre

fere

nce

to r

elay

info

rmat

ion

dire

ctly

to

prov

ider

PC

P p

rimar

y ca

re p

hysi

cian

S162

Smith et al

Hua

ng e

t al

[51

]PA

IN

Rep

ortIt

and

PAIN

Con

sultN

Pilo

t st

udy

1 N

=

9pa

tient

s w

ith b

one

met

asta

sis-

rela

ted

pain

Pilo

t st

udy

2 N

=

15

patie

nts

with

can

cer

and

bone

met

asta

sis

Phy

sici

an fo

cus

grou

pN

=

4 r

adia

tion

onco

logi

sts

1) P

ilot

test

1

Fea

sibi

lity

stud

y us

ing

a te

stndashr

etes

t w

ithin

-su

bjec

t de

sign

2) P

ilot

test

2

Fea

sibi

lity

stud

y us

ing

an 1

1-da

y te

stndashr

etes

tw

ithin

-sub

ject

des

ign

3) P

hysi

cian

focu

sgr

oup

Out

com

e m

easu

res

used

for

both

pilo

t st

udie

sndash

Acc

epta

bilit

yndash

Com

plet

enes

sndash

Tim

e to

com

plet

endash

Val

idity

Phy

sici

an fo

cus

grou

pndash

Rec

eptiv

ity t

o PA

IN

Rep

ortIt

and

PAIN

Con

sultN

Pilo

t st

udy

1

ndashM

ean

time

to c

ompl

ete

PAIN

Rep

ortIt

at

pret

est

12 m

inut

es (

SD

plusmn

4)

ndashT

ime

to c

ompl

ete

PAIN

Rep

ortIt

at

post

-te

st 1

ndash7 m

inut

es p

er p

atie

ntndash

Mea

n ac

cept

abili

ty s

core

11

2 (S

D

plusmn

18

)ndash

100

com

plet

ion

rate

Pilo

t st

udy

2ndash

Mea

n tim

e to

com

plet

e PA

IN

Rep

ortIt

at

pret

est

17 m

inut

es (

SD

plusmn

6)

ndashT

ime

to c

ompl

ete

PAIN

Rep

ortIt

at p

ostte

st

14 m

inut

es (

SD

plusmn

8)

ndashM

ean

acce

ptab

ility

sco

re 1

22

(SD

plusmn

13

)ndash

100

com

plet

ion

rate

ndashPA

IN

Con

sultN

rec

omm

ende

d a

med

ian

of

4 dr

ugs

phy

sici

ans

pres

crib

ed a

med

ian

of

3 dr

ugs

post

use

ndashP

atie

nt p

ain

inte

nsity

ave

rage

4 a

t bas

elin

e an

d 2

7 at

pos

ttest

(no

t si

gnifi

cant

)

Foc

us g

roup

ndashP

hysi

cian

s sa

w v

alue

of

PAIN

Rep

ortIt

1)

incr

ease

d ef

ficie

ncy

durin

g cl

inic

vis

it 2

) su

pple

men

ted

pain

ser

vice

con

sulta

tion

3)

prov

ided

out

com

e da

tandash

PAIN

Con

sultN

was

vie

wed

as

clin

ical

ad

junc

t bu

t fo

rmat

ting

need

ed

impr

ovem

ent

Koe

stle

r et

al

[53

]To

uch-

scre

en C

ompu

ter

Ass

essm

ent

of C

hron

icLo

w B

ack

Pai

n

N

=

30

low

bac

kpa

in p

atie

nts

Cro

ss-s

ectio

nal d

esig

nin

ter

tiary

car

e cl

inic

ndashP

atie

nt-r

atin

gs o

f er

gono

mic

desi

gn d

egre

e of

tec

hnic

aldi

fficu

lties

ac

cept

abili

ty

ease

of u

se d

ata

secu

rity

ndashM

ean

time

to c

ompl

ete

the

67-it

em t

ouch

sc

reen

27

4 m

inut

es (

SD

plusmn

138

)

Stu

dyN

ame

of C

DS

SS

ampl

eD

esig

nO

utco

mes

Ass

esse

dR

esul

ts

PC

P p

rimar

y ca

re p

hysi

cian

Tab

le 2

Con

tinue

d

Computerized Decision-Support System for Pain

S163

nonacceptance of computer recommendations canserve as significant barriers to system adoption inroutine clinical practice [365455]

User preferences regarding the presentation ofcomputer output including content formatting(eg color graphics) and length have not beensolicited in most instances either Similarly thereare few published data concerning technical diffi-culties (eg type and number of system crashes ortouch-screen calibration problems) encounteredby CDSS users Both issues have important rami-fications for future system refinements [52] Addi-tionally there is a paucity of information oncontextual circumstances (eg presence of a localldquochampionrdquo of the system) or the processes usedto integrate the CDSS into the existing clinicalworkflow key considerations for successful systemimplementation Not least testing has been con-fined almost exclusively to either inpatient ortertiary care settings with only two studies con-ducted in the primary care context to date

The effects of these systems on patient out-comes remain understudied Two studies reportedqualitative data concerning CDSS impact onpatientsrsquo perceived pain-related communicationwith their physician however sample sizes weresmall and results inconsistent [4952] One studyreported system impact on patient pain intensitylevel over time but the study lacked adequate sta-tistical power to detect clinically important differ-ences [52] Other major patient outcomes such ashealth care utilization health care costs painrelief pain medication usage communication withhealth care provider about pain functional statusand QOL have not been examined One studyreported evidence that CDSS use may invokepatient reactivity (eg vomiting intensified painsymptoms) Potential adverse effects on patientsshould be measured in future investigations [52]Similarly there is need for more extensive andconsistent examination of system impact on clini-cian pain management performance

While we sought to be as comprehensive aspossible in our literature search our review wasrestricted to only English-language studies Inaddition it is possible that there are other CDSSsunder development that we failed to identify Thelimited size of the available literature as well asthe methods used in these primary studies pre-vented us from conducting a meta-analysis ofresearch findings and from reaching more defin-itive conclusions about the impact of these systemson physician performance and patient pain func-tioning and other aspects of QOL Notably in all

the studies we examined study investigators andCDSS developers were one and the same a factthat may have resulted in more positive findings[36] Lastly we did not conduct a separate evalu-ation of the clinical appropriateness of either theCDSS algorithms or treatment recommendationsnor of the underlying logic employed to generatesuch algorithms

The potential for these computer-based sys-tems to improve the quality of chronic pain man-agement in the primary care context is substantialTo manage chronic pain effectively PCPs firstneed to conduct a comprehensive patient assess-ment [56] Information on the patientrsquos pain ex-perience history of and preferences for paintreatment psychological status approach to self-management and personal goalspriorities are keyvariables to collect during assessment as they arecritical for making an accurate diagnosis and fordeveloping an appropriate treatment plan to whichthe patient will adhere [56] An expert system-typeCDSS provides a way to elicit and integrate suchpatient-specific information in a manner that isconvenient and timely for both physicians andpatients Moreover the ensuing system-generatedrecommendations are individualized to the needsand circumstances of the specific pain patient perbest clinical practices [56]

CDSSs developed for chronic pain manage-ment have as yet however to fulfill this promiseAs our review indicates systems developed thus farhave been predominantly biomedical in focus anddesigned to assist physicians and other health careproviders in the medical management of painsymptoms (including invasive procedures andreferrals) exclusively Only a few of these systemshave reached a sufficiently advanced stage ofdevelopment to warrant more rigorous testingin large-scale randomized controlled trials[264952] Such trials are imperative for under-standing system effect on provider performanceand patient outcomes

Significantly none of the systems reviewedwere integrated with existing electronic recordssystems nor did they include reminder or docu-mentation functionalities features which have allbeen shown to increase the likelihood of physicianadoption [5758] This lack of integration mayreflect the fact that widespread adoption of elec-tronic records systems by health care institutionshas been a relatively recent occurrence Potentiallythis trend coupled with pressures from majoraccrediting agencies to document the provision ofpain screening and treatment along with the

S164

Smith et al

recent publication of primary care pain manage-ment guidelines may serve to spur additionalmore rigorous research on the use of CDSSs forchronic pain management in primary care[565960] Demonstrating the clinical value ofthese systems is a critical step in convincing healthcare organizations and clinicians that the benefitsof investing in a CDSS for pain management out-weigh potential risks In particular physiciansneed to be assured that this type of system canenhance rather than erode their decision-makingabilities and that time spent learning how to usea CDSS yields measurable improvement in patienthealth and well-being

References

1 American Pain Society Chronic pain in AmericaRoadblock to relief 1999 American Pain SocietyAPS News and Announcements Available at httpwwwampainsocorgwhatsnewtoc_roadhtmtoc

2 Lande SD The problem of pain in managed careIn Lande SD Kulich RJ eds Managed Care andPain Glenview IL American Pain Society 200019

3 Turner JA Leresche L Von Korff M Ehrlich LPrimary care back pain patient characteristics visitcontent and short term outcomes Spine199823463ndash9

4 Von Korff M Gruman J Schaefer J Curry SJ Wag-ner EH Collaborative management of chronic ill-ness Ann Intern Med 1997127(12)1097ndash102

5 Von Korff M Pain management in primary care Anindividualized stepped-care approach In GatchelRJ Turk DL eds Psychosocial Factors in PainCritical Perspectives New York The GuilfordPress 1999

6 Von Korff M Katon W Bush T et al Treatmentcosts cost offset and cost-effectiveness of collabo-rative management of depression Psychosom Med199860(2)143ndash9

7 Bertakis KD Azari R Callahan EJ Patient pain Itsinfluence on primary care physicianndashpatient inter-action Fam Med 200335(2)119ndash23

8 Green CR Wheeler JRC Laporte F Marchant BGuerrero E How well is chronic pain managedWho does it well Pain Med 20023(1)56ndash62

9 Von Roenn JH Cleeland CS Gonin R HatfieldAK Pandya KJ Physician attitudes and practice incancer pain management A survey from the EasternCooperative Oncology Group Ann Intern Med1993119121ndash6

10 Cleeland CS Cleeland LM Dar R Rinehardt LCFactors influencing physician management of can-cer pain Cancer 198658796ndash800

11 Fife BL Irick N Painter JD A comparative studyof the attitudes of physicians and nurses towards themanagement of cancer pain J Pain Symptom Man-age 19938132ndash9

12 Wilson JF Brockoop GW Kryst S Steger H WittWO Medical studentsrsquo attitudes towards painbefore and after a brief course on pain Pain199250251ndash6

13 Weinstein SM Laux LF Thornby JI et al Physi-ciansrsquo attitudes towards pain and the use of opioidanalgesics Results of a survey from the Texas Can-cer Pain Initiative South Med J 200093(5)479ndash87

14 Weinstein SM Laux LF Thornby JI et al Medicalstudentsrsquo attitudes towards pain and the use of opi-oid analgesics Implications for changing medicalschool curriculum South Med J 200093(5)472ndash8

15 Whedon M Ferrell BR Professional and ethicalconsiderations in the use of high-tech pain manage-ment Oncol Nurs Forum 1991181135ndash43

16 Ward S Goldberg N Miller-Mccauley V et alPatient-related barriers to management of cancerpain Pain 199352319ndash24

17 Pargeon KL Hailey BJ Barriers to effective cancerpain management A review of the literature J PainSymptom Manage 199918358ndash68

18 Breitbart W Passik S Mcdonald MV et al Patient-related barriers to pain management in ambulatoryAIDS patients Pain 199352319ndash24

19 Gunnarsdottir S Donovan HS Serlin RC Voge CWard S Patient-related barriers to pain manage-ment The barriers questionnaire II (BQ-II) Pain200299385ndash96

20 Arora NK Interacting with cancer patients Thesignificance of physiciansrsquo communication behaviorSoc Sci Med 200357791ndash806

21 Mccaffery M Thorpe DM Differences in percep-tion of pain and the development of adversarial rela-tionships among health care providers In Hill CSFields W eds Advances in Pain Research and Ther-apy Drug Treatment of Cancer Pain in a Drug-Oriented Society Vol 11 New York Raven Press1989

22 Ong LML de Haes JCJM Hoos AM Lammes FBDoctorndashpatient communication A review of the lit-erature Soc Sci Med 199540903ndash18

23 Jones WL Rimer BK Levy MH Kinman JL Can-cer patientsrsquo knowledge beliefs and behaviorregarding pain control regimens Implications foreducation programs Patient Educ Couns19845(4)159ndash64

24 Lukoschek P Fazzari M Marantz P Patient andphysician factors predict patientsrsquo comprehensionof health information Patient Educ Couns200350201ndash10

25 Donovan JL Blake DR Patient non-complianceDeviance or reasoned decision-making Soc SciMed 199234377ndash94

26 Garg AX Adhikari NKJ Mcdonald H et al Effectsof computerized clinical decision support systemson practitioner performance and patient outcomesa systematic review JAMA 2005293(10)1223ndash38

27 Nilasena DS Lincoln MJ A computer-generatedreminder system improves physician compliance

S162

Smith et al

Hua

ng e

t al

[51

]PA

IN

Rep

ortIt

and

PAIN

Con

sultN

Pilo

t st

udy

1 N

=

9pa

tient

s w

ith b

one

met

asta

sis-

rela

ted

pain

Pilo

t st

udy

2 N

=

15

patie

nts

with

can

cer

and

bone

met

asta

sis

Phy

sici

an fo

cus

grou

pN

=

4 r

adia

tion

onco

logi

sts

1) P

ilot

test

1

Fea

sibi

lity

stud

y us

ing

a te

stndashr

etes

t w

ithin

-su

bjec

t de

sign

2) P

ilot

test

2

Fea

sibi

lity

stud

y us

ing

an 1

1-da

y te

stndashr

etes

tw

ithin

-sub

ject

des

ign

3) P

hysi

cian

focu

sgr

oup

Out

com

e m

easu

res

used

for

both

pilo

t st

udie

sndash

Acc

epta

bilit

yndash

Com

plet

enes

sndash

Tim

e to

com

plet

endash

Val

idity

Phy

sici

an fo

cus

grou

pndash

Rec

eptiv

ity t

o PA

IN

Rep

ortIt

and

PAIN

Con

sultN

Pilo

t st

udy

1

ndashM

ean

time

to c

ompl

ete

PAIN

Rep

ortIt

at

pret

est

12 m

inut

es (

SD

plusmn

4)

ndashT

ime

to c

ompl

ete

PAIN

Rep

ortIt

at

post

-te

st 1

ndash7 m

inut

es p

er p

atie

ntndash

Mea

n ac

cept

abili

ty s

core

11

2 (S

D

plusmn

18

)ndash

100

com

plet

ion

rate

Pilo

t st

udy

2ndash

Mea

n tim

e to

com

plet

e PA

IN

Rep

ortIt

at

pret

est

17 m

inut

es (

SD

plusmn

6)

ndashT

ime

to c

ompl

ete

PAIN

Rep

ortIt

at p

ostte

st

14 m

inut

es (

SD

plusmn

8)

ndashM

ean

acce

ptab

ility

sco

re 1

22

(SD

plusmn

13

)ndash

100

com

plet

ion

rate

ndashPA

IN

Con

sultN

rec

omm

ende

d a

med

ian

of

4 dr

ugs

phy

sici

ans

pres

crib

ed a

med

ian

of

3 dr

ugs

post

use

ndashP

atie

nt p

ain

inte

nsity

ave

rage

4 a

t bas

elin

e an

d 2

7 at

pos

ttest

(no

t si

gnifi

cant

)

Foc

us g

roup

ndashP

hysi

cian

s sa

w v

alue

of

PAIN

Rep

ortIt

1)

incr

ease

d ef

ficie

ncy

durin

g cl

inic

vis

it 2

) su

pple

men

ted

pain

ser

vice

con

sulta

tion

3)

prov

ided

out

com

e da

tandash

PAIN

Con

sultN

was

vie

wed

as

clin

ical

ad

junc

t bu

t fo

rmat

ting

need

ed

impr

ovem

ent

Koe

stle

r et

al

[53

]To

uch-

scre

en C

ompu

ter

Ass

essm

ent

of C

hron

icLo

w B

ack

Pai

n

N

=

30

low

bac

kpa

in p

atie

nts

Cro

ss-s

ectio

nal d

esig

nin

ter

tiary

car

e cl

inic

ndashP

atie

nt-r

atin

gs o

f er

gono

mic

desi

gn d

egre

e of

tec

hnic

aldi

fficu

lties

ac

cept

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d

Computerized Decision-Support System for Pain

S163

nonacceptance of computer recommendations canserve as significant barriers to system adoption inroutine clinical practice [365455]

User preferences regarding the presentation ofcomputer output including content formatting(eg color graphics) and length have not beensolicited in most instances either Similarly thereare few published data concerning technical diffi-culties (eg type and number of system crashes ortouch-screen calibration problems) encounteredby CDSS users Both issues have important rami-fications for future system refinements [52] Addi-tionally there is a paucity of information oncontextual circumstances (eg presence of a localldquochampionrdquo of the system) or the processes usedto integrate the CDSS into the existing clinicalworkflow key considerations for successful systemimplementation Not least testing has been con-fined almost exclusively to either inpatient ortertiary care settings with only two studies con-ducted in the primary care context to date

The effects of these systems on patient out-comes remain understudied Two studies reportedqualitative data concerning CDSS impact onpatientsrsquo perceived pain-related communicationwith their physician however sample sizes weresmall and results inconsistent [4952] One studyreported system impact on patient pain intensitylevel over time but the study lacked adequate sta-tistical power to detect clinically important differ-ences [52] Other major patient outcomes such ashealth care utilization health care costs painrelief pain medication usage communication withhealth care provider about pain functional statusand QOL have not been examined One studyreported evidence that CDSS use may invokepatient reactivity (eg vomiting intensified painsymptoms) Potential adverse effects on patientsshould be measured in future investigations [52]Similarly there is need for more extensive andconsistent examination of system impact on clini-cian pain management performance

While we sought to be as comprehensive aspossible in our literature search our review wasrestricted to only English-language studies Inaddition it is possible that there are other CDSSsunder development that we failed to identify Thelimited size of the available literature as well asthe methods used in these primary studies pre-vented us from conducting a meta-analysis ofresearch findings and from reaching more defin-itive conclusions about the impact of these systemson physician performance and patient pain func-tioning and other aspects of QOL Notably in all

the studies we examined study investigators andCDSS developers were one and the same a factthat may have resulted in more positive findings[36] Lastly we did not conduct a separate evalu-ation of the clinical appropriateness of either theCDSS algorithms or treatment recommendationsnor of the underlying logic employed to generatesuch algorithms

The potential for these computer-based sys-tems to improve the quality of chronic pain man-agement in the primary care context is substantialTo manage chronic pain effectively PCPs firstneed to conduct a comprehensive patient assess-ment [56] Information on the patientrsquos pain ex-perience history of and preferences for paintreatment psychological status approach to self-management and personal goalspriorities are keyvariables to collect during assessment as they arecritical for making an accurate diagnosis and fordeveloping an appropriate treatment plan to whichthe patient will adhere [56] An expert system-typeCDSS provides a way to elicit and integrate suchpatient-specific information in a manner that isconvenient and timely for both physicians andpatients Moreover the ensuing system-generatedrecommendations are individualized to the needsand circumstances of the specific pain patient perbest clinical practices [56]

CDSSs developed for chronic pain manage-ment have as yet however to fulfill this promiseAs our review indicates systems developed thus farhave been predominantly biomedical in focus anddesigned to assist physicians and other health careproviders in the medical management of painsymptoms (including invasive procedures andreferrals) exclusively Only a few of these systemshave reached a sufficiently advanced stage ofdevelopment to warrant more rigorous testingin large-scale randomized controlled trials[264952] Such trials are imperative for under-standing system effect on provider performanceand patient outcomes

Significantly none of the systems reviewedwere integrated with existing electronic recordssystems nor did they include reminder or docu-mentation functionalities features which have allbeen shown to increase the likelihood of physicianadoption [5758] This lack of integration mayreflect the fact that widespread adoption of elec-tronic records systems by health care institutionshas been a relatively recent occurrence Potentiallythis trend coupled with pressures from majoraccrediting agencies to document the provision ofpain screening and treatment along with the

S164

Smith et al

recent publication of primary care pain manage-ment guidelines may serve to spur additionalmore rigorous research on the use of CDSSs forchronic pain management in primary care[565960] Demonstrating the clinical value ofthese systems is a critical step in convincing healthcare organizations and clinicians that the benefitsof investing in a CDSS for pain management out-weigh potential risks In particular physiciansneed to be assured that this type of system canenhance rather than erode their decision-makingabilities and that time spent learning how to usea CDSS yields measurable improvement in patienthealth and well-being

References

1 American Pain Society Chronic pain in AmericaRoadblock to relief 1999 American Pain SocietyAPS News and Announcements Available at httpwwwampainsocorgwhatsnewtoc_roadhtmtoc

2 Lande SD The problem of pain in managed careIn Lande SD Kulich RJ eds Managed Care andPain Glenview IL American Pain Society 200019

3 Turner JA Leresche L Von Korff M Ehrlich LPrimary care back pain patient characteristics visitcontent and short term outcomes Spine199823463ndash9

4 Von Korff M Gruman J Schaefer J Curry SJ Wag-ner EH Collaborative management of chronic ill-ness Ann Intern Med 1997127(12)1097ndash102

5 Von Korff M Pain management in primary care Anindividualized stepped-care approach In GatchelRJ Turk DL eds Psychosocial Factors in PainCritical Perspectives New York The GuilfordPress 1999

6 Von Korff M Katon W Bush T et al Treatmentcosts cost offset and cost-effectiveness of collabo-rative management of depression Psychosom Med199860(2)143ndash9

7 Bertakis KD Azari R Callahan EJ Patient pain Itsinfluence on primary care physicianndashpatient inter-action Fam Med 200335(2)119ndash23

8 Green CR Wheeler JRC Laporte F Marchant BGuerrero E How well is chronic pain managedWho does it well Pain Med 20023(1)56ndash62

9 Von Roenn JH Cleeland CS Gonin R HatfieldAK Pandya KJ Physician attitudes and practice incancer pain management A survey from the EasternCooperative Oncology Group Ann Intern Med1993119121ndash6

10 Cleeland CS Cleeland LM Dar R Rinehardt LCFactors influencing physician management of can-cer pain Cancer 198658796ndash800

11 Fife BL Irick N Painter JD A comparative studyof the attitudes of physicians and nurses towards themanagement of cancer pain J Pain Symptom Man-age 19938132ndash9

12 Wilson JF Brockoop GW Kryst S Steger H WittWO Medical studentsrsquo attitudes towards painbefore and after a brief course on pain Pain199250251ndash6

13 Weinstein SM Laux LF Thornby JI et al Physi-ciansrsquo attitudes towards pain and the use of opioidanalgesics Results of a survey from the Texas Can-cer Pain Initiative South Med J 200093(5)479ndash87

14 Weinstein SM Laux LF Thornby JI et al Medicalstudentsrsquo attitudes towards pain and the use of opi-oid analgesics Implications for changing medicalschool curriculum South Med J 200093(5)472ndash8

15 Whedon M Ferrell BR Professional and ethicalconsiderations in the use of high-tech pain manage-ment Oncol Nurs Forum 1991181135ndash43

16 Ward S Goldberg N Miller-Mccauley V et alPatient-related barriers to management of cancerpain Pain 199352319ndash24

17 Pargeon KL Hailey BJ Barriers to effective cancerpain management A review of the literature J PainSymptom Manage 199918358ndash68

18 Breitbart W Passik S Mcdonald MV et al Patient-related barriers to pain management in ambulatoryAIDS patients Pain 199352319ndash24

19 Gunnarsdottir S Donovan HS Serlin RC Voge CWard S Patient-related barriers to pain manage-ment The barriers questionnaire II (BQ-II) Pain200299385ndash96

20 Arora NK Interacting with cancer patients Thesignificance of physiciansrsquo communication behaviorSoc Sci Med 200357791ndash806

21 Mccaffery M Thorpe DM Differences in percep-tion of pain and the development of adversarial rela-tionships among health care providers In Hill CSFields W eds Advances in Pain Research and Ther-apy Drug Treatment of Cancer Pain in a Drug-Oriented Society Vol 11 New York Raven Press1989

22 Ong LML de Haes JCJM Hoos AM Lammes FBDoctorndashpatient communication A review of the lit-erature Soc Sci Med 199540903ndash18

23 Jones WL Rimer BK Levy MH Kinman JL Can-cer patientsrsquo knowledge beliefs and behaviorregarding pain control regimens Implications foreducation programs Patient Educ Couns19845(4)159ndash64

24 Lukoschek P Fazzari M Marantz P Patient andphysician factors predict patientsrsquo comprehensionof health information Patient Educ Couns200350201ndash10

25 Donovan JL Blake DR Patient non-complianceDeviance or reasoned decision-making Soc SciMed 199234377ndash94

26 Garg AX Adhikari NKJ Mcdonald H et al Effectsof computerized clinical decision support systemson practitioner performance and patient outcomesa systematic review JAMA 2005293(10)1223ndash38

27 Nilasena DS Lincoln MJ A computer-generatedreminder system improves physician compliance

Computerized Decision-Support System for Pain

S163

nonacceptance of computer recommendations canserve as significant barriers to system adoption inroutine clinical practice [365455]

User preferences regarding the presentation ofcomputer output including content formatting(eg color graphics) and length have not beensolicited in most instances either Similarly thereare few published data concerning technical diffi-culties (eg type and number of system crashes ortouch-screen calibration problems) encounteredby CDSS users Both issues have important rami-fications for future system refinements [52] Addi-tionally there is a paucity of information oncontextual circumstances (eg presence of a localldquochampionrdquo of the system) or the processes usedto integrate the CDSS into the existing clinicalworkflow key considerations for successful systemimplementation Not least testing has been con-fined almost exclusively to either inpatient ortertiary care settings with only two studies con-ducted in the primary care context to date

The effects of these systems on patient out-comes remain understudied Two studies reportedqualitative data concerning CDSS impact onpatientsrsquo perceived pain-related communicationwith their physician however sample sizes weresmall and results inconsistent [4952] One studyreported system impact on patient pain intensitylevel over time but the study lacked adequate sta-tistical power to detect clinically important differ-ences [52] Other major patient outcomes such ashealth care utilization health care costs painrelief pain medication usage communication withhealth care provider about pain functional statusand QOL have not been examined One studyreported evidence that CDSS use may invokepatient reactivity (eg vomiting intensified painsymptoms) Potential adverse effects on patientsshould be measured in future investigations [52]Similarly there is need for more extensive andconsistent examination of system impact on clini-cian pain management performance

While we sought to be as comprehensive aspossible in our literature search our review wasrestricted to only English-language studies Inaddition it is possible that there are other CDSSsunder development that we failed to identify Thelimited size of the available literature as well asthe methods used in these primary studies pre-vented us from conducting a meta-analysis ofresearch findings and from reaching more defin-itive conclusions about the impact of these systemson physician performance and patient pain func-tioning and other aspects of QOL Notably in all

the studies we examined study investigators andCDSS developers were one and the same a factthat may have resulted in more positive findings[36] Lastly we did not conduct a separate evalu-ation of the clinical appropriateness of either theCDSS algorithms or treatment recommendationsnor of the underlying logic employed to generatesuch algorithms

The potential for these computer-based sys-tems to improve the quality of chronic pain man-agement in the primary care context is substantialTo manage chronic pain effectively PCPs firstneed to conduct a comprehensive patient assess-ment [56] Information on the patientrsquos pain ex-perience history of and preferences for paintreatment psychological status approach to self-management and personal goalspriorities are keyvariables to collect during assessment as they arecritical for making an accurate diagnosis and fordeveloping an appropriate treatment plan to whichthe patient will adhere [56] An expert system-typeCDSS provides a way to elicit and integrate suchpatient-specific information in a manner that isconvenient and timely for both physicians andpatients Moreover the ensuing system-generatedrecommendations are individualized to the needsand circumstances of the specific pain patient perbest clinical practices [56]

CDSSs developed for chronic pain manage-ment have as yet however to fulfill this promiseAs our review indicates systems developed thus farhave been predominantly biomedical in focus anddesigned to assist physicians and other health careproviders in the medical management of painsymptoms (including invasive procedures andreferrals) exclusively Only a few of these systemshave reached a sufficiently advanced stage ofdevelopment to warrant more rigorous testingin large-scale randomized controlled trials[264952] Such trials are imperative for under-standing system effect on provider performanceand patient outcomes

Significantly none of the systems reviewedwere integrated with existing electronic recordssystems nor did they include reminder or docu-mentation functionalities features which have allbeen shown to increase the likelihood of physicianadoption [5758] This lack of integration mayreflect the fact that widespread adoption of elec-tronic records systems by health care institutionshas been a relatively recent occurrence Potentiallythis trend coupled with pressures from majoraccrediting agencies to document the provision ofpain screening and treatment along with the

S164

Smith et al

recent publication of primary care pain manage-ment guidelines may serve to spur additionalmore rigorous research on the use of CDSSs forchronic pain management in primary care[565960] Demonstrating the clinical value ofthese systems is a critical step in convincing healthcare organizations and clinicians that the benefitsof investing in a CDSS for pain management out-weigh potential risks In particular physiciansneed to be assured that this type of system canenhance rather than erode their decision-makingabilities and that time spent learning how to usea CDSS yields measurable improvement in patienthealth and well-being

References

1 American Pain Society Chronic pain in AmericaRoadblock to relief 1999 American Pain SocietyAPS News and Announcements Available at httpwwwampainsocorgwhatsnewtoc_roadhtmtoc

2 Lande SD The problem of pain in managed careIn Lande SD Kulich RJ eds Managed Care andPain Glenview IL American Pain Society 200019

3 Turner JA Leresche L Von Korff M Ehrlich LPrimary care back pain patient characteristics visitcontent and short term outcomes Spine199823463ndash9

4 Von Korff M Gruman J Schaefer J Curry SJ Wag-ner EH Collaborative management of chronic ill-ness Ann Intern Med 1997127(12)1097ndash102

5 Von Korff M Pain management in primary care Anindividualized stepped-care approach In GatchelRJ Turk DL eds Psychosocial Factors in PainCritical Perspectives New York The GuilfordPress 1999

6 Von Korff M Katon W Bush T et al Treatmentcosts cost offset and cost-effectiveness of collabo-rative management of depression Psychosom Med199860(2)143ndash9

7 Bertakis KD Azari R Callahan EJ Patient pain Itsinfluence on primary care physicianndashpatient inter-action Fam Med 200335(2)119ndash23

8 Green CR Wheeler JRC Laporte F Marchant BGuerrero E How well is chronic pain managedWho does it well Pain Med 20023(1)56ndash62

9 Von Roenn JH Cleeland CS Gonin R HatfieldAK Pandya KJ Physician attitudes and practice incancer pain management A survey from the EasternCooperative Oncology Group Ann Intern Med1993119121ndash6

10 Cleeland CS Cleeland LM Dar R Rinehardt LCFactors influencing physician management of can-cer pain Cancer 198658796ndash800

11 Fife BL Irick N Painter JD A comparative studyof the attitudes of physicians and nurses towards themanagement of cancer pain J Pain Symptom Man-age 19938132ndash9

12 Wilson JF Brockoop GW Kryst S Steger H WittWO Medical studentsrsquo attitudes towards painbefore and after a brief course on pain Pain199250251ndash6

13 Weinstein SM Laux LF Thornby JI et al Physi-ciansrsquo attitudes towards pain and the use of opioidanalgesics Results of a survey from the Texas Can-cer Pain Initiative South Med J 200093(5)479ndash87

14 Weinstein SM Laux LF Thornby JI et al Medicalstudentsrsquo attitudes towards pain and the use of opi-oid analgesics Implications for changing medicalschool curriculum South Med J 200093(5)472ndash8

15 Whedon M Ferrell BR Professional and ethicalconsiderations in the use of high-tech pain manage-ment Oncol Nurs Forum 1991181135ndash43

16 Ward S Goldberg N Miller-Mccauley V et alPatient-related barriers to management of cancerpain Pain 199352319ndash24

17 Pargeon KL Hailey BJ Barriers to effective cancerpain management A review of the literature J PainSymptom Manage 199918358ndash68

18 Breitbart W Passik S Mcdonald MV et al Patient-related barriers to pain management in ambulatoryAIDS patients Pain 199352319ndash24

19 Gunnarsdottir S Donovan HS Serlin RC Voge CWard S Patient-related barriers to pain manage-ment The barriers questionnaire II (BQ-II) Pain200299385ndash96

20 Arora NK Interacting with cancer patients Thesignificance of physiciansrsquo communication behaviorSoc Sci Med 200357791ndash806

21 Mccaffery M Thorpe DM Differences in percep-tion of pain and the development of adversarial rela-tionships among health care providers In Hill CSFields W eds Advances in Pain Research and Ther-apy Drug Treatment of Cancer Pain in a Drug-Oriented Society Vol 11 New York Raven Press1989

22 Ong LML de Haes JCJM Hoos AM Lammes FBDoctorndashpatient communication A review of the lit-erature Soc Sci Med 199540903ndash18

23 Jones WL Rimer BK Levy MH Kinman JL Can-cer patientsrsquo knowledge beliefs and behaviorregarding pain control regimens Implications foreducation programs Patient Educ Couns19845(4)159ndash64

24 Lukoschek P Fazzari M Marantz P Patient andphysician factors predict patientsrsquo comprehensionof health information Patient Educ Couns200350201ndash10

25 Donovan JL Blake DR Patient non-complianceDeviance or reasoned decision-making Soc SciMed 199234377ndash94

26 Garg AX Adhikari NKJ Mcdonald H et al Effectsof computerized clinical decision support systemson practitioner performance and patient outcomesa systematic review JAMA 2005293(10)1223ndash38

27 Nilasena DS Lincoln MJ A computer-generatedreminder system improves physician compliance

S164

Smith et al

recent publication of primary care pain manage-ment guidelines may serve to spur additionalmore rigorous research on the use of CDSSs forchronic pain management in primary care[565960] Demonstrating the clinical value ofthese systems is a critical step in convincing healthcare organizations and clinicians that the benefitsof investing in a CDSS for pain management out-weigh potential risks In particular physiciansneed to be assured that this type of system canenhance rather than erode their decision-makingabilities and that time spent learning how to usea CDSS yields measurable improvement in patienthealth and well-being

References

1 American Pain Society Chronic pain in AmericaRoadblock to relief 1999 American Pain SocietyAPS News and Announcements Available at httpwwwampainsocorgwhatsnewtoc_roadhtmtoc

2 Lande SD The problem of pain in managed careIn Lande SD Kulich RJ eds Managed Care andPain Glenview IL American Pain Society 200019

3 Turner JA Leresche L Von Korff M Ehrlich LPrimary care back pain patient characteristics visitcontent and short term outcomes Spine199823463ndash9

4 Von Korff M Gruman J Schaefer J Curry SJ Wag-ner EH Collaborative management of chronic ill-ness Ann Intern Med 1997127(12)1097ndash102

5 Von Korff M Pain management in primary care Anindividualized stepped-care approach In GatchelRJ Turk DL eds Psychosocial Factors in PainCritical Perspectives New York The GuilfordPress 1999

6 Von Korff M Katon W Bush T et al Treatmentcosts cost offset and cost-effectiveness of collabo-rative management of depression Psychosom Med199860(2)143ndash9

7 Bertakis KD Azari R Callahan EJ Patient pain Itsinfluence on primary care physicianndashpatient inter-action Fam Med 200335(2)119ndash23

8 Green CR Wheeler JRC Laporte F Marchant BGuerrero E How well is chronic pain managedWho does it well Pain Med 20023(1)56ndash62

9 Von Roenn JH Cleeland CS Gonin R HatfieldAK Pandya KJ Physician attitudes and practice incancer pain management A survey from the EasternCooperative Oncology Group Ann Intern Med1993119121ndash6

10 Cleeland CS Cleeland LM Dar R Rinehardt LCFactors influencing physician management of can-cer pain Cancer 198658796ndash800

11 Fife BL Irick N Painter JD A comparative studyof the attitudes of physicians and nurses towards themanagement of cancer pain J Pain Symptom Man-age 19938132ndash9

12 Wilson JF Brockoop GW Kryst S Steger H WittWO Medical studentsrsquo attitudes towards painbefore and after a brief course on pain Pain199250251ndash6

13 Weinstein SM Laux LF Thornby JI et al Physi-ciansrsquo attitudes towards pain and the use of opioidanalgesics Results of a survey from the Texas Can-cer Pain Initiative South Med J 200093(5)479ndash87

14 Weinstein SM Laux LF Thornby JI et al Medicalstudentsrsquo attitudes towards pain and the use of opi-oid analgesics Implications for changing medicalschool curriculum South Med J 200093(5)472ndash8

15 Whedon M Ferrell BR Professional and ethicalconsiderations in the use of high-tech pain manage-ment Oncol Nurs Forum 1991181135ndash43

16 Ward S Goldberg N Miller-Mccauley V et alPatient-related barriers to management of cancerpain Pain 199352319ndash24

17 Pargeon KL Hailey BJ Barriers to effective cancerpain management A review of the literature J PainSymptom Manage 199918358ndash68

18 Breitbart W Passik S Mcdonald MV et al Patient-related barriers to pain management in ambulatoryAIDS patients Pain 199352319ndash24

19 Gunnarsdottir S Donovan HS Serlin RC Voge CWard S Patient-related barriers to pain manage-ment The barriers questionnaire II (BQ-II) Pain200299385ndash96

20 Arora NK Interacting with cancer patients Thesignificance of physiciansrsquo communication behaviorSoc Sci Med 200357791ndash806

21 Mccaffery M Thorpe DM Differences in percep-tion of pain and the development of adversarial rela-tionships among health care providers In Hill CSFields W eds Advances in Pain Research and Ther-apy Drug Treatment of Cancer Pain in a Drug-Oriented Society Vol 11 New York Raven Press1989

22 Ong LML de Haes JCJM Hoos AM Lammes FBDoctorndashpatient communication A review of the lit-erature Soc Sci Med 199540903ndash18

23 Jones WL Rimer BK Levy MH Kinman JL Can-cer patientsrsquo knowledge beliefs and behaviorregarding pain control regimens Implications foreducation programs Patient Educ Couns19845(4)159ndash64

24 Lukoschek P Fazzari M Marantz P Patient andphysician factors predict patientsrsquo comprehensionof health information Patient Educ Couns200350201ndash10

25 Donovan JL Blake DR Patient non-complianceDeviance or reasoned decision-making Soc SciMed 199234377ndash94

26 Garg AX Adhikari NKJ Mcdonald H et al Effectsof computerized clinical decision support systemson practitioner performance and patient outcomesa systematic review JAMA 2005293(10)1223ndash38

27 Nilasena DS Lincoln MJ A computer-generatedreminder system improves physician compliance

Computerized Decision-Support System for Pain

S165

with diabetes preventive care guidelines Proc AnnSymp Comput Appl Med Care 1995640ndash5

28 Chambers CV Balaban DJ Charlson BL Grass-berger DM The effect of microcomputer-gener-ated reminders on influenza vaccination rates in auniversity-based family practice center J Am BoardFam Pract 1991419ndash26

29 Flanagan JR Doebbeling BN Dawson J BeekmannS Randomized study of online vaccine reminders inadult primary care Proc AMIA Symp 1999755ndash9

30 Burack RC Gimotty PA Promoting screeningmammography in inner-city settings The sustainedeffectiveness of computerized reminders in a ran-domized controlled trial Med Care 199735921ndash31

31 Rossi RA Every NR A computerized interventionto decrease the use of calcium channel blockers inhypertension J Gen Intern Med 199712672ndash8

32 Montgomery AA Fahey T Peters TJ MacintoshC Sharp DJ Evaluation of computer based clinicaldecision support system and risk chart for manage-ment of hypertension in primary care Randomizedcontrolled trial BMJ 2000320686ndash90

33 Shea S Dumouchel W Bahamonde L A meta-analysis of 16 randomized controlled trials toevaluate computer-based reminder systems for pre-ventive care in the ambulatory setting J Am MedInform Assoc 19963399ndash409

34 Unrod M Smith MY DePue J Spring B WinkelG Randomized controlled trial of a computer-based tailored intervention to increase smokingcessation counseling by primary care physicians JGen Intern Med 200722478ndash84

35 Balas EA Austin SM Mitchell JA et al The clinicalvalue of computerized information services Areview of 98 randomized clinical trails Arch FamMed 19965271ndash8

36 Hunt DL Haynes RB Hanna SE Smith K Effectsof computer-based clinical decision support systemson physician performance and patient outcome Asystematic review JAMA 1998280(15)1339ndash46

37 Revere D Dunbar PJ Review of computer-gener-ated outpatient health behavior interventions Clin-ical encounters ldquoin absentiardquo J Am Med InformAssoc 20018(1)62ndash79

38 Prochaska JO Velicer WF Redding C et al Stage-based expert systems to guide a population of pri-mary care patients to quit smoking eat healthierprevent skin cancer and receive regular mammo-grams Prev Med 200541(2)406ndash16

39 Prochaska JO Velicer WF Fava JL Rossi JS TsohJY Evaluating a population-based recruitmentapproach and a stage-based expert system inter-vention for smoking cessation Addict Behav200126(4)583ndash602

40 Strecher VJ Kreuter M Den Boer DJ et al Theeffects of computer-tailored smoking cessation mes-sages in family practice settings J Fam Pract199439(3)262ndash70

41 Strecher VJ Shiffman S West R Randomized con-trolled trial of a web-based computer-tailored smok-ing cessation program as a supplement to nicotinepatch therapy Addiction 2005100(5)682ndash8

42 Dijkstra A De Vries H Roijackers J Long-termeffectiveness of computer-generated tailored feed-back in smoking cessation Health Educ Res199813(2)207ndash14

43 Dijkstra A De Vries H Roijackers J van BreukelenG Tailored interventions to communicate stage-matched information to smokers in differentmotivational stages J Consult Clin Psychol199866(3)549ndash57

44 Kawamoto K Houlihan CA Balas EA Lobach DFImproving clinical practice using clinical decisionsupport systems A systematic review of trials toidentify features critical to success BMJ2005330765ndash73

45 Matsumura Y RHINOS A consultation system fordiagnosis of headache and facial pain ComputMethods Programs Biomed 19862365ndash71

46 Thomas J IVAN An expert system for pain controland symptom relief in advance cancer PC AI199913(4)28ndash30

47 Nielsen KD Rasmussen C Russell MB The Diag-nostic Headache Diary A headache expert systemIn Paiva T Penzel T eds European NeurologicalNetwork Amsterdam IOS Press 2000

48 Knab JH Wallace MS Wagner RL Tsoukatos JWeinger MB The use of a computer-based decisionsupport system facilitates primary care physiciansrsquomanagement of chronic pain Anesth Analg200193712ndash20

49 Wilkie DJ Huang H Berry DL et al Cancersymptom control Feasibility of a tailored interac-tive computerized program for patients Fam Com-munity Health 200124(3)48ndash62

50 Im E Chee W Decision support computer pro-gram for cancer pain management Comput InformNurs 200321(1)12ndash21

51 Huang H Wilkie DJ Zong S et al Developing acomputerized data collection and decision supportsystem for cancer pain management ComputInform Nurs 200321(4)206ndash17

52 Wilkie DJ Judge MK Berry DL Dell J Zong SGilespie R Usability of a computerized PAIN

Repor-tIt

in the general public with pain and peoplewith cancer pain J Pain Symptom Manag200325(3)213ndash24

53 Koestler ME Libby E Schofferman J Redmon TWeb-based screen computer assessment of chroniclow back pain A pilot study Comput Inform Nurs200523(5)275ndash84

54 Wyatt JC Spiegelhalter DJ Evaluating medicalexpert systems What to test and how Med Inform(Lond) 199015(3)205ndash17

55 Reisman Y Computer-based clinical decision-aidsA review of methods and assessment of systemsMed Inform (Lond) 199621179ndash97

S166

Smith et al

56 Gruener D Lande SD eds Pain Control in thePrimary Care Setting Glenview IL American PainSociety 2006

57 Shiffman RN Liaw Y Brandt CA Corb GJComputer-based guideline implementation sys-tems A systematic review of functionality andeffectiveness J Am Med Inform Assoc 19996104ndash14

58 Muller ML Ganslandt T Eich HP Lang K Ohm-ann C Prokosch HU Towards integration of

clinical decision support in commercial hospitalinformation systems using distributed reusablesoftware and knowledge components Int J MedInform 200163369ndash77

59 Phillips D for the Joint Commission on Accredita-tion of Healthcare Organizations JCAHO painmanagement standards are unveiled JAMA2000284428ndash9

60 Frankenstein RS Letters to the editor reply JAMA20002842317ndash8

S166

Smith et al

56 Gruener D Lande SD eds Pain Control in thePrimary Care Setting Glenview IL American PainSociety 2006

57 Shiffman RN Liaw Y Brandt CA Corb GJComputer-based guideline implementation sys-tems A systematic review of functionality andeffectiveness J Am Med Inform Assoc 19996104ndash14

58 Muller ML Ganslandt T Eich HP Lang K Ohm-ann C Prokosch HU Towards integration of

clinical decision support in commercial hospitalinformation systems using distributed reusablesoftware and knowledge components Int J MedInform 200163369ndash77

59 Phillips D for the Joint Commission on Accredita-tion of Healthcare Organizations JCAHO painmanagement standards are unveiled JAMA2000284428ndash9

60 Frankenstein RS Letters to the editor reply JAMA20002842317ndash8