Effectiveness of computerized decision support systems linked to electronic health records: a systematic review and meta-analysis

Abstract

We systematically reviewed randomized controlled trials (RCTs) assessing the effectiveness of computerized decision support systems (CDSSs) featuring rule- or algorithm-based software integrated with electronic health records (EHRs) and evidence-based knowledge. We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Abstracts of Reviews of Effects. Information on system design, capabilities, acquisition, implementation context, and effects on mortality, morbidity, and economic outcomes were extracted. Twenty-eight RCTs were included. CDSS use did not affect mortality (16 trials, 37395 patients; 2282 deaths; risk ratio [RR] = 0.96; 95% confidence interval [CI] = 0.85, 1.08; I(2) = 41%). A statistically significant effect was evident in the prevention of morbidity, any disease (9 RCTs; 13868 patients; RR = 0.82; 95% CI = 0.68, 0.99; I(2) = 64%), but selective outcome reporting or publication bias cannot be excluded. We observed differences for costs and health service utilization, although these were often small in magnitude. Across clinical settings, new generation CDSSs integrated with EHRs do not affect mortality and might moderately improve morbidity outcomes.

FIGURE 1—

Summary of evidence search and selection. Note. CDSS = computerized decision support systems; RCT = randomized controlled trial

FIGURE 2—

Summary of risk-of-bias assessments of the randomized controlled trials included in the meta-analyses. Note. Green (+) = low risk of bias; Yellow (?) = unclear risk of bias; Red (–) = high risk of bias.

FIGURE 3—

Forest plots from individual studies and meta-analysis for (a) mortality, all follow-up, and (b) morbidity, any disease. Note. CI = confidence interval; RR = risk ratio; W = weight. The RR and 95% CI for each study are displayed on a logarithmic scale.

FIGURE 4—

Funnel plots of observed relative risk against standard error for (a) mortality and (b) morbidity.

FIGURE 5—

“Leave-one-out” sensitivity analyses for studies with (a) mortality outcomes and (b) morbidity outcomes. Note. CI = confidence interval; RR = risk ratio. Pooled estimates are from random-effects models with 1 study omitted at a time.