Problems with clinical decision support systems
Clinical decision support systems have been around for some time. They have been developed in research and commercial settings, and are largely delivered by commercial entities. But there are challenges associated with clinical decision support systems. Just a few of these challenges are outlined below.
Most clinical decision support has been developed as rule- based systems. These have been helpful in the past, but the rule base may become difficult to manage at scale – for example when you have to manage hundreds of rules. There can be rule conflict and resultant confusion when multiple rules are operating that do not agree with each other. And rules necessarily take a single disease perspective which will not work for patients with multimorbidity. This is a big problem when up to one-third of the adult population has multimorbidity. Put simply, the clinical workforce is faced with an aging population with a growing number of complex interrelated problems. Other basic problems include the need for too much typing and alerts that interrupt the clinical workflow. Such alerts are often out of context and lead to alert fatigue and user dissatisfaction. In some cases, users switch off alerts completely as they may not be viewed as helpful, are not actionable, or may adversely impact their clinical workflow. Lastly, there is the issue of the management and maintenance of large knowledge assets that are part of clinical decision support systems – given the ongoing evolution of clinical knowledge and changing controlled medical terminology standards. These are simply too much for any single institution or provider to take on. Even large academic and clinical institutions struggle to build knowledge management teams to manage all of these clinical knowledge assets that are being deployed across multiple sites. These problems are not new – they have been known about for many years. Clinical decision support systems have struggled to overcome them. Some efforts have resulted in even more rules and alerts – the very problem we are trying to solve.
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