Strategy for development and pre-implementation validation of effective clinical decision support

Abstract

Objective Well-designed clinical decision support systems (CDSS) can reduce the problem of alert fatigue by generating patient-specific alerts. This paper describes a strategy for the development and pre-implementation validation of specific and relevant clinical rules in order to reduce alert fatigue. Methods A four-step development and validation strategy of clinical rules is presented. As an example, from March to September 2006 the ‘lithium therapy rule’ was developed with this strategy based on the Plan-Do-Check-Act cycle. 15 368 patients were retrospectively screened and 2503 patients were prospectively screened while the positive and negative predictive values (PPV/NPV) were continuously monitored. The first step is to confirm that the parameters used in the definitions are linked to the correct data in the electronic health record; the second step involves an expert team in the review process to assure that alerts generated are clinically relevant; in the third step the rule is adjusted to generate the right alerts in daily practice; and the fourth step ensures technical and therapeutic maintenance after implementation in practice. Results From September 2006 to July 2010 nine other rules were developed following exactly the same strategy. The 10 clinical rules developed showed a progression during the development and all resulted in a final therapeutic PPV of ≥89% before implementation, based on expert opinion. NPV was determined for five clinical rules and was always 100%. Conclusions The proposed strategy is effective for creating specific and reliable clinical rules that generate relevant recommendations. The inclusion of an expert team in the development process is an essential success factor. It is hoped that it will accelerate the widespread use of these promising decision support systems in practice.

Clinical Decision Support Systems

“…Key to preventing alert fatigue in active CDSS is structured development and validation of clinical rules. Much has been published on the validation of these clinical rules focusing on providing maximal clinical relevance of the recommendations outputted by the CDSS [47,[57][58][59].…”

“…Below we describe a four-step strategy to develop and implement clinical rules, which we ourselves use as part of development [57,61].…”

Preventive Prescribing of Laxatives for Opioid-induced Constipation Using Electronic Clinical Rule Implementation by Cinical Pharmacists

“…In 2008, the clinical rule for ´Opioid-Laxative Use´ was developed according to a strategy designed in our hospital. This strategy is based on the Plan-Do-Check-Act cycle and includes an expert team that optimises the quality and clinical relevance of clinical rules [10]. The 'Opioid-Laxative Use' rule was specifically selected for development based on a national study that identified high-risk patients with medication-related problems leading to hospital admission [15].…”

“…Reducing or avoiding opioid-induced constipation (OIC) is an important objective for improving the management of patients with chronic pain. Opioid dose reduction or discontinuation of opioid Retrospective research in the Catharina Hospital in Eindhoven in 2008 showed that co-prescription of a laxative was omitted at the start of therapy in 67% of clinical patients receiving opioids [9,10]. A study by Bouvy et al showed that pharmacy intervention can lead to better opioid and laxative combination therapy in the community setting [6].…”

“…In the Catharina Hospital, research on clinical rules started in 1998. Since then, many clinical rules have been developed and implemented in clinical practice: for example, the clinical rule 'NSAIDs and Prophylactic Gastro-Protection' or the clinical rule 'Renal Impairement' [10].…”