Bytes not Books
The assessment of the
benefits of active versus passive
decision support within medication management
Global initiatives from government and industry are driving a revolution in
and safety. Healthcare providers are looking to clinicians and health
information managers to
develop the systems and processes needed to support their patient safety and
care quality aims.
Middle East Health publishes this Whitepaper from First Databank about Clinical
Support and how it can improve healthcare outcomes.
Clinical Decision Support (CDS) is already
an accepted part of the healthcare environment
in the US, UK and Europe. Reducing
the risk and associated cost from Adverse
Drug Events (ADE) is a primary concern for
CDS is broadly defined as “providing
clinicians or patients with clinical knowledge
and patient-related information, intelligently
filtered or presented at appropriate
times, to enhance patient care.”(2) There are
many different forms of CDS from online
reference information to evidence based
guidance that is used to determine the most
effective treatment therapy.
Medication management is one such area
where CDS has had a positive impact on
prescribing behaviour, patient safety and
return on investment. This paper provides an
assessment of the effectiveness of active
versus passive or referential CDS within
medication management. It provides a broad
analysis of CDS and important features that
significantly improve clinical practice. It
draws upon independent, published research
to compare the effectiveness of these solutions
in reducing the incidents of ADE’s.
Active versus Passive Decision Support
Reducing the number of fatalities and harm
from avoidable ADE’s is an area of prime
concern for healthcare providers. CDS
provides an important step forward in the
support offered to clinicians at the point of care
in helping to reduce the occurrence of ADE’s.
Passive CDS is presented in a textual format with individual chapters or
highlighted for ease of navigation. The information
tends to be delivered in lengthy paragraphs
that need to be reviewed by the clinician
to find the relevant text. It relies on the
reader to fully understand the technicalities
and perceived meaning of the text. It may
also require some action to be taken to access
the information as the clinician may not be
prompted to review the information.
There are four key features of active CDS
in medication management. These are:
- Data is embedded within the electronic
health record to provide specific patient
information. Drug data can be embedded
into the patient record via a series of
technical and clinically authored algorithms.
This provides active CDS to
support the clinician in their decisionmaking
- Data is intelligently inserted into the
clinical workflow. Information is delivered
via the clinical applications and is
integrated into the workflow at the point
where a decision is required. Providing
information at the point of care, rather
than before or after the patient
encounter, aids continuity and produces
- Data is intelligently filtered to clinicians.
Setting agreed thresholds for alerting
protocols allow clinicians to receive only
the most essential, relevant messages.
- Data can be recorded via an audit trail.
Most Electronic Medical Records or
Hospital Information Systems provide a
facility for tracking and reporting upon all actions regarding patient’s
These facilities mean that insight can be
gained around problem areas, gaps or
anomalies that may occur in the
prescribing and dispensing service.
A recent study comparing active and
passive CDS found “The usage of CDSS
(Clinical Decision Support Systems) significantly
increased the percentage of patient
screened and treated from dyslipidaemia; in
addition using an alerting system increased
the screening rate significantly than the ondemand
The important difference between active
and passive CDS relates to the type of
messages provided to the clinician. Active
CDS messages are dynamic alerts which
interact with the patient’s record. With
passive CDS the onus lies with the clinician
to search for further reference or electronically
prompted “drug in view” information.
This can have a negative influence by
removing the clinician from their natural
workflow, adding extra steps to their work
and more importantly without actionable
links from or back into the patient record.
Prescribing medications is a huge responsibility
for any clinician, who must also
consider many other factors related to the
patient’s care to determine the best course of
treatment to provide. In many instances the
clinician may not have the necessary information
to hand or may forget to check it, in
time pressured situations. It is in these
circumstances that active alerts can provide life-saving prompts. Examples
- Alert that appropriate cancer
screening is due
- Drug allergy alert
- Drug interaction alert
- Under dose/overdose alerts based on
renal, liver function or age.
With passive or reference CDS many of
these features do not exist. Data is presented
as textual information or as hyperlinks
leading the end user to read, understand and
act on the information given. Whilst much
of the essential clinical information is
provided, its passive form means that clinicians
have to disseminate the information
they are presented with and decide which
elements are relevant to their patient, prior
to making a medication decision.
“Nearly 50% of medication errors have
been found to result from the fact that clinicians
have insufficient information about
the patient and the drug readily accessible at
the time it is needed.”(4)
Innovative healthcare providers are
investing in this proven technology to realise the benefits of active CDS in medication
management over traditional passive or
The Case for Active Decision Support
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.(5) This is
supported by other research that considered
seventy randomised, controlled trials. It found
that “Decision support systems significantly
improved clinical practice in 68% of trials.”(6)
The study also found that there were four
specific features strongly linked to a CDS
system’s ability to improve clinical practice.
These were that CDS should be provided as
part of the clinical workflow, delivered at
the time and location of decision-making,
should provide actionable recommendations
and also be computer based.
It concluded that “Among 32 clinical
decision support systems incorporating all
four features 94% significantly improved
clinical practice. In contrast, clinical decision
support systems lacking any of the four
features improved clinical practice in only
18 of 39 cases or 46%.”(6)
The overall recommendation was made that “Clinicians and other stakeholders
should implement clinical decision support
systems that incorporate these features
whenever feasible and appropriate.”(6)
A separate study considered the use of computerised alerts and prompts found “Most
alerts and prompts (23 out of 27) demonstrated
benefit in improving prescribing
behaviour and/or reducing error rates.”(7)
Put simply, incorporating active CDS
capabilities within the workflow is 100x
more effective when compared to applications
that only use passive or reference CDS.
For the majority of clinicians who
prescribe, and patients who receive medication
every day, active CDS provides an
essential tool in driving down the occurrence
of ADE’s all over the world.
The Benefits of Active Decision Support
over Passive Decision Support
There are many benefits associated with
using active CDS for medication management:
- Better clinical decision-making leads to
- Reduced medication errors
- Promote preventive screening and use of
evidence based recommendations
- Improved cost-effectiveness
- Increased patient convenience
- Improved quality of healthcare delivery
- Improved healthcare outcomes for
patients and patient populations.
Information which is delivered in small,
manageable, bite-sized amounts can be
assimilated quickly and easily when
compared to reading lengthy paragraphs. For
the clinician this means an increase in the
quantity and quality of patient-facing time.
Both clinicians and patients prefer this extra
time together. Patient’s perceptions of the
value of the quality and care of the service
being delivered also rise.
First, do no harm.
Cited research demonstrates active CDS in
medication management clearly drives many
positive advantages and benefits when
compared to using passive CDS. To reduce
avoidable medication errors the use of CDS
should be encouraged to improve patient safety
and drive down the occurrence of ADE’s.
Actionable, intelligently filtered,
dynamic data delivered in real-time at the point of care, directly into the
is of most benefit to clinicians, and
provides a critical support mechanism to the
busy healthcare professional. Timely recommendations
from a trusted healthcare source
provide potentially life-saving reminders at
the point of prescribing.
Consigning ADE’s to the past may one
day become a reality as forward thinking
governments and healthcare providers
demonstrate a commitment to the adoption
of active CDS in medication management.
The inclusion of active CDS for medication
management should be seen as the de facto
standard in helping to reduce the incidence
of ADE’s, improve patient safety and realise
significant cost and time efficiencies for
healthcare providers worldwide.
Clinical decision support – save US$170
billion per year in health costs. Save more
than 400,000 lives(8).
1. Lazarou J, Pomeranz BH, Corey PN. Incidence
of Adverse Drug Reactions in Hospitalized
Patients JAMA. 1998.279.15.1200-5.
2. Teich, JM, Osheroff JA, Pifer EA, et al. Clinical
decision support in electronic prescribing:
recommendations and an action plan: report of
the joint clinical decision support workgroup. J
AM Med Inform Assoc. 2005, Jul-Aug;
12(4):365-76. Epub 2005 Mar.31.
3. van Wyk JT, van Wijk MA, Sturkenboom MC,
et al. Electronic Alerts versus On-Demand
Decision Support to Improve Dyslipidemia
Treatment: A Cluster Randomised Controlled
Trial (Article Review). Circulation. 2008 Jan.
22; 117(3) 371-378; Epub, 2008 Jan.2
4. Leape LL, Bates DW, Cullen DJ, et al. Systems
analysis of adverse drug events. ADE Prevention
Study Group. JAMA 1995 Jul 5; 274(1):35-43.
5. Garg AX, Adhikari NK, McDonald H, Rosas-
Arellano MP, Devereaux PJ, Beyene J et al.
Effects of computerized clinical decision support
systems on practitioner performance and patient
outcomes: a systematic review . JAMA 2005 Mar
9; 293(10): 1223–38.
6. Kawamoto K, Houlihan CA et al. Improving
clinical practice using clinical decision support
systems: a systematic review of trials to identify
features critical to success. BM.J2005 Apr
2;330(7394):765. Epub 2005 Mar 14.
7. Schedlbauer A, Prasad V et al. What Evidence
Supports the Use of Computerized Alerts and
Prompts to Improve Clinicians’ Prescribing
Behaviour? J AM Med Inform Assoc.2009 Jul-
Aug; 16(4):531-538. Epub 2009 Apr 23.
8. Hillestad, R. Bigelow J, Bower A, Girosi F, Meili
R, Scoville R, Taylor R. Can electronic medical
record systems transform health care? Potential
health benefits, savings, and costs Health Aff
September 2005 Sep-Oct; 24:(5): 1103-17.
Adverse drug events are the fourth
of upload: 26th Sep 2012