FEATURE ARTICLE

Clinical Decision Support Complements Evidence-Based Decision Making in Dental PracticeMichael G. Newman, DDSSection of Periodontics, UCLA School of Dentistry, Los Angeles, CA

Dental professionals as well as consumers of dental health care are driving thedemand for access to reliable information so they can make more informeddecisions. Clinical decision support (CDS) includes a variety of printed andelectronic tools, systems, products, and services that make knowledge andinformation available to the user. CDS is the main way people will be able toaccess important facts, ideas, concepts, and the latest thinking about personal andpopulation-based health subjects. CDS has its greatest potential at the point of

care where it can facilitate good-quality evidence-based decision-making.

CDS ROADMAP

In 2005 the National Coordinator for Health InformationTechnology in the United States commissioned the Amer-ican Medical Informatics Association to develop a planthat would help advance Clinical Decision Support(CDS). CDS includes a variety of printed and electronictools, systems, products, and services that give the userknowledge and information to help make more informedand individualized health care decisions. The result oftheir efforts was the release, in 2006, of the Roadmap forNational Action on Clinical Decision Support.1 The Roadmaprecommends a series of activities to improve CDS avail-ability, usefulness, and effectiveness, and to increase theuse of CDS (Table 1).

The Roadmap identifies 3 major components of theCDS initiative. The authors refer to these as “pillars” and

J Evid Base Dent Pract 2007;7:1-51532-3382/$35.00© 2007 Elsevier Inc. All rights reserved.doi:10.1016/j.jebdp.2006.12.016

TABLE 1. Assistance of Clinical Decision Support to i

Clinical Decision Support assists in the improvement o

� facilitating the detection of potential medical errors� suggesting risk factors and approaches to patient ma� suggesting optimal clinical strategies based on the be� organizing the details of a treatment plan� helping to gather and present data needed to execu� communicating to third party payers

they reflect the common sense and practical approachthat good-quality CDS provides (Table 2). The 3 pillarsemphasize the use of evidence-based (EB) methods todetermine the validity and generalizability of data and theintegration of information technology (IT) that makes iteasier for high-quality information to be used at the pointof care.

Bringing EB and IT together improves the ability topersonalize treatment plans, avoid medical errors, andensure that the best treatments and alternatives are pre-sented to the patient.

MANAGING LARGE AMOUNTS OFINFORMATION

Dental and medical practitioners work in an increasinglymore difficult information environment. It is estimatedthat the medical literature is doubling every 19 years, andin some fast-moving subspecialties in medicine, such as

ove health decisions

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JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE

AIDS-related health care, it may double as quickly as every2 years.2

In 2006, Merijohn introduced the Translational Clini-cal Practice System (TCPS) in an attempt to provideguidance to clinicians trying to deal with and make senseof the information onslaught (Fig 1).3 The system pro-vides both a conceptual context and some specific sug-gestions about how to use EB essentials to answer clinicalquestions and dilemmas that often require the latest in-formation to enable good decision-making. More impor-tantly, the system helps readers manage their approach to“translating” data into tangible guidance for patient care.

Figure 1. Translational clinical practice system.3

Within an overriding context of minimizing harmand risk to patients, clinicians can use the best scien-tific evidence, apply clinical experience and judg-ment, and serve patient preferences/values in order

TABLE 2. Pillars of Clinical Decision Support*

● Best Knowledge Available When Needed: the best avall; and written, stored, and transmitted in a formatSupport (CDS) interventions that deliver the knowle

● High Adoption and Effective Use: CDS tools are widsignificant clinical value while making financial and

Continuous Improvement of Knowledge and CDS Meundergo continuous improvement based on feedbacand apply.

*Modified from A Roadmap for National Action on Clinical Decisioncds/. Accessed December 4, 2006.1

to provide clinically relevant outcomes.

2 Newman

When so many forces impinge on the clinician, having apractice philosophy that helps to deal with the high vol-umes of information is welcome.

EXAMPLES OF CDS

1. Electronic health record. CDS technology can alreadybe found in the electronic health/dental record(EHDR). EHDRs can enhance patient care becausethey make information about a patient more accessi-ble, accurate, and complete.

Computerized provider order entry (CPOE), as dif-ferentiated from handwritten paper charting, can fa-cilitate workflow and minimize transcription errors.And now a type of CPOE has been introduced by atleast 1 dental company to enhance communicationand avoid errors in the dental laboratory prescription.4

The Roadmap authors clearly state that “the storage,connectivity, and automation functions of EH(D)R’sand CPOE are necessary, but not sufficient to reachthe desired gains in health care quality. It is onlythrough CDS that EH(D)R’s and CPOE can achievetheir full potential for improving the safety, qualityand cost-effectiveness of care.”1

2. Drug prescribing. In dentistry one of the major exam-ples of integrated CDS is related to medications. Elec-tronic records systems linked to order entry systemswith CDS can supply patient data needed for properdrug dosing.5 Drug prescribing for dental patients hasbecome more difficult as the complexity of their pa-tient’s medical status and medication profiles becomegreater. CDS can help dentists by making it easier to● know the effects of patient medications on oral

structures such as the gingiva, mucosa, and tongue● prevent untoward drug interactions6

● avoid allergic reactions7

Becoming proficient in electronic information man-agement can increase confidence in the quality ofdental practice, and in the future, this daily activity may besufficient for earning CE credit. This makes a lot of sense,because every time clinicians go online to access infor-

ble clinical knowledge is well organized; accessible tomakes it easy to build and deploy Clinical Decisioninto the decision-making process

implemented, extensively used, and producerational sense to their end-users and purchaserss: both CDS interventions and clinical knowledgexperience, and data that are easy to aggregate, assess,

port, June 13, 2006. Available at: www.amia.org/inside/initiatives/

ailathatdgeelyopethodk, e

Sup

mation, they will learn something. If this activity is

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JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE

repeated many times a day, it can add up to a consid-erable investment of effort. By rewarding this effortwith continuing education credit, there is an addedbenefit and reinforcement to keeping up.

3. Clinical reference content. There are many CDS prod-ucts and services that deliver real-time clinical decisionsupport by putting evidence-based, point-of-care clini-cal reference content directly into the electronic work-flow of dental practitioners (Figs 2, 3; Table 3).8 Thisinformation can help clinicians● keep up with an overwhelming amount of

information● reduce unwanted variation in clinical practice● help make clinical decision-making more useful and

personal

Good CDS should assist rather than detract fromnormal daily activities. How to “fit” CDS into a busy

Figure 2. Example of CDS for dentistry. Mosby Elec-tronic Drug Guide Screen Shot https://secure2.us.elsevierhealth.com/pocketconsult/product.jsp?isbn�9780323023405

practice is a challenge. Making scientific evidence and

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clinical best practices information more accessiblemakes the information more useful. If the informationis more useful it will be more readily integrated intopractice.

4. EB reviews and analysis of primary articles. EB analysesand reviews of research are often more helpful than asingle study or expert opinion in guiding clinicaldecision-making. Resources that provide this secondlevel of analysis include the Cochrane Center9 andjournals such as Evidence-Based Dentistry (EBD)10 andthe Journal of Evidence-Based Dental Practice (JEBDP).11

Secondary high-quality information sources expeditetranslation, integration, and implementation of infor-mation. Other areas where analysis and reviews ofimportant information are available to dentists includemany of the dental and medical specialty professionalorganizations, the Centers for Disease Control andPrevention12 and the American Dental Association.13

DENTAL EDUCATION

In some dental schools, students are learning to master theelectronic resources necessary to gain control of the infor-mation explosion. For example at New York University Col-lege of Dentistry14 and UCLA School of Dentistry, studentsuse electronic access to JEBDP because some reviews andanalysis within the journal are required reading. At theUniversity of Michigan’s School of Dentistry students candownload and listen to class lectures on their MP3 players.15

The experiences students are getting in a more digitalworld will likely pay off in multiple ways as they enter thedental workforce where CDS will play an increasinglymore important role in managing patients.16,17 The excit-ing changes being made in some educational circles isbeing resisted in others. Research about educational bestpractices is negatively perceived by some dental facultiesaccording to Masella and Thompson.18

DOES CDS IMPROVE HEALTHCARE? SOMEEVIDENCE TO DATE

A systematic review of literature on the effect of healthinformation technology on quality, efficiency, and costsof care found 3 major benefits of CDS-like information19:

1. increased adherence to guideline-based care2. enhanced surveillance and monitoring, and3. decreased medication errors

New research suggests that the economic value of CDSis considerable. A Center for Information TechnologyLeadership analysis of the value of CPOE in ambulatorysettings found that the most profound impact arises withsophisticated clinical decision support.20 Advanced CPOEsystems were estimated to cost nearly 5 times as much asbasic CPOE, but were projected to generate over 12 times

greater financial return.21

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CHALLENGES

In 2001, the Institute of Medicine (IOM) cited studies ofunderuse, overuse, and misuse of care and came to theconclusion that the US health system “has floundered in itsability to provide consistently high quality care to all Amer-icans.”22 Of great importance was their observation that thehealth care system “frequently falls short in its ability totranslate knowledge into practice.”22 The IOM described the

Figure 3. MD Consult screen shot. http://home.mdco

TABLE 3. Free Point of Care Clinical Decision SuppoPractice

● Pocket Consult� Journal of Evidence-Based Dental Practice abstracts and

well as more than 100 other journals and clinics.� 20 medical calculators, including BMI, Glasgow Co� Daily news updates from MD Consult� Weekly drug updates from MD Consult

4 Newman

situation as “a large chasm between today’s system and thepossibilities of tomorrow.”22 The size of the knowledge gapis less important than the fact that the gap exists at all. Insome cases in medicine the gap between discovery andclinical practice integration may be for many years.

According to the Roadmap authors,1 there are severalchallenges to the wide scale adoption of CDS. Some ofthe most important include the following:

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ools available from the Journal for Evidence-Based Dental

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1. A lack of a common and portable clinical knowledgebase that can be easily and widely used in electronichealth and dental records (EHDRs) and other clinicalinformation systems.

This would avoid duplication of common knowledgethat remains stable over long periods of time. Forexample, a catalog of known drug interactions withcommonly prescribed antibiotics.

2. Barriers to adoption faced by health care providersand health systems caused by financial considerations.

Supportive policies by professional dental organiza-tions and licensing bodies would help to rectify thesedeficiencies and facilitate adoption of CDS morequickly and broadly because there would be incentivesfor using the latest knowledge to make treatment rec-ommendations and decisions.

3. Clinician resistance to CDS systems out of fear thatCDS will reduce autonomy or increase liability.

Just the opposite is likely to occur, since CDS systemsgive the clinician the most important information andthinking about the clinical question at hand. Muchmore flexibility and freedom in practice will comefrom having more information rather than from less.

4. Multiple issues designing the necessary and continu-ous evaluation of CDS.

5. Providing meaningful financial and personal incen-tives for using CDS.

The use of CDS will reduce errors, avoid over- orundertreatment and give the clinician and patient satis-faction by knowing that the best care was provided. CDS-supported continuing education credit, as mentionedearlier, will be an additional incentive for using CDS.

NEXT STOP ON THE ROADMAP

The Roadmap suggests that an incremental approach toimplementation is the most practical because no singleentity has the resources or the “authority” to mange it allby itself.1 In the future there will hopefully be an ongoingdialogue among the many CDS stakeholders.

The JEBDP will keep readers informed of CDS develop-ments through print and its own CDS services found on theJEBDP Web site: www.jebdp.com. Many of these and otheravailable CDS products are transportable to the PDA wherethe information can be used at the point of care. The JEBDPalso regularly updates and publishes a Glossary of Termsthat can always be found online.

REFERENCES

1. Oshreroff JA, Teich JM, Middleton BF, Steen EB, Wright A, DetmerDE. A Roadmap for National Action on Clinical Decision Support,June 13, 2006. Available at: www.amia.org/inside/initiatives/cds/.

Accessed December 4, 2006.

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2. Balas EA, Su KC, Solem JF, Li ZR, Brown G. Upgrading clinicaldecision support with published evidence: what can make the big-gest difference? Medinfo 1998;9(Pt 2):845-8.

3. Merijohn GK. Advances in Clinical Practice and Continuing Educa-tion: The precautionary context clinical practice model: a means toimplement the evidence-based approach. J Evid Base Dent Pract2005;5:115-24

4. Cercon Coach. Dentsply. Available at: www.cercncoarch.com. Ac-cessed December 4, 2006.

5. Horsky J, Kaufman DR, Oppenheim MI, Patel VL. Guided medica-tion dosing for inpatients with renal insufficiency. JAMA 2001;286(22):2839-44.

6. Kuperman GJ, Gandhi TK, Bates DW. Effective drug-allergy check-ing: methodological and operational issues. J Biomed Inform 2003;36(1-2):70-9.

7. Hsieh TC, Kuperman GL, Jaggi T, Hojnowski-Diaz P, Fiskio J, Wil-liams DH, Bates DW, Ghandi TK. Characteristics and Consequencesof Drug Allergy Alert Overrides in a Computerized Physician OrderEntry System. J Am Med Inform Assoc. 2004 Nov–Dec;11(6):482-491. doi:10.1197/jamia.M1556.

8. MD Consult. Elsevier. Available at: www.mdconsult.com. AccessedDecember 4, 2006.

9. www.ohg.cochrane.org. Accessed December 4, 2006.10. Evidence-based dentistry. Available at: www.nature.com/ebd. Ac-

cessed December 4, 2006.11. Journal of Evidence-Based Dental Practice Web site. Available at:

www.jebdp.com. Accessed December 4, 2006.12. National Center for Chronic Disease Prevention and Health Pro-

motion. Oral Health Resources. Available at: www.cdc.gov/OralHealth. Accessed December 4, 2006.

13. American Dental Association Web site. Evidence-based dentistry. Availableat: http://www.ada.org/prof/resources/topics/evidencebased.asp. Ac-cessed December 4, 2006.

14. Katz R. The importance of teaching critical thinking early in dentaleducation: concept, flow and history of the NYU 4-Year curriculumor ’’Miracle on 24th Street: the EBD Version.’’ J Evid Based DentPract 2006;6:1, 62-71.

15. Ascione L. Students plug in, enroll in ’iTunes U’. Schools postlectures online for use on students’ MP3 players. Available at:http://www.eschoolnews.com/news/showStory.cfm?ArticleID�6071.Accessed December 4, 2006.

16. Schleyer TKL, Thyvalikakath TP, Spallek H, Torres-Urquidy MH,Hernandez P, Yuhaniak J. Clinical Computing in General Dentistry.J Am Med Inform Assoc 2006;13:344-52. PrePrint published Febru-ary 24, 2006; doi:1197/jamia.M1990.

17. Mendonça EA. Clinical decision support systems: perspectives indentistry. J Dent Educ 2004;68(6):589-97.

18. Masella RS, Thompson TJ. Dental education and evidence-basededucational best practices: bridging the great divide. J Dent Educ2004;68(12):1266-71.

19. Dexter PR, Perkins S, Overhage JM, Maharry K, Kohler RB, Mc-Donald CJ. Ann Intern Med 2006;144(10):742-52.

20. Johnston D, Pan E, Walker J, Bates DW, Middleton B. The Value ofComputerized Provider Order Entry in Ambulatory Settings. Welle-sley, MA: Center for IT Leadership, 2003.

21. Birkmeyer CM, Lee J, Bates DW, Birkmeyer JD. Will electronicorder entry reduce health care costs? Eff Clin Pract 2002;5(2):67-74.

22. Institute of Medicine. Crossing the Quality Chasm: A New HealthSystem for the 21st Century. Washington, DC: National AcademyPress; 2001.

23. Balas EA, Su KC, Solem JF, Li ZR, Brown G. Upgrading clinicaldecision support with published evidence: what can make the big-

gest difference? Medinfo 1998;9(Pt 2):845-8.

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