Effect of clinical decision support systems on emergency medicine physicians' decision-making: A pilot scenario-based simulation study

Abstract

Background and objectives: Children with congenital heart disease (CHD) are predisposed to rapid deterioration in the face of common childhood illnesses. When they present to their local emergency departments (ED) with acute illness, rapid and accurate diagnosis and treatment is crucial to recovery and survival. Previous studies have shown that ED physicians are uncomfortable caring for patients with CHD and there is a lack of actionable guidance to aid in their decision making. To support ED physicians' key decision components (sensemaking, anticipation, and managing complexity) when managing CHD patients, a Clinical Decision Support System (CDSS) was previously designed. This pilot study evaluates the effect of this CDSS on ED physicians' decision making compared to usual care without clinical decision support.

Methods: In a pilot scenario-based simulation study with repeated measures, ED physicians managed mock CHD patients with and without the CDSS. We compared ED physicians' CHD-specific and general decision-making processes (e.g., recognizing sepsis, starting antibiotics, and managing symptoms) with and without the use of CDSS. The frequency of participants' utterances related to each key decision components of sensemaking, anticipation, and managing complexity were coded and statistically analyzed for significance.

Results: Across all decision-making components, the CDSS significantly increased ED physicians' frequency of "CHD specific utterances" (Mean = 5.43, 95%CI: 3.7-7.2) compared to the without CDSS condition (Mean = 2.05, 95%CI: 0.3-3.8) whereas there was no significant difference in frequencies of "general utterances" when using CDSS (Mean = 4.62, 95%CI: 3.1-6.1) compared to without CDSS (Mean = 5.14 95%CI: 4.4-5.9).

Conclusion: A CDSS that integrates key decision-making components (sensemaking, anticipation, and managing complexity) can trigger and enrich communication between clinicians and enhance the clinical management of CHD patients. For patients with complex and subspecialized diseases such as CHD, a well-designed CDSS can become part of a multifaceted solution that includes knowledge translation, broader communication around interpretation of information, and access to additional expertise to support CHD specific decision-making.

Keywords: clinical decision support (CDSS); congenital heart disease; decision making; digital health; emergency medicine; macrocognition; pediatric.

Figure 1

Screenshot of MyHeartPass™ prototype. Sections marked with (i) refer to elements of design pertaining to key decision requirement distinguish the patient's unique physiology based on their unique cardiac anatomy. Elements marked with (ii) capture the elements pertaining to the key decision requirement of explicitly consider CHD specific differential diagnoses to allow a more structured reflection of diagnosis; and (iii) capture the elements pertaining to the key decision requirement of select CHD appropriate interventions for each patient.

Figure 2

Effect of MyHeartPass™ on ED physicians’ general and CHD-specific decision-making. The use of MyHeartPass™ (CDSS) is seen to have increased utterances of CHD-specific decisions without effecting utterances of general decisions. Error bars represent the 95% confidence interval.