title: Adoption of clinical decision support in multimorbidity: a systematic review.
abstract: BACKGROUND
  Patients with multiple conditions have complex needs and are increasing in number as populations age. This multimorbidity is one of the greatest challenges facing health care. Having more than 1 condition generates (1) interactions between pathologies, (2) duplication of tests, (3) difficulties in adhering to often conflicting clinical practice guidelines, (4) obstacles in the continuity of care, (5) confusing self-management information, and (6) medication errors. In this context, clinical decision support (CDS) systems need to be able to handle realistic complexity and minimize iatrogenic risks.
  
  
  OBJECTIVE
  The aim of this review was to identify to what extent CDS is adopted in multimorbidity.
  
  
  METHODS
  This review followed PRISMA guidance and adopted a multidisciplinary approach. Scopus and PubMed searches were performed by combining terms from 3 different thesauri containing synonyms for (1) multimorbidity and comorbidity, (2) polypharmacy, and (3) CDS. The relevant articles were identified by examining the titles and abstracts. The full text of selected/relevant articles was analyzed in-depth. For articles appropriate for this review, data were collected on clinical tasks, diseases, decision maker, methods, data input context, user interface considerations, and evaluation of effectiveness.
  
  
  RESULTS
  A total of 50 articles were selected for the full in-depth analysis and 20 studies were included in the final review. Medication (n=10) and clinical guidance (n=8) were the predominant clinical tasks. Four studies focused on merging concurrent clinical practice guidelines. A total of 17 articles reported their CDS systems were knowledge-based. Most articles reviewed considered patients' clinical records (n=19), clinical practice guidelines (n=12), and clinicians' knowledge (n=10) as contextual input data. The most frequent diseases mentioned were cardiovascular (n=9) and diabetes mellitus (n=5). In all, 12 articles mentioned generalist doctor(s) as the decision maker(s). For articles reviewed, there were no studies referring to the active involvement of the patient in the decision-making process or to patient self-management. None of the articles reviewed adopted mobile technologies. There were no rigorous evaluations of usability or effectiveness of the CDS systems reported.
  
  
  CONCLUSIONS
  This review shows that multimorbidity is underinvestigated in the informatics of supporting clinical decisions. CDS interventions that systematize clinical practice guidelines without considering the interactions of different conditions and care processes may lead to unhelpful or harmful clinical actions. To improve patient safety in multimorbidity, there is a need for more evidence about how both conditions and care processes interact. The data needed to build this evidence base exist in many electronic health record systems and are underused.
authors.affiliation: NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Institute of Population Health, The University of Manchester, Manchester, United Kingdom. paolo.fraccaro@postgrad.manchester.ac.uk.
authors.forename: Paolo
authors.identifier: http://orcid.org/0000-0002-5213-7071
authors.initials: P
authors.lastname: Fraccaro
authors.forename: Mercedes
authors.identifier: http://orcid.org/0000-0001-9469-2068
authors.initials: M
authors.lastname: Arguello Casteleiro
authors.forename: John
authors.identifier: http://orcid.org/0000-0002-2187-9195
authors.initials: J
authors.lastname: Ainsworth
authors.forename: Iain
authors.identifier: http://orcid.org/0000-0003-3392-1650
authors.initials: I
authors.lastname: Buchan
keywords: decision support systems, management; multiple chronic diseases; multiple medications; multiple pathologies; systematic review