title: Clinical Decision Support: a 25 Year Retrospective and a 25 Year Vision.
abstract: OBJECTIVE
  The objective of this review is to summarize the state of the art of clinical decision support (CDS) circa 1990, review progress in the 25 year interval from that time, and provide a vision of what CDS might look like 25 years hence, or circa 2040.
  
  
  METHODS
  Informal review of the medical literature with iterative review and discussion among the authors to arrive at six axes (data, knowledge, inference, architecture and technology, implementation and integration, and users) to frame the review and discussion of selected barriers and facilitators to the effective use of CDS.
  
  
  RESULTS
  In each of the six axes, significant progress has been made. Key advances in structuring and encoding standardized data with an increased availability of data, development of knowledge bases for CDS, and improvement of capabilities to share knowledge artifacts, explosion of methods analyzing and inferring from clinical data, evolution of information technologies and architectures to facilitate the broad application of CDS, improvement of methods to implement CDS and integrate CDS into the clinical workflow, and increasing sophistication of the end-user, all have played a role in improving the effective use of CDS in healthcare delivery.
  
  
  CONCLUSIONS
  CDS has evolved dramatically over the past 25 years and will likely evolve just as dramatically or more so over the next 25 years. Increasingly, the clinical encounter between a clinician and a patient will be supported by a wide variety of cognitive aides to support diagnosis, treatment, care-coordination, surveillance and prevention, and health maintenance or wellness.
authors.affiliation: Blackford Middleton, Cell: +1 617 335 7098, E-Mail: bmiddlet@hsph.harvard.edu.
authors.forename: B
authors.initials: B
authors.lastname: Middleton
authors.forename: D F
authors.initials: DF
authors.lastname: Sittig
authors.forename: A
authors.initials: A
authors.lastname: Wright
mesh_terms: D020000:Decision Support Systems, Clinical / Q000266:history / Q000639:trends*; D005544:Forecasting; D049673:History, 20th Century; D049674:History, 21st Century; D006801:Humans; D008490:Medical Informatics / Q000266:history / Q000639:trends
keywords: Clinical decision support; artificial intelligence; electronic health record; expert systems; health information technology