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Clinical Decision

Support System

Course: Management Information System

Udit Kheterpal
MBA 2010-2012
Vinod Gupta School of Management
IIT Kharagpur

In India 53% of deaths are due to chronic diseases like Diabetes, HIV, Fatal Heart Attacks etc., 6000 children die
every day. The unique solution to all such problems is not a new drug or a new surgical technique, it is
Information framework called Health Management Information System (HMIS). A component of HIS is Clinical
Decision Support System (CDSS)

Clinical Decision Support System (CDSS) provides an interface to integrate medical knowledge and technology,

with the ability to sustain the clinical process and the use of knowledge from diagnosis through treatment to health

care. A CDSS intends to assist clinical and non clinical healthcare workers in their routine functions helping them

in the work that includes manipulation of data and knowledge.

CDSSs can help clinicians in the following ways:

• Maintaining Clinical records

• Managing patient records, follow ups, preventive care
• Monitoring medication orders, avoiding duplicate and unnecessary test
• Assisting Clinicians with proper diagnosis, treatment, keeping a track based on knowledge database

Full scale implementation of CDSS in India can prove to be a boon for clinicians and society at large.

Clinical decision support systems are “active knowledge systems in which we use two or more items of patient
data to generate case specific advice”[Wyatt J. Spiegelhalter D, 1991]

A clinical decision support system integrates the expert medical advice , patient related information and inference
engine to prepare case based analysis which assists medical and health professionals in the decision making
process , such as diagnosing and designing the treatment plan for a disease or a condition.

Clinical decision support system could be referred to as field in Artificial Intelligence in Medicine (AIM). Medical
artificial intelligence is concerned with the formulation of Artificial Intelligence programs that supports the
diagnosis and makes therapy recommendations. Intelligence systems today not only support medication
prescription but also the clinical laboratories and educational settings, for clinical surveillance, or in data rich
areas like public health care.

A clinical decision support system may be programmed within a Hospital and Health Management Information
System (HHMIS) along with the electronic patient record system. Artificial Intelligence could be used to analyze
large amount of patient data, searching for the complex patterns and associations which may be missed out by
humans. This type of CDSS use is known as reasoning with clinical Knowledge for e.g.: an ECG diagnosis is
rendered easy to a cardiologist but he may miss some important ECG peak with slight variation that may lead to
myocardial infarction but using CDSS will notify every small change in the report.
Another important feature practiced through CDSS is Evidence Based Medicine. Evidence based
medicine means where the cases from the history are used as references for the present condition or situation,
the reference may be from the same patient’s past record or record of the hospital or the community.

Data flow diagram for a Evidence based medicine May be of a type below


Previous cases




Importance of CDSS

1. Reduces medication errors and ADR’s (adverse drug reactions)

CDSS is important from all patient, clinician and management point of view because of its capability of
reduction in medical errors. Due to reduced adverse drug reactions there is reduction in average length of
stay of patient that spares a bed for a new patient, who could occupy that bed and pay even better for
that bed.
It secures a reputation for the hospital as well as the physician which is important to have better patient
input to the hospital in future.
Thus the hospital gains are in two terms saving from reduced length of stay of patient and better trust of
patient in hospital that creates word of mouth publicity for hospital.
A study undertaken at Brigham and women’s hospital in Boston, Massachusetts developed by the
hospital to study CDSS using drug alerts and suggested drug dosages found out 55% reduction in the
adverse drug events following implementation of the system the rate of ADR events fell from 10.6 per
1000 patient days to 4.9 per 1000 patient days. The second study after 4 years of implementation
demonstrated 86% reduction in the ADR cases.

2. Remote patient monitoring

Remote patient monitoring is possible through Clinical decision support systems. Under NRHM (national
rural health mission) 2002 the RMP’s are graded and trained to treat patients at rural sub-centers where
resources are scarce and Doctors and physicians are reluctant to pay visits to such areas. Telemedicine
and CDSS can be a boon in such cases. It may lead to better utilization of the resources e.g. doctors and
availability of healthcare to the rural people.

3. Enhances the prescribing behavior

Clinical Decision Support System can help selecting the combination of a more cost effective drug. The
prescribing behavior may be supported in the following ways:
a. May prompt to select an inexpensive generic drug when an expensive drug was being ordered
b. May present the complete list of drugs available for the medicine ordered in that particular case.
c. The recommended frequency and dosage of the drug required.
d. Prompts or suggests when two mutually reactive drugs are ordered.
e. Prompt to suggest physician to use anticoagulants for patient prescribed bed rest.
4. Patient safety

The basic function of a healthcare system of patient safety is supported through this system of CDSS. As
it supports the decision making process in diagnosis of the patient e.g. pop ups appear in the form of
drugs patient is allergic to retrieved from the past medical records.
5. Clinical decision support system provides with improved compliance with clinical pathways and

Order, entry, and results reporting with embedded CDSS increases compliance with the clinical pathways
and the treatment guidelines.

Challenges to the implementation of CDSS

Challenges and barriers in the implementations of CDSS may be grouped into:

i. Clinical challenges
ii. Technical challenges
iii. Management limitations and maintenance challenges
iv. Cost barriers
v. Security threats

Clinical Challenges

CDSS retrieves the information from clinical data repository for decision making. No clinical data base stores all
the information that is self sufficient or complete. The patient’s data is usually partly available and converting
whole data to electronic form is a very tedious job. Computers can assist but not replace the human in solving the
clinical cases.

A large roadblock to Clinical Decision Support System acceptance is lack in integration of the components of the
CDSS. Data is provided by the healthcare workers to the IT people who design the search engines on the basis of
given information. But no stress is laid on how the clinicians are going to use that system.

Another clinical challenge is the alert fatigue .The system shows so much of alerts such that the clinicians stop
paying attention to the warnings that may lead to an ineffective system. Clinicians believe themselves to be
supreme in diagnosis and are not ready to subdue to an artificial intelligence system.

Technical Barriers

Biological systems are complicated systems where no two situations or conditions are alike so to develop a sound
clinical decision support system based on evidence based medicine is a big challenge.
Maintenance Challenges

New researches and technical developments are ever prevalent in the present era of science and technology.
New drug resistant strains of various infectious agents develop so a clinical decision system needs to be updated
with latest information and research for decisions given by the system to be viable accurate and reliable.

Such maintenance of the system with new advancements is a tough task.

Cost barriers

India is a country where complete electronic records are still not available and converting such data is a costly

Expenditures also need to be incurred on training of the staff to adopt the new system.

Updating of the system with new advances to keep it compliant with the other systems also bears a huge cost.

Security threats

Another challenge to the use of CDSS is the security threat. The information shared on the system may be used
for illegal purposes. Viruses may corrupt the files and the data stored in the clinical data repository be lost.

Managerial Approach to overcome the above challenges and barriers

To increase user acceptance

• By motivation training and education of the clinical non clinical staff using the system.
• Developing better user interfaces. This could be done by involving the user at the design stage. Keeping
their needs and desires in mind the system should be developed.
• Convenience of the end user should be kept in mind at designing stage.
• Constraints under whish the user works should be considered at this stage.

Performance evaluation of the system needs to be done from time to time

• Evaluation of the functions of the system in terms of sensitivity, specificity of diagnostic test and reliability
of the system.
• Evaluation could be done on two basis:
 Process measures
 Outcome measures
Studying the cost effectiveness

Primary motive of any organization in implementing a new technology is reduction in cost incurred for labor. From
economic point of view costs and benefits should be kept in balance.

Costs of implementing the CDSS system include

 Hardware costs: equipments required for input storage and retrieval of data
 Software costs: system software cost includes operating system costs, costs for clinical data repository,
networking costs compliers etc.
 Application software costs
 Management, training ,education and maintenance costs
 Overhead costs

Benefits of introducing CDSS

 Introduces efficiency in the system

 Improves quality care
 Reduction in clinical as well as non clinical errors
 Time needed to report the reports from diagnostics and laboratories is reduced
 Reduced length of stay of patient

Though most of the benefits of introducing the CDSS are intangible these should be evaluated using a suitable
system of input output analysis:

Cost benefit analysis

Cost effectiveness analysis

Cost utility analysis

To overcome safety challenges

• Introduction of a strong antivirus in the system and regular system scans to be carried.
• Back up files to be prepared and stored separately
• Introduction of network security codes against use of information illegally by unauthorized users this could
be done by
 incorporating password systems.
 use of encryption codes and decryption keys.
A diagram explaining the current status, Research to be done and the benefits which can be reaped out of
successful implementation of CDSS
CDSS in India so far and the way forward

There have been a few attempts to implement partial functionality of CDSS. Some of them are:

1) eClinician, a CDSS with limited number of users

2) Isabel- a CDSS using pattern recognition technique
3) Dell is designing an HMIS incorporating CDSS for MAX Devki devi hospital new delhi but has not
implemented it so far
4) A project named iMediK going on in IIT Kharagpur in collaboration of different departments and School of
Medical Sciences and Technology which focuses on management of pediatric HIV conditions.

So there have been some attempts but a full-fledged implementation of CDSS is still not a reality. The basic
issues faced are:

• Clinical Drug Repository is not complete

• The software acquired do not have data for diseases prevalent in Indian conditions
• One of the aim for CDSS is to help rural population but it requires a lot of training as still majority of
population not computer savvy

The CDSS system on successful implementation can also facilitate public health research and data collection by
automated surveys. Some basic hygiene procedures like water testing integration can be made viable that can
report to some central quality monitoring organization. Technology can be taken forward to handle the supply
chain management of healthcare products, vaccines, nutritional supplements etc. The data from field, hospitals
and insurance disbursements can be collated to track or estimation of per capita cost of health care help in
decision making.

The complete implementation of CDSS in corporate hospitals still seems to be a distant reality but nevertheless,
efforts are being put in this direction. With the IT industry booming in India the need of the hour is for a
collaborative action of the key parties

• The Government of India

• The Medical fraternity
• IT giants

The government of India is determined to assign a Unique Identifier (UId) to each and every Indian. On the similar
terms a unique Health Identifier (HID) must be assigned to every patient corresponding to which all his past
medical records, conditions etc can be mapped and as such he/she will be able to undergo the treatment
irrespective of the Hospital or city he was treated at.

A dedicated effort in this direction could really be beneficial for a country like India where in the population is large
and diseases are huge in number.


• Research paper on Providing healthcare services in rural India: Innovative application on mobile
technology by Dr. Priyesh Tiwari MD ,School of Population Health, University of Auckland,
Private Bag 92019, Auckland Mail Centre, Auckland, New Zealand
• www.medvarsity.com
• Information system for healthcare management 6 edition :- By Charles J. Austin , Stuart B. Boxerman
• http://en.wikipedia.org/wiki/Clinical_decision_support_system