Future Research

In the previous chapter, we identified several areas in which rigorous evidence related to CDSSs/KMSs was lacking. In this chapter we propose activities through which these identified gaps could be filled by future research studies that investigate issues related to CDSS/KMS breadth of content, content delivery, decision support recipients, outcomes, and implementation. First, in the area of content, CDSSs/KMSs need to mature to the next generation, in which the breadth of comorbid conditions for a given patient are routinely addressed. Such studies will need to explore how advice about multiple care issues and disparate CDSSs/KMSs can be reconciled and how recommendations should be prioritized to avoid alert fatigue. Additionally, further investigation is needed to better understand (1) how local adoption of general knowledge into CDSSs/KMSs affects outcomes and provider acceptance, (2) whether specific types of general knowledge are better suited for implementation in CDSSs/KMSs, and (3) how differences in types of general knowledge contained in locally developed and commercially developed CDSSs/KMSs improve health care quality.

Along related lines of inquiry, studies are also needed to determine how CDSS/KMS content can be delivered most effectively for each CDSS/KMS niche. Such studies can determine if interruptive (pop-up alerts and reminders) or noninterruptive (order sets, smart forms, dashboards) are preferable; or how users should interact with the content from a specific type of CDSS (push versus pull, mandatory versus voluntary versus no user response, explanation versus no explanation for noncompliance, etc.).

Future studies will also need to explore who the optimal recipients of clinical decision support advice should be. With the growth of team-based care delivery models, studies are needed to ascertain who on the team, other than physicians, should receive which type of advice, how the delivery of advice can be orchestrated to facilitate team-based care coordination, and how the delivery of advice can be best integrated into team-based care.

More studies are needed to demonstrate how CDSSs/KMSs impact hard clinical outcomes to make real differences in health and wellness and not just improve health care process measures. Additionally, the costs of CDSSs/KMSs need to be investigated, and the economic attractiveness of clinical decision support needs to be determined. The case needs to be made for CDSS/KMS cost-effectiveness and subsequent return on investment in order to promote and expand CDSS/KMS utilization. Future studies also need to explore the unintended consequences of clinical decision support, particularly as multiple comorbid conditions are included and recommendations are delivered to multiple members of a care delivery team. As outcomes are measured with disparate CDSSs/KMSs in diverse environments, the need to standardize metrics and models for workload, efficiency, costs, health care process measures, and clinical outcomes across systems must be addressed. Research is needed to determine what metrics best assess the effectiveness of clinical decision support and how these metrics can be standardized. Standardization of these outcomes and metrics will also facilitate the evaluation of CDSSs/KMSs.

Finally, in the area of future investigation, studies evaluating the impact of KMSs are needed across the board. The KMS field is in its infancy, and such studies need to demonstrate when and how knowledge retrieval systems and point-of-care knowledge references are effective and useful. For both CDSSs and KMSs, additional research is needed to determine the best study designs to evaluate the effectiveness of these interventions.

With regard to promoting extensive use of clinical decision support, the following important needs must be addressed. First, there is a need for consistent underlying frameworks for describing CDSSs/KMSs such as the “CDS Five Rights”¹⁸⁹ to aid in the aggregation and synthesis of results. Second, models for porting CDSSs/KMSs across settings will need to be developed and evaluated. Studies will need to validate the concept of CDSS knowledge sharing across applications and institutions as proposed in recent position papers.^190,191 Can centralized knowledge repositories be effective in meeting the clinical decision support needs for region or the nation as a whole? At the level of individual systems, it will be useful to identify which CDSS/KMS features genuinely make a difference in effectiveness and user satisfaction. Third, from the analysis conducted through this report, we have identified a cluster of features associated with a favorable impact of a CDSS/KMS; however, the many features are interrelated, and the available studies do not allow us to isolate individual features or even feature groups. As CDSSs/KMSs become more ubiquitous, studies can be performed that assess them with and without selected features in order to determine with greater clarity the relative importance of individual features.

Fourth, in addition to the features of the CDSS/KMS itself, characteristics of the environment and workflow into which a CDSS/KMS is deployed, and characteristics of the intended users, needed to be identified and investigated so that the impact of these characteristics on the success of the CDSS/KMS can be determined. Fifth, well-described RCTs are most needed to investigate the impact of those characteristics; however, exploration into the strengths and limitations of the evidence provided by quasi-experimental and observational studies is also warranted. Once the system, environmental, workflow, and user characteristics are delineated with regard to their influence on CDSS/KMS effectiveness, the system, environment, workflow, and users can be proactively adapted to optimize CDSS/KMS integration. Lastly, as CDSSs/KMSs continue to play a critical role in health care reform, future research is needed to understand (1) how CDSSs/KMSs can aid in the transformation of care delivery models such as accountable care organizations and patient-centered medical homes, (2) how to integrate CDSSs/KMSs with workflow tools such as medical registries and provider-provider messaging capabilities, and (3) how to integrate CDSSs/KMSs with workflow-oriented quality improvement programs.