Quality of Decision Support in Computerized Provider Order Entry: Systematic Literature Review
Notice bibliographique
Résumé
BACKGROUND: Computerized decision support systems have raised a lot of hopes and expectations in the field of order entry. Although there are numerous studies reporting positive impacts, concerns are increasingly high about alert fatigue and effective impacts of these systems. One of the root causes of fatigue alert reported is the low clinical relevance of these alerts. OBJECTIVE: The objective of this systematic review was to assess the reported positive predictive value (PPV), as a proxy to clinical relevance, of decision support systems in computerized provider order entry (CPOE). METHODS: A systematic search of the scientific literature published between February 2009 and March 2015 on CPOE, clinical decision support systems, and the predictive value associated with alert fatigue was conducted using PubMed database. Inclusion criteria were as follows: English language, full text available (free or pay for access), assessed medication, direct or indirect level of predictive value, sensitivity, or specificity. When possible with the information provided, PPV was calculated or evaluated. RESULTS: Additive queries on PubMed retrieved 928 candidate papers. Of these, 376 were eligible based on abstract. Finally, 26 studies qualified for a full-text review, and 17 provided enough information for the study objectives. An additional 4 papers were added from the references of the reviewed papers. The results demonstrate massive variations in PPVs ranging from 8% to 83% according to the object of the decision support, with most results between 20% and 40%. The best results were observed when patients' characteristics, such as comorbidity or laboratory test results, were taken into account. There was also an important variation in sensitivity, ranging from 38% to 91%. CONCLUSIONS: There is increasing reporting of alerts override in CPOE decision support. Several causes are discussed in the literature, the most important one being the clinical relevance of alerts. In this paper, we tried to assess formally the clinical relevance of alerts, using a near-strong proxy, which is the PPV of alerts, or any way to express it such as the rate of true and false positive alerts. In doing this literature review, three inferences were drawn. First, very few papers report direct or enough indirect elements that support the use or the computation of PPV, which is a gold standard for all diagnostic tools in medicine and should be systematically reported for decision support. Second, the PPV varies a lot according to the typology of decision support, so that overall rates are not useful, but must be reported by the type of alert. Finally, in general, the PPVs are below or near 50%, which can be considered as very low.
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Comment cette classification a été obtenuedéplier
Prédiction distillée sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Apprise à partir de 10 348 étiquettes directes de Codex et de 10 348 étiquettes directes de Gemma. Le mode candidate est l'union des têtes enseignantes seuillées; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont ni des étiquettes humaines ni des étiquettes directes de modèles de pointe.
Scores Codex et Gemma par catégorie
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,018 | 0,007 |
| Méta-épidémiologie (sens strict) | 0,001 | 0,000 |
| Méta-épidémiologie (sens large) | 0,009 | 0,001 |
| Bibliométrie | 0,001 | 0,002 |
| Études des sciences et des technologies | 0,000 | 0,000 |
| Communication savante | 0,000 | 0,000 |
| Science ouverte | 0,001 | 0,001 |
| Intégrité de la recherche | 0,003 | 0,004 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,001 | 0,001 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; les deux têtes enseignantes s’accordent sur ce qui est montré ici.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».