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FEATURE ARTICLE
Clinical Decision Support Complements EvidenceBased Decision Making in Dental Practice
Michael G. Newman, DDS
Section of Periodontics, UCLA School of Dentistry, Los Angeles, CA
Dental professionals as well as consumers of dental health care are driving the
demand for access to reliable information so they can make more informed
decisions. Clinical decision support (CDS) includes a variety of printed and
electronic tools, systems, products, and services that make knowledge and
information available to the user. CDS is the main way people will be able to
access important facts, ideas, concepts, and the latest thinking about personal and
population-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 Information
Technology in the United States commissioned the American Medical Informatics Association to develop a plan
that would help advance Clinical Decision Support
(CDS). CDS includes a variety of printed and electronic
tools, systems, products, and services that give the user
knowledge and information to help make more informed
and individualized health care decisions. The result of
their efforts was the release, in 2006, of the Roadmap for
National Action on Clinical Decision Support.1 The Roadmap
recommends a series of activities to improve CDS availability, usefulness, and effectiveness, and to increase the
use of CDS (Table 1).
The Roadmap identifies 3 major components of the
CDS initiative. The authors refer to these as “pillars” and
J Evid Base Dent Pract 2007;7:1-5
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© 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.jebdp.2006.12.016
they reflect the common sense and practical approach
that good-quality CDS provides (Table 2). The 3 pillars
emphasize the use of evidence-based (EB) methods to
determine the validity and generalizability of data and the
integration of information technology (IT) that makes it
easier for high-quality information to be used at the point
of care.
Bringing EB and IT together improves the ability to
personalize treatment plans, avoid medical errors, and
ensure that the best treatments and alternatives are presented to the patient.
MANAGING LARGE AMOUNTS OF
INFORMATION
Dental and medical practitioners work in an increasingly
more difficult information environment. It is estimated
that the medical literature is doubling every 19 years, and
in some fast-moving subspecialties in medicine, such as
TABLE 1. Assistance of Clinical Decision Support to improve health decisions
Clinical Decision Support assists in the improvement of health management decisions by:






facilitating the detection of potential medical errors
suggesting risk factors and approaches to patient management
suggesting optimal clinical strategies based on the best clinical knowledge and cost-effectiveness considerations
organizing the details of a treatment plan
helping to gather and present data needed to execute a plan
communicating to third party payers
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
TABLE 2. Pillars of Clinical Decision Support*
● Best Knowledge Available When Needed: the best available clinical knowledge is well organized; accessible to
all; and written, stored, and transmitted in a format that makes it easy to build and deploy Clinical Decision
Support (CDS) interventions that deliver the knowledge into the decision-making process
● High Adoption and Effective Use: CDS tools are widely implemented, extensively used, and produce
significant clinical value while making financial and operational sense to their end-users and purchasers
Continuous Improvement of Knowledge and CDS Methods: both CDS interventions and clinical knowledge
undergo continuous improvement based on feedback, experience, and data that are easy to aggregate, assess,
and apply.
*Modified from A Roadmap for National Action on Clinical Decision Support, June 13, 2006. Available at: www.amia.org/inside/initiatives/
cds/. Accessed December 4, 2006.1
AIDS-related health care, it may double as quickly as every
2 years.2
In 2006, Merijohn introduced the Translational Clinical Practice System (TCPS) in an attempt to provide
guidance to clinicians trying to deal with and make sense
of the information onslaught (Fig 1).3 The system provides both a conceptual context and some specific suggestions about how to use EB essentials to answer clinical
questions and dilemmas that often require the latest information to enable good decision-making. More importantly, 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 harm
and risk to patients, clinicians can use the best scientific evidence, apply clinical experience and judgment, and serve patient preferences/values in order
to provide clinically relevant outcomes.
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When so many forces impinge on the clinician, having a
practice philosophy that helps to deal with the high volumes of information is welcome.
EXAMPLES OF CDS
1. Electronic health record. CDS technology can already
be found in the electronic health/dental record
(EHDR). EHDRs can enhance patient care because
they make information about a patient more accessible, accurate, and complete.
Computerized provider order entry (CPOE), as differentiated from handwritten paper charting, can facilitate workflow and minimize transcription errors.
And now a type of CPOE has been introduced by at
least 1 dental company to enhance communication
and avoid errors in the dental laboratory prescription.4
The Roadmap authors clearly state that “the storage,
connectivity, and automation functions of EH(D)R’s
and CPOE are necessary, but not sufficient to reach
the desired gains in health care quality. It is only
through CDS that EH(D)R’s and CPOE can achieve
their full potential for improving the safety, quality
and cost-effectiveness of care.”1
2. Drug prescribing. In dentistry one of the major examples of integrated CDS is related to medications. Electronic records systems linked to order entry systems
with CDS can supply patient data needed for proper
drug dosing.5 Drug prescribing for dental patients has
become more difficult as the complexity of their patient’s medical status and medication profiles become
greater. 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
6
● prevent untoward drug interactions
7
● avoid allergic reactions
Becoming proficient in electronic information management can increase confidence in the quality of
dental practice, and in the future, this daily activity may be
sufficient for earning CE credit. This makes a lot of sense,
because every time clinicians go online to access information, they will learn something. If this activity is
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JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
clinical best practices information more accessible
makes the information more useful. If the information
is more useful it will be more readily integrated into
practice.
4. EB reviews and analysis of primary articles. EB analyses
and reviews of research are often more helpful than a
single study or expert opinion in guiding clinical
decision-making. Resources that provide this second
level of analysis include the Cochrane Center9 and
journals such as Evidence-Based Dentistry (EBD)10 and
the Journal of Evidence-Based Dental Practice (JEBDP).11
Secondary high-quality information sources expedite
translation, integration, and implementation of information. Other areas where analysis and reviews of
important information are available to dentists include
many of the dental and medical specialty professional
organizations, the Centers for Disease Control and
Prevention12 and the American Dental Association.13
DENTAL EDUCATION
Figure 2. Example of CDS for dentistry. Mosby Electronic Drug Guide Screen Shot https://secure2.
us.elsevierhealth.com/pocketconsult/product.jsp?
isbn⫽9780323023405
repeated many times a day, it can add up to a considerable investment of effort. By rewarding this effort
with continuing education credit, there is an added
benefit and reinforcement to keeping up.
3. Clinical reference content. There are many CDS products and services that deliver real-time clinical decision
support by putting evidence-based, point-of-care clinical reference content directly into the electronic workflow of dental practitioners (Figs 2, 3; Table 3).8 This
information 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 from
normal daily activities. How to “fit” CDS into a busy
practice is a challenge. Making scientific evidence and
Volume 7, Number 1
In some dental schools, students are learning to master the
electronic resources necessary to gain control of the information explosion. For example at New York University College of Dentistry14 and UCLA School of Dentistry, students
use electronic access to JEBDP because some reviews and
analysis within the journal are required reading. At the
University of Michigan’s School of Dentistry students can
download and listen to class lectures on their MP3 players.15
The experiences students are getting in a more digital
world will likely pay off in multiple ways as they enter the
dental workforce where CDS will play an increasingly
more important role in managing patients.16,17 The exciting changes being made in some educational circles is
being resisted in others. Research about educational best
practices is negatively perceived by some dental faculties
according to Masella and Thompson.18
DOES CDS IMPROVE HEALTHCARE? SOME
EVIDENCE TO DATE
A systematic review of literature on the effect of health
information technology on quality, efficiency, and costs
of care found 3 major benefits of CDS-like information19:
1. increased adherence to guideline-based care
2. enhanced surveillance and monitoring, and
3. decreased medication errors
New research suggests that the economic value of CDS
is considerable. A Center for Information Technology
Leadership analysis of the value of CPOE in ambulatory
settings found that the most profound impact arises with
sophisticated clinical decision support.20 Advanced CPOE
systems were estimated to cost nearly 5 times as much as
basic CPOE, but were projected to generate over 12 times
greater financial return.21
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JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
Figure 3. MD Consult screen shot. http://home.mdconsult.com/php/64597335-2/home.html
CHALLENGES
In 2001, the Institute of Medicine (IOM) cited studies of
underuse, overuse, and misuse of care and came to the
conclusion that the US health system “has floundered in its
ability to provide consistently high quality care to all Americans.”22 Of great importance was their observation that the
health care system “frequently falls short in its ability to
translate knowledge into practice.”22 The IOM described the
situation as “a large chasm between today’s system and the
possibilities of tomorrow.”22 The size of the knowledge gap
is less important than the fact that the gap exists at all. In
some cases in medicine the gap between discovery and
clinical practice integration may be for many years.
According to the Roadmap authors,1 there are several
challenges to the wide scale adoption of CDS. Some of
the most important include the following:
TABLE 3. Free Point of Care Clinical Decision Support Tools available from the Journal for Evidence-Based Dental
Practice
●
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Pocket Consult
䡩 Journal of Evidence-Based Dental Practice abstracts and tables of contents automatically delivered to your PDA as
well as more than 100 other journals and clinics.
䡩 20 medical calculators, including BMI, Glasgow Coma Scale, Sodium Deficit, and Metric Unit Conversion
䡩 Daily news updates from MD Consult
䡩 Weekly drug updates from MD Consult
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JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
1. A lack of a common and portable clinical knowledge
base that can be easily and widely used in electronic
health and dental records (EHDRs) and other clinical
information systems.
This would avoid duplication of common knowledge
that remains stable over long periods of time. For
example, a catalog of known drug interactions with
commonly prescribed antibiotics.
2. Barriers to adoption faced by health care providers
and health systems caused by financial considerations.
Supportive policies by professional dental organizations and licensing bodies would help to rectify these
deficiencies and facilitate adoption of CDS more
quickly and broadly because there would be incentives
for using the latest knowledge to make treatment recommendations and decisions.
3. Clinician resistance to CDS systems out of fear that
CDS will reduce autonomy or increase liability.
Just the opposite is likely to occur, since CDS systems
give the clinician the most important information and
thinking about the clinical question at hand. Much
more flexibility and freedom in practice will come
from having more information rather than from less.
4. Multiple issues designing the necessary and continuous evaluation of CDS.
5. Providing meaningful financial and personal incentives for using CDS.
The use of CDS will reduce errors, avoid over- or
undertreatment and give the clinician and patient satisfaction by knowing that the best care was provided. CDSsupported continuing education credit, as mentioned
earlier, will be an additional incentive for using CDS.
NEXT STOP ON THE ROADMAP
The Roadmap suggests that an incremental approach to
implementation is the most practical because no single
entity has the resources or the “authority” to mange it all
by itself.1 In the future there will hopefully be an ongoing
dialogue among the many CDS stakeholders.
The JEBDP will keep readers informed of CDS developments through print and its own CDS services found on the
JEBDP Web site: www.jebdp.com. Many of these and other
available CDS products are transportable to the PDA where
the information can be used at the point of care. The JEBDP
also regularly updates and publishes a Glossary of Terms
that can always be found online.
REFERENCES
1. Oshreroff JA, Teich JM, Middleton BF, Steen EB, Wright A, Detmer
DE. 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 clinical
decision support with published evidence: what can make the biggest difference? Medinfo 1998;9(Pt 2):845-8.
3. Merijohn GK. Advances in Clinical Practice and Continuing Education: The precautionary context clinical practice model: a means to
implement the evidence-based approach. J Evid Base Dent Pract
2005;5:115-24
4. Cercon Coach. Dentsply. Available at: www.cercncoarch.com. Accessed December 4, 2006.
5. Horsky J, Kaufman DR, Oppenheim MI, Patel VL. Guided medication dosing for inpatients with renal insufficiency. JAMA 2001;
286(22):2839-44.
6. Kuperman GJ, Gandhi TK, Bates DW. Effective drug-allergy checking: 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, Williams DH, Bates DW, Ghandi TK. Characteristics and Consequences
of Drug Allergy Alert Overrides in a Computerized Physician Order
Entry System. J Am Med Inform Assoc. 2004 Nov–Dec;11(6):482491. doi:10.1197/jamia.M1556.
8. MD Consult. Elsevier. Available at: www.mdconsult.com. Accessed
December 4, 2006.
9. www.ohg.cochrane.org. Accessed December 4, 2006.
10. Evidence-based dentistry. Available at: www.nature.com/ebd. Accessed 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 Promotion. Oral Health Resources. Available at: www.cdc.gov/
OralHealth. Accessed December 4, 2006.
13. American Dental Association Web site. Evidence-based dentistry. Available
at: http://www.ada.org/prof/resources/topics/evidencebased.asp. Accessed December 4, 2006.
14. Katz R. The importance of teaching critical thinking early in dental
education: concept, flow and history of the NYU 4-Year curriculum
or ’’Miracle on 24th Street: the EBD Version.’’ J Evid Based Dent
Pract 2006;6:1, 62-71.
15. Ascione L. Students plug in, enroll in ’iTunes U’. Schools post
lectures 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 February 24, 2006; doi:1197/jamia.M1990.
17. Mendonça EA. Clinical decision support systems: perspectives in
dentistry. J Dent Educ 2004;68(6):589-97.
18. Masella RS, Thompson TJ. Dental education and evidence-based
educational best practices: bridging the great divide. J Dent Educ
2004;68(12):1266-71.
19. Dexter PR, Perkins S, Overhage JM, Maharry K, Kohler RB, McDonald CJ. Ann Intern Med 2006;144(10):742-52.
20. Johnston D, Pan E, Walker J, Bates DW, Middleton B. The Value of
Computerized Provider Order Entry in Ambulatory Settings. Wellesley, MA: Center for IT Leadership, 2003.
21. Birkmeyer CM, Lee J, Bates DW, Birkmeyer JD. Will electronic
order entry reduce health care costs? Eff Clin Pract 2002;5(2):67-74.
22. Institute of Medicine. Crossing the Quality Chasm: A New Health
System for the 21st Century. Washington, DC: National Academy
Press; 2001.
23. Balas EA, Su KC, Solem JF, Li ZR, Brown G. Upgrading clinical
decision support with published evidence: what can make the biggest difference? Medinfo 1998;9(Pt 2):845-8.
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