HB 3072007

HB 3072007

Handbook
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Guide to the principles and desirable features of clinical decision support systems

This Handbook was prepared by Committee IT-014, Health Informatics. It was approved on behalf of the Council of Standards Australia on 15 October 2007. This Handbook was published on 31 December 2007.

The following are represented on Committee IT-014: Australian Association of Pathology Practices Australian Electrical and Electronic Manufacturers Association Australian Information Industry Association Australian Institute of Health and Welfare Australian Institute of Radiography Australian Medical Association Australian Private Hospitals Association Central Queensland University Commonwealth Department of Health and Ageing Consumers Federation of Australia Consumers Health Forum of Australia CSIRO e-Health Research Centre Department of Health (South Australia) Department of Health Western Australia Department of Human Services, Victoria Engineers Australia Health Informatics Society of Australia Health Information Management Association of Australia HL7 Australia Medical Industry Association of Australia Medical Software Industry Association National Health Information Management Principal Committee NSW Health Department Pharmacy Guild of Australia Pharmaceutical Society of Australia Queensland Health Royal Australian and New Zealand College of Radiologists Royal Australian College of General Practitioners Royal Australian College of Medical Administrators Royal College of Nursing, Australia Royal College of Pathologists of Australasia Society of Hospital Pharmacists of Australia University of Sydney

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Additional Interests: Cerner Corporation La Trobe University McCauley Software

Standards Australia wishes to acknowledge the participation of the expert individuals that contributed to the development of this Handbook through their representation on the Committee.

Keeping Standards up-to-date Australian Standards are living documents that reflect progress in science, technology and systems. To maintain their currency, all Standards are periodically reviewed, and new editions are published. Between editions, amendments may be issued. Standards may also be withdrawn. It is important that readers assure themselves they are using a current Standard, which should include any amendments that may have been published since the Standard was published. Detailed information about Australian Standards, drafts, amendments and new projects can be found by visiting www.standards.org.au Standards Australia welcomes suggestions for improvements, and encourages readers to notify us immediately of any apparent inaccuracies or ambiguities. Contact us via email at mail@standards.org.au, or write to Standards Australia, GPO Box 476, Sydney, NSW 2001.

HB 3072007

Handbook
This is a free 6 page sample. Access the full version at http://infostore.saiglobal.com.

Guide to the principles and desirable features of clinical decision support systems

First published as HB 3072007.

COPYRIGHT Standards Australia All rights are reserved. No part of this work may be reproduced or copied in any form or by any means, electronic or mechanical, including photocopying, without the written permission of the publisher. Published by Standards Australia GPO Box 476, Sydney, NSW 2001, Australia ISBN 0 7337 8482 8

HB 3072007

PREFACE
The mission of Standards Australia's IT-014 Health Informatics Technical Committee is to recommend for adoption by Standards Australia, standards and related materials within the domain of e-health that are demonstrably required in the Australian health sector, and, are implementable, maintainable and fit for purpose. (For further information about IT-014, visit www.e-health.standards.org.au) . This Handbook has been developed by the Standards Australia Committee IT-014, Health Informatics, to meet a critical health care safety need. Systems are being developed and implemented in health care to support the management of knowledge and provision of up to date, best practice guidance to clinicians at the point of care. For these systems to be clinically safe there is a need for them to be developed and maintained in a manner that supports best information and implemented to provide suitable information to support clinical decision making. This document identifies the principle elements of quality clinical decision support systems and the features that should be available when information is presented to clinicians to support their decision making. This Handbook has been prepared with input from clinical workshops and individual review by clinicians, health software vendors, consumers, researchers and health professional colleges in an effort to improve the quality of clinical information systems used in Australian health care. Standards Australia wishes to thank the Department of Health and Ageing for their continued financial support in helping us to develop this Handbook.

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HB 3072007

CONTENTS
Page SECTION 1 INTRODUCTION 1.1 RATIONALE .............................................................................................................. 4 1.2 SCOPE ....................................................................................................................... 4 1.3 PURPOSE ................................................................................................................... 4 1.4 APPLICATION ........................................................................................................... 5 1.5 STRUCTURE OF THE HANDBOOK ........................................................................ 6 SECTION 2 TYPES OF CLINICAL DECISION SUPPORT SYSTEMS 2.1 WHAT IS A CLINICAL DECISION SUPPORT SYSTEM? ...................................... 7 2.2 WHAT ARE THE TYPES OF DECISION SUPPORT SYSTEMS?............................ 7 2.3 MACHINE PROCESSING OF KNOWLEDGE IN CLINICAL DECISION SUPPORT SYSTEMS ................................................................................................. 8 SECTION 3 KEY PRINCIPLES AND DOMAIN SPECIFIC ISSUES 3.1 INTRODUCTION ....................................................................................................... 9 3.2 KEY PRINCIPLES...................................................................................................... 9 3.3 DOMAIN SPECIFIC ISSUES ................................................................................... 12 SECTION 4 COMPONENTS OF CLINICAL DECISION SUPPORT SYSTEMS 4.1 INTRODUCTION ..................................................................................................... 14 4.2 KNOWLEDGE.......................................................................................................... 14 4.3 THE SYSTEM........................................................................................................... 17 SECTION 5 SYSTEM IMPLEMENTATION AND MAINTENANCE 5.1 IMPLEMENTATION OF A CDSS ........................................................................... 19 5.2 MAINTENANCE ...................................................................................................... 19 SECTION 6 BIBLIOGRAPHY.............................................................................................. 21

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HB 3072007

STANDARDS AUSTRALIA Handbook Guide to the principles and desirable features of clinical decision support systems

SECT ION
1.1 RATIONALE

I NTRODU CT IO N

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Australian health care organizations, from primary care to tertiary hospital services, are introducing clinical information systems. These systems provide computer processable clinical information in the patients record. This information can be linked to knowledge held in computer systems to provide up-to-date information and advise clinicians and health consumers about current best practice in health care. These systems can also identify trends and alert clinicians to changes in patient condition that should be considered. Clinical decision support systems (CDSS) operate in the background behind the patient record system. Such systems are being developed and implemented in health care in Australia to improve the safety and quality of health care and to improve the efficiency of health care service provision [8]. For these systems to be clinically safe there is a need for both the systems and the knowledge represented in them to be developed and maintained in a manner that supports best information. Implementation of the systems requires consideration of clinical practice and how this varies in different clinical settings and varies the type of clinical decisionmaking appropriate to a given clinical situation. This Handbook identifies the principal elements of quality clinical decision support systems and the features that should be available when information is presented to clinicians to support their decision-making. 1.2 SCOPE This Handbook defines the types of clinical decision support systems used in health care and provides guidance on the (a) (b) (c) (d) functional features of clinical decision support systems required to support clinical decision making; key principles for presentation of knowledge in clinical decision support systems; principal content elements required for decision support system development; and principal governance processes required for the maintenance of clinical knowledge represented in clinical decision support systems.

1.3 PURPOSE In general, decision support systems alert, remind, support interpretation, assist practice, and critique, diagnose and manage patient care [6]. These requirements can be grouped for functional purposes as follows: (a) (b) Alerts and reminderAs a response to specified individual health care situations or trends. Diagnostic assistanceCDSS can come up with a likely diagnosis based on patient specific data.

Standards Australia

www.standards.org.au

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HB 307-2007, Guide to the principles and desirable features of clinical decision support systems
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