title: Precision diagnosis: a view of the clinical decision support systems (CDSS) landscape through the lens of critical care.
abstract: Improving diagnosis and treatment depends on clinical monitoring and computing. Clinical decision support systems (CDSS) have been in existence for over 50 years. While the literature points to positive impacts on quality and patient safety, outcomes, and the avoidance of medical errors, technical and regulatory challenges continue to retard their rate of integration into clinical care processes and thus delay the refinement of diagnoses towards personalized care. We conducted a systematic review of pertinent articles in the MEDLINE, US Department of Health and Human Services, Agency for Health Research and Quality, and US Food and Drug Administration databases, using a Boolean approach to combine terms germane to the discussion (clinical decision support, tools, systems, critical care, trauma, outcome, cost savings, NSQIP, APACHE, SOFA, ICU, and diagnostics). References were selected on the basis of both temporal and thematic relevance, and subsequently aggregated around four distinct themes: the uses of CDSS in the critical and surgical care settings, clinical insertion challenges, utilization leading to cost-savings, and regulatory concerns. Precision diagnosis is the accurate and timely explanation of each patient's health problem and further requires communication of that explanation to patients and surrogate decision-makers. Both accuracy and timeliness are essential to critical care, yet computed decision support systems (CDSS) are scarce. The limitation arises from the technical complexity associated with integrating and filtering large data sets from diverse sources. Provider mistrust and resistance coupled with the absence of clear guidance from regulatory bodies further retard acceptance of CDSS. While challenges to develop and deploy CDSS are substantial, the clinical, quality, and economic impacts warrant the effort, especially in disciplines requiring complex decision-making, such as critical and surgical care. Improving diagnosis in health care requires accumulation, validation and transformation of data into actionable information. The aggregate of those processes-CDSS-is currently primitive. Despite technical and regulatory challenges, the apparent clinical and economic utilities of CDSS must lead to greater engagement. These tools play the key role in realizing the vision of a more 'personalized medicine', one characterized by individualized precision diagnosis rather than population-based risk-stratification.
authors.affiliation: Uniformed Services University of the Health Sciences, Bethesda, MD, USA. arnaud.belard.ctr@usuhs.edu.|Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA. arnaud.belard.ctr@usuhs.edu.
authors.forename: Arnaud
authors.initials: A
authors.lastname: Belard
authors.affiliation: Emory University and Grady Memorial Hospital, Atlanta, GA, USA.|Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA.
authors.forename: Timothy
authors.initials: T
authors.lastname: Buchman
authors.affiliation: Uniformed Services University of the Health Sciences, Bethesda, MD, USA.|Naval Medical Research Center, Bethesda, MD, USA.|Walter Reed National Military Medical Center, Bethesda, MD, USA.|Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Forsberg
authors.affiliation: Uniformed Services University of the Health Sciences, Bethesda, MD, USA.|Walter Reed National Military Medical Center, Bethesda, MD, USA.|Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA.
authors.forename: Benjamin K
authors.initials: BK
authors.lastname: Potter
authors.affiliation: Emory University and Grady Memorial Hospital, Atlanta, GA, USA.|Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Dente
authors.affiliation: Duke University, Durham, NC, USA.|Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA.
authors.forename: Allan
authors.initials: A
authors.lastname: Kirk
authors.affiliation: Uniformed Services University of the Health Sciences, Bethesda, MD, USA.|Walter Reed National Military Medical Center, Bethesda, MD, USA.|Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA.
authors.forename: Eric
authors.initials: E
authors.lastname: Elster
mesh_terms: D000465:Algorithms; D003422:Critical Care / Q000379:methods*; D020000:Decision Support Systems, Clinical; D018795:Device Approval; D004867:Equipment Design; D017048:Health Care Costs; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control; D016343:Monitoring, Intraoperative / Q000295:instrumentation; D008991:Monitoring, Physiologic / Q000295:instrumentation / Q000379:methods*; D061214:Patient Safety; D057285:Precision Medicine / Q000191:economics* / Q000379:methods*; D015203:Reproducibility of Results; D012306:Risk; D012815:Signal Processing, Computer-Assisted; D016896:Treatment Outcome; D014481:United States; D014486:United States Food and Drug Administration
keywords: CDSS; Clinical decision support systems; Complex care; Critical care; Healthcare analytics; Personalized medicine