title: Evidence-based decision support for pediatric rheumatology reduces diagnostic errors.
abstract: BACKGROUND
  The number of trained specialists world-wide is insufficient to serve all children with pediatric rheumatologic disorders, even in the countries with robust medical resources. We evaluated the potential of diagnostic decision support software (DDSS) to alleviate this shortage by assessing the ability of such software to improve the diagnostic accuracy of non-specialists.
  
  
  METHODS
  Using vignettes of actual clinical cases, clinician testers generated a differential diagnosis before and after using diagnostic decision support software. The evaluation used the SimulConsult® DDSS tool, based on Bayesian pattern matching with temporal onset of each finding in each disease. The tool covered 5405 diseases (averaging 22 findings per disease). Rheumatology content in the database was developed using both primary references and textbooks. The frequency, timing, age of onset and age of disappearance of findings, as well as their incidence, treatability, and heritability were taken into account in order to guide diagnostic decision making. These capabilities allowed key information such as pertinent negatives and evolution over time to be used in the computations. Efficacy was measured by comparing whether the correct condition was included in the differential diagnosis generated by clinicians before using the software ("unaided"), versus after use of the DDSS ("aided").
  
  
  RESULTS
  The 26 clinicians demonstrated a significant reduction in diagnostic errors following introduction of the software, from 28% errors while unaided to 15% using decision support (p < 0.0001). Improvement was greatest for emergency medicine physicians (p = 0.013) and clinicians in practice for less than 10 years (p = 0.012). This error reduction occurred despite the fact that testers employed an "open book" approach to generate their initial lists of potential diagnoses, spending an average of 8.6 min using printed and electronic sources of medical information before using the diagnostic software.
  
  
  CONCLUSIONS
  These findings suggest that decision support can reduce diagnostic errors and improve use of relevant information by generalists. Such assistance could potentially help relieve the shortage of experts in pediatric rheumatology and similarly underserved specialties by improving generalists' ability to evaluate and diagnose patients presenting with musculoskeletal complaints.
  
  
  BACKGROUND
  ClinicalTrials.gov ID: NCT02205086.
authors.affiliation: SimulConsult, Chestnut Hill, MA, USA.
authors.forename: Michael M
authors.initials: MM
authors.lastname: Segal
authors.affiliation: DuPont Hospital for Children, Wilmington, DE and Thomas Jefferson University, Philadelphia, PA, USA.
authors.forename: Balu
authors.initials: B
authors.lastname: Athreya
authors.affiliation: Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA.
authors.forename: Mary Beth F
authors.initials: MB
authors.lastname: Son
authors.affiliation: Edmond and Lily Safra Children's Hospital, Tel-Hashomer, Ramat-Gan, Israel and Tel Aviv University, Tel Aviv, Israel.
authors.forename: Irit
authors.initials: I
authors.lastname: Tirosh
authors.affiliation: Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA.
authors.forename: Jonathan S
authors.initials: JS
authors.lastname: Hausmann
authors.affiliation: National Univesity Hospital, Singapore, Singapore.
authors.forename: Elizabeth Y N
authors.initials: EY
authors.lastname: Ang
authors.affiliation: Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA.
authors.forename: David
authors.initials: D
authors.lastname: Zurakowski
authors.affiliation: SimulConsult, Chestnut Hill, MA, USA.
authors.forename: Lynn K
authors.initials: LK
authors.lastname: Feldman
authors.affiliation: Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA. robert.sundel@childrens.harvard.edu.
authors.forename: Robert P
authors.initials: RP
authors.lastname: Sundel
mesh_terms: D002648:Child; D003661:Decision Support Techniques; D003951:Diagnostic Errors / Q000517:prevention & control; D019317:Evidence-Based Medicine; D006801:Humans; D012216:Rheumatic Diseases / Q000175:diagnosis*; D012984:Software
keywords: Computer software; Decision support; Diagnosis; Diagnostic errors; Medical informatics; Pediatric rheumatology