Clinical decision support system

(CDSS)
• Knowledge-based systems
Knowledge based systems are artificial intelligent tools working
in a narrow domain to provide intelligent decisions with
justification.

Knowledge is acquired and represented using various knowledge

representation techniques rules, frames and scripts.

The basic advantages offered by such system are documentation

of knowledge, intelligent decision support, self learning,
reasoning and explanation.
• Clinical decision support system (CDSS or CDS)
is an interactive decision support system (DSS) Computer
Software, which is designed to assist physicians and other
health professionals with decision making tasks, as
determining diagnosis of patient data.

A working definition has been proposed by Dr. Robert

Hayward of the Centre for Health Evidence; "Clinical Decision
Support systems link health observations with health
knowledge to influence health choices by clinicians for
improved health care".
 Purpose/Goal
The main purpose of modern CDSS is to assist clinicians at the point of care.
This means that a clinician would interact with a CDSS to help determine
diagnosis, analysis, etc. of patient data.
Previous theories of CDSS were to use the CDSS to literally make decisions for
the clinician. The clinician would input the information and wait for the CDSS
to output the “right” choice and the clinician would simply act on that output.
The new methodology of using CDSS to assist forces the clinician to interact
with the CDSS utilizing both the clinician’s knowledge and the CDSS to make a
better analysis of the patients data than either human or CDSS could make on
their own. Typically the CDSS would make suggestions of outputs or a set of
outputs for the clinician to look through and the clinician officially picks useful
information and removes erroneous CDSS suggestions.
• There are two main types of CDSS:
• Knowledge-Based
• NonKnowledge-Based
• Features of a Knowledge-Based CDSS
Most CDSS consist of three parts, the knowledge base, inference engine,
and mechanism to communicate.
The knowledge base contains the rules and associations of compiled data
which most often take the form of IF-THEN rules. If this was a system for
determining drug interactions, then a rule might be that IF drug X is taken
AND drug Y is taken THEN alert user. Using another interface, an
advanced user could edit the knowledge base to keep it up to date with
new drugs.
The inference engine combines the rules from the knowledge base with
the patient’s data.
The communication mechanism will allow the system to show the results
to the user as well as have input into the system
• Features of a non-Knowledge-Based CDSS
CDSS’s that do not use a knowledge base use a
form of artificial intelligence called machine
learning, which allow computers to learn from
past experiences and/or find patterns in clinical
data.
Two types of non-knowledge-based systems are
artificial neural networks and genetic algorithms.
 Artificial neural networks
• Artificial neural networks use nodes and
weighted connections between them to analyze
the patterns found in the patient data to derive
the associations between the symptoms and a
diagnosis. This eliminates the need for writing
rules and for expert input. However since the
system cannot explain the reason it uses the
data the way it does, most clinicians don’t use
them for reliability and accountability reasons
 Genetic Algorithms
• Genetic Algorithms are based on simplified evolutionary processes
using directed selection to achieve optimal CDSS results. The
selection algorithms evaluate components of random sets of
solutions to a problem.
• The solutions that come out on top are then recombined and
mutated and run through the process again. This happens over and
over till the proper solution is discovered.
• They are the same as neural networks in that they derive their
knowledge from patient data.
• Non-knowledge-based networks often focus on a narrow list of
symptoms like ones for a single disease as opposed to the knowledge
based approach which cover many different diseases to diagnosis
 Effectiveness

• A 2005 systematic review by Garg et al. of 100 studies

concluded that CDSs improved practitioner performance in
64% of the studies. The CDSs improved patient outcomes in
13% of the studies.
• the CDSs is integrated into the clinical workflow rather than
as a separate log-in or screen.
• the CDSs is electronic rather than paper-based templates.
• the CDSs provides decision support at the time and location
of care rather than prior to or after the patient encounter.
• the CDSs provides (active voice) recommendations for care,
not just assessments.
 Challenges to Adoption

• Clinical Challenges
• complexity of clinical workflows and the
demands on staff time high, care must be taken
by the institution deploying the support system
to ensure that the system becomes a fluid and
integral part of the workflow. To this end CDSSs
have met with varying amounts of success, while
others suffer from common problems preventing
or reducing successful adoption and acceptance.
• Technical Challenges
Clinical decision support systems face steep technical
challenges in a number of areas. Biological systems are
profoundly complicated, and a clinical decision may
utilize an enormous range of potentially relevant data.
For example, an electronic evidence-based medicine
system may potentially consider a patient’s symptoms,
medical history, family history and genetics, as well as
historical and geographical trends of disease
occurrence
• Maintenance
One of the core challenges facing CDSS is
difficulty in incorporating the extensive quantity
of clinical research being published on an
ongoing basis. In a given year, tens of thousands
of clinical trials are published.[5] Currently, each
one of these studies must be manually read,
evaluated for scientific legitimacy, and
incorporated into the CDSS in an accurate way.
• Evaluation
• In order for a CDSS to offer value, it must demonstrably improve
clinical workflow or outcome. Evaluation of CDSS is the process of
quantifying its value to improve a system’s quality and measure its
effectiveness.
• The evaluation benchmark for a CDSS depends on the system’s
goal: for example, a diagnostic decision support system may be
rated based upon the consistency and accuracy of its classification
of disease (as compared to physicians or other decision support
systems). An evidence-based medicine system might be rated
based upon a high incidence of patient improvement, or higher
financial reimbursement for care providers.
 Examples of CDSS

• Zynx Health – the most prominent organization in the

CDSS marketplace, whose CDSS is linked to a
statistically significant percentage of hospital
discharges nationwide.
• MYCIN, one of the first expert systems to be
developed in the 1970s, it does ethiological diagnoses
of bacterial diseases.
• CADUCEUS, a medical expert system that could
diagnose 1000 diseases.
• Internist-I, a computer-assisted diagnostic tool.