Wednesday, November 5, 2014

Two Recent Research Briefs Reiterate the Need for Clinical Decision Support

One of the seminal papers in informatics was published in 1978, when Octo Barnett and colleagues demonstrated that while computer-based feedback could positively impact physician decision-making, that impact went away when the feedback was removed. This has always been a rationale for clinical decision support (CDS), which helps clinicians because it reminds them to do the right thing, and that does not impart learning.

Two recent research briefs demonstrate how challenging is the task of getting physicians to be appropriate stewards of antibiotics and have implications for CDS. Antibiotics were one of the miracles of 20th century medicine, leading to substantial ability to fight infection. They are still an important armamentarium of medicine, but their value is threatened by growing resistance of organisms [2].

One research brief finds that the likelihood of antibiotic prescribing becomes higher as day goes on, which the researchers call "decision fatigue" [3]. Another brief shows that implementation of a physician audit and feedback program resulted in reducing inappropriate antibiotic prescribing, but that removal of the program resulted in a return toward baseline prescribing habits [4]. This finding has been found in other similar programs [5].

Practicing medicine is a complex task. Although physicians have always been assumed to maintain the entire knowledge base in their heads, decades of informatics-related research has shown otherwise. Of course, the way we implement CDS is imperfect, often providing advice that physicians do not need [6]. A big challenge going forward will be to optimize the signal vs. noise and determine the best ways to deliver that signal.


1. Barnett, GO, Winickoff, R, et al. (1978). Quality assurance through automated monitoring and concurrent feedback using a computer-based medical information system. Medical Care. 16: 962-970.
2. Anonymous (2013). Antibiotic Resistance Threats in the United States, 2013. Atlanta, GA, Centers for Disease Control and Prevention.
3. Linder, JA, Doctor, JN, et al. (2014). Time of day and the decision to prescribe antibiotics. JAMA Internal Medicine. Epub ahead of print.
4. Gerber, JS, Prasad, PA, et al. (2014). Durability of benefits of an outpatient antimicrobial stewardship intervention after discontinuation of audit and feedback. Journal of the American Medical Association. Epub ahead of print.
5. Arnold, SR and Straus, SE (2005). Interventions to improve antibiotic prescribing practices in ambulatory care. Cochrane Database of Systematic Reviews. 2005(4): CD003539.
6. Nanji, KC, Slight, SP, et al. (2014). Overrides of medication-related clinical decision support alerts in outpatients. Journal of the American Medical Informatics Association. 21: 487-491.

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