The impact of pharmacy computerised clinical decision support on prescribing, clinical and patient outcomes: a systematic review of the literature.
OBJECTIVE
Computerised clinical decision support systems (CDSSs) are being used increasingly to support evidence-based decision-making by health care professionals. This systematic review evaluated the impact of CDSSs targeting pharmacists on physician prescribing, clinical and patient outcomes. We compared the impact of CDSSs addressing safety concerns (drug interactions, contraindications, dose monitoring and adjustment) and those focusing on medicines use in line with guideline recommendations (hereafter referred to as Quality Use of Medicines, or QUM). We also examined the influence of clinical setting (institutional versus ambulatory care), system- or user-initiation of CDSS, prescribing versus clinical outcomes reported and use of multi-faceted versus single interventions on system effectiveness.


METHODS
We searched Medline, Embase, CINAHL and PsycINFO (1990-2009) for methodologically adequate studies (experiments and strong quasi-experiments) comparing a CDSS with usual pharmacy care. Individual study results are reported as positive trends or statistically significant results in the direction of the intentions of the CDSS being tested. Studies are aggregated and compared as the proportions of studies showing the effectiveness of the CDSS on the majority (> or = 50%) of outcomes reported in the individual study.


RESULTS
Of 21 eligible studies, 11 addressed safety and 10 QUM issues. CDSSs addressing safety issues were more effective than CDSSs focusing on QUM (10/11 versus 4/10 studies reporting statistically significant improvements in favour of CDSSs on > or = 50% of all outcomes reported; P = 0.01). A number of QUM studies noted the limited contact between pharmacists and physicians relating to QUM treatment recommendations. More studies demonstrated CDSS benefits on prescribing outcomes than clinical outcomes (10/10 versus 0/3 studies; P = 0.002). There were too few studies to assess the impact of system- versus user-initiated CDSS, the influence of setting or multi-faceted interventions on CDSS effectiveness.


CONCLUSIONS
Our study demonstrated greater effectiveness of safety-focused compared with QUM-focused CDSSs. Medicine safety issues are traditional areas of pharmacy activity. Without good communication between pharmacists and physicians, the full benefits of QUM-focused CDSSs may not be realised. Developments in pharmacy-based CDSSs need to consider these inter-professional relationships as well as computer-system enhancements.
Robertson
Jane
J
Discipline of Clinical Pharmacology, School of Medicine and Public Health, The University of Newcastle, Newcastle, Australia. Jane.Robertson@newcastle.edu.au
Walkom
Emily
E
Pearson
Sallie-Anne
SA
Hains
Isla
I
Williamsone
Margaret
M
Newby
David
D
D016303:Clinical Pharmacy Information Systems / Q000458:organization & administration*; D020000:Decision Support Systems, Clinical / Q000458:organization & administration*; D019317:Evidence-Based Medicine; D006801:Humans; D017063:Outcome Assessment, Health Care; D010593:Pharmaceutical Services / Q000458:organization & administration; D010595:Pharmacists / Q000458:organization & administration; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000592:standards*; D011787:Quality of Health Care