title: Enabling health care decisionmaking through clinical decision support and knowledge management.
abstract: OBJECTIVE
  To catalogue study designs used to assess the clinical effectiveness of CDSSs and KMSs, to identify features that impact the success of CDSSs/KMSs, to document the impact of CDSSs/KMSs on outcomes, and to identify knowledge types that can be integrated into CDSSs/KMSs.
  
  
  METHODS
  MEDLINE(®), CINAHL(®), PsycINFO(®), and Web of Science(®).
  
  
  METHODS
  We included studies published in English from January 1976 through December 2010. After screening titles and abstracts, full-text versions of articles were reviewed by two independent reviewers. Included articles were abstracted to evidence tables by two reviewers. Meta-analyses were performed for seven domains in which sufficient studies with common outcomes were included.
  
  
  RESULTS
  We identified 15,176 articles, from which 323 articles describing 311 unique studies including 160 reports on 148 randomized control trials (RCTs) were selected for inclusion. RCTs comprised 47.5 percent of the comparative studies on CDSSs/KMSs. Both commercially and locally developed CDSSs effectively improved health care process measures related to performing preventive services (n = 25; OR 1.42, 95% confidence interval [CI] 1.27 to 1.58), ordering clinical studies (n = 20; OR 1.72, 95% CI 1.47 to 2.00), and prescribing therapies (n = 46; OR 1.57, 95% CI 1.35 to 1.82). Fourteen CDSS/KMS features were assessed for correlation with success of CDSSs/KMSs across all endpoints. Meta-analyses identified six new success features: Integration with charting or order entry system. Promotion of action rather than inaction. No need for additional clinician data entry. Justification of decision support via research evidence. Local user involvement. Provision of decision support results to patients as well as providers. Three previously identified success features were confirmed: Automatic provision of decision support as part of clinician workflow. Provision of decision support at time and location of decisionmaking. Provision of a recommendation, not just an assessment. Only 29 (19.6%) RCTs assessed the impact of CDSSs on clinical outcomes, 22 (14.9%) assessed costs, and 3 assessed KMSs on any outcomes. The primary source of knowledge used in CDSSs was derived from structured care protocols.
  
  
  CONCLUSIONS
  Strong evidence shows that CDSSs/KMSs are effective in improving health care process measures across diverse settings using both commercially and locally developed systems. Evidence for the effectiveness of CDSSs on clinical outcomes and costs and KMSs on any outcomes is minimal. Nine features of CDSSs/KMSs that correlate with a successful impact of clinical decision support have been newly identified or confirmed.
authors.forename: David
authors.initials: D
authors.lastname: Lobach
authors.forename: Gillian D
authors.initials: GD
authors.lastname: Sanders
authors.forename: Tiffani J
authors.initials: TJ
authors.lastname: Bright
authors.forename: Anthony
authors.initials: A
authors.lastname: Wong
authors.forename: Ravi
authors.initials: R
authors.lastname: Dhurjati
authors.forename: Erin
authors.initials: E
authors.lastname: Bristow
authors.forename: Lori
authors.initials: L
authors.lastname: Bastian
authors.forename: Remy
authors.initials: R
authors.lastname: Coeytaux
authors.forename: Gregory
authors.initials: G
authors.lastname: Samsa
authors.forename: Vic
authors.initials: V
authors.lastname: Hasselblad
authors.forename: John W
authors.initials: JW
authors.lastname: Williams
authors.forename: Liz
authors.initials: L
authors.lastname: Wing
authors.forename: Michael
authors.initials: M
authors.lastname: Musty
authors.forename: Amy S
authors.initials: AS
authors.lastname: Kendrick
mesh_terms: D003657:Decision Making; D020000:Decision Support Systems, Clinical / Q000458:organization & administration*; D003695:Delivery of Health Care / Q000458:organization & administration*; D005260:Female; D006801:Humans; D058436:Knowledge Management; D008297:Male; D011314:Preventive Health Services / Q000458:organization & administration; D016032:Randomized Controlled Trials as Topic; D016896:Treatment Outcome